Thorax (1971), 26, 296.
Unilateral hilar or paratracheal adenopathyin sarcoidosis: a
study of 38 cases
RICHARD W. SPANN, EDWARD C. ROSENOW, III,RICHARD A. DEREMEE, and
W. EUGENE MILLER
Mayo Clinic, Rochester, Minnesota
The diagnosis of pulmonary sarcoidosis should be considered when
unilateral hilar enlargementor a paratracheal mass is present. With
this diagnosis in mind, a scalene node biopsy ormediastinoscopy may
prevent unnecessary thoracotomy. It is believed that the unilateral
stageis only an evanescent stage before the development or
regression of bilateral hilarlymphadenopathy.
Sarcoidosis is a disease of unknown cause that ischaracterized
by the presence of non-caseousgranuloma. The diagnosis is made
whenever thishistological finding occurs in the absence of
otherknown causes. of non-caseating granulomas andwhenever
compatible clinical and radiographicfindings are present. The usual
chest radiographicfindings in sarcoidosis are (1) bilateral hilar
andoccasionally right paratracheal adenopathy,(2) thoracic
lymphadenopathy and pulmonarydensities, (3) pulmonary densities
without lympha-denopathy, and (4) predominant
pulmonaryfibrosis.
Occasionally, the clue as to the possible clinicaldiagnosis of
pulmonary sarcoidosis is the presenceof bilateral hilar
lymphadenopathy. Sarcoidosis isnot usually considered in the
differential diagnosisof unilateral hilar enlargement or of right
para-tracheal adenopathy alone, but it should be.
MATERIAL AND FINDINGS
A review of the chest radiographs in 800 histo-logically
diagnosed cases of sarcoidosis at the MayoClinic from 1960 through
1969 disclosed 38 cases inwhich the initial unbiased radiographic
interpretationwas unilateral right hilar enlargement (22
patients),left hilar enlargement (12 patients), or right
para-tracheal mass (4 patients). A right paratracheal masswas noted
in six of the patients with unilateral hilarlymphadenopathy; thus,
a total of 10 of the 38patients had right paratracheal adenopathy.
Of the800 patients whose chest radiographs were reviewed,472 had
mediastinal adenopathy. Therefore, approxi-mately 8% of mediastinal
lymphadenopathy presentedunilaterally.The differential diagnosis
most commonly included
lymphoma or bronchogenic carcinoma and, less
frequently, sarcoidosis. The diagnosis was confirmedin all
cases; cultures for acid-fast bacilli and fungiwere negative in all
cases. In retrospect, in some ofthe radiographs, the opposite hilus
appearedsuspiciously involved but was not considered so untilafter
the diagnosis had been confirmed histologically.Patients considered
initially to have bilateral hilarinvolvement were not included in
this study.
Positive histological confirmation was obtained byscalene node
biopsy in 26 cases, by thoracotomy in8, by mediastinoscopy in 2,
and by bronchoscopyand muscle biopsy in 1 each. Follow-up
radiographswere available from four months to six years in 26cases.
The disease remained stationary in three, pro-gressed to bilateral
involvement in three, andregressed to normal in 20. A purified
protein deri-vative test was done in 24 patients, and four
hadpositive reactions. Six patients presented witherythema
nodosum.
THREE REPRESENTATIVE CASES
CASE 1 A 59-year-old man had evidence of a righthilar mass on a
routine chest film (Fig. Ia) and wasreferred to the Mayo Clinic for
further evaluation.He was asymptomatic, except for residuals of a
recentchest cold, and there were no abnormal findings onphysical
examination. Results of routine laboratorystudies were within
normal limits. In retrospect, theleft hilus was suspiciously
involved but was not con-sidered so until after the diagnosis had
been estab-lished at thoracotomy. Thoracotomy was preceded
bynegative bronchoscopy and negative scalene nodebiopsy. Cultures
for acid-fast bacilli and fungi fromthe removed lymph nodes were
also negative. Atomogram of the right hilus showed evidence of
themass (Fig. lb).
CASE 2 A 56-year-old woman came to the MayoClinic for evaluation
of an adenomatous goitre.
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Unilateral hilar or paratracheal adenopathy in sarcoidosis: a
study of 38 cases
Evidence of a left hilar mass was found on a routinechest film
(Fig. 2). A colloid goitre was removed atthyroidectomy, at which
time the surgeon alsoremoved lymph nodes from the upper
mediastinum,which showed non-caseous granuloma. A chest radio-graph
four months later revealed no change in theleft hilar mass.
CASE 3 A 29-year-old woman had evidence of aright paratracheal
mass on a chest film taken forevaluation of a mild cough of six
months' duration(Fig. 3). Results of physical examination were
nega-tive, with the exception of mild hypertension. A
lowhaemoglobin level of 11-5 g/100 ml was consideredto be due to an
unrelated iron-deficiency anaemia.The serum calcium level was
raised on threeoccasions, being 10-4, 10-1, and 10-5. mg/100
ml(normal 8-9 to 10-1 mg). One year later the serumcalcium level
was 9-9 mg/100 ml. Tissue removed atmediastinoscopy showed
non-caseous granuloma. Allcultures were negative. A purified
protein derivativetest with 250 tuberculin units and histoplasmin
skintests were negative. A chest radiograph one year laterrevealed
that the mass had almost completely dis-appeared.
DISCUSSION
Recently, Kent (1965) stressed the importance ofconsidering
sarcoidosis in the differential diag-nosis of unilateral hilar
lymphadenopathy, alongwith tuberculosis, lymphoma, bronchogenic
carci-noma, and metastatc carcinoma. His reportdescribed a patient
in who in unilateral left hilarlymphadenopathy regressed and was
followedthree years later by development of right
hilarlymphadenopathy. Some authors have emphasizedthat hilar
enlargement may be unilateral in sar-coidosis (Gendel, Young, and
Greiner, 1952;Kerley, 1956; Longcope and Freiman, 1952;Turiaf,
1964). There are many other reports of oneto four patients with
unilateral hilar involvement(Citron, 1958; Hedvall, 1960; James,
1961;Lofgren, 1953; Miech, Morand, Janser, Reys,and Witz, 1965;
Moyer and Ackerman, 1950-;Nitter, 1953; Rudberg-Roos, 1962;
Scadding,1950; Siltzbach, 1955; Susmano and Carleton,1970;
Williams, 1961). Most of these reports areone part of a large
series of patients with sar-coidosis. Ellis and Renthal (1962)
noted 13 patientswith unilateral hilar lymphadenopathy out of
76patients with hilar lymphadenopathy. In many ofthe patients
bilateral hilar lymphadenopathy sub-sequently developed.
It is believed that hilar lymphadenopathy is thefirst stage of
development of pulmonary sar-coidosis; not unlikely, the
lympadenopathy beginsas or regresses to a unilateral or an
asymmetricstage.
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