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Tsukita H, Koyama K, Ishinari T, Takahashi A, Miyabe K, Umakoshi M, Yoshida M, Kudo-Asabe Y, Nishida A, Otsuka N, Yasui O, Kato I, Fukushima N, Goto A. A case of pancreatic PEComa with prominent inflammatory cell infiltration: the inflammatory subtype is a distinct histologic group of PEComa. Diagn Pathol 2024; 19:59. [PMID: 38622713 PMCID: PMC11017648 DOI: 10.1186/s13000-024-01485-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/06/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND PEComa is a mesenchymal tumor that can occur in various organs including the uterus and soft tissues. PEComas are composed of perivascular epithelioid cells, and angiomyolipoma (AML), clear cell sugar tumor (CCST), and lymphangiomyomatosis (LAM) are considered lesions of the same lineage as tumors of the PEComa family. Histologically, a common PEComa shows solid or sheet-like proliferation of epithelioid cells. This is accompanied by an increase in the number of dilated blood vessels. Here, we report a case of pancreatic PEComa with marked inflammatory cell infiltration. CASE PRESENTATION A 74-year-old male patient underwent an appendectomy for acute appendicitis. Postoperative computed tomography and magnetic resonance imaging revealed a 30 × 25 mm non-contrast-enhanced circular lesion in the tail of the pancreas. The imaging findings were consistent with a malignant tumor, and distal pancreatectomy was performed. Histologically, most area of the lesion was infiltrated with inflammatory cells. A few epithelioid cells with large, round nuclei, distinct nucleoli, and eosinophilic granular cytoplasm were observed. Spindle-shaped tumor cells were observed. Delicate and dilated blood vessels were observed around the tumor cells. Immunohistochemically, the atypical cells were positive for αSMA, Melan A, HMB-45, and TFE3. The cytological characteristics of the tumor cells and the results of immunohistochemical staining led to a diagnosis of pancreatic PEComa. CONCLUSIONS A histological variant known as the inflammatory subtype has been defined for hepatic AML. A small number of tumor cells present with marked inflammatory cell infiltration, accounting for more than half of the lesions, and an inflammatory myofibroblastic tumor-like appearance. To our knowledge, this is the first report of pancreatic PEComa with severe inflammation. PEComa is also a generic term for tumors derived from perivascular epithelioid cells, such as AML, CCST, and LAM. Thus, this case is considered an inflammatory subtype of PEComa. It has a distinctive morphology that is not typical of PEComa. This histological phenotype should be widely recognized.
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Affiliation(s)
- Hikaru Tsukita
- Department of Cellular and Organ Pathology, Akita University Graduate School of Medicine, 1- 1-1 Hondo, Akita-shi, Akita, 010-8543, Japan
- Department of Pathology, Nihonkai General Hospital, Sakata, Japan
| | - Kei Koyama
- Department of Cellular and Organ Pathology, Akita University Graduate School of Medicine, 1- 1-1 Hondo, Akita-shi, Akita, 010-8543, Japan.
| | - Takahiro Ishinari
- Department of Cellular and Organ Pathology, Akita University Graduate School of Medicine, 1- 1-1 Hondo, Akita-shi, Akita, 010-8543, Japan
| | - Ayana Takahashi
- Department of Cellular and Organ Pathology, Akita University Graduate School of Medicine, 1- 1-1 Hondo, Akita-shi, Akita, 010-8543, Japan
- Department of Pathology, Nihonkai General Hospital, Sakata, Japan
| | - Ken Miyabe
- Department of Cellular and Organ Pathology, Akita University Graduate School of Medicine, 1- 1-1 Hondo, Akita-shi, Akita, 010-8543, Japan
| | - Michinobu Umakoshi
- Department of Cellular and Organ Pathology, Akita University Graduate School of Medicine, 1- 1-1 Hondo, Akita-shi, Akita, 010-8543, Japan
- Department of Pathology, Akita City Hospital, Akita, Japan
| | - Makoto Yoshida
- Department of Cellular and Organ Pathology, Akita University Graduate School of Medicine, 1- 1-1 Hondo, Akita-shi, Akita, 010-8543, Japan
| | - Yukitsugu Kudo-Asabe
- Department of Cellular and Organ Pathology, Akita University Graduate School of Medicine, 1- 1-1 Hondo, Akita-shi, Akita, 010-8543, Japan
| | - Akiko Nishida
- Department of Pathology, Nihonkai General Hospital, Sakata, Japan
| | - Naohiko Otsuka
- Department of Surgery, Noshiro Yamamoto Medical Association Hospital, Noshiro, Japan
| | - Ouki Yasui
- Department of Surgery, Noshiro Yamamoto Medical Association Hospital, Noshiro, Japan
| | - Ikuma Kato
- Department of Molecular Pathology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | | | - Akiteru Goto
- Department of Cellular and Organ Pathology, Akita University Graduate School of Medicine, 1- 1-1 Hondo, Akita-shi, Akita, 010-8543, Japan
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Esposito I, Yavas A, Häberle L. [Histopathologic diagnosis of solid and cystic pancreatic lesions with a focus on ductal adenocarcinoma : A vademecum for daily practice]. PATHOLOGIE (HEIDELBERG, GERMANY) 2024; 45:5-18. [PMID: 38191761 DOI: 10.1007/s00292-023-01288-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/14/2023] [Indexed: 01/10/2024]
Abstract
Pancreas pathology is constantly evolving and can present various challenges for pathologists. This paper is focused on providing helpful hints for daily routine diagnostics. During histopathological analysis of pancreas biopsies, pancreatic ductal adenocarcinoma must be distinguished not only from other solid neoplasms, but especially from its mimicker, autoimmune pancreatitis. This can be achieved by a systematic workup following clear diagnostic criteria. When analyzing samples from cystic pancreatic lesions, mucin-producing neoplasms must be detected due to their role as pancreatic cancer precursors; molecular analyses can help considerably with their detection and distinction. During frozen section examination, evaluation of the pancreatic neck margin and analysis of unclear lesions of the liver are two important tasks, which are explained further in this article. A special challenge is the evaluation of neoadjuvant treated pancreatic cancer, which requires a detailed macroscopic and microscopic workup. Finally, current advances in precision oncology and emerging approaches for pancreatic cancer within this field are discussed. With the advancement of technical possibilities and their increasingly broad implementation, the classification systems in pancreatic pathology will continue to gain in complexity, but also in accuracy.
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Affiliation(s)
- Irene Esposito
- Institut für Pathologie, Heinrich-Heine-Universität und Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - Aslihan Yavas
- Institut für Pathologie, Heinrich-Heine-Universität und Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
| | - Lena Häberle
- Institut für Pathologie, Heinrich-Heine-Universität und Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
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3
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Zavrtanik H, Tomažič A. Is Surgery in Autoimmune Pancreatitis Always a Failure? MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020193. [PMID: 36837395 PMCID: PMC9961097 DOI: 10.3390/medicina59020193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/14/2023] [Accepted: 01/15/2023] [Indexed: 01/21/2023]
Abstract
Autoimmune pancreatitis is a rare form of chronic pancreatitis of presumed autoimmune etiology. Due to significant overlap in clinical and imaging characteristics, misdiagnosis as a pancreatic malignancy is common. As a result, a significant number of patients undergo a major pancreatic resection, associated with considerable morbidity, for a disease process that generally responds well to corticosteroid therapy. In the past ten years, important advances have been made in understanding the disease. Several diagnostic criteria have been developed to aid in diagnosis. Despite this, pancreatic resection may still be required in a subset of patients to reliably exclude pancreatic malignancy and establish a definite diagnosis of autoimmune pancreatitis. This article aimed to define the role of surgery in autoimmune pancreatitis, if any. For this purpose, published case series of patients with a diagnosis of autoimmune pancreatitis, based on the histopathological examination of surgical specimens, were reviewed and patients' clinical, radiological and serological details were assessed. At the end, histopathologic examinations of patients who underwent pancreatic resection at our department in the last 10 years were retrospectively reviewed in order to identify patients with autoimmune pancreatitis and assess their clinical characteristics.
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4
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Thompson ED, Zhang ML, VandenBussche CJ. The Diagnostic Challenge of Evaluating Small Biopsies from the Pancreatobiliary System. Surg Pathol Clin 2022; 15:435-453. [PMID: 36049827 DOI: 10.1016/j.path.2022.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Examination of fine needle aspirations and small core biopsies of the pancreas can be an extremely difficult and treacherous area for the diagnostic pathologist. The pancreas often yields small and often fragmented specimens, which, in combination with the morphologic overlap between numerous neoplastic and nonneoplastic mimickers, generate multiple potential diagnostic pitfalls. The authors review this challenging topic and provide insight into resolving these pitfalls using morphologic pattern recognition and ancillary testing.
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Affiliation(s)
- Elizabeth D Thompson
- Department of Pathology, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, USA; Department of Oncology, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, USA
| | - M Lisa Zhang
- Department of Pathology, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114 USA
| | - Christopher J VandenBussche
- Department of Pathology, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, USA; Department of Oncology, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, USA.
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5
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Notohara K. Biopsy diagnosis of type 1 autoimmune pancreatitis: Does it bring a conclusion or confusion? DEN OPEN 2022; 2:e82. [PMID: 35310716 PMCID: PMC8828250 DOI: 10.1002/deo2.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/10/2021] [Indexed: 05/11/2023]
Abstract
A biopsy-based diagnosis of type 1 autoimmune pancreatitis (AIP) is now feasible via an endoscopic ultrasound-guided fine-needle biopsy, but there are potential issues to address. The benefits of acquiring large tissue samples include more successful immunostaining for Immunoglobulin G4 and more identifications of storiform fibrosis, obliterative phlebitis, and the ductal lesions of type 1 AIP. However, storiform fibrosis may not be present in all the type 1 AIP lesions. An interobserver agreement study revealed only slight-to-moderate agreement among pathologists diagnosing the histological findings of type 1 AIP. Potential reasons for disagreement are the different time phases of the inflammation (which result in heterogeneous histological pictures), a focal appearance of the typical histological findings, and the different definitions used by pathologists. We have thus devised guidance for diagnosing type 1 AIP based on biopsy tissues. In this guidance, we define each histological finding of type 1 AIP, for example, storiform fibrosis as a swirling arrangement of inflammatory cells, spindle-shaped cells, and delicate collagens as a unit. The necessity of elastic stains for identifying obliterative phlebitis is explained, with examples of mimickers. Another important purpose of a biopsy in type 1 AIP cases is differentiation from pancreatic ductal adenocarcinoma (PDAC). In this situation, acinar-ductal metaplasia observed in type 1 AIP is a mimicker of PDAC and should not be confused. For the resolution of potential disagreements among pathologists, a multi-disciplinary approach with the collaboration of clinicians, radiologists, and pathologists is necessary to avoid confusion.
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Affiliation(s)
- Kenji Notohara
- Department of Anatomic PathologyKurashiki Central HospitalOkayamaJapan
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6
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Update on classification, diagnosis, and management of immunoglobulin G4-related disease. Chin Med J (Engl) 2022; 135:381-392. [PMID: 34985023 PMCID: PMC8869566 DOI: 10.1097/cm9.0000000000001891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized chronic fibro-inflammatory autoimmune disease, and its recognition has been constantly increasing worldwide over the last few years. A correct and timely recognition, as well as appropriate intervention, is crucial for the treatment of IgG4-RD. For certain subtypes of IgG4-RD, organ-specific criteria are formulated to make the diagnosis more accurate. New biomarkers have emerged in the recent years to aid the disease diagnosis, its prognosis prediction, as well as therapy response monitoring. Although recurrence is very common in IgG4-RD, glucocorticoid is still the first-line treatment for the majority of patients. The factors that affect the likelihood of disease relapse are multifaceted. The selection strategy of various steroid-sparing agents is still being explored. Besides, when patients have special sites involvement leading to severe clinical conditions, surgical operation or interventional therapy should also be considered. An update on classification, diagnosis, and management of IgG4-RD is provided in the current study to fully elucidate the recommended clinical practice of this mysterious disease.
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7
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Cho Y, Anderson EW, Guevara SJ, Miyara SJ, Maria N, Metz CN, Zafeiropoulos S, Giannis D, Wang J, Abidoye O, Mumford JM, Aronsohn J, Molmenti E, Sohail H. Diagnostic Dilemma of Paraneoplastic Rheumatic Disorders: Case Series and Narrative Review. Cureus 2021; 13:e19993. [PMID: 34984145 PMCID: PMC8715838 DOI: 10.7759/cureus.19993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 11/27/2022] Open
Abstract
Paraneoplastic rheumatic disorder (RD) is a disorder that may present before, concurrent with, or after the diagnosis of malignancy. Paraneoplastic RDs are a clinical expression of occult cancer that is not directly related to a tumor or metastasis and manifests as rheumatoid symptoms. The RD is determined by the organ system affected by articular, muscular, cutaneous, vascular, or miscellaneous symptoms. Each case is challenging to diagnose because cancer may present with similar symptoms as a common rheumatic disorder. Of note, the majority of cases have minimal responsiveness or no responsiveness to standard rheumatoid treatment. Therefore, it is imperative to recognize and treat the underlying cancer accordingly. Herein, we present four different diagnostic dilemma cases of RD: case #1 - leukocytoclastic vasculitis and C3 glomerulopathy, case #2 - scleroderma, case #3 - Raynaud’s syndrome and possible lupus-like syndrome, and case #4 - inflammatory myositis. Institutional IRB approval was obtained for this case series. We will discuss and review the literature on each topic. In addition, we will mention a review of paraneoplastic rheumatoid arthritis. As rheumatic disease is associated with the use of immune checkpoint inhibitors (ICIs) for cancer treatment, we will briefly discuss some of the most common rheumatic presentations in the setting of these drugs. This case review aims to inform clinicians about the atypical presentation of paraneoplastic RD and to highlight the need for interdisciplinary management between rheumatologists, oncologists, and primary care practitioners.
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8
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Yoon SB, Moon SH, Song TJ, Kim JH, Kim MH. Endoscopic ultrasound-guided fine needle aspiration versus biopsy for diagnosis of autoimmune pancreatitis: Systematic review and comparative meta-analysis. Dig Endosc 2021; 33:1024-1033. [PMID: 33030283 DOI: 10.1111/den.13866] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/01/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) is recommended for guiding the acquisition of pancreatic tissue in patients with suspected autoimmune pancreatitis (AIP). Data comparing EUS-guided fine needle aspiration (FNA) and fine needle biopsy (FNB) sampling in the diagnosis of AIP are limited. METHODS A comprehensive literature search of the PubMed, EMBASE, and Ovid MEDLINE databases was conducted until April 2020. The pooled rates of diagnostic yield for the histologic criteria of AIP, histologic tissue procurement, and adverse events were compared between FNA and FNB. Diagnostic yields were also compared between 19 gauge (G) and 22G needles. RESULTS This meta-analysis included nine studies comprising 309 patients with AIP who underwent FNA and seven studies comprising 131 patients who underwent FNB. The pooled diagnostic yields for level 1 or 2 histology criteria of AIP were 55.8% (95% confidence interval (CI) 37.0-73.9%, I2 = 91.1) for FNA and 87.2% (95% CI 68.8-98.1%, I2 = 69.4) for FNB (P = 0.030). The pooled histologic procurement rates for FNA and FNB were 91.3% (95% CI, 84.9-97.6%, I2 = 82.9) and 87.0% (95% CI, 77.8-96.1%, I2 = 40.0), respectively (P = 0.501). Adverse events were comparable between two groups. When analyzed by needle size, the diagnostic yield was better with a 19G needle than with a 22G needle (88.9% vs. 60.6%, P = 0.023). CONCLUSIONS The diagnostic yield may be better with FNB needles than with FNA needles for the diagnosis of AIP, despite the similar rate of histologic tissue procurement. A quantitative definition for the histologic sample adequacy for AIP may be warranted.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea.,Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
| | - Tae Jun Song
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jong Hyeok Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea.,Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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9
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Kraft A, Gaida MM. [Acute and chronic pancreatitis-summary of the most common types of pancreatitis]. DER PATHOLOGE 2021; 42:501-508. [PMID: 34279680 DOI: 10.1007/s00292-021-00964-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 11/24/2022]
Abstract
Pancreatitis harbors a spectrum of different inflammatory changes of the pancreas of variable etiology and histopathology. In this context, common variants have to be distinguished from rare variants to optimize therapy. Each type of pancreatitis has characteristic features such as the age of patients and clinical presentation as well as the composition of the inflammatory infiltrates and histological changes.
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Affiliation(s)
- Anne Kraft
- Institut für Pathologie, Universitätsmedizin der JGU Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - Matthias M Gaida
- Institut für Pathologie, Universitätsmedizin der JGU Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland. .,Joint Unit Immunpathologie, Translationale Onkologie, Universitätsmedizin Mainz und Institut für Pathologie Universitätsmedizin Mainz, 55131, Mainz, Deutschland.
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Gambella A, Falco EC, Metovic J, Maletta F, De Angelis C, Maragliano R, Uccella S, Pacchioni D, Papotti M. Amyloid-Rich Pancreatic Neuroendocrine Tumors: a Potential Diagnostic Pitfall in Endoscopic Ultrasound-Guided Fine Needle Aspiration Cytology (EUS-FNAC). Endocr Pathol 2021; 32:318-325. [PMID: 32399832 DOI: 10.1007/s12022-020-09625-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Pancreatic neuroendocrine tumors (PanNETs) are rare neoplasms that include even rarer variants that may pose different diagnostic problems, especially in fine needle aspiration cytology (FNAC). We describe the diagnostic clues of the amyloid-rich variant of PanNETs in endoscopic ultrasound (EUS)-guided fine needle aspiration cytology (EUS-FNAC). Three cases of PanNETs with an amyloid-rich stromal component were retrieved and retrospectively reviewed. For every case, the pancreatic lesion was investigated by a EUS-FNAC procedure. The final diagnosis was supported by immunocytochemistry and Congo red staining. All cases had similar EUS-FNAC features: neoplastic cells were entrapped in an eosinophilic, homogeneous dense and amorphous matrix. The neuroendocrine nature was confirmed by immunoexpression of synaptophysin and chromogranin A, while the amorphous stroma was characterized as amyloid based on positive Congo red staining. Regarding the hormonal profile, no insulin or proinsulin reactivity was observed, but all cases were diffusely positive for amylin. The diagnosis of uncommon variants of PanNETs, such as the amyloid-rich, is challenging especially in EUS-FNAC procedures because of a unique and misleading morphology, potentially mimicking fibrotic conditions and amyloid deposition within systemic amyloidosis. In cytology specimens, the presence of amorphous material requires amyloid deposition to be considered in the differential diagnosis of pancreatic neoplasms with neuroendocrine phenotype.
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Affiliation(s)
- Alessandro Gambella
- Division of Pathology, Città della Salute e della Scienza Hospital, Turin, Italy
| | | | - Jasna Metovic
- Department of Oncology, University of Turin, Turin, Italy
| | - Francesca Maletta
- Division of Pathology, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Claudio De Angelis
- Division of Gastroenterology, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Roberta Maragliano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Silvia Uccella
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Donatella Pacchioni
- Division of Pathology, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Mauro Papotti
- Department of Oncology, University of Turin, Turin, Italy.
- Anatomia Patologica, Università di Torino, Via Santena 7, I-10126, Torino, Italy.
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Minh Thong P, Dang Luu V, Tra My TT, Xuan Hien N, Anh Tuan T, Minh Duc N. IgG4-Related Sclerosing Cholangitis Mimicking Cholangiocarcinoma. Case Rep Oncol 2021; 14:39-46. [PMID: 33776680 PMCID: PMC7983604 DOI: 10.1159/000513029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 11/19/2022] Open
Abstract
IgG4-related sclerosing cholangitis (IgG4-SC) is a relatively newly identified disease that is frequently associated with autoimmune pancreatitis. The differential diagnosis between cholangiocarcinoma, primary sclerosing cholangitis, and IgG4-SC can be challenging due to significant overlap among the clinical and imaging characteristics. We report the case of a 71-year-old woman who was diagnosed with IgG4-related disease based on increased serum IgG4 levels, imaging, and clinical presentation, which showed systemic involvement, including sclerosing cholangitis and kidneys. The patient presented with chronic jaundice. Magnetic resonance imaging revealed bile duct strictures and the dilatation of upstream bile ducts, smooth wall thickening with uniform enhancement in the delayed phase, and no vascular infiltration. Multiple low-density, wedge-shaped areas were identified in both kidneys, which were hypointense on T2-weighted images and hyperintense on diffusion-weighted images. The serum IgG4 levels of this patient were elevated to nearly 10-fold the normal upper limit. A diagnosis of IgG4-SC associated with IgG4-related kidney was made. Based on this case, pre-surgery IgG4 serum treatment in patients with non-malignant bile duct stenosis was recommended to exclude IgG4-SC.
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Affiliation(s)
- Pham Minh Thong
- Department of Radiology, Ha Noi Medical University, Hanoi, Vietnam.,Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Vu Dang Luu
- Department of Radiology, Ha Noi Medical University, Hanoi, Vietnam.,Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Thieu-Thi Tra My
- Department of Radiology, Ha Noi Medical University, Hanoi, Vietnam
| | | | | | - Nguyen Minh Duc
- Department of Radiology, Ha Noi Medical University, Hanoi, Vietnam.,Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam.,Department of Radiology, Children's Hospital 2, Ho Chi Minh City, Vietnam
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12
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Kim JS, Choi WH, Lee KA, Kim HS. Immunosuppressant treatment for IgG4-related sclerosing cholangitis: A case report. World J Clin Cases 2021; 9:267-273. [PMID: 33511195 PMCID: PMC7809666 DOI: 10.12998/wjcc.v9.i1.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/09/2020] [Accepted: 11/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Immunoglobulin G4-related disease (IgG4-RD) is a multi-system fibroin-flammatory disorder that can involve any organ, including the salivary glands, pancreas, and biliary tree. Treatment of immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) is similar to that for IgG4-RD, but progression is irreversible in some cases. We present a case of IgG4-SC in which an immuno-suppressant induced marked clinical and radiologic improvement.
CASE SUMMARY A 63-year-old male presented with a prominent itching sensation and wholebody jaundice. He showed obstructive-pattern jaundice, an elevated IgG4 level, and infiltration of a large number of IgG4-positive cells in the ampulla of Vater. The imaging findings of intrahepatic duct (IHD) and common bile duct dilation, an elevated serum IgG4 level, and characteristic histological findings led to diagnosis of IgG4-SC that compatible with the 2019 ACR/EULAR classification criteria. We planned to treat the patient with high-dose glucocorticoid (GC), followed by cyclophosphamide pulse therapy. After treatment with high-dose GC and an immunosuppressant, imaging studies showed that IHD dilatation had completely resolved.
CONCLUSION Prompt diagnosis and appropriate treatment of IgG4-SC are important. Because there is a risk of relapse of IgG4-SC, the GC dose should be gradually reduced, and a maintenance immunosuppressant should be given.
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Affiliation(s)
- Jong-Sun Kim
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul 04401, South Korea
| | - Won Ho Choi
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul 04401, South Korea
| | - Kyung-Ann Lee
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul 04401, South Korea
| | - Hyun-Sook Kim
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul 04401, South Korea
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13
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Perez Giraldo GS, Ortiz Garcia JG. Immune-Mediated Disorders Affecting the Spinal Cord and the Spine. Curr Neurol Neurosci Rep 2021; 21:3. [PMID: 33392785 PMCID: PMC7779105 DOI: 10.1007/s11910-020-01088-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW To review the most recent advances and provide a description of the most common autoimmune diseases causing myelitis and selective spine disorders. The ultimate goal of this article is to facilitate the prompt recognition of these diseases. RECENT FINDINGS The recent discovery of biomarkers such as aquaporin 4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) antibodies has changed our understanding of autoimmune diseases affecting the spinal cord as well as their treatment and outcomes. Autoimmune neurology is an increasingly evolving field that encompasses a broad spectrum of autoimmune-inflammatory diseases of the central nervous system (CNS) and peripheral nervous system (PNS). Autoimmune disorders of the spinal cord are a heterogeneous group of myelopathies with a broad differential diagnosis and many of them have been recently identified. Prompt recognition of these myelopathies is important as some of them are treatable, which could improve patient outcomes and prevent disability.
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Affiliation(s)
- Gina S Perez Giraldo
- Department of Neurology, The University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd. Suite 2547, Oklahoma City, OK, 73104, USA
| | - Jorge G Ortiz Garcia
- Department of Neurology, The University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd. Suite 2547, Oklahoma City, OK, 73104, USA.
- Division of Critical Care Neurology, The University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd. Suite 2547, Oklahoma City, OK, 73104, USA.
- Division of Stroke and Cerebrovascular Disorders, The University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd. Suite 2547, Oklahoma City, OK, 73104, USA.
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Goyal S, Sakhuja P. Autoimmune pancreatitis: Current perspectives. INDIAN J PATHOL MICR 2021; 64:S149-S159. [PMID: 34135159 DOI: 10.4103/ijpm.ijpm_59_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Over the last two decades, our knowledge and understanding regarding the pathogenesis and biology of autoimmune pancreatitis (AIP) have improved tremendously. Type 1 AIP or IgG4-related pancreatitis (IgG4-RP) is now believed to be the prototype of the multisystemic IgG4-related disease. In view of clinical features like obstructive jaundice and mass-forming lesions in the pancreas in elderly men, type 1 AIP often mimics pancreatic cancer. IgG4-related sclerosing cholangitis concomitantly involving the extrahepatic and intrahepatic biliary tree is the most common extrapancreatic involvement seen in up to 80% of these patients, which needs to distinguish from cholangiocarcinoma. Histology is characterised by lymphoplasmacytic inflammation, abundant IgG4 positive plasma cell infiltration, storiform fibrosis and obliterative phlebitis. Apart from histology, high serum IgG4 levels, pancreatic parenchymal and duct imaging findings and other organ involvement aid in diagnosis especially in cases where definitive histology is not evident. Also, these parameters lay the foundation of various diagnostic criteria proposed over last few years. On the contrary, histology alone is the mainstay for establishing diagnosis of idiopathic duct-centric pancreatitis (IDCP) as it lacks any specific serological marker or imaging. Since both types of AIP respond dramatically to corticosteroid treatment, a biopsy is crucial to establish the preoperative diagnosis and to exclude malignancy so as to avoid unnecessary surgery. This review discusses the morphologic spectrum, treatment and prognosis of IgG4-RP and IDCP with an emphasis on approach to diagnosis with relevant histologic features, differential diagnoses and the challenges faced during biopsy interpretation.
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Affiliation(s)
- Surbhi Goyal
- Department of Pathology, GIPMER, New Delhi, India
| | - Puja Sakhuja
- Department of Pathology, GIPMER, New Delhi, India
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Oppong KW, Maheshwari P, Nayar MK, Darne A, Parkinson D, Leeds JS, Haugk B. Utility of endoscopic ultrasound-guided fine-needle biopsy in the diagnosis of type 1 autoimmune pancreatitis. Endosc Int Open 2020; 8:E1855-E1861. [PMID: 33269321 PMCID: PMC7695513 DOI: 10.1055/a-1236-3266] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Accepted: 07/23/2020] [Indexed: 12/18/2022] Open
Abstract
Background and study aims Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) performs poorly in the histological diagnosis of type 1 autoimmune pancreatitis (AIP). The aim of this study was to assess the performance of fine-needle biopsy (FNB) comparing reverse bevel (RB) and fork-tip (FT) needles. Patients and methods A retrospective study of prospectively maintained databases was performed. Patients with a final diagnosis of type 1 AIP who underwent EUS-FNB during diagnostic workup were included. Pathology reports were reviewed and classified as per international consensus diagnostic criteria (ICDC). The Primary outcome was EUS-FNB sensitivity in diagnosing type 1 AIP. Results Between March 2011 and December 2018, 24 patients with a final diagnosis of type 1 AIP underwent FNB. Six patients underwent biopsy with the RB needle and 18 with the FT needle. Mean age (± SD) 62.2 (± 11.4), 17 (70.8 %) male. No RB samples were diagnostic compared to 14 (78 %) FT; P = 0.001; of which 13 (72 %) were level 1. In eight (44 %) of FT cases a diagnosis was not possible without histology. Initial biopsy was diagnostic in five (62.5 %) of these cases. Including repeat biopsy, seven (87 %) had a diagnosis made by FT needle. Obliterative phlebitis (44 %) was the least frequently identified pathological feature and immunoglobulin (IgG)4 + plasma cells > 10 per high power field (78 %) the most common. Conclusion The FT needle demonstrated good performance for diagnosing type 1 AIP. The results support the preferential use of this core biopsy needle for EUS pancreatic tissue sampling.
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Affiliation(s)
- Kofi W. Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Pardeep Maheshwari
- HPB Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Manu K. Nayar
- HPB Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Antony Darne
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Daniel Parkinson
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - John S. Leeds
- HPB Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom,Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Beate Haugk
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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16
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Yoon SB, Moon SH, Kim JH, Song TJ, Kim MH. The use of immunohistochemistry for IgG4 in the diagnosis of autoimmune pancreatitis: A systematic review and meta-analysis. Pancreatology 2020; 20:1611-1619. [PMID: 33060017 DOI: 10.1016/j.pan.2020.10.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/01/2020] [Accepted: 10/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The diagnosis of autoimmune pancreatitis (AIP) remains challenging, especially when serum IgG4 is normal or imaging features are indeterminate. We performed a systematic review and meta-analysis to evaluate the performance of IgG4 immunostaining of pancreatic, biliary, and ampullary tissues as a diagnostic aid for AIP. METHODS A comprehensive literature search of the PubMed, EMBASE, and Ovid MEDLINE databases was conducted until February 2020. The methodological quality of each study was assessed according to the Quality Assessment of Diagnostic Accuracy Studies checklist. A random-effects model was used to summarize the diagnostic odds ratio and other measures of accuracy. RESULTS The meta-analysis included 20 studies comprising 346 patients with AIP and 590 patients with other pancreatobiliary diseases, including 371 pancreatobiliary malignancies. The summary estimates for tissue IgG4 in discriminating AIP and controls were as follows: diagnostic odds ratio 38.86 (95% confidence interval (CI), 18.70-80.75); sensitivity 0.64 (95% CI, 0.59-0.69); specificity 0.93 (95% CI, 0.91-0.95). The area under the curve was 0.939 for tissue IgG4 in discriminating AIP and controls. Subgroup analysis revealed no significant difference in diagnostic accuracy according to control groups (pancreatobiliary cancer versus other chronic pancreatitis) and sampling site (pancreas versus bile duct/ampulla). CONCLUSIONS Current data demonstrate that IgG4 immunostaining of pancreatic, biliary, and ampullary tissue has a high specificity but moderate sensitivity for diagnosing AIP. IgG4 immunostaining may be useful in supporting a diagnosis of AIP when AIP is clinically suspected, but a combination of imaging and serology does not provide a conclusive diagnosis.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea; Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea.
| | - Jong Hyeok Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea; Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
| | - Tae Jun Song
- Department of Internal Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea
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17
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Chen L, Orr CE, Wang T. Prevalence of histological features resembling autoimmune pancreatitis in neoplastic pancreas resections. Histopathology 2020; 77:673-677. [PMID: 32608526 DOI: 10.1111/his.14197] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/25/2020] [Indexed: 02/06/2023]
Abstract
AIMS Types 1 and 2 autoimmune pancreatitis (AIP) can mimic pancreatic neoplasia. Due to the small quantity of tissue in mass-targeted pancreas biopsies, inflammatory features may raise the differential of AIP. However, the frequency of AIP-like histology in neoplastic pancreas is not well characterised. Therefore, the specificity of inflammatory lesions on biopsy with respect to the diagnosis of AIP is uncertain. METHODS AND RESULTS Neoplastic pancreas resections performed at our institution between 2008 and 2019 were retrospectively reviewed. Features of AIP types 1 and 2 were assessed in the non-neoplastic areas. If features of immunoglobulin (Ig)G4-associated AIP were seen, IgG4 immunohistochemistry was performed. We identified 163 neoplastic pancreas resections. Of these, 34 had one or more types of inflammatory lesions in non-neoplastic pancreatic tissue. Dense lymphoplasmacytic inflammation mimicking type 1 AIP was found in six cases with mild to moderately increased IgG4-positive plasma cells. Neutrophilic infiltrates in small intralobular ducts were found in 20 cases. Mild extralobular ductitis or duct microabscess was found in 10 specimens. Marked neutrophilic duct destruction that resembled granulocytic epithelial lesions was found in 12 cases. Some cases showed multiple features. CONCLUSION Approximately 20% of neoplastic pancreas resections showed focal areas that could raise the differential of AIP. More cases showed neutrophilic predominant inflammation as seen in type 2 autoimmune pancreatitis, compared to dense lymphoplasmacytic infiltrates seen in type 1 AIP. Pathologists must be cautious when making a diagnosis of AIP on biopsy tissue based on histological findings alone.
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Affiliation(s)
- Lina Chen
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Christine E Orr
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Tao Wang
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
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Glinka J, Calderón F, de Santibañes M, Hyon SH, Gadano A, Mullen E, Pol M, Spina J, de Santibañes E. Early pancreatic cancer in IgG4-related pancreatic mass: A case report. World J Gastrointest Surg 2019; 11:443-448. [PMID: 31879536 PMCID: PMC6912071 DOI: 10.4240/wjgs.v11.i12.443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 09/18/2019] [Accepted: 11/07/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND IgG4-related disease can manifest diversely, including autoimmune pancreatitis and IgG4-related cholangiopathy. We are reporting a very unusual cause of pancreatic cancer triggered in a previously unknown IgG4-related disease.
CASE SUMMARY A 75-year-old man was diagnosed with a 43 mm × 33 mm pancreatic head tumor after consulting for abdominal pain and jaundice. A pancreaticoduodenectomy was carried out uneventfully, and the histopathology report showed an early stage of acinar-cell pancreatic cancer. The patient reconsulted on the 30th postoperative day with fever, jaundice and asthenia. Magnetic resonance cholangiopancreatography evidenced an extense bile duct stricture. A percutaneous biliary drainage proved to be ineffective, even after exchanging it with larger bore drainage. Reviewing the surgical specimen, features compatible with IgG4-related disease were observed. Consequently, empiric treatment with steroids was initiated achieving excellent results.
CONCLUSION IgG4-related disease may cause chronic inflammation of the pancreas and can condition pancreatic malignancies.
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Affiliation(s)
- Juan Glinka
- Department of General Surgery, Hepato-bilio-pancreatic Unit, Hospital Italiano de Buenos Aires, Buenos Aires C1181ACH, Argentina
| | - Francisco Calderón
- Department of General Surgery, Hepato-bilio-pancreatic Unit, Hospital Italiano de Buenos Aires, Buenos Aires C1181ACH, Argentina
| | - Martín de Santibañes
- Department of General Surgery, Hepato-bilio-pancreatic Unit, Hospital Italiano de Buenos Aires, Buenos Aires C1181ACH, Argentina
| | - Sung Ho Hyon
- Department of General Surgery, Image Guided Minimally Invasive Surgery Unit, Hospital Italiano de Buenos Aires, Buenos Aires C1181ACH, Argentina
| | - Adrián Gadano
- Hepatology Section, Hospital Italiano Buenos Aires, Buenos Aires C1181ACH, Argentina
| | - Eduardo Mullen
- Department of Surgical Pathology, Hospital Italiano de Buenos Aires, Buenos Aires C1181ACH, Argentina
| | - Melina Pol
- Department of Surgical Pathology, Hospital Italiano de Buenos Aires, Buenos Aires C1181ACH, Argentina
| | - Juan Spina
- Department of Radiology, Hospital Italiano de Buenos Aires, Buenos Aires C1181ACH, Argentina
| | - Eduardo de Santibañes
- Department of General Surgery, Hepato-bilio-pancreatic Unit, Hospital Italiano de Buenos Aires, Buenos Aires C1181ACH, Argentina
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19
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Nowak V, Agaimy A, Kristiansen G, Gütgemann I. Increased IgG4-positive plasma cells in nodular-sclerosing Hodgkin lymphoma: a diagnostic pitfall. Histopathology 2019; 76:244-250. [PMID: 31373020 DOI: 10.1111/his.13965] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 07/30/2019] [Indexed: 02/06/2023]
Abstract
AIMS Despite increasing interest in the recently established immunoglobulin 4-related disease (IgG4-RD), its pathogenesis and aetiology remain largely unclear. Characteristic histopathological features are one of the key elements of diagnosis, including 'storiform' fibrosis, obliterative phlebitis, increased lymphoplasmacytic infiltration and increased levels of IgG4 in serum and tissue. Histopathological features of IgG4-RD are striking but not specific, and can pose a pitfall for surgical pathologists. This paper aims to determine the actual amount of IgG4+ plasma cells in nodular-sclerosing Hodgkin lymphoma (NSHL) and its potential to be misdiagnosed in routine clinical practice. METHODS AND RESULTS IgG4+ plasma cells per high-power field (HPF) and the ratio of IgG4+ versus IgG+ plasma cells (IgG4/IgG ratio) in lymph node biopsies of 24 patients with nodular-sclerosing Hodgkin lymphoma (NSHL) were determined using immunohistochemistry and consensus scoring criteria as used for IgG4-RD. Ten lymph node biopsies with reactive follicular hyperplasia were assessed for comparison. Higher numbers of IgG4+ plasma cells (P < 0.001) were observed in NSHL versus follicular hyperplasia (mean 34 versus 8 per HPF) with a mean IgG4/IgG ratio of 0.38 versus 0.18. Five cases (21%) fulfilled the consensus criteria of IgG4-RD, with >50 IgG4+ plasma cells per HPF and an IgG4/IgG ratio of >0.4. The mean count of IgG4+ plasma cells per HPF in NSHL varied greatly (3-88) with increased numbers of IgG4+ plasma cells seen near areas of fibrosclerosis. CONCLUSIONS Significantly higher levels of IgG4+ plasma cells are common in NSHL, emphasising the need to exclude Reed-Sternberg cells by morphology and immunohistochemistry in biopsies where IgG4-RD is suspected.
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Affiliation(s)
- Verena Nowak
- Institute of Pathology, Rheinisch Friedrich-Wilhelm University, University Hospital Bonn, Bonn, Germany
| | - Abbas Agaimy
- Institute of Pathology, Friedrich-Alexander University Nuremberg-Erlangen, University Hospital Erlangen, Erlangen, Germany
| | - Glen Kristiansen
- Institute of Pathology, Rheinisch Friedrich-Wilhelm University, University Hospital Bonn, Bonn, Germany
| | - Ines Gütgemann
- Institute of Pathology, Rheinisch Friedrich-Wilhelm University, University Hospital Bonn, Bonn, Germany
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20
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Gonzalez HH, Skrove JL, Rosen S, Sobrado J. A Curious Case of Autoimmune Pancreatitis with IgG4-related Sclerosing Cholangitis. Cureus 2019; 11:e4153. [PMID: 31058036 PMCID: PMC6488342 DOI: 10.7759/cureus.4153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) is a novel entity that belongs to the immune-mediated fibroinflammatory class of IgG4-related diseases (IgG4-RD). IgG4-SC is noted to be one of the most frequent manifestations of extra-pancreatic disease among IgG4-RD, which is significantly different from primary SC (PSC) and cholangiocarcinoma (CC) as is evident in the varied approaches to treatment. IgG4-RD includes IgG4-SC and autoimmune pancreatitis (AIP). Herein, we presented a case of IgG4-SC in a patient with obstructive jaundice secondary to AIP. We have also discussed the current recommendations for diagnostic and treatment modalities, with an emphasis on the issues that arise in obtaining a definitive classification of disease.
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Affiliation(s)
- Hector H Gonzalez
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Jamie L Skrove
- Internal Medicine, Larkin Community Hospital, South Miami, USA
| | - Seth Rosen
- Gastroenterology, Larkin Community Hospital, South Miami, USA
| | - Javier Sobrado
- Internal Medicine, Larkin Community Hospital, South Miami, USA
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IgG4-Related Sclerosing Cholangitis Involving the Intrahepatic Bile Ducts Diagnosed with Liver Biopsy. Case Rep Pathol 2018; 2018:2309293. [PMID: 30305974 PMCID: PMC6165622 DOI: 10.1155/2018/2309293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/15/2018] [Accepted: 08/14/2018] [Indexed: 11/18/2022] Open
Abstract
IgG4-related disease is characterized by lymphoplasmacytic inflammation and fibrosis, often leading to mass-forming lesions in different organs. When IgG4-related disease affects the bile ducts, it is called IgG4-related sclerosing cholangitis. A 74-year-old male complained of dysphagia and abdominal pain. Endoscopic retrograde cholangiography and magnetic resonance cholangiography revealed bile duct changes suspicious of a bile duct carcinoma or cholangitis. Liver biopsy showed storiform fibrosis, lymphoplasmacytic infiltration, obliterative phlebitis, and a portal-based inflammatory nodule with expansion of a portal tract. Hot spots revealed 339 IgG4-positive cells per high power field (HPF) and an IgG4/IgG ratio of 72%. Eight months earlier, an inguinal lymph node had been removed, showing expanded interfollicular zones and increased plasma cells. Hot spots revealed 593 IgG4-positive cells and an IgG4/IgG ratio of 92%. The serum IgG4 of the patient was elevated nearly 10 times upper limit of normal. The diagnosis of IgG4-related sclerosing cholangitis associated with IgG4-related lymphadenopathy was made. There was good response to treatment with prednisolone and azathioprine. The differentiation of IgG4-related sclerosing cholangitis from primary sclerosing cholangitis and bile duct carcinoma is often difficult. Liver biopsy only rarely contributes to this setting, but we describe and report in detail a case where liver biopsy showed a portal-based inflammatory nodule with the characteristic features of this disease.
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Abstract
The diagnostic approach to pancreaticobiliary disease requires a multidisciplinary team in which the cytopathologist plays a crucial role. Fine-needle aspiration, obtained by endoscopic ultrasound, is the diagnostic test of choice for pancreatic lesions. Preoperative clinical management depends on many factors, many of which rely on accurate cytologic assessment. Pancreaticobiliary cytology is wrought with diagnostic pitfalls. Clinical history, imaging studies, cytology samples, and ancillary tests, including immunohistochemistry, biochemical analysis, and genetic sequencing, are integral to forming a complete diagnosis and guiding optimal patient management. This article reviews clinical aspects and the diagnostic work-up of commonly encountered diagnostic entities within the field of pancreatic cytology.
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Affiliation(s)
- Raza S Hoda
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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Detlefsen S, de Vos JD, Tanassi JT, Heegaard NHH, Fristrup C, Schaffalitzky de Muckadell OB. Value of anti-plasminogen binding peptide, anti-carbonic anhydrase II, immunoglobulin G4, and other serological markers for the differentiation of autoimmune pancreatitis and pancreatic cancer. Medicine (Baltimore) 2018; 97:e11641. [PMID: 30075546 PMCID: PMC6081052 DOI: 10.1097/md.0000000000011641] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The diagnosis of autoimmune pancreatitis (AIP) and its differential diagnosis from pancreatic cancer (PC) can be challenging. In this retrospective study, we aimed to evaluate the value of anti-plasminogen binding peptide (a-PBP), immunoglobulin G4 (IgG4), and anti-carbonic anhydrase-II (a-CA-II), together with other serological markers whose value is not fully elucidated.The serum levels of a-PBP, IgG4, IgG, anti-nuclear antibodies (ANA), anti-lactoferrin (a-LF), a-CA-II, and rheumatoid factor (RF) were evaluated in patients with AIP (n = 29), PC (n = 17), pancreatic neuroendocrine neoplasm (P-NEN, n = 12), and alcoholic chronic pancreatitis (ACP, n = 41). ANCA were measured in the AIP patients.There was no statistically significant difference in mean a-PBP values in AIP compared with PC. A ROC curve showed that, when using a cut-off of 38.3 U, low values of a-PBP had a sensitivity and specificity of 45% and 71% for differentiating AIP from PC. The sensitivity and specificity of IgG4 (cut-off 1.4 g/L) for differentiating AIP from PC was 45% and 88%, but rose to 52% and 88% when using a cut-off of 1.09 g/L. When using this cut-off, the sensitivity and specificity for differentiating type 1 AIP from PC was 68% and 88%. None of the other markers were significantly changed in AIP versus PC. For differentiation of type 1 and type 2 AIP, the only significant differences were IgG4 in type 1 AIP (P < .01), with a sensitivity of 68% and a specificity of 80%, and c-ANCA elevations found in some type 2 AIP patients (P < .05).The only serological marker for which we found a statistically significant difference in mean values between AIP and PC was IgG4. However, the value of IgG4 for the distinction of AIP from PC was limited, probably in part due to the relatively high number of type 2 AIP patients in our study. In accord with recent publications, our data do not support a role of increased serum a-PBP for the diagnosis of AIP.
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Affiliation(s)
- Sönke Detlefsen
- Department of Pathology
- Odense Pancreas Center (OPAC), Odense University Hospital
- Institute of Clinical Research, University of Southern Denmark
| | - Jesper D. de Vos
- Institute of Clinical Research, University of Southern Denmark
- Department of Medical Gastroenterology, Odense University Hospital, Odense
| | - Julia T. Tanassi
- Department of Autoimmunology and Biomarkers, Statens Serum Institute, Copenhagen
| | - Niels H. H. Heegaard
- Department of Autoimmunology and Biomarkers, Statens Serum Institute, Copenhagen
- Department of Clinical Biochemistry and Pharmacology
| | - Claus Fristrup
- Odense Pancreas Center (OPAC), Odense University Hospital
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Ove B. Schaffalitzky de Muckadell
- Institute of Clinical Research, University of Southern Denmark
- Department of Medical Gastroenterology, Odense University Hospital, Odense
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Sulieman I, Mahfouz A, AlKuwari E, Szabados L, Elmoghazy W, Elaffandi A, Khalaf H. IgG4-related disease mimicking pancreatic cancer: Case report and review of the literature. Int J Surg Case Rep 2018; 50:100-105. [PMID: 30096533 PMCID: PMC6082998 DOI: 10.1016/j.ijscr.2018.07.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 07/26/2018] [Indexed: 12/12/2022] Open
Abstract
Pancreatic masses pose a diagnostic challenge, and cancer has to be always considered. IgG4-related disease is a rare cause of pancreatic masses. Biopsy from the pancreas is not always required if histopathology from a more accessible peripheral site lesion confirms the diagnosis. Multiorgan involvement and aortitis should raise suspicion of IgG4-related disease.
Introduction Most patients with pancreatic masses pose a diagnostic challenge when a benign lesion is suspected, and often, resection is needed before a benign diagnosis is confirmed. Presentation of case A 57 years old male patient presented with a pancreatic head mass, obstructive jaundice and submandibular lymph node enlargement. He also had a history of recurrent eye pain and redness, skin lesions, and benign prostatic hypertrophy. MRI showed a pancreatic head mass with double duct sign, aortic thickening, bilateral renal lesions, diffuse lymph node enlargement, and prostatic enlargement. FDG-PET/CT demonstrated abnormal uptake corresponding to the MRI lesions, and there were elevated IgG4 levels on blood investigations. Biopsy of an inguinal lymph node revealed infiltrates with IgG4 plasma cells, consistent with the diagnosis of IgG4 disease. The patient was treated with IV steroids and showed significant improvement. Discussion IgG4 related disease is a rare entity that is characterized by lesions that show heavy infiltration with IgG4 positive plasma cells, storiform fibrosis, and obliterative phlebitis. The pancreas is the most commonly involved organ, but several other organ systems are involved, and this helps in clinical suspicion of the diagnosis. A biopsy from any easily accessible site that shows the characteristic histological features is sufficient for diagnosis. Patients respond quickly to steroids, but recurrence is frequent. Conclusion IgG4 related disease is a rare cause of pancreatic tumorous lesions that need a high index of suspicion for diagnosis and should be differentiated from pancreatic neoplastic lesions.
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Affiliation(s)
- Ibnouf Sulieman
- Department of Surgery, Division of Organ Transplant, Hamad General Hospital, Doha, PO Box 3050, Qatar.
| | - Ahmed Mahfouz
- Department of Radiology, Hamad General Hospital, Doha, PO Box 3050, Qatar.
| | - Einas AlKuwari
- Department of Pathology, Hamad General Hospital, Doha, PO Box 3050, Qatar.
| | - Lajos Szabados
- Department of Nuclear Medicine, Hamad General Hospital, Doha, PO Box 3050, Qatar.
| | - Walid Elmoghazy
- Department of Surgery, Division of Organ Transplant, Hamad General Hospital, Doha, PO Box 3050, Qatar.
| | - Ahmed Elaffandi
- Department of Surgery, Division of Organ Transplant, Hamad General Hospital, Doha, PO Box 3050, Qatar.
| | - Hatem Khalaf
- Department of Surgery, Division of Organ Transplant, Hamad General Hospital, Doha, PO Box 3050, Qatar.
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