Systemic Sarcoidosis First Manifesting in a Tattoo in the Setting of Immune Checkpoint Inhibition: A Case Report

Kim C, Gao J, Shannon V, Mays S and Radtke SA

Department of Genetics, The University of Texas MD Anderson Cancer Center, USA
Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, USA
Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, USA
Department of Dermatology, The University of Texas Health Science Center at Houston McGovern Medical School, USA

^*Correspondance to: Arlene Siefker-Radtke 

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Abstract:

A 52-year-old man with metastatic urothelial carcinoma of the left renal pelvis was treated with surgical resection and chemotherapy. Immune checkpoint therapy with anti-CTLA-4 (ipilimumab) and anti-PD1 (nivolumab) was initiated after the patient failed conventional chemotherapy. The patient had several large cosmetic tattoos placed on both arms many years prior to the cancer diagnosis. While on immunotherapy, thickened, hyperkeratotic papular lesions developed along the outer edges of the tattoos. Similar lesions also appeared over his face, and he developed arthralgias. Surveillance imaging following two cycles of immunotherapy demonstrated a mixed response of the lung metastases but definite progression of disease in the surgical bed and enlargement of mediastinal, hilar and retroperitoneal lymph nodes. Immunotherapy was discontinued after the second cycle due to presumed disease progression. A biopsy of one of the skin lesions revealed noncaseating granulomatosis, consistent with cutaneous sarcoidosis. The skin and mediastinal lymph node biopsies were culture-negative. Pathology of the lymph nodes also demonstrated noncaseating granulomas with no evidence of malignancy, indicating that the patient’s radiographic finding “mediastinal disease progression” was actually Lofgren syndrome sarcoidosis. After several weeks of high dose prednisone therapy, significant regression of the diffuse lymphadenopathy and skin lesions was seen on CT imaging studies, while the true metastatic lesions within the lung parenchyma and surgical bed remained unchanged. This case demonstrates that extrapulmonary sarcoidosis associated with immune checkpoint blockade can be mistaken for malignancy and may be misleading, resulting in premature termination of potentially efficacious treatments. Therefore, when in doubt, it is important to conduct histopathology of metastases before discontinuation of immune checkpoint therapy.

Keywords:

Immune checkpoint blockade; Urothelial cancer; Sarcoid

Cite the Article:

Kim C, Gao J, Shannon V, Mays S, Radtke SA. Systemic Sarcoidosis First Manifesting in a Tattoo in the Setting of Immune Checkpoint Inhibition: A Case Report. Ann Clin Case Rep. 2016; 1: 1032.