Pulmonary Sarcoidosis: Imaging and Diagnostic Limitations

Abstract

Background

Pulmonary sarcoidosis is a multisystemic granulomatous disease with a broad spectrum of pulmonary manifestations, ranging from reversible hilar lymphadenopathy and perilymphatic nodules to irreversible pulmonary fibrosis. The heterogeneity complicates clinical and radiological differentiation.

Objective

This review presents the typical radiological patterns of pulmonary sarcoidosis, evaluates diagnostic modalities, and highlights the importance for prognosis and therapy of distinguishing between reversible and irreversible lesions.

Materials & Methods

A comprehensive literature search focused on recent publications and guidelines, emphasizing imaging techniques and clinically relevant correlations.

Results

Conventional chest radiography using Scadding criteria provides a simple and cost-effective method of stage classification, but it also has limitations in terms of accuracy and in correlation with lung function. Computed tomography (CT) is the most precise imaging modality, showing characteristic features such as symmetrical hilar and mediastinal lymphadenopathy, multiple micro- and macronodules with confluent consolidations, and upper lobe predominance. Advanced stages reveal fibrotic remodeling with linear opacities, traction bronchiectasis, and prognostically relevant honeycombing. Complications include pulmonary hypertension, venous compressions, and secondary fungal infections. Magnetic resonance imaging (MRI) is used primarily for cardiac sarcoidosis detection, while positron emission tomography (PET) can better assess inflammatory activity and therapy monitoring. Differential diagnosis with regard to other granulomatous, infectious, and neoplastic diseases is essential, and it requires an interdisciplinary approach.

Conclusion

Pulmonary sarcoidosis requires a multimodal diagnostic approach, with CT playing a central role in staging and prognosis. Differentiation between reversible and fibrotic lesions is critical for therapeutic decisions. Future research should optimize imaging and integrate clinical, radiological, and functional parameters to improve patient care.

Key Points

• Pulmonary sarcoidosis presents a wide spectrum of pulmonary manifestations ranging from reversible nodules and lymphadenopathy to irreversible fibrotic patterns, with diagnosis being clinically and radiologically challenging.

• Computed tomography is the most precise imaging modality for stage classification and prognosis.

• Differentiating reversible inflammatory from irreversible fibrotic lesions is crucial for therapy planning.

• Differential diagnosis from other granulomatous, infectious, and neoplastic diseases requires an interdisciplinary approach.

Citation Format

• Kostova J, Andreisek G, Müller MA. Pulmonary Sarcoidosis: Imaging and Diagnostic Limitations. Rofo 2025; DOI 10.1055/a-2722-6934

Keywords

sarcoidosis - CT-high resolution - thorax - diagnostic radiology - treatment effects - fibrosis, cystic

Publikationsverlauf

Eingereicht: 09. Juni 2025

Angenommen nach Revision: 08. Oktober 2025

Artikel online veröffentlicht:
12. November 2025

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