AJR Integrative Imaging

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LIFELONG LEARNING
FOR RADIOLOGY

Imaging Features of Sarcoidosis on MDCT, FDG PET,

and PET/CT
Hima B. Prabhakar1, Chad B. Rabinowitz1, Fiona K. Gibbons2, Walter J. ODonnell2, Jo-Anne O. Shepard3, and Suzanne L. Aquino3

Objective
The objectives of this article are to discuss the epidemiology
and natural history of sarcoidosis; to review the classic imaging
features of sarcoidosis on radiography, CT, and 67Ga nuclear
medicine scans; and to present clinical examples of sarcoidosis
as seen on PET and PET/CT in the chest, abdomen and pelvis,
and bones.

Conclusion
The imaging features of sarcoidosis are diverse and can be
seen on a variety of imaging techniques. It is important for radiologists and nuclear medicine physicians to recognize the common imaging features and patterns of sarcoidosis in order to
raise the possibility in the appropriate clinical setting.

Introduction
Sarcoidosis is a multiorgan granulomatous disease with a
wide variety of imaging features. Imaging abnormalities can
commonly be seen on chest radiography, MDCT, 67Ga scans,
FDG PET, and PET/CT. FDG uptake from sarcoidosis is nonspecific and can mimic other disease processes, including lymphoma and diffuse metastatic disease. When combined with
imaging features on other techniques, such as MDCT, FDG
uptake can be useful in monitoring therapeutic response in
patients with known sarcoidosis. Because imaging features of
sarcoidosis can overlap considerably with those of malignant
disorders, it is important for both radiologists and nuclear
medicine specialists to be aware of the many varied presentations of sarcoidosis in order to suggest the diagnosis in the
appropriate clinical setting.
Sarcoidosis is a systemic and chronic disease of unknown
cause [1]. The characteristic histologic lesion, a noncaseating
granuloma, has been described as affecting all organ systems,
although they are most frequently seen affecting the lungs [2].

The imaging features of sarcoidosis are protean and can

be shown with a variety of imaging techniques. Diagnostic
imaging can not only help suggest a diagnosis in asymptomatic patients, but can also help in monitoring therapeutic
response in symptomatic patients. FDG uptake on PET in
patients with sarcoidosis is nonspecific and can mimic that
in malignancies such as lymphoma and diffuse metastatic
disease [2].

Epidemiology
Sarcoidosis has a worldwide distribution and typically affects young to middle-aged adults. The highest prevalence of
the disease is found in African-Americans, Swedes, and Danes.
In the United States, the incidence rate of sarcoidosis is 35.5
cases per 100,000 in blacks and 10.9 cases per 100,000 in
whites. Additionally, the disease incidence is slightly higher in
women than in men [3].

Clinical Presentation and Natural History

Because sarcoidosis affects multiple organ systems, presentation varies from nonspecific constitutional symptoms to
those related to specific organ involvement. Symptoms related
to lung involvement (dyspnea and cough) can lead to chest
radiographs that eventually yield the diagnosis of sarcoid.
One third of patients have peripheral lymphadenopathy, most
commonly involving the cervical, axillary, and inguinal lymph
nodes. One quarter of patients show characteristic skin lesions, including erythema nodosum and lupus pernio [3].
The natural history of sarcoidosis varies significantly
from patient to patient. The disease spontaneously remits in
up to one third of patients, but is chronic and progressive in
up to 30%. There is a 15% fatality rate from the disease,
most commonly resulting from severe respiratory or cardiac
involvement [3].

Keywords: CT, FDG PET, MDCT, PET/CT, sarcoidosis

DOI:10.2214/AJR.07.7001
Received March 8, 2007; accepted after revision June 11, 2007.
1
Abdominal Imaging and Interventional Radiology, Department of Radiology, Massachusetts General Hospital, 55 Fruit St., FND 270, Boston, MA 02114. Address correspondence to
H. B. Prabhakar (himaprab@gmail.com).

Department of Pulmonary/Critical Care Medicine, Massachusetts General Hospital, Boston, MA.

Thoracic Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA.

AJR 2008;190:S1S6 0361803X/08/1903S1 American Roentgen Ray Society

AJR:190, March 2008

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Prabhakar et al.

Fig. 1Stage 1 sarcoidosis in 54-year-old man with biopsy-proven sarcoidosis.

Frontal chest radiograph shows right paratracheal and bilateral hilar lymphadenopathy (arrows) and clear lungs.

Fig. 2Pulmonary nodules in peribronchovascular distribution in 44-year-old

woman with sarcoidosis. High-resolution chest CT image shows multiple tiny pulmonary nodules centered in peribronchovascular distribution (upper arrow). Small
pulmonary nodules can also be seen lining right major fissure (lower arrow).

Fig. 3Abdominal lymphadenopathy in 38-year-old man with biopsy-proven

sarcoidosis. Contrast-enhanced axial CT image of upper abdomen shows multiple periaortic lymph nodes (arrows).

Fig. 4Lambda () sign on 67Ga scan in 26-year-old man with biopsy-proven sarcoidosis. Anterior image of chest shows increased tracer uptake in right paratracheal and bilateral hilar lymph nodes, in configuration known as lambda sign.

Classic Imaging Features of Sarcoidosis

MDCT
Lymphadenopathy and parenchymal involvement in the
neck and chest are more readily shown on MDCT. In the
neck, palpable cervical lymphadenopathy is identified in
one third of patients, usually in the posterior triangle. In
the chest, paratracheal, mediastinal, and bilateral hilar
lymphadenopathy are most commonly identified. Characteristic parenchymal lesions include pulmonary nodules,
typically in a peribronchovascular distribution or along fissures [2] (Fig. 2). Less commonly, alveolar consolidation can
be seen with air bronchograms, cavitation, and fibrosis [4].
In the abdomen, lesions are less characteristic, mimicking systemic diseases such as lymphoma, diffuse metastatic
disease, or granulomatous or mycobacterial infection. In

Radiography
Chest radiographic features include mediastinal and bilateral hilar lymphadenopathy, parenchymal opacities, and,
in more advanced cases, parenchymal fibrosis. A clinical
staging system based on the chest radiograph has been devised to monitor disease in patients with sarcoidosis as well
as to predict patient prognosis. The five-part staging system ranges from stage 0 (no radiographic abnormality) to
stage 4 (pulmonary fibrosis), with varying degrees of
lymphadenopathy and pulmonary parenchymal abnormalities in between. Spontaneous remission is more commonly
seen in patients with stage 1 disease (Fig. 1) than in patients
with more advanced stages [3].

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Imaging Features of Sarcoidosis

is nonspecific in both intensity and pattern, and is not generally useful in making an initial diagnosis. Additionally, marked
FDG uptake in lymph nodes and parenchymal organs can be
an important mimic of malignancy, specifically lymphoma
and diffuse metastatic disease. Despite this, FDG uptake can
decrease when sarcoidosis is treated, and PET can be useful in
monitoring the effectiveness of therapy [8, 9].
Although FDG uptake is nonspecific in sarcoidosis, combining the imaging features of sarcoidosis on CT with uptake on PET can make combined FDG PET/CT a useful
technique in monitoring disease progression or remission.
Additionally, if characteristic patterns of chest CT lesions
are identified (as described previously), along with typical
patterns of lymphadenopathy, the disease can be suggested
on the basis of FDG PET/CT findings. Histologic proof,
however, often is still required because of the importance of
excluding malignancies, particularly lymphoma [10].

Clinical Examples on FDG PET and PET/CT

Fig. 5Palpable submental lymph node with FDG uptake in 56-year-old woman
with palpable submental lymph node. Axial fused contrast-enhanced PET/CT image shows enlarged left submental lymph node (arrow) with increased FDG uptake. Lesion was biopsied and was consistent with sarcoidosis.

addition to diffuse lymphadenopathy (Fig. 3), nonspecific

parenchymal lesions have been described, usually in the
spleen and liver [4]. Diffuse hepatic involvement can progress in some cases to confluent hepatic fibrosis [2].
Gallium-67 Scanning
Gallium-67 imaging has been widely used in the diagnosis
of sarcoidosis. Gallium-67 is taken up in lesions with increased blood flow, typically in lesions having an inflammatory or infectious cause. In sarcoidosis, a characteristic pattern of uptake in the chest has been described as the lambda
sign: paratracheal and bilateral hilar uptake [5] (Fig. 4). Another pattern of uptake is called the panda sign, caused by
uptake in the lacrimal and parotid glands. Although this pattern can be seen in other entities, such as lymphoma and
HIV, the bilateral symmetric involvement of the glands is
more typical of sarcoidosis [6]. Additionally, when the panda
sign is seen in conjunction with the lambda sign, it is highly
specific for sarcoidosis [5].
FDG PET and PET/CT
FDG PET is an important clinical tool in the evaluation of
known or suspected malignancy. Uptake of the tracer is nonspecific, however, and is related to tissue metabolism. Thus,
the agent is also readily taken up in some infectious and inflammatory conditions. Prior studies show increased FDG
uptake in active sarcoidosis [7, 8]. FDG uptake in sarcoidosis

AJR:190, March 2008

Head and Neck

Head and neck involvement by sarcoidosis is usually identified as cervical lymphadenopathy, seen in approximately
one third of patients [2]. On FDG PET, increased uptake has
been described in these lymph nodes (Fig. 5), as well as in the
parotid glands, in a similar distribution to that seen with 67Ga
scanning [7].
Chest
Although the radiographic and CT features of sarcoidosis
have been well described in the chest, few articles have specifically addressed patterns of FDG uptake in the lungs. Mediastinal and hilar lymphadenopathy from sarcoidosis shows
increased FDG uptake, as in other parts of the body (Fig. 6).
Lung parenchymal involvement and FDG uptake is less well
described; however, it has been shown that FDG PET can
detect lung involvement by sarcoidosis in patients after transplantation [9].
Abdomen
Again, as elsewhere in the body, abdominal lymph nodes
secondary to sarcoidosis can show increased FDG activity
[7]. Parenchymal lesions in the abdomen have also been described as showing increased FDG uptake. For example,
sarcoidosis is known to cause splenomegaly and low-density
focal lesions in the spleen that have been reported to have
increased FDG uptake on PET [11] (Fig. 7).
Musculoskeletal
Bone involvement in sarcoidosis can be seen in up to one
third of patients, usually in the hands and feet. Less commonly, axial skeletal involvement can be seen. In both cases,
lesions of sarcoid can be either osteolytic or osteosclerotic,
and their nonspecific appearance can make diagnosis difficult. Increased activity can be seen on bone scintigraphy.

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Prabhakar et al.

B
Fig. 6Confluent parenchymal lung nodules and mediastinal and bilateral hilar
lymphadenopathy with increased FDG uptake in 56-year-old woman with biopsyproven sarcoidosis.
AC, Axial CT image (A) shows confluent parenchymal lung nodules (yellow arrows) and mediastinal and bilateral hilar lymphadenopathy (blue arrows). These
abnormalities show increased FDG uptake on fused PET/CT (B) and unfused
PET (C) images.

Fig. 7Splenic lesions with uptake from sarcoidosis in 43-year-old woman with history of Hodgkins lymphoma.
AC, Images from combined PET/CT show low-density lesions (arrows, A and C) in spleen on coronal CT image (A). Lesions show increased FDG uptake on fused PET/
CT (B) and unfused PET (C) images. Because of patients history of lymphoma, she underwent splenectomy to assess cause of lesion, and pathology revealed noncaseating granulomas consistent with sarcoidosis. Sarcoidosis is known to cause splenomegaly and low-density focal lesions in the spleen and has been reported to
have increased FDG uptake on PET scans [11].

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Imaging Features of Sarcoidosis

Fig. 8Skeletal uptake in 56-year-old woman with known sarcoidosis in neck,

who presented with pelvic bone pain.
AC, Images from combined PET/CT scan show multiple subtle sclerotic lesions
(arrows) in bilateral iliac bones on axial CT image (A). These lesions show increased FDG uptake on fused PET/CT (B) and unfused PET (C) images. Biopsy of
left iliac bone lesion was consistent with sarcoidosis.

Fig. 9Follicular lymphoma and asymptomatic pulmonary sarcoidosis in 44-year-old woman

with history of grade 3 follicular lymphoma that is now in remission. Patient underwent transbronchial biopsy to evaluate small lymph nodes in chest, which revealed noncaseating granulomas consistent with sarcoidosis. Whole-body PET image shows marked FDG uptake in bilateral
axillae and left paratracheal regions (upper arrows), as well as in abdomen (lower arrows). Distribution of adenopathy is more consistent with lymphoma than with sarcoidosis, especially because of lack of significant hilar or mediastinal lymphadenopathy. Biopsy of left axillary lymph
node revealed follicular lymphoma.

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Additionally, case reports have described increased FDG

uptake in skeletal sarcoidosis (Fig. 8). In conjunction with
the more characteristic findings of sarcoidosis, such as mediastinal lymphadenopathy, bone involvement from sarcoid
can be suggested in patients with increased focal bone FDG
uptake rather than diffuse metastatic disease [12, 13].

Sarcoidosis as a Mimic of Malignancy

The most common radiologic finding in sarcoidosis is intrathoracic lymphadenopathy, seen in up to 85% of patients
[2]. Abdominal lymphadenopathy is seen 30% of cases, with
massive lymphadenopathy (lymph nodes > 2 cm) seen in 10%
of patients [4]. Given the presence of lymphadenopathy in
such a large percentage of patients with sarcoidosis, it is not
surprising that one of the more common differential considerations in these patients is lymphoma. Additionally, as described previously, musculoskeletal involvement in sarcoidosis
can manifest as increased focal uptake throughout the skeleton, which can mimic diffuse metastatic disease [12, 13].
To further complicate matters, a known association exists
between sarcoidosis and lymphoma, described in 1986 by
Brinker and called sarcoidosislymphoma syndrome [14].
Several cases studies have been published describing the association of chronic active sarcoidosis and systemic lymphoma,
both Hodgkins and non-Hodgkins lymphoma [15, 16] (Fig.
9). Using data from patients with respiratory sarcoidosis who
had registered with the Danish Institute of Clinical Epidemiology, Brinker determined that patients with sarcoidosis are
at 5.5 times increased risk of developing a lymphoproliferative disorder as other patients in the same age group [14].

Conclusion
The imaging features of sarcoidosis are diverse and can
be shown on a variety of imaging techniques. FDG uptake
on PET in patients with sarcoidosis is variable and can
mimic malignancies such as lymphoma and diffuse metastatic disease. It is important for radiologists and nuclear
medicine physicians to recognize the common imaging fea-

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tures and patterns of sarcoidosis in order to raise the possibility in the appropriate clinical setting.
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