617028
research-article2015
IJSXXX10.1177/1066896915617028International Journal of Surgical PathologyTarjan et al
Case Reports
Renal Angiomyolipoma With Sarcoid Granulomas: Report of a Unique Case
International Journal of Surgical Pathology 1–4 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896915617028 ijs.sagepub.com
Gabor Tarjan, MD1, George J. Kim, MD1,2, and Mohamed Rizwan Haroon Al Rasheed, MBBS2
Abstract Angiomyolipoma is a mesenchymal neoplasm characterized by the coexpression of melanocytic and smooth muscle markers. Sarcoidosis is a multisystem disorder of unknown etiology, which presents with characteristic nonnecrotizing granulomas and rarely involves the kidney. The coexistence of renal sarcoidosis with renal neoplasms is exceedingly rare and was reported only with renal cell carcinoma. Renal sarcoidosis associated with a nonepithelial renal neoplasm, such as an angiomyolipoma has never been reported. We present the first reported case of sarcoid granulomas in a renal angiomyolipoma, including morphologic and immunohistochemical features. Keywords kidney, sarcoidosis, perivascular epithelioid cell neoplasm (PEComa), granulomatosis
Introduction
Case Report
Angiomyolipomas are mesenchymal neoplasms thought to originate from perivascular epithelioid cells. These tumors are typically composed of a mixture of smooth muscle, adipose tissue, and abnormal blood vessels in variable proportions. Similar to other members of the perivascular epithelioid cell neoplasm (PEComa) family, angiomyolipoma tumor cells characteristically co-express melanocytic (melan A/Mart1, HMB-45, tyrosinase) and smooth muscle markers (actin, desmin). Sarcoidosis is a multisystem disorder of unknown etiology, postulated to be an autoimmune response to an infection or an unidentified environmental agent. It is characterized histologically by nonnecrotizing granulomas. Sarcoidosis is a diagnosis of exclusion; other possible causes of granuloma formation need to be ruled out to confirm this diagnosis. Sarcoidosis may involve any organ system. Pulmonary (95%), skin (15.9%), lymphatic (15.2%), and ocular (11.8%) involvement were found to be the most common in a registry of 736 patients.1 Renal sarcoidosis is seen less frequently, either as part of a multisystem disease or, rarely, as the sole location of the disease. In the aforementioned series of 736 patients, the incidence of renal sarcoidosis was 0.7%.1 Renal sarcoidosis associated with renal neoplasms is exceedingly rare and was only reported with renal cell carcinoma.2 To our knowledge, renal sarcoidosis coexisting with a nonepithelial renal neoplasm, such as an angiomyolipoma, has never been reported. We describe, for the first time, a unique case of renal sarcoidosis in an angiomyolipoma.
A 42-year-old male former smoker and former butcher, with a medical history significant for asthma, presented with a productive cough for 1 year. Chest computed tomography (CT) revealed reticular opacities throughout the lungs, subpleural fibrosis, and mediastinal and bilateral hilar lymphadenopathy suggestive of sarcoidosis. Cultures were negative for acid fast bacteria. Transbronchial and mediastinal lymph node biopsies supported the diagnosis of sarcoidosis by showing noncaseating granulomas (Figure 1) with negative stains for acid fast bacteria and fungi. The chest CT also demonstrated 3 right renal masses and a normal left kidney. The subsequent abdominal CT with triple phase kidney protocol redemonstrated a right 25 mm solid midpole lesion, a right 10 mm solid midpole lesion, and a right 25 mm solid inferior pole lesion (Figure 2). These lesions were concerning for renal cell carcinoma, metastatic lesions, or sarcoidosis. There was no hematuria, dysuria, or increase in urination frequency. All 3 lesions were thought to reflect the same diagnosis and therefore percutaneous biopsy of one of the renal masses was performed. Repeat CTs did not show any change in size or 1
John H. Stroger Jr Hospital of Cook County, Chicago, IL, USA University of Illinois at Chicago, Chicago, IL, USA
2
Corresponding Author: Mohamed Rizwan Haroon Al Rasheed, Department of Pathology, University of Illinois at Chicago, 840 South Wood Street, Suite 130 CSN, Chicago, IL 60612, USA. Email: [email protected]
Downloaded from ijs.sagepub.com at Duquesne University on March 8, 2016
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International Journal of Surgical Pathology
Figure 1. A small nonnecrotizing granuloma in the transbronchial biopsy (arrow) (hematoxylin and eosin; original magnification 200×).
blending into the muscular layer of midsize blood vessels (Figure 3A). Rare intermixed clear spaces indicating adipocytes were also appreciated (Figure 3B). Within this tissue, several distinctive small, tight, cell groups were noted. They were composed of multinucleated giant cells and epithelioid cells with eosinophilic to vacuolated cytoplasm, suggestive of nonnecrotizing granulomas (Figure 3C). Mitotic activity and necrosis were absent both in the spindle cell component and in the granulomas. Immunohistochemical analyses for smooth muscle actin (clone: 1A4), CD68 (clone: KP-1), AE1/3 (cytokeratin cocktail), Cam 5.2 (clone: B22.1&B23.1), HMB-45 (antimelanosome), Mart1 (clone: A103), desmin (clone: R-11), CD34 (clone: QBEND/10), and CD117 (clone: 9.7) were performed on formalin-fixed, paraffin-embedded tissues at Alverno Laboratories, using commercially available antibodies (Ventana Cell Marque) and Ventana on board epitope retrieval. In situ hybridization for Epstein-Barr virus (EBV)– encoded RNA (EBER 1 DNA Probe) was also performed. The lesion was immunoreactive for Mart1 (Figure 3D), smooth muscle actin (Figure 3E), desmin (Figure 3F), and HMB-45, consistent with angiomyolipoma. The granulomas were negative for these markers. On the contrary, cells of the presumed granulomas were positive for CD68, supporting their histiocytic nature while the rest of the tissue was not immunoreactive (Figure 3G). None of the components showed immunoreactivity for AE1/3, Cam 5.2 cytokeratins, CD34, or CD117, effectively ruling out sarcomatoid carcinoma, solitary fibrous tumor/hemangiopericytoma, and gastrointestinal stromal tumor, respectively. The negative EBER excluded an EBV-induced smooth muscle cell tumor. No acid fast bacteria or fungi were seen on AFB (acid fast bacilli) and GMS (Gomori methenamine silver) stains.
Comment
Figure 2. The abdominal computed tomography scan demonstrates 3 separate right renal masses (arrows).
appearance of the renal lesions during the 9-month followup period.
Pathologic Findings Three tissue cores, measuring up to 1.5 cm in length and 0.1 cm in diameter, were received labeled as “renal mass.” Microscopic evaluation revealed oval to spindle cells with bland nuclei, voluminous eosinophilic cytoplasm, and indistinct cell borders in a vaguely fascicular pattern, focally
Most angiomyolipomas are solitary lesions, but about onefifth are multiple. The presence of multiple angiomyolipomas should raise suspicion of tuberous sclerosis complex. There was no evidence of tuberous sclerosis in our case. As mentioned before, angiomyolipomas are composed of a mixture of smooth muscle, adipose tissue, and blood vessels. Although adipose tissue is classically a major component of the tumor, predominance of smooth muscle is not uncommon.3 Small angiomyolipomas, in particular, may be composed primarily of smooth muscle and a core biopsy may yield only the smooth muscle component. This could lead to the inclusion of smooth muscle tumors, such as leiomyoma or leiomyosarcoma in the differential diagnosis. However, the myomelanocytic immunoprofile, for example, coexpression of myoid and melanocytic markers, is pathognomonic of a PEComa, in this case, an angiomyolipoma. Noncaseating sarcoid granulomas in the kidney were first described by Garland and Thomson in 1933.4 The reported
Downloaded from ijs.sagepub.com at Duquesne University on March 8, 2016
3
Tarjan et al
Figure 3. (A) Smooth muscle component and vascular component of angiomyolipoma (hematoxylin and eosin; original magnification 50×). (B) Adipose component and smooth muscle component of angiomyolipoma (hematoxylin and eosin; original magnification 50×). (C) Small nonnecrotizing granulomas (arrows) embedded within the angiomyolipoma (hematoxylin and eosin; original magnification 200×). (D) Angiomyolipoma shows strong and patchy positivity with Mart1 immunohistostain (with red chromogen; original magnification 100×). (E) The cells of angiomyolipoma are immunoreactive for smooth muscle actin while the granuloma remain negative (with brown chromogen; original magnification 200×). (F) Angiomyolipoma shows strong and patchy positivity with desmin immunohistostain (with brown chromogen; original magnification 100×). (G) The granulomas selectively express CD68 (with brown chromogen; original magnification 200×).
Downloaded from ijs.sagepub.com at Duquesne University on March 8, 2016
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International Journal of Surgical Pathology
incidence of renal sarcoidosis varies (0.75 to 10%), in part due to varying definitions used in different studies.5-8 In general, the diagnosis of sarcoidosis rests on the demonstration of characteristic noncaseating granulomas and the exclusion of other important causes of granuloma formation, such as berylliosis or other occupational exposures, Wegener granulomatosis, tuberculosis, and fungal infection. We did not detect any polarizable granulomainciting foreign substances in the kidney biopsy, and AFB and GMS stains did not reveal acid fast bacteria or fungi, respectively. These were also not observed in the lung and mediastinal lymph node biopsies. Additionally, no clinical or pathologic evidence of a vasculitic disease was present. Finally, a sarcoid-like reaction should be excluded. Sarcoid-like reactions are thought to be caused by antigenic factors derived from the tumor cells, eliciting an immunological hypersensitivity reaction resulting in epithelioid cell granuloma formation. Immunohistochemical analysis of tumor-related sarcoid reactions revealed that these represent a T-cell-mediated immune response, leading to histological appearance and cell distribution similar to that in sarcoidosis and other granulomatous conditions.9 Interestingly, both sarcoidosis and sarcoid-like reaction consistently express angiotensin I converting enzyme in epithelioid and giant cells, which suggests they share a common inflammatory pathway.9 These sarcoid-like reactions, which may occur in the tumor itself or in the tumordraining lymph nodes, were found in 13.8% of patients with Hodgkin’s disease, 7.3% of cases of non-Hodgkin lymphomas, and 4.4% of carcinomas, including cases of renal cell carcinoma.10,11 However, sarcoid-like reaction associated with sarcoma appears to be extremely rare.12,13 Additionally, our patient did not receive any drugs, such as tumor necrosis factor-α antagonists, that are known to induce sarcoid-like granulomatosis.14 Given these data and our patient’s coexisting pulmonary sarcoidosis, we believe that our case represents a unique manifestation of sarcoidosis in renal angiomyolipoma. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Baughman R, Teirstein A, Judson M, et al; Case Control Etiologic Study of Sarcoidosis (ACCESS) Research Group. Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med. 2001;164(10 pt 1):1885-1889. 2. Bottone AC, Labarbera M, Asadourian A, Barman A, Richie C. Renal sarcoidosis coexisting with hypernephroma. Urology. 1993;41:157-159. 3. Milner J, McNeil B, Alioto J, et al. Fat poor renal angiomyolipoma: patient, computerized tomography and histological findings. J Urol. 2006;176:905-909. 4. Garland H, Thomson J. Ureo-parotid tuberculosis. Q J Med. 1933;2:157-177. 5. Awasthi A, Nada R, Malhotra P, Goel R, Joshi K. Fatal renal failure as the first manifestation of sarcoidosis diagnosed on necropsy in a young man: a case report. J Clin Pathol. 2004;57:1101-1103. 6. Fernandez-Giron F, Fernandez Mora F, Conde-Garcia J, et al. Granulomatous interstitial nephritis, hypercalcemia and rapidly progressive kidney failure secondary to sarcoidosis with exclusive renal involvement. Am J Nephrol. 2001;21:514-516. 7. Miyoshi K, Okura T, Manabe S, Watanabe S, Fukuoka T, Higaki J. Granulomatous interstitial nephritis due to isolated renal sarcoidosis. Clin Exp Nephrol. 2004;8:279-282. 8. Robson M, Banerjee D, Hopster D, Cairns HS. Seven cases of granulomatous interstitial nephritis in the absence of extrarenal sarcoid. Nephrol Dial Transplant. 2003;18:280-284. 9. Kurata A, Terado Y, Schulz A, Fujioka Y, Franke FE. Inflammatory cells in the formation of tumor-related sarcoid reactions. Hum Pathol. 2005;36:546-554. 10. Brincker H. Sarcoid reactions in malignant tumours. Cancer Treat Rev. 1986;13:147-156. 11. Ouellet S, Albadine R, Sabbagh R. Renal cell carcinoma associated with peritumoral sarcoid-like reaction without intratumoral granuloma. Diagn Pathol. 2012;7:28. doi:10.1186/1746-1596-7-28. 12. Sumiyoshi A, Sabnnoe Y, Tanaka K. Rhabdomyosarcoma of the esophagus—a case report with sarcoid-like lesions in its draining lymph nodes and spleen. Acta Path Jap. 1972;22:581-589. 13. Llombart A, Escudero JM. The incidence and significance of epithelioid and sarcoid-like cellular reaction in the stromata of malignant tumours. A morphological and experimental study. Eur J Cancer. 1970;6:545-551. 14. Tong D, Manolios N, Howe G, Spencer D. New onset sarcoid-like granulomatosis developing during anti-TNF therapy: an under-recognized complication. Intern Med J. 2012;42:89-94.
Downloaded from ijs.sagepub.com at Duquesne University on March 8, 2016
research-article2015
IJSXXX10.1177/1066896915617028International Journal of Surgical PathologyTarjan et al
Case Reports
Renal Angiomyolipoma With Sarcoid Granulomas: Report of a Unique Case
International Journal of Surgical Pathology 1–4 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896915617028 ijs.sagepub.com
Gabor Tarjan, MD1, George J. Kim, MD1,2, and Mohamed Rizwan Haroon Al Rasheed, MBBS2
Abstract Angiomyolipoma is a mesenchymal neoplasm characterized by the coexpression of melanocytic and smooth muscle markers. Sarcoidosis is a multisystem disorder of unknown etiology, which presents with characteristic nonnecrotizing granulomas and rarely involves the kidney. The coexistence of renal sarcoidosis with renal neoplasms is exceedingly rare and was reported only with renal cell carcinoma. Renal sarcoidosis associated with a nonepithelial renal neoplasm, such as an angiomyolipoma has never been reported. We present the first reported case of sarcoid granulomas in a renal angiomyolipoma, including morphologic and immunohistochemical features. Keywords kidney, sarcoidosis, perivascular epithelioid cell neoplasm (PEComa), granulomatosis
Introduction
Case Report
Angiomyolipomas are mesenchymal neoplasms thought to originate from perivascular epithelioid cells. These tumors are typically composed of a mixture of smooth muscle, adipose tissue, and abnormal blood vessels in variable proportions. Similar to other members of the perivascular epithelioid cell neoplasm (PEComa) family, angiomyolipoma tumor cells characteristically co-express melanocytic (melan A/Mart1, HMB-45, tyrosinase) and smooth muscle markers (actin, desmin). Sarcoidosis is a multisystem disorder of unknown etiology, postulated to be an autoimmune response to an infection or an unidentified environmental agent. It is characterized histologically by nonnecrotizing granulomas. Sarcoidosis is a diagnosis of exclusion; other possible causes of granuloma formation need to be ruled out to confirm this diagnosis. Sarcoidosis may involve any organ system. Pulmonary (95%), skin (15.9%), lymphatic (15.2%), and ocular (11.8%) involvement were found to be the most common in a registry of 736 patients.1 Renal sarcoidosis is seen less frequently, either as part of a multisystem disease or, rarely, as the sole location of the disease. In the aforementioned series of 736 patients, the incidence of renal sarcoidosis was 0.7%.1 Renal sarcoidosis associated with renal neoplasms is exceedingly rare and was only reported with renal cell carcinoma.2 To our knowledge, renal sarcoidosis coexisting with a nonepithelial renal neoplasm, such as an angiomyolipoma, has never been reported. We describe, for the first time, a unique case of renal sarcoidosis in an angiomyolipoma.
A 42-year-old male former smoker and former butcher, with a medical history significant for asthma, presented with a productive cough for 1 year. Chest computed tomography (CT) revealed reticular opacities throughout the lungs, subpleural fibrosis, and mediastinal and bilateral hilar lymphadenopathy suggestive of sarcoidosis. Cultures were negative for acid fast bacteria. Transbronchial and mediastinal lymph node biopsies supported the diagnosis of sarcoidosis by showing noncaseating granulomas (Figure 1) with negative stains for acid fast bacteria and fungi. The chest CT also demonstrated 3 right renal masses and a normal left kidney. The subsequent abdominal CT with triple phase kidney protocol redemonstrated a right 25 mm solid midpole lesion, a right 10 mm solid midpole lesion, and a right 25 mm solid inferior pole lesion (Figure 2). These lesions were concerning for renal cell carcinoma, metastatic lesions, or sarcoidosis. There was no hematuria, dysuria, or increase in urination frequency. All 3 lesions were thought to reflect the same diagnosis and therefore percutaneous biopsy of one of the renal masses was performed. Repeat CTs did not show any change in size or 1
John H. Stroger Jr Hospital of Cook County, Chicago, IL, USA University of Illinois at Chicago, Chicago, IL, USA
2
Corresponding Author: Mohamed Rizwan Haroon Al Rasheed, Department of Pathology, University of Illinois at Chicago, 840 South Wood Street, Suite 130 CSN, Chicago, IL 60612, USA. Email: [email protected]
Downloaded from ijs.sagepub.com at Duquesne University on March 8, 2016
2
International Journal of Surgical Pathology
Figure 1. A small nonnecrotizing granuloma in the transbronchial biopsy (arrow) (hematoxylin and eosin; original magnification 200×).
blending into the muscular layer of midsize blood vessels (Figure 3A). Rare intermixed clear spaces indicating adipocytes were also appreciated (Figure 3B). Within this tissue, several distinctive small, tight, cell groups were noted. They were composed of multinucleated giant cells and epithelioid cells with eosinophilic to vacuolated cytoplasm, suggestive of nonnecrotizing granulomas (Figure 3C). Mitotic activity and necrosis were absent both in the spindle cell component and in the granulomas. Immunohistochemical analyses for smooth muscle actin (clone: 1A4), CD68 (clone: KP-1), AE1/3 (cytokeratin cocktail), Cam 5.2 (clone: B22.1&B23.1), HMB-45 (antimelanosome), Mart1 (clone: A103), desmin (clone: R-11), CD34 (clone: QBEND/10), and CD117 (clone: 9.7) were performed on formalin-fixed, paraffin-embedded tissues at Alverno Laboratories, using commercially available antibodies (Ventana Cell Marque) and Ventana on board epitope retrieval. In situ hybridization for Epstein-Barr virus (EBV)– encoded RNA (EBER 1 DNA Probe) was also performed. The lesion was immunoreactive for Mart1 (Figure 3D), smooth muscle actin (Figure 3E), desmin (Figure 3F), and HMB-45, consistent with angiomyolipoma. The granulomas were negative for these markers. On the contrary, cells of the presumed granulomas were positive for CD68, supporting their histiocytic nature while the rest of the tissue was not immunoreactive (Figure 3G). None of the components showed immunoreactivity for AE1/3, Cam 5.2 cytokeratins, CD34, or CD117, effectively ruling out sarcomatoid carcinoma, solitary fibrous tumor/hemangiopericytoma, and gastrointestinal stromal tumor, respectively. The negative EBER excluded an EBV-induced smooth muscle cell tumor. No acid fast bacteria or fungi were seen on AFB (acid fast bacilli) and GMS (Gomori methenamine silver) stains.
Comment
Figure 2. The abdominal computed tomography scan demonstrates 3 separate right renal masses (arrows).
appearance of the renal lesions during the 9-month followup period.
Pathologic Findings Three tissue cores, measuring up to 1.5 cm in length and 0.1 cm in diameter, were received labeled as “renal mass.” Microscopic evaluation revealed oval to spindle cells with bland nuclei, voluminous eosinophilic cytoplasm, and indistinct cell borders in a vaguely fascicular pattern, focally
Most angiomyolipomas are solitary lesions, but about onefifth are multiple. The presence of multiple angiomyolipomas should raise suspicion of tuberous sclerosis complex. There was no evidence of tuberous sclerosis in our case. As mentioned before, angiomyolipomas are composed of a mixture of smooth muscle, adipose tissue, and blood vessels. Although adipose tissue is classically a major component of the tumor, predominance of smooth muscle is not uncommon.3 Small angiomyolipomas, in particular, may be composed primarily of smooth muscle and a core biopsy may yield only the smooth muscle component. This could lead to the inclusion of smooth muscle tumors, such as leiomyoma or leiomyosarcoma in the differential diagnosis. However, the myomelanocytic immunoprofile, for example, coexpression of myoid and melanocytic markers, is pathognomonic of a PEComa, in this case, an angiomyolipoma. Noncaseating sarcoid granulomas in the kidney were first described by Garland and Thomson in 1933.4 The reported
Downloaded from ijs.sagepub.com at Duquesne University on March 8, 2016
3
Tarjan et al
Figure 3. (A) Smooth muscle component and vascular component of angiomyolipoma (hematoxylin and eosin; original magnification 50×). (B) Adipose component and smooth muscle component of angiomyolipoma (hematoxylin and eosin; original magnification 50×). (C) Small nonnecrotizing granulomas (arrows) embedded within the angiomyolipoma (hematoxylin and eosin; original magnification 200×). (D) Angiomyolipoma shows strong and patchy positivity with Mart1 immunohistostain (with red chromogen; original magnification 100×). (E) The cells of angiomyolipoma are immunoreactive for smooth muscle actin while the granuloma remain negative (with brown chromogen; original magnification 200×). (F) Angiomyolipoma shows strong and patchy positivity with desmin immunohistostain (with brown chromogen; original magnification 100×). (G) The granulomas selectively express CD68 (with brown chromogen; original magnification 200×).
Downloaded from ijs.sagepub.com at Duquesne University on March 8, 2016
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International Journal of Surgical Pathology
incidence of renal sarcoidosis varies (0.75 to 10%), in part due to varying definitions used in different studies.5-8 In general, the diagnosis of sarcoidosis rests on the demonstration of characteristic noncaseating granulomas and the exclusion of other important causes of granuloma formation, such as berylliosis or other occupational exposures, Wegener granulomatosis, tuberculosis, and fungal infection. We did not detect any polarizable granulomainciting foreign substances in the kidney biopsy, and AFB and GMS stains did not reveal acid fast bacteria or fungi, respectively. These were also not observed in the lung and mediastinal lymph node biopsies. Additionally, no clinical or pathologic evidence of a vasculitic disease was present. Finally, a sarcoid-like reaction should be excluded. Sarcoid-like reactions are thought to be caused by antigenic factors derived from the tumor cells, eliciting an immunological hypersensitivity reaction resulting in epithelioid cell granuloma formation. Immunohistochemical analysis of tumor-related sarcoid reactions revealed that these represent a T-cell-mediated immune response, leading to histological appearance and cell distribution similar to that in sarcoidosis and other granulomatous conditions.9 Interestingly, both sarcoidosis and sarcoid-like reaction consistently express angiotensin I converting enzyme in epithelioid and giant cells, which suggests they share a common inflammatory pathway.9 These sarcoid-like reactions, which may occur in the tumor itself or in the tumordraining lymph nodes, were found in 13.8% of patients with Hodgkin’s disease, 7.3% of cases of non-Hodgkin lymphomas, and 4.4% of carcinomas, including cases of renal cell carcinoma.10,11 However, sarcoid-like reaction associated with sarcoma appears to be extremely rare.12,13 Additionally, our patient did not receive any drugs, such as tumor necrosis factor-α antagonists, that are known to induce sarcoid-like granulomatosis.14 Given these data and our patient’s coexisting pulmonary sarcoidosis, we believe that our case represents a unique manifestation of sarcoidosis in renal angiomyolipoma. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Baughman R, Teirstein A, Judson M, et al; Case Control Etiologic Study of Sarcoidosis (ACCESS) Research Group. Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med. 2001;164(10 pt 1):1885-1889. 2. Bottone AC, Labarbera M, Asadourian A, Barman A, Richie C. Renal sarcoidosis coexisting with hypernephroma. Urology. 1993;41:157-159. 3. Milner J, McNeil B, Alioto J, et al. Fat poor renal angiomyolipoma: patient, computerized tomography and histological findings. J Urol. 2006;176:905-909. 4. Garland H, Thomson J. Ureo-parotid tuberculosis. Q J Med. 1933;2:157-177. 5. Awasthi A, Nada R, Malhotra P, Goel R, Joshi K. Fatal renal failure as the first manifestation of sarcoidosis diagnosed on necropsy in a young man: a case report. J Clin Pathol. 2004;57:1101-1103. 6. Fernandez-Giron F, Fernandez Mora F, Conde-Garcia J, et al. Granulomatous interstitial nephritis, hypercalcemia and rapidly progressive kidney failure secondary to sarcoidosis with exclusive renal involvement. Am J Nephrol. 2001;21:514-516. 7. Miyoshi K, Okura T, Manabe S, Watanabe S, Fukuoka T, Higaki J. Granulomatous interstitial nephritis due to isolated renal sarcoidosis. Clin Exp Nephrol. 2004;8:279-282. 8. Robson M, Banerjee D, Hopster D, Cairns HS. Seven cases of granulomatous interstitial nephritis in the absence of extrarenal sarcoid. Nephrol Dial Transplant. 2003;18:280-284. 9. Kurata A, Terado Y, Schulz A, Fujioka Y, Franke FE. Inflammatory cells in the formation of tumor-related sarcoid reactions. Hum Pathol. 2005;36:546-554. 10. Brincker H. Sarcoid reactions in malignant tumours. Cancer Treat Rev. 1986;13:147-156. 11. Ouellet S, Albadine R, Sabbagh R. Renal cell carcinoma associated with peritumoral sarcoid-like reaction without intratumoral granuloma. Diagn Pathol. 2012;7:28. doi:10.1186/1746-1596-7-28. 12. Sumiyoshi A, Sabnnoe Y, Tanaka K. Rhabdomyosarcoma of the esophagus—a case report with sarcoid-like lesions in its draining lymph nodes and spleen. Acta Path Jap. 1972;22:581-589. 13. Llombart A, Escudero JM. The incidence and significance of epithelioid and sarcoid-like cellular reaction in the stromata of malignant tumours. A morphological and experimental study. Eur J Cancer. 1970;6:545-551. 14. Tong D, Manolios N, Howe G, Spencer D. New onset sarcoid-like granulomatosis developing during anti-TNF therapy: an under-recognized complication. Intern Med J. 2012;42:89-94.
Downloaded from ijs.sagepub.com at Duquesne University on March 8, 2016
