Sarcoid-like Reaction Research Articles

Particular findings on lung CT in patients undergoing immunotherapy for bronchogenic carcinoma.

SummaryBackgroundImmune checkpoint inhibitors have become a valuable tool in the therapeutic strategy against metastasized non-small cell lung cancer (NSCLC) as they represent an effective and safe treatment option for many patients; however, the treatment response and side effects of this class of drugs can considerably differ compared to classical chemotherapeutics. The aim of this study was to highlight specific radiological pulmonary findings of NSCLC patients treated with immune checkpoint inhibitors.Methods and resultsMedical records and images of prospectively collected data from 70 patients with advanced NSCLC, treated with immune checkpoint inhibitors, were reviewed. Of the patients two experienced an initial increase in tumor size, followed by a decrease in tumor size that was described as pseudoprogression. Another patient developed a sarcoid-like reaction accompanied by clinical improvements and radiological treatment response. A further two patients developed immune checkpoint-associated pulmonary injury that was clinically and radiologically classified as pneumonitis, which responded well to anti-inflammatory treatment.ConclusionManagement of patients with NSCLC using immune checkpoint inhibitors requires a knowledge of specific clinical and radiological findings. Both oncologists and radiologists have to be aware of the most common types, including atypical response patterns, such as a sarcoid-like reaction and pseudoprogression as well as of the pulmonary side effects that can encompass pneumonitis.

Operational Considerations in Emergency Radiology

<dm:abstracts xmlns:dm="http://www.elsevier.com/xml/dm/dtd"><ce:abstract xmlns:ce="http://www.elsevier.com/xml/common/dtd" id="abs0001" view="all" class="author"><ce:section-title id="cesectitle0001">ABSTRACT</ce:section-title><ce:abstract-sec id="abss0001" view="all"><ce:simple-para id="spara012" view="all">The diverse imaging manifestations of thoracic metastatic disease often challenge accurate interpretation. Malignant cells usually arrive via the bloodstream but find fertile substrates within the pulmonary circulation, lymphatic networks, branching airways, and pleural envelope. Unusual metastatic nodules cavitate, calcify, or hemorrhage. Widespread intravascular tumor may induce pulmonary hypertension. In lymphangitic carcinomatosis the deep and superficial lymphatic networks expand with tumorlets, with consequent parenchymal congestion. Nodal lymphomas can spread retrograde via lymphatic pathways, forming multilobar consolidations that mimic pneumonia. Sarcoid-like reactions occasionally develop in thoracic nodes and lung in settings of malignancy or immunotherapy, and are often confused with tumor recurrence.</ce:simple-para></ce:abstract-sec></ce:abstract></dm:abstracts>

Sarcoid-like reaction: Hodgkin's lymphoma is a hypothesis.

Sarcoid-like reaction: Hodgkin's lymphoma is a hypothesis.

A Spectrum of Metastatic Disease in the Chest: Insights for the Radiologist

ABSTRACT The diverse imaging manifestations of thoracic metastatic disease often challenge accurate interpretation. Malignant cells usually arrive via the bloodstream but find fertile substrates within the pulmonary circulation, lymphatic networks, branching airways, and pleural envelope. Unusual metastatic nodules cavitate, calcify, or hemorrhage. Widespread intravascular tumor may induce pulmonary hypertension. In lymphangitic carcinomatosis the deep and superficial lymphatic networks expand with tumorlets, with consequent parenchymal congestion. Nodal lymphomas can spread retrograde via lymphatic pathways, forming multilobar consolidations that mimic pneumonia. Sarcoid-like reactions occasionally develop in thoracic nodes and lung in settings of malignancy or immunotherapy, and are often confused with tumor recurrence.

A CASE OF STIMULANT DESIGNER DRUG-INDUCED SARCOIDOSIS

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Sarcoidosis, a well-recognized cause of systemic granulomatous disease, has both infectious and non-infectious etiologies. Current literature suggests industrial dust exposure can lead to granulomatous disease, particularly involving the lung. However, there is currently no report of systemic granulomatous disease caused by stimulant designer drugs, such as 4-methylcathinone (4-MEC), which have become a growing public health concern in recent years. We present a patient diagnosed with granulomatous liver disease resembling sarcoid, following exposure to 4-MEC. CASE PRESENTATION: A 30-year-old man of Peruvian descent with a history of intravenous 4-MEC use, presented with 5 months of sweats and 25-pound weight loss. He denied recent travel or occupational exposures. Physical exam revealed massive hepatosplenomegaly. Initial workup was significant for elevated liver-specific alkaline phosphatase. Imaging showed diffuse abdominal lymphadenopathy. Extensive workup was negative for infections, hematologic malignancies and autoimmune diseases. Liver biopsy revealed non-caseating granulomas and refractile material. The diagnosis of a sarcoid-like reaction to particulate matter from 4-MEC injection was made. DISCUSSION: The etiology of sarcoidosis is unclear, making it a diagnosis of exclusion. It is therefore important to have a broad differential diagnosis, ruling out the presence of infectious agents such as mycobacteria, fungi and parasites, environmental and occupational exposures such as beryllium, organic antigens, autoimmune diseases and various medications, all of which can cause a granulomatous response. Our patient’s only significant exposure was to 4-MEC, a synthetic derivative of the pharmacologically active alkaloid, cathinone, which is a stimulant similar to 3,4-Methylenedioxymethamphetamine (MDMA). In sarcoidosis, elevated alkaline phosphatase is a more common laboratory abnormality than elevated transaminases. This combined with the absence of liver lesions should prompt a workup for a systemic disease process. Non-caseating granulomas are the hallmark histologic feature of sarcoidosis. Possible pathophysiologic explanations for sarcoid-like reactions include: the formation of non-caseating granulomas with secretion of lysozyme, collagenase and angiotensin-converting enzyme (ACE) in response to foreign particles of 4-MEC; or rapid influx of neutrophils around the foreign body resulting in macrophage activation, similar to talc granulomatosis. CONCLUSIONS: The etiology of sarcoidosis remains an enigma. Our case highlights the disease pathophysiology, emphasizes the importance of maintaining a broad differential diagnosis, and encourages consideration of other factors such as stimulant designer drugs in the etiology of non-caseating granulomatous disease. Reference #1: Dubaniewicz A. [The diagnostic algorithm of practice in pulmonary and extrapulmonary sarcoidosis]. Pol Merkur Lekarski. 2018 Mar 27;44(261):101-109. Review. Polish. PubMed PMID: 29601557. Reference #2: Pereiro T, Golpe A, Lourido T, Valdés L. Extrapulmonary Tumors and Sarcoidosis. An Incidental or Real association? Arch Bronconeumol. 2018 Oct;54(10):531-533. https://doi.org/10.1016/j.arbres.2018.01.036. Epub 2018 Mar 6. English, Spanish. PubMed PMID: 29523377. Reference #3: Chopra A, Nautiyal A, Kalkanis A, Judson MA. Drug-Induced Sarcoidosis-Like Reactions. Chest. 2018 Sep;154(3):664-677. https://doi.org/10.1016/j.chest.2018.03.056. Epub 2018 Apr 24. Review. PubMed PMID: 29698718 DISCLOSURES: No relevant relationships by Thomas Botta, source=Web Response No relevant relationships by Ishwar Giri, source=Web Response No relevant relationships by Viren Kaul, source=Web Response No relevant relationships by Jishu Motta, source=Web Response No relevant relationships by Rahila Ogunnaike, source=Web Response No relevant relationships by Lauren Pischel, source=Web Response No relevant relationships by Rutvik Shah, source=Web Response No relevant relationships by Sophia Shimer, source=Web Response

30. The paradox

IntroductionIncidental findings on investigations is not uncommon in rheumatology practice. Here such an incidental finding has led to dramatic change in the management of the underlying disease.Case descriptionA 38-year-old gentleman known to have ankylosing spondylitis (AS) since 2008, with radiologically evident sacroilitis on X-ray and MRI, was reviewed routinely in clinic and reported pain and restriction of neck movement and subsequent MRI cervical spine in April 2017 has shown incidental finding of apical fibrosis, but no AS activity.He denied constitutional and respiratory symptoms apart from occasional dry cough. Chest X-ray and high resolution CT scan confirmed the same findings of apical fibrosis in addition to bilateral reticulonodular and fisural changes. Blood tests showed angiotensin converting Eezyme level ACE 65 U/L (normal range 8-65), C-reactive protein <5.Bronchoscopy/biopsy showed non-caseating epitheliod granuloma. ZN stain and culture showed no TB infection. He was reviewed by the respiratory team and felt findings could conceivably fit with sarcoidosis.His dry cough has improved after Benepali was discontinued in June 2017 and no steroids were given. However, had a flare of AS symptoms (ribs and lower back pain and stiffness, right SIJ pain) despite regular etoricoxib and required to start on secukinumab.DiscussionBenepali (Etanercept biosimilar) sounds not different from the originator biologic in causing sarcoid-like reactions commonly present as skin rash and lung lesions. Etanercept is associated with a large majority of reported anti-TNF induced sarcoid-like cases, not effective in treating sarcoidosis and may even exacerbate it.However, there are few reports of adalimumab induced sarcoid-like reactions that resolved when treated with etanercept. Paradoxical reaction to one TNF alfa inhibitor does not preclude the use of other TNF blocking agents including etanercept.Key learning pointsLung lesions after exposure to anti-TNF warrants investigating a wide range of differential diagnoses. Paradoxical sarcoid-like reactions can occur with anti-TNF treatment and resolves on discounting it. Alternative biologic in ankylosing spondylitis might be a challenge.Conflicts of interestThe authors have declared no conflicts of interest.

Unusual Imaging Findings Associated with Germ Cell Tumors.

Germ cell tumors, because they contain immature and mature elements, can differentiate into different tissue types. They can exhibit unusual imaging features or manifest in a syndromic fashion. The authors describe these features and assign them to one of the following categories: (a) unusual manifestations of metastatic disease (growing teratoma syndrome, choriocarcinoma syndrome, ossified metastases, and gliomatosis peritonei); (b) autoimmune manifestations (sarcoidlike reaction and paraneoplastic syndromes); (c) endocrine syndromes (sex hormone production, struma ovarii, and struma carcinoid); or (d) miscellaneous conditions (ruptured dermoid cyst, squamous cell carcinoma arising from a mature teratoma, Currarino triad, fetus in fetu, pseudo-Meigs syndrome, and pancreatitis). Rare conditions associated with germ cell tumors demonstrate characteristic imaging findings that can help lead to the appropriate diagnosis and management recommendations. When evaluating for potential metastatic disease, alternative benign diagnoses should be considered (eg, growing teratoma syndrome, ossified metastases, ruptured dermoid cyst, gliomatosis peritonei, and sarcoidlike reaction), which may impact management. Germ cell tumors may also lead to life-threatening complications such as extensive hemorrhage from choriocarcinoma metastases or the rupture of mature teratomas, cases in which timely diagnosis is crucial. Autoimmune and endocrine manifestations such as paraneoplastic encephalitis, autoimmune hemolytic anemia, and hyperthyroidism may occur owing to the presence of germ cell tumors and can create a diagnostic dilemma for clinicians. Knowledge of the syndromic and unusual imaging findings associated with germ cell tumors helps guide appropriate management. ©RSNA, 2019.

The mystery of Black Pete make-up: a sarcoid-like foreign-body reaction.

The mystery of Black Pete make-up: a sarcoid-like foreign-body reaction.

Frequency and imaging features of abdominal immune-related adverse events in metastatic lung cancer patients treated with PD-1 inhibitor.

To investigate the frequency and imaging features of radiographically evident abdominal immune-related adverse events (irAEs) in patients with metastatic non-small-cell lung cancer (NSCLC) treated with PD-1 inhibitors. This retrospective study included 137 patients with metastatic NSCLC treated with PD-1 inhibitor nivolumab monotherapy (75 women; median age: 65years), who had a baseline CT and at least one follow-up abdomen CT during therapy. Baseline and all follow-up abdominal CTs performed for monitoring of nivolumab therapy were reviewed to identify the organ-specific abdominal irAEs including colitis/enteritis, hepatitis, biliary toxicity, pancreatitis, nephritis, sarcoid-like reaction, and pancreatic and adrenal atrophy. Their frequency and imaging features were described. Eighteen (13%) patients had radiologically identified abdominal irAEs (median 2.1months after starting nivolumab; interquartile range 1.17-5.83months); 16 patients developed enteritis/colitis (12 pancolitis, two segmental colitis, one enterocolitis, one enteritis), two hepatitis, one adrenalitis. One patient with hepatitis also developed colitis/enteritis. Radiographic abdominal irAE occurred after nivolumab therapy was discontinued in six patients before any subsequent therapy was started. IrAEs prompted nivolumab interruption and treatment with steroids in four patients (three colitis/enteritis, one hepatitis). Most common CT features of colitis/enteritis included mesenteric hyperemia (n = 15), bowel wall thickening (n = 13), mucosal hyperenhancement (n = 10), and fluid-filled colon (n = 9). Abdominal irAEs were detected on CT in 13% of NSCLC patients treated with nivolumab, and colitis, in the pancolitis form, was the most common irAE. Given the expanding role of immunotherapy, radiologists should be aware of the frequency and imaging manifestations of abdominal irAEs and the impact on patient management.

Postmalignancy sarcoid-like reaction

Postmalignancy sarcoid-like reaction

Sarcoid-Like Reaction after Lymphoma Treatment

Sarcoid-Like Reaction after Lymphoma Treatment

Hilar and mediastinal sarcoid-like reaction after the treatment of malignant tumors: imaging features and natural course on 18F-FDG-PET/CT.

This study aimed to assess the imaging features and natural course of hilar and mediastinal sarcoid-like reaction on 18F-fluorodeoxyglucose (FDG) PET/CT after the treatment of malignancies. Sixteen patients with the appearance of sarcoid-like reaction seen on 18F-FDG-PET/CT after treatment were included. Hilar and mediastinal lymph node metastases were pathologically or clinically ruled out. Posttreatment 18F-FDG-PET/CT imaging features were assessed. The maximum standardized uptake values of sarcoid-like reaction were 3.8-13.6 (mean 6.8). FDG uptake of hilar nodes was symmetrical in 12 (75%) patients and asymmetrical in 4 (25%). The time interval between the initiation of therapy and appearance of sarcoid-like reaction was 9-86months (median 27.1months). Among 14 patients who underwent further follow-up using 18F-FDG-PET/CT, sarcoid-like reaction regressed in 11 (79%) patients and did not regress in 3 (21%) patients. The time interval between the appearance of sarcoid-like reaction and its regression was 3-80months (median, 8.5months). After the treatment of malignancies, benign sarcoid-like reaction was rarely observed during follow-up. Although sarcoid-like reaction appeared a long time after the treatment of malignancies, it frequently and spontaneously regressed in a relatively short period of time.

Esophageal cancer associated with a sarcoid-like reaction and systemic sarcoidosis in lymph nodes: supportive findings of [18F]-fluorodeoxyglucose positron emission tomography\u2013computed tomography during neoadjuvant therapy

BackgroundIn patients with esophageal cancer, differentiation between lymph node metastasis and lymphadenopathies from sarcoidosis or sarcoid-like reactions of lymph nodes is clinically important. Herein, we report two esophageal cancer cases with lymph node involvement of sarcoid-like reaction or sarcoidosis.Case presentationOne patient received chemotherapy and the other chemoradiotherapy as initial treatments. In both cases, [18F]-fluorodeoxyglucose positron emission tomography–computed tomography (FDG-PET/CT) was performed before and after chemo(radio)therapy. After the treatment, FDG uptake was not detected in the primary tumor, but it was slightly reduced in the hilar and mediastinal lymph nodes in both cases. These non-identical responses to chemo(radio)therapy suggest the presence of sarcoid-like reaction of lymph nodes associated with squamous cell carcinoma of the esophagus. Curative surgical resection was performed as treatment.ConclusionsThese FDG-PET/CT findings may be helpful to distinguish between metastasis and sarcoidosis-associated lymphadenopathy in esophageal cancer.

Thoracic and cutaneous sarcoid-like reaction associated with anti-PD-1 therapy: longitudinal monitoring of PD-1 and PD-L1 expression after stopping treatment

BackgroundImmune checkpoint inhibitors (ICI) target T cell inhibitory pathways that are responsible for cancer tolerance by down-modulating immune functions. ICI have revolutionized patients care with lung cancer. Nevertheless, restoring endogenous antitumor T-cell responses can induce immune related adverse events, such as sarcoidosis.Case presentationWe report here the first case of a thoracic and cutaneous sarcoid-like reaction in a patient with a relapsing unresectable non-small cell lung cancer (NSCLC) treated with nivolumab, an anti-PD-1 mAb. The expression of PD-1 and its ligands, PD-L1 and PD-L2, was assessed by flow cytometry on peripheral blood mononuclear cells (PBMC) and compared to patients who had discontinued nivolumab therapy without having developed any immune related adverse events. PD-L1 expression was transiently increased on B cells, T cells and monocytes, whereas PD-L2 expression was not modulated. PD-1 was transiently undetectable when PD-L1 was maximal, before returning to basal level. Sarcoidosis spontaneously resolved, without corticotherapy.ConclusionThis case sheds the light on a complex regulation of PD-L1 expression in vivo on PBMC after nivolumab arrest and triggers the question of monitoring the expression of immune checkpoint on immune cells during and after treatment with ICI.

A rare presentation of pulmonary sarcoidosis as a solitary lung mass: a case report

BackgroundSarcoidosis is a multisystem, chronic granulomatous disease of unknown etiology that predominantly affects the lungs. Pulmonary sarcoidosis classically presents with constitutional symptoms and computed tomographic scan findings of bilateral, symmetric micronodules in a peribronchovascular distribution with upper and middle lung zone predominance accompanied by bilateral, symmetric hilar lymphadenopathy. A solitary lung mass is a rare finding for pulmonary sarcoidosis, and with its associated constitutional symptoms, it strongly mimics a malignancy. We aimed to provide further insight into the broad differential diagnosis of a lung mass by describing our experiences in the care of a patient who presented with clinical and radiographic features of lung cancer who was ultimately found to have an atypical manifestation of stage II pulmonary sarcoidosis.Case presentationA 44-year-old African American woman with a history of childhood asthma and type 2 diabetes mellitus presented with shortness of breath. After being treated for a presumed asthma exacerbation with prednisone, she experienced worsening dyspnea, night sweats, and unintentional weight loss. Further evaluation revealed a large left lower lobe mass and hilar lymphadenopathy. A computed tomography-guided biopsy of the lung mass revealed a multifocal non-necrotizing granuloma with multinucleated giant cells. Although consistent with sarcoidosis, this finding could represent a sarcoid-like reaction secondary to an occult malignancy. A more extensive repeat biopsy via bronchoscopy and mediastinoscopy revealed granulomatous inflammation without evidence of malignancy or infection. These procedures confirmed the diagnosis of pulmonary sarcoidosis, and she was started on treatment with high-dose prednisone. Her treatment course was complicated by hyperglycemia necessitating insulin therapy, but after 3 months of therapy, she reported improvement in her dyspnea, and repeat imaging revealed a significant decrease in the size of the lung mass and lymphadenopathy. Given her clinical and radiographic response, she was continued on a prednisone taper.ConclusionsAtypical manifestations of pulmonary sarcoidosis are diagnostically challenging because the clinical and radiographic features of the disease mimic those of a malignancy. We aimed to illustrate a unique etiology of a lung mass and the importance of maintaining a broad differential diagnosis. Nonetheless, with the possibility of a malignancy, a high index of suspicion is necessary for timely diagnosis and optimal management.

Sarcoid-like reaction associated with lung adenocarcinoma: A case report

A 71-year-old woman with a history of left lower lobe lobectomy 4 years ago for adenocarcinoma of the lung presented with new mediastinal and bilateral hilar lymphadenopathy on surveillance imaging, suspicious for disease recurrence. She underwent an endobronchial ultrasound-guided transbronchial needle aspiration of the lymph nodes and histology yielded non-necrotizing epithelioid granulomas with no evidence of malignancy. A diagnosis of sarcoid-like reaction associated with lung adenocarcinoma was made. The significance of this rare condition is discussed.

Sarcoid-like reactions in patients receiving modern melanoma treatment.

The development of cancer immunotherapy and targeted therapy has reached an important inflection point in the history of melanoma. Immune checkpoint inhibitors and kinase inhibitors are today’s standard of care treatments in advanced melanoma patients. Treatment-related toxicities can be very intriguing and quite challenging. Sarcoidosis is a multisystemic granulomatous disease characterized by an aberrant immune response to unknown antigens, whereas sarcoid-like reactions (SLRs) refer to localized clinical features. We carried out a single-center observational study in patients with stage IIB–IV melanoma treated with BRAF/MEK inhibitors and immune checkpoint inhibitors. A description of the sarcoidosis-related manifestations was provided from patients’ records. We observated eight cases of SLRs in a cohort of 200 patients. The clinical courses were characterized by a variety of symptoms, accompanied by cutaneous signs and extracutaneous manifestations such as bilateral, hilar lymphadenopathy. We identified a histologically granulomatous inflammation involving the skin, the lungs, and the lymph nodes. Two patients presented with cutaneous lesions only, and three patients had lung involvement only. Three patients achieved complete and partial response of the melanoma disease, and three patients had stable disease. Disease progression was documented in two patients. The reported immune-related adverse events were mild to severe and in most of the cases were continued without any treatment cessation. SLRs appear during treatment with both kinase and immune checkpoint inhibitors. Awareness of these can avoid misdiagnosis of disease progression and unnecessary treatment changes.

Thoracic Imaging of Solid Tumor Patients Treated with Immune Checkpoint Inhibitors

Immune checkpoint inhibitors harness the patient’s own immune system to fight cancer. They are now approved for treating a number of solid malignancies, with more agents and indications expected in the coming months and years. Because of their unique mechanism of action, these agents may lead to unusual imaging appearances. Rare patients may experience pseudoprogression, whereby tumors may initially increase in size or number despite response to therapy. Many patients will experience autoimmune side effects including pneumonitis, which may lead to respiratory compromise and will necessitate cessation of therapy. Occasionally pneumonitis or a sarcoid-like reaction can mimic metastatic disease. It is imperative that radiologists be aware of these unusual imaging manifestations in patients on immunotherapy so that they are able to assist oncologists in appropriately treating these patients. In particular, we urge caution in interpreting new or enlarging lesions, since these may not always mean progression of disease. Additionally, radiologists should look out for potential immune-related side effects of these therapies.

Coal worker’s pneumoconiosis and sarcoid-like reaction mimicking lymph node metastases in a patient with lung cancer: A case report

Sarcoid-like reactions occur in a small percentage of cancer patients. This reaction causeslymph nodes to appear hypermetabolic when viewed with Fludeoxyglucose-Positron EmissionTomography (FDG-PET). This is clinically important, because it could be confused with tumormetastasis and could affect the staging and treatment of the cancer. In addition to sarcoid-likereactions and metastasis, several other disease processes can cause lymph nodes to appearhypermetabolic with FDG-PET, including coal worker’s pneumoconiosis. We present the caseof a 61-year-old coal miner who was diagnosed with lung cancer. FDG-PET showed increaseduptake in ipsilateral and contralateral mediastinal lymph. The patient had bronchoscopy withendobronchial ultrasound (EBUS) guided biopsy of the mass and needle aspiration of bilaterallymph nodes of the mediastinum. All the biopsies were negative. The patient then had a leftupper lobectomy and left mediastinal lymph node dissection. The PET findings were originallyattributed to metastasis of the tumor, but pathology of the ipsilateral nodes showed silicoticchanges due to pneumoconiosis and non-caseating granulomas from a sarcoid-like reaction.Because the ipsilateral lymph nodes had no evidence of metastasis and EBUS biopsy ofthe contralateral nodes was negative, it was unlikely that the changes in the contralateralnodes were due to metastasis, and no adjuvant treatment was offered. At more than oneyear after surgery, the patient remains stable with no evidence of recurrence, and we haveclinical assurance that the changes in the lymph nodes were due to the sarcoid-like reactionand pneumoconiosis and not metastasis. FDG-PET is useful for detection of lung cancer, butpathology is necessary for staging and determining treatment for the patient.

Ipilimumab Lung Toxicity

SESSION TITLE: Lung Pathology 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: A patient being treated with Ipilimumab developed granulomatous lung disease. CASE PRESENTATION: A 54 year old man was being treated for stage IIIc Melanoma with Ipilimumab. After his second infusion he developed a rash. Biopsy of a palmar lesion showed non-caseating granulomas. He developed dry cough and chest CT (Image 1) showed mediastinal lymphadenopathy and scattered sub centimeter lung nodules. The imaging findings were concerning for metastatic disease. A bronchoscopy with EBUS and fine needle aspiration of hilar and subcarinal lymph nodes was performed. Lymph node biopsy revealed non-caseating granulomas in both left hilar and subcarinal sites. Flow cytometry on lymph node FNA showed no clonal populations and a CD4/CD8 ratio of 4. The patient was treated with Prednisone for 2 months with resolution of his symptoms and improvement in CT findings (Image 2). He continues to receive Ipilimumab infusions for Melanoma therapy without any recurrence of his granulomatous disease. DISCUSSION: Novel immunotherapy agents have revolutionized the treatment of certain cancers in recent years. Some of these work by activating the immune system to aid in fighting tumor burden. Ipilimumab blocks CTLA-4, a T-cell activation checkpoint molecule, thereby promoting immunity against the tumor (1). It has been shown to improve survival in metastatic Melanoma and has become part of the standard treatment regimen (2). There have been case reports of a granulomatous sarcoid-like reaction to these medications (3). Lung manifestations can be mistaken for progression of the underlying malignancy. Clinicians should be aware of this important reaction and pursue tissue diagnosis to differentiate the two. CONCLUSIONS: Novel immunotherapy agents are being used to treat certain kinds of cancer. An important consideration of these treatments is the effect of activation of the immune system on other organs. A pulmonary sarcoid like reaction can resemble metastatic disease on imaging. Our case illustrates the importance of pursuing tissue diagnosis. A short course of steroids resulted in resolution of the pulmonary findings. Reference #1: O’Day SJ, et al. Targeting cytotoxic T-lymphocyte antigen-4 (CTLA-4). Cancer, 110: 2614-2627. Reference #2: Hodi FS et al. Improved Survival with Ipilimumab in Patients with Metastatic Melanoma. N Engl J Med 2010; 363:711-23. Reference #3: Reule RB, North JP. Cutaneous and pulmonary sarcoidosis-like reaction associated with ipilimumab. J Am Acad Dermatol. 2013;69(5):e272-e273. DISCLOSURE: The following authors have nothing to disclose: Esha Oommen, Joanne Allam No Product/Research Disclosure Information