(Chest. 2001;120:316-317.)
© 2001
American College of Chest Physicians
Treatment of a Solitary Pulmonary Sarcoidosis Mass by CT-Guided Direct Intralesional Injection of Corticosteroid*
Marc A. Judson, MD, FCCP and
Renan Uflacker, MD
*
From the Division of Vascular and Interventional Radiology (Dr. Uflacker) and Division of Pulmonary and Critical Care Medicine (Dr. Judson), Medical University of South Carolina, Charleston, SC.
*
From the Department of Internal Medicine (Drs. Elesber and Kent), Mayo Graduate School of Medicine, and the Department of Pulmonary and Critical Care Medicine (Dr. Jennings), Mayo Clinic, Rochester, MN.
Correspondence to: Ahmad A. Elesber, MD, Mayo Clinic, 200 1st St SW, Rochester, MN 55905; e-mail: elesber.ahmad{at}mayo.edu
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Abstract
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A case is reported of 38-year-old woman with chest pain attributed
to a left lung sarcoidosis mass. The mass failed to diminish and
symptoms failed to resolve with systemic corticosteroid therapy.
CT-guided direct intralesional transthoracic injection of dexamethasone
resulted in resolution of the patient’s symptoms and a dramatic
reduction in the size of the mass within 2 months.
Key Words: corticosteroid • injection • lung mass • sarcoidosis • therapy
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Introduction
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A solitary
lung mass is a very rare thoracic presentation of
sarcoidosis.1
When pulmonary sarcoidosis requires
treatment, systemic corticosteroids are usually
effective.2
We report a case of pulmonary sarcoidosis that
presented as a left lung mass that was refractory to treatment with
oral corticosteroids. Transthoracic injection of corticosteroids under
CT guidance was effective in reducing the size of the lung lesion and
improving symptoms.
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Case Report
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A 38-year-old white woman presented with left-sided anterior
pleuritic chest pain (duration, 3 months). Pulmonary sarcoidosis had
been diagnosed using bronchoscopy with transbronchial biopsy 5 years
previously. The patient had no known history of beryllium exposure, and
all bronchoscopy specimens were negative for mycobacteria and fungi.
She had received treatment with prednisone for 3 years, and this had
been discontinued 2 years prior to presentation. She had no history,
signs, or symptoms of extrapulmonary sarcoidosis.
She was examined by her local physician, who requested a chest
radiograph and prescribed antibiotics for presumed pneumonia. Neither
her pleuritic chest pain nor the lung lesion on chest radiograph
improved. She was then prescribed prednisone, 40 mg/d, without
significant improvement over 2 months. She was referred to our medical
center.
She denied fever, night sweats, weight loss, hemoptysis, or any
constitutional symptoms. She remained active and in excellent physical
condition, other than left-sided pleuritic chest pain. She was a
lifelong nonsmoker, had no history of tuberculosis, and had several
negative tuberculosis skin test results. Physical
examination revealed a mildly obese, mildly cushingoid,
healthy-appearing white woman. Vital signs were normal. There was
tenderness to compression over the left anterior chest wall. Spirometry
revealed a mild restrictive ventilatory defect that was unchanged from
spirometry performed 4 years previously. A chest radiograph (Fig 1
) showed a normal mediastinum and a left upper lung mass.
A transthoracic core needle biopsy of the left lung lesion revealed
noncaseating granuloma. The specimen was negative for mycobacteria and
fungi, and revealed no crystals by polarized light examination. The
patient was prescribed prednisone, 60 mg/d for 1 month, without any
significant change in the lung mass on chest radiograph; there was no
improvement in her chest pain. Chest CT scan (Fig 2
, top) revealed a 4 x 7-cm left upper lobe mass extending
to the anterior pleural surface.
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Figure 2.. Top: Chest CT scan at presentation
showing a 4 x 7-cm intraparenchymal left lung mass. Mediastinal
lipomatosis, probably related to oral corticosteroid use, is also seen.
Bottom: Chest CT scan 2 months after injection showing a
marked reduction in the size of the lung mass to 2 x 3 cm.
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A CT fluoroscopy-guided transthoracic needle injection of
dexamethasone, 32 mg, into the lesion was performed under local
anesthesia and IV conscious sedation. Three 23-gauge needles were
introduced percutaneously at three different levels of the lesion.
Approximately 10 to 11 mg of dexamethasone were injected into each
site. No significant pain or discomfort was produced by the injection.
The patient was kept overnight in the hospital for observation. Six
weeks later, the patient returned and noted significant improvement in
her pleuritic chest pain. Repeat chest CT scan (Fig 2
,
bottom) performed 2 months after injection revealed a
dramatic reduction in the size of the left lung lesion.
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Discussion
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Pulmonary sarcoidosis often does not require treatment, as the
disease often causes no symptoms or is self-limiting.2
When a decision is made to treat pulmonary sarcoidosis, corticosteroids
are the primary agent recommended.2
Several randomized
trials3
4
have shown that corticosteroids are superior to
placebo in the short term (3 to 7 months) for acute pulmonary
sarcoidosis, as measured by improved radiographic findings and
spirometry. However, most randomized trials3
4
5
6
do not
demonstrate a long-term benefit (
5 years after therapy). Indeed a
retrospective study7
suggested that treatment with
corticosteroids may promote relapse of sarcoidosis.
Corticosteroid injections have been advocated for localized
sarcoidosis lesions that do not require systemic therapy. The classical
example of this is the use of corticosteroid injections for sarcoidosis
skin lesions.8
Direct corticosteroid injections have also
been successfully used for sarcoidosis of the palatine
tonsils,9
larynx,10
and
conjunctiva.11
12
A computer search of the medical
literature failed to identify any other case of pulmonary sarcoidosis
treated by direct injection of corticosteroid into the lesion. We
suspect that such treatment will rarely be required because it is rare
for pulmonary sarcoidosis to present as a solitary lesion; in these
patients, treatment is usually not necessary because the pulmonary
lesion rarely causes symptoms.
Although another diagnosis is possible in this case, we
feel secure that the pulmonary lesion is sarcoidosis. A transthoracic
core needle biopsy of the lesion revealed noncaseating granuloma that
was negative for mycobacteria and fungi, and revealed no crystals by
polarized light examination. It is rare but possible for carcinoma and
sarcoidosis to coexist in a solitary pulmonary nodule,13
but we think this is unlikely given that the patient was a lifelong
nonsmoker, was 38 years old, and had no other evidence of malignancy.
This case reiterates that intralesional injection of corticosteroid may
be useful for localized manifestations of sarcoidosis. Modern imaging
guidance allows precise percutaneous needle placement within lesions
even in remote locations, potentially expanding the use of the
technique. Although such therapy is most useful for skin sarcoidosis,
it seems to be effective in other circumstances, including rare
instances of isolated symptomatic sarcoidosis pulmonary lesions.
Received for publication November 2, 2000.
Accepted for publication December 5, 2000.
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References
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Abstract
Introduction
