AJR Integrative Imaging
LIFELONG LEARNING
Imaging Features of Sarcoidosis on MDCT, FDG PET,
and PET/CT
Hima B. Prabhakar1, Chad B. Rabinowitz1, Fiona K. Gibbons2, Walter J. O’Donnell2, 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 ra-
diologists and nuclear medicine physicians to recognize the com-
mon 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 non-
specific and can mimic other disease processes, including lym-
phoma 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 presenta-
tions 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].
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.
2
Thoracic Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA.
3
AJR 2008;190:S1–S6 0361–803X/08/1903–S1 © American Roentgen Ray Society
AJR:190, March 2008 S1
FOR RADIOLOGY
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 asymptom-
atic 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 af-
fects 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, presen-
tation 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 le-
sions, 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 1–5% fatality rate from the disease,
most commonly resulting from severe respiratory or cardiac
involvement [3].
 Prabhakar et al.
Fig. 1—Stage 1 sarcoidosis in 54-year-old man with biopsy-proven sarcoidosis.
Frontal chest radiograph shows right paratracheal and bilateral hilar lymphade-
nopathy (arrows) and clear lungs.
Fig. 3—Abdominal lymphadenopathy in 38-year-old man with biopsy-proven
sarcoidosis. Contrast-enhanced axial CT image of upper abdomen shows mul-
tiple periaortic lymph nodes (arrows).
Classic Imaging Features of Sarcoidosis
Radiography
Chest radiographic features include mediastinal and bi-
lateral hilar lymphadenopathy, parenchymal opacities, and,
in more advanced cases, parenchymal fibrosis. A clinical
staging system based on the chest radiograph has been de-
vised to monitor disease in patients with sarcoidosis as well
as to predict patient prognosis. The five-part staging sys-
tem ranges from stage 0 (no radiographic abnormality) to
stage 4 (pulmonary fibrosis), with varying degrees of
lymphadenopathy and pulmonary parenchymal abnormal-
ities 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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Fig. 2—Pulmonary nodules in peribronchovascular distribution in 44-year-old
woman with sarcoidosis. High-resolution chest CT image shows multiple tiny pul-
monary nodules centered in peribronchovascular distribution (upper arrow). Small
pulmonary nodules can also be seen lining right major fissure (lower arrow).
Fig. 4—Lambda (λ) sign on 67Ga scan in 26-year-old man with biopsy-proven sar-
coidosis. Anterior image of chest shows increased tracer uptake in right paratra-
cheal and bilateral hilar lymph nodes, in configuration known as “lambda sign.”
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. Charac-
teristic parenchymal lesions include pulmonary nodules,
typically in a peribronchovascular distribution or along fis-
sures [2] (Fig. 2). Less commonly, alveolar consolidation can
be seen with air bronchograms, cavitation, and fibrosis [4].
In the abdomen, lesions are less characteristic, mimick-
ing systemic diseases such as lymphoma, diffuse metastatic
disease, or granulomatous or mycobacterial infection. In
 Imaging Features of Sarcoidosis
Fig. 5—Palpable submental lymph node with FDG uptake in 56-year-old woman
with palpable submental lymph node. Axial fused contrast-enhanced PET/CT im-
age shows enlarged left submental lymph node (arrow) with increased FDG up-
take. 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 prog-
ress 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 in-
creased blood flow, typically in lesions having an inflamma-
tory or infectious cause. In sarcoidosis, a characteristic pat-
tern of uptake in the chest has been described as the “lambda
sign:” paratracheal and bilateral hilar uptake [5] (Fig. 4). An-
other pattern of uptake is called the “panda sign,” caused by
uptake in the lacrimal and parotid glands. Although this pat-
tern 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 non-
specific, however, and is related to tissue metabolism. Thus,
the agent is also readily taken up in some infectious and in-
flammatory conditions. Prior studies show increased FDG
uptake in active sarcoidosis [7, 8]. FDG uptake in sarcoidosis
AJR:190, March 2008 S3
is nonspecific in both intensity and pattern, and is not gener-
ally 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, com-
bining the imaging features of sarcoidosis on CT with up-
take 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
Head and Neck
Head and neck involvement by sarcoidosis is usually iden-
tified 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 spe-
cifically addressed patterns of FDG uptake in the lungs. Me-
diastinal 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 trans-
plantation [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 de-
scribed 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 com-
monly, 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 diffi-
cult. Increased activity can be seen on bone scintigraphy.
 Prabhakar et al.

A B

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

A B C

Fig. 7—Splenic lesions with uptake from sarcoidosis in 43-year-old woman with history of Hodgkin’s lymphoma.
A–C, 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 patient’s history of lymphoma, she underwent splenectomy to assess cause of lesion, and pathology revealed nonca-
seating 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].

S4 AJR:190, March 2008

 Imaging Features of Sarcoidosis

A B

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

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

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

with history of grade 3 follicular lymphoma that is now in remission. Patient underwent trans-
bronchial biopsy to evaluate small lymph nodes in chest, which revealed noncaseating granulo-
mas 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). Distri-
bution of adenopathy is more consistent with lymphoma than with sarcoidosis, especially be-
cause of lack of significant hilar or mediastinal lymphadenopathy. Biopsy of left axillary lymph
node revealed follicular lymphoma.

AJR:190, March 2008 S5

 Prabhakar et al.
Additionally, case reports have described increased FDG
uptake in skeletal sarcoidosis (Fig. 8). In conjunction with
the more characteristic findings of sarcoidosis, such as me-
diastinal 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 in-
trathoracic 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 consider-
ations in these patients is lymphoma. Additionally, as de-
scribed previously, musculoskeletal involvement in sarcoidosis
can manifest as increased focal uptake throughout the skele-
ton, 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 “sarcoidosis–lymphoma syndrome” [14].
Several cases studies have been published describing the asso-
ciation of chronic active sarcoidosis and systemic lymphoma,
both Hodgkin’s and non-Hodgkin’s lymphoma [15, 16] (Fig.
9). Using data from patients with respiratory sarcoidosis who
had registered with the Danish Institute of Clinical Epidemi-
ology, Brinker determined that patients with sarcoidosis are
at 5.5 times increased risk of developing a lymphoprolifera-
tive 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 meta-
static disease. It is important for radiologists and nuclear
medicine physicians to recognize the common imaging fea-
S6 AJR:190, March 2008
tures and patterns of sarcoidosis in order to raise the pos-
sibility in the appropriate clinical setting.
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