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Kimura K, Koizumi K, Masuda S, Makazu M, Kubota J, Teshima S. A suspected case of serum IgG4-negative type 1 autoimmune pancreatitis detected due to localized pancreatic duct narrowing: a case report. Clin J Gastroenterol 2024:10.1007/s12328-024-01993-0. [PMID: 38834827 DOI: 10.1007/s12328-024-01993-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 05/29/2024] [Indexed: 06/06/2024]
Abstract
A 50-year-old woman was referred to our hospital with elevated serum amylase levels. Physical examination revealed no jaundice or abdominal tenderness. Serum IgG4 was negative. Computed tomography revealed a localized pancreatic duct narrowing in the pancreatic head, with caudal pancreatic duct dilation and an intraductal papillary mucinous neoplasm. Pancreatic enlargement was not observed. Endoscopic ultrasonography (EUS) showed a small hypoechoic mass. Although EUS-guided, fine-needle aspiration was performed, no diagnosis was established. Endoscopic retrograde pancreatography showed a localized narrowing in the main pancreatic duct of the pancreatic head. A biopsy of the narrowing was performed through the minor papilla because of difficult access from the major papilla. The specimen showed the infiltration of numerous IgG4-positive plasma cells, suggesting type 1 autoimmune pancreatitis (AIP). Six months later, magnetic resonance cholangiopancreatography revealed improvement in the narrowing without specific treatment. The patient presented with localized narrowing of the pancreatic duct and caudal duct dilation, which was distinct from pancreatic cancer. Diagnostic difficulties arose from negative serum IgG4 results, the lack of typical imaging characteristics of AIP, and failure to meet the AIP criteria according to the relevant Japanese and international guidelines. However, AIP was suspected and surgery was successfully avoided through a biopsy.
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Affiliation(s)
- Karen Kimura
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
| | - Kazuya Koizumi
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Sakue Masuda
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Makomo Makazu
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Jun Kubota
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Shinichi Teshima
- Department of Diagnostic Pathology, Shonan Kamakura General Hospital, Kanagawa, Japan
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2
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Yang X, Zhou H, Wang W, Yan C, Ji G. Recent advances in IgG4-related autoimmune pancreatitis. Pathol Res Pract 2024; 257:155331. [PMID: 38678849 DOI: 10.1016/j.prp.2024.155331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/16/2024] [Accepted: 04/24/2024] [Indexed: 05/01/2024]
Abstract
The incidence of IgG4-related autoimmune pancreatitis (IgG4-AIP) is high in Asia and other countries, and unnecessary treatment is often undertaken due to both missed diagnosis and misdiagnosis in clinical practice. Although IgG4-AIP has attracted increasing attention, the details of IgG4-AIP pathogenesis and systemic immune response, including its relationship to tumor pathogenesis, are still unclear. In recent years, research on serum immunological detection, pathological features, clinical manifestations, diagnosis and treatment measures for IgG4-AIP has gradually increased. It is of great importance to summarize and discuss the latest progress regarding IgG4-AIP disease.
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Affiliation(s)
- Xisheng Yang
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Haikun Zhou
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Weidong Wang
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Chunyu Yan
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Gang Ji
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China.
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3
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Murata Y, Haneda M, Miyakawa N, Nishida S, Kajihara N, Maeda S, Ono K, Hanatani S, Igata M, Takaki Y, Motoshima H, Kishikawa H, Araki E. Autoimmune Polyglandular Syndrome Type 3 Complicated with IgG4-related Disease. Intern Med 2024; 63:425-431. [PMID: 37344441 PMCID: PMC10901709 DOI: 10.2169/internalmedicine.1270-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
A 52-year-old Japanese woman developed type 1 diabetes mellitus (type 1 DM) at 41 years old. She became complicated with Hashimoto's disease and showed swelling of both submandibular glands, which was diagnosed as IgG4-related disease (IgG4-RD). This is a rare case of a Japanese patient with autoimmune polyglandular syndrome type 3A (APS-3A) coexisting with autoimmune thyroid disease (AITD) and type 1 DM complicated by IgG4-RD. Bilateral submandibular gland resection was successfully performed without steroid therapy. We discuss the possibility that the immunological pathogenic mechanisms of APS-3A and IgG4-RD are related.
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Affiliation(s)
- Yusuke Murata
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Japan
| | - Masaki Haneda
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Japan
| | - Nobukazu Miyakawa
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Japan
| | - Saiko Nishida
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Japan
| | - Nobuhiro Kajihara
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Japan
| | - Sarie Maeda
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Japan
| | - Kaoru Ono
- Department of Metabolic Medicine, Faculty of Life Science, Kumamoto University, Japan
| | - Satoko Hanatani
- Department of Metabolic Medicine, Faculty of Life Science, Kumamoto University, Japan
| | - Motoyuki Igata
- Department of Metabolic Medicine, Faculty of Life Science, Kumamoto University, Japan
| | | | | | | | - Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Science, Kumamoto University, Japan
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4
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Li Y, Song H, Meng X, Li R, Leung PSC, Gershwin ME, Zhang S, Sun S, Song J. Autoimmune pancreatitis type 2 (idiopathic duct-centric pancreatitis): A comprehensive review. J Autoimmun 2023; 140:103121. [PMID: 37826920 DOI: 10.1016/j.jaut.2023.103121] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/20/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
Autoimmune pancreatitis (AIP) is an uncommon fibro-inflammatory disorder precipitated by autoimmune/inflammatory reactions. Currently, there are two clinical subtypes of AIP (type 1 [AIP-1] and type 2 [AIP-2]) that correspond to two histologic descriptors (lymphoplasmacytic sclerosing pancreatitis and idiopathic duct-centric pancreatitis, respectively). While our understanding of AIP-1 has evolved considerably over the years, little is known about AIP-2 due to its rarity, often leading to misdiagnosis, delayed treatment, and even unnecessary surgical resection. Compared to AIP-1, AIP-2 exhibits distinct clinical and histologic features. Because AIP-2 is a pancreas-restricted disease without a specific serum marker, the evaluation of histologic features (e.g., granulocytic epithelial lesions) is essential for an accurate diagnosis. Patients with AIP-2 respond well to glucocorticoids, with anti-tumor necrosis factor-alpha antibodies as a promising alternative therapy. The prognosis of AIP-2 is generally favorable and relapse is uncommon. Here, we provide an overview of our current knowledge on the clinical features, diagnosis, therapeutic regimens, prognosis, and putative mechanisms underlying AIP-2. Notably, the diagnostic differentiation between AIP-2, especially the mass-forming/focal type, and pancreatic cancer is important, but challenging. In this regard, endoscopic ultrasound-guided core biopsy has a key role, but novel diagnostic markers and modalities are clearly needed.
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Affiliation(s)
- Yang Li
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China
| | - Hanyi Song
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China
| | - Xiangzhen Meng
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China
| | - Runzhuo Li
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China
| | - Patrick S C Leung
- Division of Rheumatology/Allergy and Clinical Immunology, School of Medicine, University of California, Davis, CA 95616 USA
| | - M Eric Gershwin
- Division of Rheumatology/Allergy and Clinical Immunology, School of Medicine, University of California, Davis, CA 95616 USA
| | - Shucheng Zhang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China.
| | - Siyu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China.
| | - Junmin Song
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China.
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5
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Kim SR, Kim SK, Koma YI, Sasaki M, Asai A, Nishikawa H. Hepatic Inflammatory Pseudotumor-Focusing on Its Heterogeneity. Diagnostics (Basel) 2023; 13:2857. [PMID: 37685395 PMCID: PMC10486865 DOI: 10.3390/diagnostics13172857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/16/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
Hepatic inflammatory pseudotumors (IPTs) are defined as benign, non-malignant, non-metastasizing tumors characterized by the presence of myofibroblastic spindle cells, hetorogenous populations of inflammatory cells, particularly plasma cells, lymphocytes and macrophages, as well as locations of fibrosis and necrosis without cellular anaplasia or atypical mitoses. Despite subsequent reports in the references, hepatic IPT remains difficult to diagnose; while posing major issues specifically for its differential diagnosis compared with that of other various benign diseases and malignant hepatic tumors. Histopathological findings are always a requisite for confirming the diagnosis, particularly given that the pathogenesis of IPT remains ambiguous to date. Hepatic IPT is a heterogeneous entity in terms of its clinical features, pathological findings, and pathogenesis. Once the diagnosis is confirmed, however, needless surgery such as wedge resection and lobectomy should be avoided. Here, we discuss the heterogeneity of hepatic IPT, its clinical features, pathological findings, and pathogenesis, and describe its differential diagnosis.
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Affiliation(s)
- Soo Ryang Kim
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-0801, Japan;
| | - Soo Ki Kim
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-0801, Japan;
| | - Yu-ichiro Koma
- Department of Pathology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Motoko Sasaki
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa 920-8640, Japan
| | - Akira Asai
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan
| | - Hiroki Nishikawa
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan
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6
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Seki M, Ninomiya E, Saiura A, Takahashi Y, Inoue Y, Katori M, Yamamoto N, Takamatsu M, Kato Y, Yamada K, Matsueda K, Ohkura Y. Clinicopathological study of surgically treated non-neoplastic diseases of the pancreas with special reference to autoimmune pancreatitis. Langenbecks Arch Surg 2023; 408:223. [PMID: 37270454 DOI: 10.1007/s00423-023-02944-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 05/14/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE After the popularization of serum immunoglobulin G4 (IgG4) measurement and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in our institute, surgical resection for non-neoplastic diseases of the pancreas became less common. Although the incidence of such false-positive cases was clarified in the 10-year period after the introduction of these measures (2009-2018), these data were not compared with the 30 years before 2009 (1979-2008). This study was performed to determine the percentage of autoimmune pancreatitis (AIP) that was included during the latter period and how the numbers of false-positive cases differed between the two periods. METHODS From 1979 to 2008, 51 patients had clinical suspicion of pancreatic carcinoma (false-positive disease). Among these 51 patients, 32 non-alcoholic patients who had tumor-forming chronic pancreatitis (TFCP) were clinically, histologically, and immunohistochemically compared with 11 patients who had TFCP during the latter 10-year period. RESULTS Retrospective IgG4 immunostaining of false-positive TFCP revealed 14 (35.0%) cases of AIP in the former 30 years versus 5 (45.5%) in the latter 10 years. There were 40 (5.9%) cases of TFCP among 675 patients in the former 30 years and 11 (0.9%) among 1289 patients in the latter 10 years. CONCLUSIONS When the TFCP ratio of pancreatic resections and the AIP ratio of false-positive TFCPs were compared between the two periods, the TFCP ratio was 5.9% versus 0.9% and the AIP ratio was 35.0% versus 45.5%, respectively. It can thus be speculated that IgG4 measurement and EUS-FNA are absolutely imperative for the diagnosis of TFCP.
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Affiliation(s)
- Makoto Seki
- Departments of Hepato-Biliary-Pancreatic Surgery, Cancer Institute of the Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-Ku, Tokyo, 135-8558, Japan.
- Department of Surgery, Mitaka Central Hospital, 5-23-10, Kami-Renjaku, Mitaka City, Tokyo, 181-0012, Japan.
| | - Eiji Ninomiya
- Department of Endoscopy, Kasumigaseki Building Clinic, 3-5-2-2F, Kasumigaseki, Chiyoda-Ku, Tokyo, 100-6012, Japan
| | - Akio Saiura
- Departments of Hepato-Biliary-Pancreatic Surgery, Cancer Institute of the Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-Ku, Tokyo, 135-8558, Japan
- Department of Hepato-Biliary-Pancreatic Surgery, Juntendo University Hospital, 2-1-1, Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
| | - Yu Takahashi
- Departments of Hepato-Biliary-Pancreatic Surgery, Cancer Institute of the Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-Ku, Tokyo, 135-8558, Japan
| | - Yosuke Inoue
- Departments of Hepato-Biliary-Pancreatic Surgery, Cancer Institute of the Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-Ku, Tokyo, 135-8558, Japan
| | - Masamichi Katori
- Departments of Pathology, Cancer Institute of the Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-Ku, Tokyo, 135-8558, Japan
| | - Noriko Yamamoto
- Departments of Pathology, Cancer Institute of the Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-Ku, Tokyo, 135-8558, Japan
| | - Manabu Takamatsu
- Departments of Pathology, Cancer Institute of the Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-Ku, Tokyo, 135-8558, Japan
| | - Yo Kato
- Departments of Pathology, Cancer Institute of the Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-Ku, Tokyo, 135-8558, Japan
| | - Keiko Yamada
- Departments of Diagnostic Radiology, Cancer Institute of the Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-Ku, Tokyo, 135-8558, Japan
| | - Kiyoshi Matsueda
- Departments of Diagnostic Radiology, Cancer Institute of the Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-Ku, Tokyo, 135-8558, Japan
| | - Yasuo Ohkura
- Department of Pathology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-8618, Japan
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Creech ZA, Shastri D, Hussain MW, Ikram W, MacElwee M. A Case of Autoimmune Pancreatitis Presenting As Alcohol-Induced Necrotizing Pancreatitis. Cureus 2023; 15:e39616. [PMID: 37388613 PMCID: PMC10300237 DOI: 10.7759/cureus.39616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2023] [Indexed: 07/01/2023] Open
Abstract
Autoimmune pancreatitis (AIP) is an inflammatory condition of the pancreas, commonly characterized by elevated levels of immunoglobulin G (IgG) 4. Diagnosis of this condition can be challenging in patients with risk factors for other pancreatitis etiologies and requires a comprehensive approach utilizing clinical, radiologic, and laboratory findings. Here, we present a case of an individual with a history of multiple prior hospitalizations for alcoholic pancreatitis, who presented with symptoms of abdominal pain, nausea, and vomiting. Computed tomography (CT) imaging revealed intra-abdominal abscesses and findings consistent with pancreatitis. Further laboratory results revealed elevated lipase and IgG4 levels, indicating AIP as the underlying cause. This case highlights the importance of considering AIP as a differential diagnosis in individuals presenting with pancreatic disease.
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Affiliation(s)
- Zachary A Creech
- Department of Internal Medicine, Creighton University School of Medicine, Phoenix, USA
| | - Divya Shastri
- Department of Internal Medicine, Creighton University School of Medicine, Phoenix, USA
| | | | - Waleed Ikram
- Department of Internal Medicine, Creighton University School of Medicine, Phoenix, USA
| | - Mark MacElwee
- Department of Internal Medicine, Valleywise Health Medical Center, Phoenix, USA
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8
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Okazaki K, Ikeura T, Uchida K. Recent progress on the treatment of type 1 autoimmune pancreatitis and IgG4-related disease. Mod Rheumatol 2023; 33:237-241. [PMID: 35737955 DOI: 10.1093/mr/roac054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/03/2022] [Accepted: 05/23/2022] [Indexed: 12/12/2022]
Abstract
IgG4-related disease (IgG4-RD) is a fibroinflammatory disorder recognized as a novel clinical entity with either synchronous or metachronous multiorgan involvement. Autoimmune pancreatitis (AIP) is classified into two types: type 1 AIP as a pancreatic manifestation of IgG4-RD and type 2 AIP with granulocytic epithelial lesion and occasional association with ulcerative colitis. Although the pathogenic mechanism still remains unclear, possible multipathogenic factors such as genetic factors, disease-specific or related antigens, and abnormal innate or adaptive immunity may be involved in the development of IgG4-RD. Many immunocytes including M2 macrophages, plasmablasts, B cells, and T-cells (Th2-CD4+T, follicular helper T-cells, and CD4+SLAMF7+cytotoxic T-cells) play important roles in the pathogenesis. Conventional induction and maintenance therapies with glucocorticoid or rituximab are recommended in all symptomatic patients with active IgG4-RD. In those at risk for irreversible damage in any organs, this should be done urgently, regardless of symptoms. As no randomized clinical trials other than glucocorticoid maintenance therapy for type 1 AIP have been performed, the comprehensive management for IgG4-RD has not been established yet. Targeted treatment approaches against the plasmablast to B cell lineage and the CD4+ SLAMF7+ cytotoxic T-cell seem to be promising for the future-directed treatment.
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Affiliation(s)
- Kazuichi Okazaki
- Department of Internal Medicine, Kansai Medical University Kori Hospital, Neyagawa, Osaka, Japan
| | - Tsukasa Ikeura
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Osaka, Japan
| | - Kazushige Uchida
- Department of Gastroenterology and Hepatology, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
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9
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Ito T, Ikeura T, Notohara K, Masuda M, Nakamaru K, Nakayama S, Shimatani M, Takaoka M, Okazaki K, Naganuma M. A case of type 2 autoimmune pancreatitis with spontaneous remission. Clin J Gastroenterol 2023; 16:297-302. [PMID: 36696084 DOI: 10.1007/s12328-022-01753-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/27/2022] [Indexed: 01/26/2023]
Abstract
A 70-year-old man with epigastric pain was referred to our hospital. Computed tomography and magnetic resonance imaging showed the diffusely enlarged pancreas compared to his normal pancreas 6 months prior to presentation. Serum levels of IgG4 and amylase were normal, while C-reactive protein was slightly elevated. Endoscopic ultrasound-guided fine-needle biopsy of the pancreas revealed acinar-ductal metaplasia with neutrophil infiltration and without infiltration of IgG4-positive plasma cells. After the clinical diagnosis of type 2 autoimmune pancreatitis (AIP), his symptoms spontaneously improved without steroid therapy. Three months later, radiological findings showed improved pancreas size and serological findings. The pathological diagnosis of type 2 AIP using endoscopic ultrasound-guided fine-needle biopsy is challenging, particularly for proving granulocyte epithelial lesions. This was a valuable type 2 AIP case in which the images before, at the time of onset, and at the time of spontaneous remission were evaluated.
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Affiliation(s)
- Takashi Ito
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Tsukasa Ikeura
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan.
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Masataka Masuda
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Koh Nakamaru
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Shinji Nakayama
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Masaaki Shimatani
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Makoto Takaoka
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | | | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
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Ha J, Choi SH, Kim KW, Kim JH, Kim HJ. MRI features for differentiation of autoimmune pancreatitis from pancreatic ductal adenocarcinoma: A systematic review and meta-analysis. Dig Liver Dis 2022; 54:849-856. [PMID: 34903501 DOI: 10.1016/j.dld.2021.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The accurate differential diagnosis between autoimmune pancreatitis (AIP) and pancreatic ductal adenocarcinoma (PDAC) is clinically important. We aimed to determine significant MRI features for differentiating AIP from PDAC, including assessment of diffusion-weighted imaging (DWI). METHODS We performed a systematic search using three databases. The pooled diagnostic odds ratio was calculated using a bivariate random effects model to determine significant MRI features for differentiating AIP from PDAC. The pooled sensitivity and specificity were calculated. The qualitative systematic review for DWI assessment was performed. RESULTS Of nine studies (775 patients), multiple main pancreatic duct (MPD) strictures, absence of upstream marked MPD dilatation, peripancreatic rim, and duct penetration sign were significant MRI features for differentiating AIP from PDAC. Absence of MPD dilatation had the highest pooled sensitivity (87%, 95% CI=68-96%), whereas peripancreatic rim had the highest pooled specificity (100%, 95% CI=88-100%). Of 12 studies evaluating DWI, seven reported statistically significant differences in apparent diffusion coefficient (ADC) values between AIP and PDAC; however, four reported lower ADC values in AIP than in PDAC, but three reported the opposite result. CONCLUSION The four significant MRI features can be useful to differentiate AIP from PDAC, but DWI assessment might be limited.
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Affiliation(s)
- Jiyeon Ha
- Department of Radiology, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sang Hyun Choi
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea.
| | - Kyung Won Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea
| | - Jin Hee Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea
| | - Hyoung Jung Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea
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11
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Recent Progress on the Roles of Regulatory T Cells in IgG4-Related Disease. IMMUNO 2022. [DOI: 10.3390/immuno2020026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IgG4-related disease (RD) is a proposed concept of systemic inflammatory condition from Japanese researchers. Patients with IgG4-RD manifest several immunological and histological characterizations in the organs involved, including elevated levels of serum IgG4 and lympho-plasmacytic infiltration, storiform fibrosis, IgG4-positive plasma cells infiltration, and obstructive phlebitis. Nevertheless, the pathogenesis of IgG4-RD still remains unclear. It has been made clear that several immune cells with regulatory function play a vital part in several diseases. In particular, abnormalities in the function and proportion of regulatory T cells (Tregs) are implicated in several diseases, and their part in IgG4-RD has been investigated. This review offers an overview of the research in IgG4-RD related to Tregs. Herein, the basic information of Tregs, knowledge gained from animal models involving Tregs, and the role of IgG4-RD has been provided. We also included the immunological mechanisms of IgG4-RD based on the data accumulated so far in our hypothesis.
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12
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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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13
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Jin Q, Ge Y, Chen X, Tan C, Huang Z, Wang B, Zhang B, Peng Q, Wang X, Wang G. The Clinical Phenotype of Chinese Patients With Autoimmune Pancreatitis Differs Significantly From Western Patients. Front Med (Lausanne) 2022; 9:771784. [PMID: 35321468 PMCID: PMC8935039 DOI: 10.3389/fmed.2022.771784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 01/31/2022] [Indexed: 11/29/2022] Open
Abstract
Aim To characterize the clinical features of autoimmune pancreatitis (AIP) in China and compare differences between our Chinese cohort and Western cohorts. Methods This was a retrospective study of patients with AIP that was carried out in the China-Japan Friendship Hospital between January 2010 and April 2021. We included a total of 50 patients (46 males and 4 females) aged between 27 and 86 years who fulfilled the international Consensus Diagnostic (ICD) Criteria. For comparative purposes, we included data from seven representative Western cohorts. Result When comparing Chinese and Western patients, we found that obstructive jaundice was the most frequent initial symptom (68 vs. 43%, P < 0.001). Extra-pancreatic organ involvement was more common in Chinese patients (68 vs. 30%, P < 0.001). Sclerosing cholangitis was the most frequent extrapancreatic lesion (48 vs. 24%, P = 0.001). The elevation of serum IgG4 was more obvious in our cohort (86 vs. 49%, P < 0.001). Conversely, the rates of ANA-positivity were significantly higher in Western populations (17 vs. 50%, P = 0.006). With regards to imaging, diffuse swelling was significantly more common in China (44 vs. 27%, P = 0.021). Steroid therapy was used more frequently in our Chinese patients (84 vs. 59%, P = 0.001). The steroid-response rate was also significantly higher in our Chinese patients (85 vs. 54%, P = 0.001); However, the rate of resection was higher in Western cohorts (2 vs. 31%, P < 0.001). There was no significant difference between the two populations with regards to recurrence rate (33 vs. 33%, P = 1.000). Conclusion This study identified significant differences between Chinese and Western populations of patients with AIP. Within the Chinese population, AIP was more likely to have jaundice and extra-pancreatic organ involvement, and elevated serum IgG4 levels. Chinese patients were also showed favorable responses to treatment with glucocorticoids.
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Affiliation(s)
- Qiwen Jin
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yongpeng Ge
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Xixia Chen
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Chang Tan
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Zhenguo Huang
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Bei Wang
- Department of Pathology, China-Japan Friendship Hospital, Beijing, China
| | - Bo Zhang
- Department of Ultrasound, China-Japan Friendship Hospital, Beijing, China
| | - Qinglin Peng
- Beijing Key Lab for Immune-Mediated Inflammatory Diseases, Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Xiaodi Wang
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Guochun Wang
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Guochun Wang
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14
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Kanno A, Miwata T, Nagai H, Ikeda E, Ando K, Kawasaki Y, Tada Y, Yokoyama K, Tamada K, Fukushima N, Kawarai Lefor A, Yamamoto H. Endoscopic ultrasound-guided pancreatic sampling for the histopathological diagnosis of autoimmune pancreatitis. Dig Endosc 2022; 34:420-427. [PMID: 34233051 DOI: 10.1111/den.14076] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/21/2021] [Accepted: 07/06/2021] [Indexed: 12/25/2022]
Abstract
Autoimmune pancreatitis (AIP), which is characterized by pancreatic enlargement and irregular narrowing of the main pancreatic duct, is difficult to differentiate from malignancy. The irregular narrowing of the pancreatic duct, which can be detected via endoscopic retrograde cholangiopancreatography, is a characteristic feature of AIP; however, distinguishing between localized AIP and pancreatic cancer based on pancreatic duct imaging is difficult. This study overviews the efficacy of endoscopic ultrasound (EUS)-guided pancreatic sampling for the histopathological diagnosis of AIP. Recent enhancements in needle biopsy methodologies and technologies have contributed to improvement in the diagnostic efficacy of this technique. The guidance provided in this study for the histological diagnosis of AIP is anticipated to further advance in the histopathological diagnosis of AIP using EUS-guided pancreatic sampling.
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Affiliation(s)
- Atsushi Kanno
- Department of, Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Tetsurou Miwata
- Department of, Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Hiroki Nagai
- Department of, Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Eriko Ikeda
- Department of, Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan.,Pathology, Jichi Medical University, Tochigi, Japan
| | - Kozue Ando
- Department of, Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan.,Pathology, Jichi Medical University, Tochigi, Japan
| | - Yuki Kawasaki
- Department of, Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Yamato Tada
- Department of, Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Kensuke Yokoyama
- Department of, Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Kiichi Tamada
- Department of, Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | | | | | - Hironori Yamamoto
- Department of, Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
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15
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Kamisawa T. Immunoglobulin G4-related Disease: A New Systemic Disease Emerging in Japan. JMA J 2022; 5:23-35. [PMID: 35224257 PMCID: PMC8826784 DOI: 10.31662/jmaj.2021-0113] [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: 06/17/2021] [Accepted: 10/05/2021] [Indexed: 11/16/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a fibro-inflammatory disease characterized by organ enlargement and elevated serum IgG4 levels. In 2003, IgG4-RD was proposed as a distinct form of IgG4-related systemic disease based on a histopathological study involving patients with autoimmune pancreatitis. IgG4-RD occurs mainly in older men and can affect almost any organ simultaneously or metachronously. Pathophysiologically, IgG4-RD occurs when an autoantigen triggers an immune response characterized by Th2 predominance with increased production of cytokines, such as interleukin 4 (IL-4), IL-5, IL-10, IL-13, and tumor growth factor-β (TGF-β), in the affected organ. IL-10 and TGF-β produced by the increased number of regulatory T cells induce a switch from B cells to IgG4-producing plasma cells and fibrosis, respectively. The characteristic histological features consist of dense infiltration of lymphocytes and IgG4-positive plasma cells, storiform fibrosis, and obliterative phlebitis. IgG4-RD is diagnosed based on a combination of clinical, serological, radiological, and histopathological findings. Differentiating IgG4-RD from malignant tumors or similar inflammatory diseases in the affected organs is important. The 2019 America College of Rheumatology/European League against Rheumatism classification criteria for IgG4-RD have high diagnostic sensitivity and specificity. IgG4-RD generally responds well to treatment with steroids, and a swift response is reassuring and provides further diagnostic confirmation. However, relapses are common during tapering or after cessation of steroids. In Japan, low-dose steroid maintenance therapy is usually given to prevent a relapse. B-cell depletion with rituximab is effective in patients resistant to or dependent on steroids. Most patients with IgG4-RD who receive steroid therapy show good short-term clinical, morphological, and functional outcomes. However, long-term outcomes, such as relapse, fibrosis development, and associated malignancies, have not been clearly defined. Therefore, novel treatment strategies, including rituximab, need to be tested in international randomized controlled clinical trials.
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Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
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16
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Uchida K, Okazaki K. Current status of type 1 (IgG4-related) autoimmune pancreatitis. J Gastroenterol 2022; 57:695-708. [PMID: 35916965 PMCID: PMC9522839 DOI: 10.1007/s00535-022-01891-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/30/2022] [Indexed: 02/04/2023]
Abstract
In 1995, Yoshida et al. proposed first the concept of "autoimmune pancreatitis" (AIP). Since then, AIP has been accepted as a new pancreatic inflammatory disease and is now divided two subtypes. Type 1 AIP affected immunoglobulin G4 (IgG4) and implicates the pancreatic manifestation of IgG4-related disease, while type 2 is characterized by neutrophil infiltration and granulocytic epithelial lesions (GEL). Recent research has clarified the clinical and pathophysiological aspects of type 1 AIP, which is more than type 2 among the Japanese population. However, many details remain unclear about the pathogenesis and progression of this disease. In this review, we discuss the current knowledge and recent advances relating to type 1 AIP.
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Affiliation(s)
- Kazushige Uchida
- grid.278276.e0000 0001 0659 9825Department of Gastroenterology and Hepatology, Kochi Medical School, Kochi University, Okocho-Kohasu, Nankoku, Kochi 783-8505 Japan
| | - Kazuichi Okazaki
- grid.410783.90000 0001 2172 5041Kansai Medical University Kouri Hospital, 8-45 Kourihondori, Neyagawa, Osaka 572-8551 Japan
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17
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Miyagawa K, Kumamoto K, Shinohara N, Watanabe T, Kumei S, Yoneda A, Nebuya S, Koya Y, Oe S, Kume K, Yoshikawa I, Harada M. Autoimmune Pancreatitis with Gastric Cancer: Some IgG4-related Diseases May Be Paraneoplastic Syndrome. Intern Med 2022; 61:2155-2160. [PMID: 35850987 PMCID: PMC9381340 DOI: 10.2169/internalmedicine.8590-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 70-year-old man was referred to our department for the treatment of early gastric cancer. Contrast-enhanced computed tomography (CT) incidentally showed diffuse enlargement of the pancreas with a capsule-like rim, and blood tests showed elevated serum IgG4 levels, leading to a diagnosis of autoimmune pancreatitis (AIP). Endoscopic treatment for gastric cancer was performed, and pathological findings showed adenocarcinoma with abundant IgG4-positive plasma cell infiltration. Thereafter, the serum IgG4 levels normalized, and the findings of AIP disappeared on CT without steroid treatment. These findings suggest that the gastric cancer activated an IgG4-related immune response, resulting in the development of AIP.
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Affiliation(s)
- Koichiro Miyagawa
- The Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Keiichiro Kumamoto
- The Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Nobuhiko Shinohara
- The Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Tatsuyuki Watanabe
- The Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Shinsuke Kumei
- The Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Akitoshi Yoneda
- The Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Satoru Nebuya
- The Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Yudai Koya
- The Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Shinji Oe
- The Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Keiichiro Kume
- The Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Ichiro Yoshikawa
- Department of Endoscopy, University Hospital of Occupational and Environmental Health, Japan
| | - Masaru Harada
- The Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
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18
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Patterson KN, Trout AT, Shenoy A, Abu-El-Haija M, Nathan JD. Solid pancreatic masses in children: A review of current evidence and clinical challenges. Front Pediatr 2022; 10:966943. [PMID: 36507125 PMCID: PMC9732489 DOI: 10.3389/fped.2022.966943] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 11/03/2022] [Indexed: 11/26/2022] Open
Abstract
Pancreatic tumors in children are infrequently encountered in clinical practice. Their non-specific clinical presentation and overlapping imaging characteristics often make an accurate preoperative diagnosis difficult. Tumors are categorized as epithelial or non-epithelial, with epithelial tumors further classified as tumors of the exocrine or endocrine pancreas. Although both are tumors of the exocrine pancreas, solid pseudopapillary neoplasm is the most prevalent solid pancreatic tumor in children, while pancreatoblastoma is the most common malignant tumor. Insulinoma is the most common pediatric pancreatic tumor of the endocrine pancreas. Malignant tumors require a complete, often radical, surgical resection. However, pancreatic parenchyma-sparing surgical procedures are utilized for benign tumors and low-grade malignancy to preserve gland function. This review will discuss the epidemiology, pathophysiology, clinical and diagnostic characteristics, and management options associated with both common and rare solid pancreatic masses in children. We will also discuss current challenges encountered in their evaluation and treatment.
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Affiliation(s)
- Kelli N Patterson
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Departments of Radiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Archana Shenoy
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Department of Pathology, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Maisam Abu-El-Haija
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jaimie D Nathan
- Department of Abdominal Transplant and Hepatopancreatobiliary Surgery, Nationwide Children's Hospital, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
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19
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Wen H, Li Q, Lu N, Su YY, Ma PH, Zhang MX. Intestinal flora and pancreatitis: Present and future. Shijie Huaren Xiaohua Zazhi 2021; 29:1269-1275. [DOI: 10.11569/wcjd.v29.i22.1269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The role of intestinal flora in human health and diseases has attracted more and more attention. At present, there have been some reports on the relationship between intestinal flora and pancreatitis. These reports reveal that intestinal flora plays some important roles in the occurrence and development of pancreatitis. The specific mechanisms of action are unclear, but there is preliminary consensus that intestinal microbiome dysregulation promotes inflammatory changes in the pancreas. This paper summarizes the correlation between intestinal flora and pancreatitis, in order to provide some references and ideas for further research.
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Affiliation(s)
- Hua Wen
- Xi'an Medical University, Xi'an 710000, Shaanxi Province, China,Department of Gastroenterology, The First Affiliated Hospital of Xi'an Medical University, Xi'an 710077, Shaanxi Province, China
| | - Qian Li
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Medical University, Xi'an 710077, Shaanxi Province, China
| | - Ning Lu
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Medical University, Xi'an 710077, Shaanxi Province, China
| | - Yuan-Yuan Su
- Xi'an Medical University, Xi'an 710000, Shaanxi Province, China,Department of Gastroenterology, The First Affiliated Hospital of Xi'an Medical University, Xi'an 710077, Shaanxi Province, China
| | - Pei-Han Ma
- The Second Clinical Medical College, Shaanxi University of Traditional Chinese Medicine, Xianyang 712046, Shaanxi Province, China
| | - Ming-Xin Zhang
- The Second Clinical Medical College, Shaanxi University of Traditional Chinese Medicine, Xianyang 712046, Shaanxi Province, China
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20
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Notohara K. Histological features of autoimmune pancreatitis and IgG4-related sclerosing cholangitis with a correlation with imaging findings. J Med Ultrason (2001) 2021; 48:581-594. [PMID: 34669070 DOI: 10.1007/s10396-021-01148-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/03/2021] [Indexed: 12/12/2022]
Abstract
Autoimmune pancreatitis (AIP) is characterized by a tumefactive inflammatory lesion resembling pancreatic carcinoma. Type 1 AIP is a pancreatic manifestation of IgG4-related disease characterized by unique histological features that can be identified on imaging. The capsule-like rim, which is a collar of hypertrophic lesion surrounding the pancreas, consists of lymphoplasmacytic infiltration and fibrosis, and storiform fibrosis is often identified. Hypertrophic lesions of various microscopic architectures such as the ducts, veins (obliterative phlebitis), arteries (periarteritis), and nerves are observed without parenchymal damage. The pancreatic lobules keep their contours, but the acinar cells are diminished and replaced by numerous inflammatory cells. These features provide clues to arrive at a diagnosis of type 1 AIP and to distinguish it from pancreatic carcinoma on imaging. In contrast, type 2 AIP is an epithelium-centered inflammation involving the ducts and lobules. Neutrophilic infiltration in the epithelium and/or lumens (granulocytic epithelial lesion) is a characteristic finding. Lobular swelling due to inflammation is the cause of pancreatic enlargement. IgG4-related sclerosing cholangitis is histologically similar to the hypertrophic ductal lesion in type 1 AIP and characterized by wall thickening due to inflammation and luminal stenosis. The epithelium is intact, which is different from bile duct carcinomas and primary sclerosing cholangitis, the latter of which is characterized by inflammation targeting the epithelium. Although the histological features of type 1 AIP and IgG4-related sclerosing cholangitis are unique, the biopsy diagnosis of these diseases has limitations, which should be recognized by clinicians.
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Affiliation(s)
- Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan.
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21
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Kanno A, Tamada K, Fukushima N, Lefor AK, Yamamoto H. Endoscopic ultrasound-guided tissue acquisition for the histopathological diagnosis of autoimmune pancreatitis. J Med Ultrason (2001) 2021; 48:555-563. [PMID: 34669069 DOI: 10.1007/s10396-021-01144-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/28/2021] [Indexed: 01/22/2023]
Abstract
Autoimmune pancreatitis (AIP) is a disease concept that originated in Japan. It is characterized by diffuse pancreatic enlargement and irregular narrowing of the main pancreatic duct. Although the usefulness of the histological diagnosis of AIP using endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) and EUS-guided fine-needle biopsy (FNB) has been reported, enhanced diagnostic performance is expected with improvements in tissue collection methods and fine-needle techniques. Guidance for establishing the tissue diagnosis of AIP has been developed and is useful for histological evaluation. Histopathological diagnosis by EUS-FNA/FNB is expected to play a central role in AIP diagnosis in the future.
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Affiliation(s)
- Atsushi Kanno
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Kiichi Tamada
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | | | | | - Hironori Yamamoto
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
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22
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Qureshi A, Ghobrial Y, De Castro J, Siami-Namini K, Newman KA. Autoimmune pancreatitis - What we know and what do we have to know? Autoimmun Rev 2021; 20:102912. [PMID: 34280553 DOI: 10.1016/j.autrev.2021.102912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 05/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Ammar Qureshi
- Eisenhower Health, Internal Medicine Residency Program, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America.
| | - Youssef Ghobrial
- Eisenhower Health, Internal Medicine Residency Program, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America
| | - Joline De Castro
- Eisenhower Health, Internal Medicine Residency Program, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America
| | - Koushan Siami-Namini
- Eisenhower Health, Department of Pathology, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America.
| | - Kam A Newman
- University of California, Riverside (UCR), School of Medicine, Eisenhower Health, Internal Medicine Residency Program, Division of Rheumatology, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America.
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23
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Kawazoe T, Inoue T, Tobisawa S, Sugaya K, Shimizu T, Miyamoto K, Goto M, Yokogawa N, Azuma S, Itagaki S, Nishida K, Morita Y, Nagao M, Isozaki E. Immunoglobulin G4-related Disease Accompanied by Peripheral Neuropathy: A Report of Two Cases. Intern Med 2021; 60:1941-1947. [PMID: 33456044 PMCID: PMC8263177 DOI: 10.2169/internalmedicine.6461-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Due to its rarity and the limited literature, the clinicopathological characteristics of peripheral nerve involvement in immunoglobulin G4 (IgG4)-related disease are unknown. We present two cases of IgG4-related disease, accompanied by peripheral neuropathy, presenting as unilateral ptosis (case 1) and sclerosing cholangitis (case 2), respectively. In both cases, sural nerve biopsy indicated vasculitis as the underlying pathophysiology; the peripheral neuropathy was refractory to corticosteroid therapy. In contrast to the previously proposed pathomechanism of IgG4-related neuropathy (direct lymphoplasmacytic infiltration), the pathological findings in our cases suggest that vasculitis occurs secondary to systemic autoimmune conditions.
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Affiliation(s)
- Tomoya Kawazoe
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Tomoyuki Inoue
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Shinsuke Tobisawa
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Keizo Sugaya
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Toshio Shimizu
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Kazuhito Miyamoto
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Manaka Goto
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Japan
| | - Naoto Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Japan
| | - Sanami Azuma
- Department of Otolaryngology-Head and Neck Surgery, Tokyo Metropolitan Tama Medical Center, Japan
| | - Shingo Itagaki
- Department of Pathology, Tokyo Metropolitan Tama Medical Center, Japan
| | - Kenji Nishida
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Tama Medical Center, Japan
| | - Yasuhiro Morita
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Japan
| | - Masahiro Nagao
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Eiji Isozaki
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
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24
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Sekito T, Ishii Y, Serikawa M, Tsuboi T, Kawamura R, Tsushima K, Nakamura S, Hirano T, Fukiage A, Mori T, Ikemoto J, Kiyoshita Y, Saeki S, Tamura Y, Miyamoto S, Chayama K. The role of apparent diffusion coefficient value in the diagnosis of localized type 1 autoimmune pancreatitis: differentiation from pancreatic ductal adenocarcinoma and evaluation of response to steroids. Abdom Radiol (NY) 2021; 46:2014-2024. [PMID: 33386451 DOI: 10.1007/s00261-020-02907-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study was to clarify the usefulness of the apparent diffusion coefficient (ADC) value in the differential diagnosis of localized autoimmune pancreatitis (AIP) and pancreatic ductal adenocarcinoma (PDAC) and the evaluation of response to steroids. METHODS This study retrospectively analyzed 40 patients with localized AIP and 71 patients with PDAC who underwent abdominal MRI with DWI (b = 0 and 1000 s/mm2). Their ADC values at the lesion sites and five MRI findings useful for diagnosing AIP were evaluated. In addition, ADC values before and after steroid therapy were compared in 28 patients with localized AIP. RESULTS The median ADC value was significantly lower for localized AIP than for PDAC (1.057 × 10-3 vs 1.376 × 10-3 mm2/s, P < 0.001). In the ROC curve analysis, the area under the curve was 0.957 and optimal cut-off value of ADC for differentiating localized AIP from PDAC was 1.188 × 10-3 mm2/s. ADC value ≤ 1.188 × 10-3 mm2/s showed the highest sensitivity and accuracy among the MRI findings (92.6% and 90.7%, respectively), and when combined with one or more other MRI findings, showed 96.3% specificity. The median ADC values before and after steroid therapy (mean 7.9 days) were 1.061 × 10-3 and 1.340 × 10-3 mm2/s, respectively, and ADC values were significantly elevated after steroid induction (P < 0.001). CONCLUSION The measurement of ADC values was useful for the differential diagnosis of localized AIP and PDAC and for the early determination of the effect of steroid therapy.
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Affiliation(s)
- Tsuyoshi Sekito
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yasutaka Ishii
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Masahiro Serikawa
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Tomofumi Tsuboi
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Ryota Kawamura
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Ken Tsushima
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shinya Nakamura
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Tetsuro Hirano
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Ayami Fukiage
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takeshi Mori
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Juri Ikemoto
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yusuke Kiyoshita
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Sho Saeki
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yosuke Tamura
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Sayaka Miyamoto
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
- Research Center for Hepatology and Gastroenterology, Hiroshima University, Hiroshima, Japan
- RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
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Sun Y, Pan D, Kang K, Sun MJ, Li YL, Sang LX, Chang B. Eosinophilic pancreatitis: a review of the pathophysiology, diagnosis, and treatment. Gastroenterol Rep (Oxf) 2021; 9:115-124. [PMID: 34026218 PMCID: PMC8128011 DOI: 10.1093/gastro/goaa087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 09/24/2020] [Accepted: 11/01/2020] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic pancreatitis (EP) is an extremely rare disease caused by purely eosinophilic infiltration of the pancreas. EP is prone to being misdiagnosed as pancreatic cancer, causing unnecessary economic and physical harm to the patient. We report three cases of EP that were cured by steroids without relapse from 2017 to now. The clinical data of the three patients, including clinical manifestations, serological manifestations, imaging (ultrasound, computed tomography, and MRI), pathological diagnosis and treatment, and telephone follow-up of all patients, were retrospectively analysed. In addition, a literature search was conducted on the Web of Science and PubMed databases using key terms related to EP, considering case reports with no restrictions on the date of publication or language. In conclusion, we analysed 19 cases and determined the diagnostic criteria for EP. The diagnostic algorithm for EP can be used to diagnose EP easily. We hope that our standards and algorithm can reduce the rate of misdiagnosis and contribute to clinical diagnosis and treatment. In addition, we expect to evaluate more EP cases to test our diagnostic criteria and design a systematic diagnostic flow chart.
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Affiliation(s)
- Yue Sun
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang, Liaoning, P. R. China
| | - Dan Pan
- Department of Geriatrics, First Affiliated Hospital, China Medical University, Shenyang, Liaoning, P. R. China
| | - Kai Kang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang, Liaoning, P. R. China
| | - Ming-Jun Sun
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang, Liaoning, P. R. China
| | - Yi-Ling Li
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang, Liaoning, P. R. China
| | - Li-Xuan Sang
- Department of Geriatrics, First Affiliated Hospital, China Medical University, Shenyang, Liaoning, P. R. China
| | - Bing Chang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang, Liaoning, P. R. China
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26
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Usami Y, Sugano M, Uehara T, Koinuma M, Ishimine N, Kawasaki K, Yamauchi K, Hamano H, Honda T. Cut-off values of serum IgG4 among three reagents, including a novel IgG4 reagent: a multicenter study. Sci Rep 2021; 11:7280. [PMID: 33790306 PMCID: PMC8012344 DOI: 10.1038/s41598-021-86024-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 03/04/2021] [Indexed: 12/26/2022] Open
Abstract
Elevated serum IgG4 is a useful marker of IgG4-related disease (IgG4-RD) activity. However, there is no uniformity in the cut-off values of IgG4 among the various reagents. The aim of this study was to compare the measured and cut-off values of IgG4 assessed using three different reagents. This study enrolled 466 IgG4-RD and non-IgG4-RD patients who required measurement of serum IgG4 levels to diagnose or treat IgG4-RD. Serum IgG4 was measured using three reagents: N-assay LA IgG4 Nittobo (Nittobo), BS-NIA IgG4 (TBS), and N Latex IgG4 (Siemens). The values obtained using the three reagents were compared, and cut-off values were calculated for each. Although there was good correlation among the results with the three reagents, the measured and cut-off values were all different. The Nittobo values were 1.4 times the TBS values and the TBS values were almost half those of the Siemens values. ROC curve analysis showed cut-off values for the Nittobo, TBS, and Siemens reagents of 1.42, 1.31, and 2.38 g/L, respectively. The measured and cut-off values of serum IgG4 vary depending on the reagents used for the assay, although there is good correlation among the values measured by the three reagents.
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Affiliation(s)
- Yoko Usami
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Mitsutoshi Sugano
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Takeshi Uehara
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan. .,Department of Laboratory Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Masayoshi Koinuma
- Faculty of Pharmaceutical Sciences, Teikyo Heisei University, Tokyo, Japan.,Center of Clinical Research, Shinshu University Hospital, Matsumoto, Japan
| | - Nau Ishimine
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Kenji Kawasaki
- Department of Laboratory Medicine, Chiba University School of Medicine, Chiba, Japan
| | - Kazuyoshi Yamauchi
- Department of Laboratory Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | | | - Takayuki Honda
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan.,Department of Laboratory Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
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27
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IgG4-related disease manifesting as symptoms of appendicitis: Case report and literature review. Clin J Gastroenterol 2021; 14:626-632. [PMID: 33460019 DOI: 10.1007/s12328-020-01337-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
Immunoglobulin G subclass 4 (IgG4)-related disease is a recently described fibroinflammatory condition. Reports of appendix involvement are extremely limited. A young man with abdominal pain and symptoms of acute appendicitis accompanied by the finding of an appendix-dependent tumor during surgery is presented. Histopathological study revealed lymphoplasmocytic infiltrate, storiform fibrosis and obliterative phlebitis. The number of IgG4-positive plasma cells was greater than 50 per high power field. Postsurgical steroid treatment and radiological findings are also described.
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28
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Tsutsumi K, Ueki T, Noma Y, Omonishi K, Ohno K, Kawahara S, Oda T, Kato H, Okada H. Utility of a 21-gauge Menghini-type biopsy needle with the rolling method for an endoscopic ultrasound-guided histological diagnosis of autoimmune pancreatitis: a retrospective study. BMC Gastroenterol 2021; 21:21. [PMID: 33413133 PMCID: PMC7789626 DOI: 10.1186/s12876-020-01590-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/21/2020] [Indexed: 12/20/2022] Open
Abstract
Background The histological diagnosis of autoimmune pancreatitis (AIP) by an endoscopic ultrasound (EUS)-guided approach is still challenging. Methods We investigated the utility of the 21-gauge Menghini-type biopsy needle with the rolling method for the histological diagnosis of AIP, in comparison with conventional 22-gauge needles. Among total 28 patients, rate of definitive histological diagnosis, acquired sample area of tissue, rate of histopathological diagnosis of AIP, and adverse events were retrospectively analyzed. Results Definitive histological diagnoses were successfully accomplished in all 14 patients (100%) treated with a Menghini-type needle, and in 57% of cases (8/14) treated with conventional 22-gauge needles (P < 0.001). The median sample area of the tissue, except for blood contamination, was remarkably larger by the Menghini-type needle than by conventional-type needles (6.2 [IQR, 4.5–8.8] versus 0.7 [IQR, 0.2–2.0] mm2, P < 0.001), and the area per punctures was approximately 4 times larger (1.4 [IQR: 0.9–2.9] versus 0.3 [IQR: 0.1–0.6] mm2/puncture, P < 0.001). Based on the International Consensus Diagnostic Criteria, lymphoplasmacytic infiltration, abundant IgG4-postive cells, storiform fibrosis, and obliterative phlebitis were found in 86%/29%, 64%/0%, 36%/0%, and 7%/0% patients who were treated with the Menghini-type needle and conventional-type needles, respectively. Consequently, histopathological diagnosis with type 1 AIP (lever 1 or 2) was achieved in 9 patients (64%) treated with the Menghini-type needle and in no patient treated with conventional-type needles (P < 0.001). Two patients who had mild post-procedural pancreatitis improved with conservative treatment, and no bleeding occurred in patients treated with the Menghini-type needle. Conclusion EUS-guided rolling method with the 21-gauge Menghini-type biopsy needle is useful for the histopathological diagnosis of AIP, due to its abundant acquisition of good-quality tissue from the pancreas.
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Affiliation(s)
- Koichiro Tsutsumi
- Departments of Internal Medicine, Fukuyama City Hospital, 5-23-1, Zao-cho, Fukuyama-City, Hiroshima, 721-8511, Japan. .,Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan.
| | - Toru Ueki
- Departments of Internal Medicine, Fukuyama City Hospital, 5-23-1, Zao-cho, Fukuyama-City, Hiroshima, 721-8511, Japan
| | - Yasuhiro Noma
- Department of Internal Medicine, National Hospital Organization Fukuyama Medical Center, 4-14-17, Okinogami-cho, Fukuyama-City, Hiroshima, 720-8520, Japan
| | - Kunihiro Omonishi
- Departments of Internal Medicine and Pathology, Fukuyama City Hospital, 5-23-1, Zao-cho, Fukuyama-City, Hiroshima, 721-8511, Japan
| | - Kyotaro Ohno
- Departments of Internal Medicine and Pathology, Fukuyama City Hospital, 5-23-1, Zao-cho, Fukuyama-City, Hiroshima, 721-8511, Japan
| | - Soichiro Kawahara
- Departments of Internal Medicine, Fukuyama City Hospital, 5-23-1, Zao-cho, Fukuyama-City, Hiroshima, 721-8511, Japan
| | - Takashi Oda
- Departments of Internal Medicine, Fukuyama City Hospital, 5-23-1, Zao-cho, Fukuyama-City, Hiroshima, 721-8511, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
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29
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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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30
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Facciorusso A, Barresi L, Cannizzaro R, Antonini F, Triantafyllou K, Tziatzios G, Muscatiello N, Hart PA, Wani S. Diagnostic yield of endoscopic ultrasound-guided tissue acquisition in autoimmune pancreatitis: a systematic review and meta-analysis. Endosc Int Open 2021; 9:E66-E75. [PMID: 33403238 PMCID: PMC7775812 DOI: 10.1055/a-1293-7279] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/28/2020] [Indexed: 02/08/2023] Open
Abstract
Background and study aims There is limited evidence on the diagnostic performance of endoscopic ultrasound (EUS)-guided tissue acquisition in autoimmune pancreatitis (AIP). The aim of this meta-analysis was to provide a pooled estimate of the diagnostic performance of EUS-guided fine-needle aspiration (FNA) and fine-needle biopsy (FNB) in patients with AIP. Patients and methods Computerized bibliographic search was performed through January 2020. Pooled effects were calculated using a random-effects model by means of DerSimonian and Laird test. Primary endpoint was diagnostic accuracy compared to clinical diagnostic criteria. Additional outcomes were definitive histopathology, pooled rates of adequate material for histological diagnosis, sample adequacy, mean number of needle passes. Diagnostic sensitivity and safety data were also analyzed. Results Fifteen studies with 631 patients were included, of which four were prospective series and one randomized trial. Overall diagnostic accuracy of EUS tissue acquisition was 54.7 % (95 % confidence interval, 40.9 %-68.4 %), with a clear superiority of FNB over FNA (63 %, 52.7 % to 73.4 % versus 45.7 %, 26.5 %-65 %; p < 0.001). FNB provided level 1 of histological diagnosis in 44.2 % of cases (30.8 %-57.5 %) as compared to 21.9 % (10 %-33.7 %) with FNA ( P < 0.001). The rate of definitive histopathology of EUS tissue sampling was 20.7 % (12.9 %-28.5 %) and it was significantly higher with FNB (24.3 %, 11.8 %-36.8 %) as compared to FNA (14.7 %, 5.4 %-23.9 %; P < 0.001). Less than 1 % of subjects experienced post-procedural acute pancreatitis. Conclusion The results of this meta-analysis demonstrate that the diagnostic performance of EUS-guided tissue acquisition is modest in patients with AIP, with an improved performance of FNB compared to FNA.
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Affiliation(s)
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS – ISMETT), Palermo, Italy
| | - Renato Cannizzaro
- Oncological Gastroenterology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Filippo Antonini
- Gastroenterology and Endoscopy Unit, Marche Polytechnic University, A. Murri Hospital, Fermo, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine – Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine – Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
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31
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Kuraishi Y, Uehara T, Watanabe T, Ashihara N, Ozawa M, Kanai K, Kawa S. Corticosteroids prevent the progression of autoimmune pancreatitis to chronic pancreatitis. Pancreatology 2020; 20:1062-1068. [PMID: 32800575 DOI: 10.1016/j.pan.2020.07.408] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 07/05/2020] [Accepted: 07/28/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVES Patients with autoimmune pancreatitis (AIP) sometimes progress to chronic pancreatitis (CP). We evaluated the ability of corticosteroids to prevent the progression to CP. METHODS We defined patients with definitive findings of CP (stones in the main pancreatic duct [MPD] or multiple pancreatic calcifications) as having severe calcification (SC). A total of 145 AIP patients were enrolled. We measured the duration between AIP diagnosis and SC development and retrospectively compared the time to SC development between patients with and without steroids. Multivariate analysis for factors associated with SC were performed. RESULTS Nineteen (13%) patients progressed to SC. Since 95 patients had pancreatic head swelling and SC was found in these patients only, our analysis focused mainly on these at-risk populations. In Kaplan-Meier analysis limited to patients with pancreatic head swelling, the incidence of SC was significantly lower in patients with steroids than in those without (hazard ratio [HR] 0.18, 95% confidence interval [CI] 0.07-0.52; p < 0.001). Multivariate testing of patients with pancreatic head swelling confirmed that steroid therapy was significantly associated with a lower incidence of SC (HR 0.11, 95% CI 0.03-0.34; p < 0.001), while MPD dilation at AIP diagnosis was related to a higher incidence of SC (HR 4.02, 95% CI 1.43-11.7; p = 0.009). CONCLUSIONS Corticosteroids appeared to prevent progression to CP in AIP patients, especially in those with pancreatic head swelling. Patients with both pancreatic head swelling and MPD dilation at diagnosis have a higher incidence of progression to CP. Steroid therapy is suggested for these high-risk cases.
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Affiliation(s)
- Yasuhiro Kuraishi
- Department of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Takeshi Uehara
- Department of Laboratory Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan.
| | - Takayuki Watanabe
- Department of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Norihiro Ashihara
- Department of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Makiko Ozawa
- Department of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Keita Kanai
- Department of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Shigeyuki Kawa
- Department of Internal Medicine, Matsumoto Dental University, Shiojiri, Nagano, Japan
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32
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NOTOHARA K. Histological features of type 1 autoimmune pancreatitis: Reevaluation for effective diagnosis of biopsies. ACTA ACUST UNITED AC 2020. [DOI: 10.2958/suizo.35.272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Kenji NOTOHARA
- Department of Anatomic Pathology, Kurashiki Central Hospital
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33
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Notohara K, Kamisawa T, Fukushima N, Furukawa T, Tajiri T, Yamaguchi H, Aishima S, Fukumura Y, Hirabayashi K, Iwasaki E, Kanno A, Kasashima S, Kawashima A, Kojima M, Kubota K, Kuraishi Y, Mitsuhashi T, Naito Y, Naitoh I, Nakase H, Nishino T, Ohike N, Sakagami J, Shimizu K, Shiokawa M, Uehara T, Ikeura T, Kawa S, Okazaki K. Guidance for diagnosing autoimmune pancreatitis with biopsy tissues. Pathol Int 2020; 70:699-711. [PMID: 32767550 DOI: 10.1111/pin.12994] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 12/14/2022]
Abstract
The biopsy-based diagnosis of autoimmune pancreatitis (AIP) is difficult but is becoming imperative for pathologists due to the increased amount of endoscopic ultrasound-guided biopsy tissue. To cope with this challenge, we propose guidance for the biopsy diagnosis of type 1 AIP. This guidance is for pathologists and comprises three main parts. The first part includes basic issues on tissue acquisition, staining, and final diagnosis, and is intended for gastroenterologists as well. The second part is a practical guide for diagnosing type 1 AIP based on the AIP clinical diagnostic criteria 2018. Inconsistent histological findings, tips for evaluating IgG4 immunostaining and key histological features including the ductal lesion and others are explained. Storiform fibrosis and obliterative phlebitis are diagnostic hallmarks but are sometimes equivocal. Storiform fibrosis is defined as spindle-shaped cells, inflammatory cells and fine collagen fibers forming a flowing arrangement. Obliterative phlebitis is defined as fibrous venous obliteration with inflammatory cells. Examples of each are provided. The third part describes the differentiation of AIP from pancreatic ductal adenocarcinoma (PDAC), focusing on histological features of acinar-ductal metaplasia in AIP, which is an important mimicker of PDAC. This guidance will help standardize pathology reports of pancreatic biopsies for diagnosing type 1 AIP.
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Affiliation(s)
- Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | | | | | - Toru Furukawa
- Department of Histopathology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Takuma Tajiri
- Department of Diagnostic Pathology, Tokai University Hachioji Hospital, Tokyo, Japan
| | | | - Shinichi Aishima
- Department of Pathology and Microbiology, Faculty of Medicine, Saga University, Saga, Japan
| | - Yuki Fukumura
- Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
| | | | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Atsushi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan.,Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Satomi Kasashima
- Department of Clinical Laboratory Science, Kanazawa University, Ishikawa, Japan
| | - Atsuhiro Kawashima
- Department of Diagnostic Pathology, National Hospital Organization Kanazawa Medical Center, Ishikawa, Japan
| | - Motohiro Kojima
- Division of Pathology, Research Center for Innovative Oncology, National Cancer Center, Chiba, Japan
| | - Kensuke Kubota
- Depatment of Endoscopy, Yokohama City University Hospital, Kanagawa, Japan
| | - Yasuhiro Kuraishi
- Department of Gastroenterology, Shinshu University School of Medicine, Nagano, Japan
| | - Tomoko Mitsuhashi
- Department of Surgical Pathology, Hokkaido University Hospital, Hokkaido, Japan
| | - Yoshiki Naito
- Department of Diagnostic Pathology, Kurume University Hospital, Fukuoka, Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Takayoshi Nishino
- Department of Gastroenterology, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Nobuyuki Ohike
- Department of Pathology, Showa University Fujigaoka Hospital, Kanagawa, Japan
| | - Junichi Sakagami
- Department of Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Fukuchiyama City Hospital, Kyoto, Japan
| | - Kyoko Shimizu
- Department of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masahiro Shiokawa
- Department of Gastroenterology, Kyoto University Hospital, Kyoto, Japan
| | - Takeshi Uehara
- Department of Laboratory Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Tsukasa Ikeura
- Department of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Shigeyuki Kawa
- Department of Internal Medicine, Matsumoto Dental University, Nagano, Japan
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Notohara K, Kamisawa T, Kanno A, Naitoh I, Iwasaki E, Shimizu K, Kuraishi Y, Motoya M, Kodama Y, Kasashima S, Nishino T, Kubota K, Sakagami J, Ikeura T, Kawa S, Okazaki K. Efficacy and limitations of the histological diagnosis of type 1 autoimmune pancreatitis with endoscopic ultrasound-guided fine needle biopsy with large tissue amounts. Pancreatology 2020; 20:834-843. [PMID: 32624418 DOI: 10.1016/j.pan.2020.05.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/20/2020] [Accepted: 05/29/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We examined the efficacy and limitations of acquiring large specimens by endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for diagnosing type 1 autoimmune pancreatitis (AIP). METHODS Patients from 12 institutions with non-neoplastic diseases or pancreatic ductal adenocarcinoma (PDAC) with large EUS-FNB specimens were investigated. Slides stained with hematoxylin-eosin, elastic, IgG4, and IgG stains were evaluated. The IgG4- and IgG-positive cell numbers were counted in three foci. The diagnoses were based on the Japan Pancreas Society 2011 (JPS 2011) criteria and the International Consensus Diagnostic Criteria (ICDC). RESULTS We analyzed 85 non-neoplastic (definite type 1 AIP in 73/85 based on the ICDC) cases and 64 PDAC cases. IgG4-positive cells were numerous (>10 in 85.9%), and the IgG4/IgG ratios were high (>40% in 81.2%). Plasma cell crushing by an artifact caused unsuccessful immunostaining, notably in smaller samples. Tissue lengths were an important factor for the presence of storiform fibrosis and obliterative phlebitis, but storiform fibrosis was equivocal even in large tissues. A definite or possible histological diagnosis was achieved in 45.9% (39/85) and 41.2% (35/85), respectively, and contributed to the definite final diagnosis of type 1 AIP in 33.3% (ICDC) and 55.6% (JPS 2011) in cases with segmental/focal lesions. In the PDAC group, >10 IgG4-positive cells was rare (2/58), but elastic stains revealed fibrous venous occlusions in 10.3% (6/58). CONCLUSIONS EUS-FNB with large tissue amounts was useful for diagnosing type 1 AIP, notably by facilitating successful IgG4 immunostaining, but definite diagnosis may not be achieved even in cases with large specimens.
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Affiliation(s)
- Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Kurashiki, Japan.
| | | | - Atsushi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kyoko Shimizu
- Department of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yasuhiro Kuraishi
- Department of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masayo Motoya
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yuzo Kodama
- Department of Gastroenterology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Satomi Kasashima
- Department of Clinical Laboratory Science, Kanazawa University, Kanazawa, Japan
| | - Takayoshi Nishino
- Department of Gastroenterology, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Kensuke Kubota
- Department of Endoscopy, Yokohama City University Hospital, Yokohama, Japan
| | - Junichi Sakagami
- Department of Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tsukasa Ikeura
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
| | - Shigeyuki Kawa
- Department of Internal Medicine, Matsumoto Dental University, Shiojiri, Japan
| | - Kazuichi Okazaki
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
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Satou A, Notohara K, Zen Y, Nakamura S, Yoshino T, Okazaki K, Sato Y. Clinicopathological differential diagnosis of IgG4-related disease: A historical overview and a proposal of the criteria for excluding mimickers of IgG4-related disease. Pathol Int 2020; 70:391-402. [PMID: 32314497 DOI: 10.1111/pin.12932] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/16/2020] [Accepted: 03/30/2020] [Indexed: 12/15/2022]
Abstract
IgG4-related disease (RD) is a relatively new entity, which was first proposed in 2001. Since then, clinical and pathological characteristics of the disease have been investigated. As IgG4-RD has been studied extensively, the diagnostic criteria for IgG4-RD of each organ and the comprehensive diagnostic criteria for IgG4-RD have also been developed. However, one of the biggest challenges in the field is distinguishing between IgG4-RD and mimickers, which show overlapping features with IgG4-RD. It is now known that some non-IgG4-RDs may meet the diagnostic criteria of IgG4-RD and can be misdiagnosed as IgG4-RD. However, accurate diagnosis is crucial, as the treatments for IgG4-RD and those for other diseases that may be misdiagnosed as IgG4-RD are different. This prompted us to create and propose comprehensive exclusion criteria for IgG4-RD. In this review, we have described the comprehensive exclusion criteria for IgG4-RD, with a historical overview of the disease. These exclusion criteria were recently created by the Research Program for Intractable Disease of the Ministry of Health, Labor, and Welfare of Japan, All Japan IgG4 team, to support correct and accurate diagnosis of IgG4-RD.
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Affiliation(s)
- Akira Satou
- Department of Surgical Pathology, Aichi Medical University Hospital, Aichi, Japan.,The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan
| | - Kenji Notohara
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Yoh Zen
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Institute of Liver Studies, King's College Hospital & King's College London, London, UK
| | - Shigeo Nakamura
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Aichi, Japan
| | - Tadashi Yoshino
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Department of Pathology, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Kazuichi Okazaki
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Yasuharu Sato
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Department of Pathology, Okayama University Graduate School of Medicine, Okayama, Japan.,Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
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36
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Nwaduru C, Pillai A. Serum negative immunoglobulin G4-associated cholangiopathy mimicking hilar cholangiocarcinoma: A case report and review. INTERNATIONAL JOURNAL OF HEPATOBILIARY AND PANCREATIC DISEASES 2020. [DOI: 10.5348/100087z04cn2020cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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37
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Pancreaticobiliary involvement in treated type 1 autoimmune pancreatitis: Imaging pattern and risk factors for disease relapse. Eur J Radiol 2019; 120:108673. [DOI: 10.1016/j.ejrad.2019.108673] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/31/2019] [Accepted: 09/12/2019] [Indexed: 01/04/2023]
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38
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39
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Zen Y, Deshpande V. Tumefactive Inflammatory Diseases of the Pancreas. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:82-93. [PMID: 30558726 DOI: 10.1016/j.ajpath.2018.05.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/16/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
Advances in the past two decades have resulted in the recognition of several tumefactive pancreatic lesions that, on histologic evaluation, show a varying combination of inflammation and fibrosis. Autoimmune pancreatitis, the prototypic tumefactive pancreatic fibroinflammatory lesion, is composed of two distinct diseases, type 1 autoimmune pancreatitis and the less common type 2 autoimmune pancreatitis. Although designated as autoimmune pancreatitis, the two diseases show little morphologic or pathogenic overlap. In type 1 disease, subsets of T lymphocytes (type 2 helper T cells, regulatory T cells, and T follicular helper 2 cells) are hypothesized to drive the inflammatory reaction. The B-cell response is characterized by an oligoclonal expansion of plasmablasts, with dominant clones that vary among patients and distinct clones that emerge at the time of relapse. Although the precise role of IgG4 in this condition remains uncertain, recent studies suggest that other IgG subclasses (eg, IgG1) may mediate the immune reactions, whereas IgG4 represents a response to dampen excessive inflammation. A recent study of type 2 autoimmune pancreatitis highlights the role of CXCL8 (alias IL-8), with duct epithelium and infiltrating T lymphocytes expressing this chemokine; the latter may contribute to the distinct form of neutrophilic inflammation in this disease. The review also highlights other forms of mass-forming chronic pancreatitis: follicular pancreatitis, groove pancreatitis, and those associated with rheumatologic diseases.
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Affiliation(s)
- Yoh Zen
- Department of Diagnostic Pathology, Kobe University, Kobe, Japan
| | - Vikram Deshpande
- The James Homer Wright Pathology Laboratories, Massachusetts General Hospital, Boston, Massachusetts.
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40
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Hruban RH, Klimstra DS, Zamboni G, Klöppel G. A semicentennial of pancreatic pathology: the genetic revolution is here, but don't throw the baby out with the bath water! Hum Pathol 2019; 95:99-112. [PMID: 31521627 DOI: 10.1016/j.humpath.2019.08.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 12/19/2022]
Abstract
The last 50 years have witnessed an explosion in our understanding of the pathology of pancreatic diseases. Entities known to exist 50 years ago have been defined more precisely and are now better classified. New entities, previously not recognized, have been discovered and can now be treated. Importantly, new tools have been developed that have unraveled the fundamental biological drivers of a number of pancreatic diseases. Many of these same tools have also been applied clinically, supplementing the tried and true hematoxylin and eosin stained slide with a plethora of new, highly sensitive and specific tests that improve diagnostic accuracy and delineate best treatments. As exciting as these many advances are, our knowledge of pancreatic pathology remains incomplete, and there is much to be learned.
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Affiliation(s)
- Ralph H Hruban
- The Sol Goldman Pancreatic Cancer Research Center, Departments of Pathology and Oncology, the Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA.
| | - David S Klimstra
- The Department of Pathology, Memorial Sloan Kettering Cancer Center, NY, USA
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41
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Abstract
OBJECTIVE. The purpose of this article is to present the pathologic and clinical features of IgG4-related sclerosing cholangitis (ISC), illustrate the associated imaging findings, and discuss treatment of the disorder. CONCLUSION. ISC is an inflammatory disorder involving the biliary system and resulting in strictures. Although often associated with autoimmune pancreatitis, it may be an isolated disease. Differentiation of ISC from other forms of cholangitis and cholangiocarcinoma is difficult but necessary for management. Imaging is important in diagnosing and assessing the extent of disease and planning a management strategy.
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42
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Abstract
Autoimmune pancreatitis (AIP) is an entity that has been recognized since 1961. Prior to the discovery of elevated serum IgG4 as a useful biomarker for its diagnosis, Dr. Yoshida in 1995 first described the entity of AIP, which in retrospect closely resembles the current concept of type 1 AIP. Since the discovery of IgG4 as a biomarker (the IgG4-era), a novel concept of IgG4-related disease (IgG4-RD) has been accepted as being comprised of two subtypes of AIP: type 1 defined as the pancreatic manifestation of IgG4-RD, and type 2 characterized by granulocytic epithelial lesions. The characteristic features of type 1 AIP are increased serum IgG4 levels, lymphoplasmacytic sclerosing pancreatitis (abundant infiltration of IgG4+ plasmocytes and lymphocytes, storiform fibrosis, and obliterative phlebitis), extrapancreatic manifestations of IgG4-RD (e.g., sclerosing cholangitis, sclerosing sialadenitis, retroperitoneal fibrosis), and steroid responsiveness. These entities can be differentiated from mimickers by a combination of serum IgG4 level, imaging features, and histopathological findings. The current first-line therapy is corticosteroids, or rituximab in high-risk patients with steroid intolerance. Although relapse rates are high, treatment of relapsed disease remains experimental.
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Affiliation(s)
- Kazuichi Okazaki
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Shinmachi, Hirakata, Osaka, 573-1197, Japan.
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43
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Hegade VS, Sheridan MB, Huggett MT. Diagnosis and management of IgG4-related disease. Frontline Gastroenterol 2019; 10:275-283. [PMID: 31288262 PMCID: PMC6583577 DOI: 10.1136/flgastro-2018-101001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 09/09/2018] [Accepted: 09/29/2018] [Indexed: 02/04/2023] Open
Abstract
IgG subclass 4-related disease (IgG4-RD) is a rare but increasingly recognised fibroinflammatory condition known to affect multiple organs. IgG4-RD is characterised by unique histological features of lymphoplasmacytic infiltration, storiform fibrosis and obliterative phlebitis. In this review we describe the pancreaticobiliary manifestations of IgG4-RD, with particular emphasis on type 1 autoimmune pancreatitis (AIP) and IgG4-related sclerosing cholangitis (IgG4-SC). AIP and IgG4-SC can pose diagnostic challenges to the clinician as they may mimic pancreatic cancer and primary sclerosing cholangitis, respectively. We discuss current knowledge, clinical diagnostic criteria and recent advances and summarise the evidence base for current therapeutic approaches for AIP and IgG4-SC.
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Affiliation(s)
- Vinod S Hegade
- Department of Gastroenterology, St James University Hospital, Leeds, UK
| | - Maria B Sheridan
- Department of Radiology, St James University Hospital, Leeds, UK
| | - Matthew T Huggett
- Department of Gastroenterology, St James University Hospital, Leeds, UK
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44
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Abstract
Immunoglobulin (Ig)G4-related sclerosing cholangitis (IgG4-SC) is a biliary tract manifestation of IgG4-related diseases (IgG4-RD); a subgroup of SC defined as a condition with progressive stenosis and destruction of the bile ducts due to diffuse inflammation and fibrosis. IgG4-SC is clinically characterized by the (a) chronic elevation of cholestatic enzyme levels, (b) significant elevation of serum IgG4 levels, (c) diffuse or segmental narrowing of intra and/or extra hepatic bile ducts with thickening of the bile duct wall in imaging studies, (d) marked lymphoplasmacytic and IgG4-positive plasma cell infiltration and fibrosis in histology, (e) presence of IgG4-RD in other organs, mainly involving autoimmune pancreatitis, and (f) excellent response to corticosteroids. The diagnosis of IgG4-SC is based on a combination of these findings. Although the IgG4-SC diagnosis is different from that of primary sclerosing cholangitis (PSC) or biliary and pancreatic malignancies, it is extremely important to diagnose or suspect IgG4-SC appropriately; as the incorrect diagnosis of PSC or malignant diseases may lead to the progression of fibrosis in patients due to untreated chronic cholestasis, or to unnecessary major surgical resections. Although its etiology remains unclear, recent studies of IgG4-SC have attempted to clarify the roles of the IgG4 molecule and novel autoantibodies detected in patients with IgG4-SC.
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Affiliation(s)
- Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
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45
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Kuraishi Y, Watanabe T, Muraki T, Ashihara N, Ozawa M, Nakamura A, Kanai K, Hamano H, Kawa S. Effectiveness of steroid therapy for pancreatic cysts complicating autoimmune pancreatitis and management strategy for cyst-related complications. Scand J Gastroenterol 2019; 54:773-779. [PMID: 31164010 DOI: 10.1080/00365521.2019.1623307] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objectives: Autoimmune pancreatitis (AIP) sometimes becomes complicated with pancreatic cysts, although their detailed characteristics and management strategy have not been fully determined. We aimed to clarify the efficiency of steroid therapy and the risk factors for cyst formation and cyst-related complications. Methods: One hundred sixty-three AIP patients were retrospectively analyzed for relevant factors of cyst formation. We compared subjects with and without steroids to evaluate drug effectiveness on cyst size change and investigated the factors associated with cyst-related complications. Results: Thirty-two patients (19.6%) had complicating pancreatic cyst formation, and 40 cystic lesions of ≥10 mm in size were detected. Multivariate analysis revealed a drinking habit, abdominal/back pain, and elevated serum amylase to be significantly associated with cyst formation. Steroid-treated cysts became significantly reduced in size in the short-term and disappeared significantly more frequently within 1-year as compared with non-treated ones, which was confirmed by multivariate analysis. Six of 40 cysts exhibited cyst-related complications significantly associated with multilocular morphology and larger size. Conclusions: Steroid therapy is an effective choice for cysts developing in AIP to promote the release of pancreatic juice stasis. Larger lesions with multilocular morphology should be monitored closely for cyst-related complications and be considered strong candidates for steroid therapy.
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Affiliation(s)
- Yasuhiro Kuraishi
- Department of Gastroenterology, Shinshu University School of Medicine , Matsumoto , Japan
| | - Takayuki Watanabe
- Department of Gastroenterology, Shinshu University School of Medicine , Matsumoto , Japan
| | - Takashi Muraki
- Department of Gastroenterology, North Alps Medical Center Azumi Hospital , Ikeda , Japan
| | - Norihiro Ashihara
- Department of Gastroenterology, Shinshu University School of Medicine , Matsumoto , Japan
| | - Makiko Ozawa
- Department of Gastroenterology, Shinshu University School of Medicine , Matsumoto , Japan
| | - Akira Nakamura
- Department of Gastroenterology, Shinshu University School of Medicine , Matsumoto , Japan
| | - Keita Kanai
- Department of Gastroenterology, Shinshu University School of Medicine , Matsumoto , Japan
| | - Hideaki Hamano
- Department of Gastroenterology, Shinshu University School of Medicine , Matsumoto , Japan
| | - Shigeyuki Kawa
- Department of Internal Medicine, Matsumoto Dental University , Shiojiri , Japan
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46
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Vashi B, Khosroshahi A. IgG4-Related Disease with Emphasis on Its Gastrointestinal Manifestation. Gastroenterol Clin North Am 2019; 48:291-305. [PMID: 31046976 DOI: 10.1016/j.gtc.2019.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IgG4-related disease is an immune-mediated fibroinflammatory condition with a diverse spectrum of organ involvement, commonly in the pancreas and bile ducts among other organs such as salivary and lacrimal glands. Classic histopathologic findings are the gold standard for confirmation of diagnosis, although diagnosis remains challenging, as biomarkers to date are neither sufficient nor necessary. Glucocorticoids are the most effective initial treatment, generally having a dramatic response, although limited clinical evidence exists regarding effective maintenance therapy. This review summarizes key GI manifestations of this condition for the practicing gastroenterologist and addresses the pathology, disease mechanism, and current therapeutic recommendations.
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Affiliation(s)
- Bijal Vashi
- Department of Medicine, Emory University, 200 Whitehead Building, 615 Michael Street, Atlanta, GA 30322, USA
| | - Arezou Khosroshahi
- Department of Medicine, Emory University, 244 Whitehead Building, 615 Michael Street, Atlanta, GA 30322, USA.
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47
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Abstract
Autoimmune pancreatitis (AIP) is a rare disorder characterized by prompt clinical response to corticosteroids. Lost tolerance to a variety of pancreatic antigens and subsequent development of autoantibodies are presumably involved in the initiation of AIP. Even pediatric patients have been reported with features of AIP, and awareness of this disorder is increasing among different clinicians. The terms lymphoplasmacytic sclerosing pancreatitis and idiopathic duct-centric pancreatitis refer to the different histologic patterns of AIP, named type 1 and type 2, respectively. A combination of serologic, radiologic, and histologic investigations is needed to assess diagnosis of AIP and rule out neoplastic disorders. In addition, type 1 AIP can be distinguished by raised levels of serum immunoglobulin G4 and should be considered as part of systemic immunoglobulin G4-related disease. Conversely, type 2 AIP is frequently reported in younger patients and has less clear immune-mediated pathogenetic mechanisms. The natural history of pediatric AIP is obscure, and the diagnostic usefulness of different autoimmune abnormalities found in adults with AIP is limited for children. Tips to manage pediatric patients with AIP have been recently drafted through a set of recommendation statements. This review describes the current data about AIP and the pathogenic contribution of specific autoantibodies expressly in the pediatric population.
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48
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Kamisawa T, Zen Y, Nakazawa T, Okazaki K. Advances in IgG4-related pancreatobiliary diseases. Lancet Gastroenterol Hepatol 2019; 3:575-585. [PMID: 30047448 DOI: 10.1016/s2468-1253(18)30121-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 03/30/2018] [Accepted: 04/04/2018] [Indexed: 02/07/2023]
Abstract
Autoimmune pancreatitis is an unusual form of pancreatitis that is histologically characterised by a massive infiltration of lymphocytes and IgG4-positive plasma cells and storiform fibrosis. The disease is recognised as a pancreatic manifestation of IgG4-related disease. IgG4-related sclerosing cholangitis is a biliary counterpart that is typically associated with autoimmune pancreatitis. Two parallel immunological responses are thought to underlie the pathophysiology of these diseases: a pro-inflammatory, tissue-destructive process and an anti-inflammatory feedback response, which probably relates to IgG4 production. These diseases should be differentiated from conditions with a similar presentation (eg, pancreatobiliary malignancy, primary sclerosing cholangitis) by comparison of serum IgG4 concentration, imaging features, other organ involvement, histology, and steroid responsiveness. Corticosteroids are first-line drugs, although rituximab has been shown to effectively deplete B cells in IgG4-related disease. Although the risk of relapse is high, no standardised treatment protocol exists for relapsed cases.
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Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Bunkyo-ku, Tokyo, Japan.
| | - Yoh Zen
- Department of Diagnostic Pathology, Kobe University, Chuo-ku, Kobe, Japan
| | - Takahiro Nakazawa
- Department of Gastroenterology, Japanese Red Cross Nagoya Daini Hospital, Showa-ku, Nagoya, Japan
| | - Kazuichi Okazaki
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Osaka, Japan
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49
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Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a recently established systemic disease that is characteristically associated with elevated serum immunoglobulin G4 (IgG4) levels and believed to be caused by autoimmune mechanisms. The clinical features of IgG4-RD include (i) systemic distribution, (ii) imaging findings of swelling, nodules, and/or wall thickening, (iii) high serum IgG4 levels, (iv) abundant IgG4-bearing plasma cell infiltration and fibrosis in affected organs, (v) a favorable response to corticosteroid therapy, and (vi) coexistence with other IgG4-RD manifestations simultaneously or in a metachronous fashion. The concept of IgG4-RD was established based on the culmination of specific discoveries. Specifically, a close association between autoimmune pancreatitis (AIP) and high serum IgG4 levels, massive IgG4-bearing plasma cell infiltration in pancreatic tissues affected by AIP, and systemic other organ involvements in AIP with similar IgG4-bearing plasma cell features opened the gateway from AIP to IgG4-RD. The systemic distribution of IgG4-RD seems to be capable of affecting every organ, causing well-established members including AIP, lacrimal and salivary gland lesions such as Mikulicz’s disease, respiratory diseases, sclerosing cholangitis, kidney diseases, and retroperitoneal fibrosis. IgG4-RD has been diagnosed worldwide, and international collaboration efforts on the disease have led to consensus publications on its nomenclature, pathology findings, and management approach. The algorithms developed for the comprehensive diagnostic criteria for IgG4-RD have remarkably increased detection sensitivity. Oral glucocorticoids are the first-line agents for remission induction, and certain patients with high disease activity may benefit from maintenance therapy afterwards. Originally, IgG4-RD had been considered reversible and to have a good prognosis; however, long-term afflictions sometimes result in transition to advanced-stage conditions with dysfunction and/or complicating malignancy. The immunological abnormalities in IgG4-RD have been reported in both innate and adaptive immune systems; however, it remains unclear whether IgG4 has a pathogenic role or a protective one in disease onset and progression.
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Affiliation(s)
- Shigeyuki Kawa
- Department of Internal Medicine, Matsumoto Dental University, Shiojiri, Japan
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50
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Kwon DH, Kallakury B, DeBrito P, Azumi N. IgG4-Related Appendiceal Disease: A First Case Report Fulfilling All Pathological Diagnostic Criteria and With Concomitant S100-Positive Dendritic/Schwann Cell Hyperplasia. Int J Surg Pathol 2019; 27:541-546. [DOI: 10.1177/1066896919830213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IgG4-related disease is a recent entity that has been described in a wide variety of organ systems. A 46-year-old female presented with acute appendicitis accompanied by a mass-forming lesion, raising a concern for neoplasm, and therefore, hemicolectomy was performed. The lesion revealed a dense lymphoplasmacytic infiltrate accompanied by storiform fibrosis and obliterative phlebitis. The IgG4/IgG plasma cell ratio was >50%, and the number of IgG4-positive plasma cells was >100/high-power field. In order to assess the IgG4/IgG plasma cell ratio, MUM1 was employed instead of IgG to successfully estimate the plasma cell concentration. There was also a concomitant hyperplasia of S100-positive cell, which could represent dendritic or Schwannian origin and possibly play a pathophysiologic role. The hyperplasia was significant by itself that it may mimic a mass-forming lesion. This newly described entity of the past decade deserves increased recognition due to clinical implication and surgical morbidity. This is the first case of IgG4-related disease in the appendix to our knowledge that fully satisfied all the pathological diagnostic criteria. We would like to also highlight our innovative approach of evaluating the IgG4/IgG plasma cell.
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Affiliation(s)
| | | | | | - Norio Azumi
- Georgetown University Hospital, Washington, DC, USA
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