Diagnosis distribution in cases with granulomatous inflammation in lung, pleura, and lymph node biopsies: an experience from a tertiary level single center chest diseases and thoracic surgery hospital

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Selma Aydogan Eroglu
Tekin Yildiz
Esin Sonkaya
Murat Kavas
Fatma Ozbaki
Lale Sertcelik
Aycim Sen
Tulin Sevim


Granuloma, Diagnosis, Necrosis


Background: Granulomatous inflammation is found in a wide range of diseases, and most commonly associated with sarcoidosis and tuberculosis. Granulomas are pathologically classified into two main groups; necrotic and non-necrotic.

Objectives: The aim of this study was to evaluate the radiological, laboratory, and pathological findings of a large patient population with granuloma in biopsy samples, to determine the final diagnostic distribution.

Methods: This study was designed as a retrospective, descriptive, observational, cross-sectional study. It was conducted in patients with granulomatous inflammation detected in lung, pleural, mediastinal, hilar, and/or peripheral lymph node biopsies. Demographic information, radiological, microbiological, and laboratory results of the patients were obtained via the information processing system of the hospital. The diagnoses recorded were re-evaluated by at least two experienced clinicians and the final diagnosis distributions were made.

Results: A total of 392 patients were included in the study. Non-necrotizing inflammation was detected in 268 patients, and necrotizing granulomatous inflammation was found in 124 patients. The most common cause of non-necrotizing inflammation was sarcoidosis, and tuberculosis in the case of necrotizing inflammation. A total of 77.2% of sarcoidosis patients had non-necrotizing inflammation and 54.3% of the tuberculosis patients had necrotizing inflammation. In the diagnosis distribution of granulomatous inflammation sarcoidosis, mycobacterium infections (especially tuberculosis), sarcoid reaction due to malignancy, pneumoconiosis, granulomatosis with polyangiitis and hypersensitivity pneumonitis were detected, respectively. A total of 392 patients were diagnosed with 13 different diseases. We detected a small number of patients with cyst hydatid, benign fibrous histiocytoma, and cryptogenic organizing pneumonia as the causes of granulomatous inflammation.  In 15 patients (3.8%) no specific diagnosis could be made.

Conclusions: The diagnosis of granulomatous inflammation detected in biopsy samples is common for clinicians and a differential diagnosis is difficult in many cases. Clinical findings, laboratory results, and radiological features should be evaluated in detail and the final decision should be made from the multidisciplinary findings. The presence of necrosis in tissue samples alone is not a reliable finding for a final diagnosis.

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1) Ohshimo S, Guzman J, Costabel U, Bonella F. Differential diagnosis of granulomatous lung disease: clues and pitfalls. Eur Respir Rev 2017; 26:170012.
2) Al-Harbi A, Al-Otaibi S, Abdulrahman A,Al-Jahdali F, Al-Harbi F, Bamefleh H, et al. Lung granuloma: A clinicopathologic study of 158 cases. Ann Thorac Med 2017; 12(4):278–81.
3) Nazarullah A, Nilson R, Jose Maselli D, Jagirdar J. Incidence and a etiologies of pulmonary granulomatous inflammation: A decade of experience. Respirology 2015; 20:115–21.
4) Mukhopadhyay S, Farver CF, Vaszar LT, Dempsey OJ, Popper HH, Mani H, et al. Causes of pulmonary granulomas: A retrospective study of 500 cases from seven countries. J Clin Pathol 2012; 65:51–7.
5) Woodard BH, Rosenberg SI, Farnham R, Adams DO. Incidence and nature of primary granulomatous inflammation in surgically removed material. Am J Surg Pathol 1982; 6(2): 119-29.
6) Mukhopadhyay S, Gal AA. Granulomatous Lung Disease an Approach to the Differential Diagnosis. Archives of Pathology & Laboratory Medicine 2010; 134(5):667-90.
7) Dhooria S, Agarwal R, Aggarwal AN, Bal A, Gupta N, Gupta D. Differentiating tuberculosis from sarcoidosis by sonographic characteristics of lymph nodes on endobronchial ultrasonography: A study of 165 patients. J Thorac Cardiovasc Surg 2014; 148:662-7.
8) Guleria R, Mahashur A, Ghoshal AG, Thomas PK, Raghu G, Baughman RP . Challenges in diagnosing sarcoidosis in tuberculosis endemic regions: Clinical scenario in India. SarcoidosisVasc Diffuse Lung Dis 2016; 33(4):381-4.
9) Brincker H. Sarcoid reactions in malignant tumours. Cancer Treat Rev 1986; 13(3):147-56.se Lung Dis 2016; 33(4):381-4.
10)Cohen PR, Kurzrock R. Sarcoidosis and malignancy. Clinics in Dermatology 2007; 25(3):326-33.
11) Katz A, Lattes R. Granulomatous Thymoma or Hodgkin’s disease of Thymus? A clinical and histologic study and a re-evaluation. Cancer 1969; 23(1):1-15.
12) Ravaglia C, Gurioli C, Casoni GL, Romagnoli M, Tomassetti S, Gurioli C, et al. Sarcoid-like lesion is a frequent benign cause of lymphadenopathy in neoplastic patients. European Respiratory Journal 2013; 41:754-5.
13)Singer AJ. Sarcoidosis and renal cell carcinoma. Infect Urol. 2002;15:4.
14) Iftikhar A, Cheema MAI, Ramachandran P, Sahnic S. Sarcoid-like reaction associated with renal cell carcinoma – A case report. Respir Med Case Rep 2019; 27:100847.
15) Kojima M, Nakamura S, Fujisaki M, Hirahata S, Hasegawa H, Maeda D, et al. Sarcoid-like reaction in the regional lymph nodes and spleen in gastric carcinoma: a clinicopathologic study of five cases. Gen DiagnPathol 1997; 142(5-6):347-52.
16) R Bässler, F Birke. Histopathology of tumour associated sarcoid-like stromal reaction in breast cancer. An analysis of 5 cases with immunohistochemical investigations. Virchows Arch A Pathol Anat Histopathol 1988; 412(3):231-9.
17) Lynch MC, Graber EM, Johnson TS. Epithelioid Sarcoma Resembling Benign Fibrous Histiosytoma. Cutis 2015; 95(2):83-6.
18) Almadani N, Almutairi B, Alassiri AH. Primary Subcutaneous Hydatid Cyst with Palisading Granulomatous Reaction. Case Reports in Pathology 2013:126541.
19) Deonarain J, Sing Y, Calonje E, Singh B. Subcutaneous palisading granulomatous pseudocysts of Echinococcus granulosus origin. Journal of Cutaneous Pathology 2009; 36(2):240-5.
20) Feinstein MB, DeSouza SA, Moreira AL, Stover DE, Robert TH, Iyriboz TA, et al. A comparison of the pathological, clinical and radiographical, features of cryptogenic organising pneumonia, acute fibrinous and organising pneumonia and granulomatous organising pneumonia. J ClinPathol 2015; 68:441–7.
21) Erbay M, Ozsu S, Ayaydın Mürtezaoglu ES, Turkyılmaz A, Ozcelik N, Bulbul Y, et al. Mediastinal/hiler granulomatoz lenfadenit etyolojisi. Tuberk Toraks 2018; 66(3):212-6.

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