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Takeda S, Kawaratani H, Takami M, Inoue Y, Matsuda T, Kubo T, Fujinaga M, Ozutsumi T, Furukawa M, Kitagawa K, Sawada Y, Uejima M, Mitoro A, Yamao J, Yoshiji H. Isolated Pancreatic Sarcoidosis Diagnosed by Endoscopic Ultrasound-guided Fine-needle Aspiration. Intern Med 2020; 59:1407-1412. [PMID: 32161217 PMCID: PMC7332622 DOI: 10.2169/internalmedicine.4034-19] [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: 12/03/2022] Open
Abstract
We herein report a 52-year-old man with multiple hypoechoic lesions in the body and tail of the pancreas detected during a screening ultrasound. Computed tomography (CT) showed no lesions other than those in the pancreas and peripheral lymph nodes. Contrast-enhanced CT identified hypovascular tumors in the pancreas. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) demonstrated partial fibrosis and noncaseating granulomas with Langhans giant cells. To our knowledge, this is the first report of isolated pancreatic sarcoidosis diagnosed by EUS-FNA. Although pancreatic sarcoidosis is very rare, clinicians should be aware of this possibility in patients presenting with multiple hypovascular pancreatic tumors.
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Affiliation(s)
- Soichi Takeda
- Department of Gastroenterology, Nara Medical University, Japan
| | | | | | - Yuta Inoue
- Department of Gastroenterology, Nara Medical University, Japan
| | - Takuya Matsuda
- Department of Gastroenterology, Nara Medical University, Japan
| | - Takuya Kubo
- Department of Gastroenterology, Nara Medical University, Japan
| | | | | | | | - Kou Kitagawa
- Department of Gastroenterology, Nara Medical University, Japan
| | - Yasuhiko Sawada
- Department of Gastroenterology, Nara Medical University, Japan
| | - Masakazu Uejima
- Department of Gastroenterology, Nara Medical University, Japan
| | - Akira Mitoro
- Department of Gastroenterology, Nara Medical University, Japan
| | - Junichi Yamao
- Department of Gastroenterology, Nara Medical University, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Japan
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Azemoto N, Kumagi T, Koizumi M, Kuroda T, Yamanishi H, Ohno Y, Imamura Y, Takeshita E, Soga Y, Ikeda Y, Onji M, Hiasa Y. Diagnostic Challenge in Pancreatic Sarcoidosis Using Endoscopic Ultrasonography. Intern Med 2018; 57:231-235. [PMID: 29033431 PMCID: PMC5820042 DOI: 10.2169/internalmedicine.9084-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
We herein report a 55-year-old woman who presented with erythema and bilateral hilar lymphadenopathy 4 months prior to the detection of pancreatic lesions on an ultrasound. A skin biopsy showed evidence of sarcoidosis. The largest lesion in the tail of the pancreas was hypoechoic on endoscopic ultrasonography (EUS). The lesion was initially iso-enhanced on contrast enhanced-EUS (CE-EUS) but subsequently became hypoenhanced. The lesion revealed heterogeneous components of both soft and hard tissue on EUS elastography. She was ultimately diagnosed with pancreatic sarcoidosis based on the presence of noncaseating granulomas seen on pancreatic tissue retrieved through an EUS-guided fine needle aspiration biopsy.
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Affiliation(s)
- Nobuaki Azemoto
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
- National Hospital Organization Shikoku Cancer Center, Japan
| | - Teru Kumagi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
| | - Mitsuhito Koizumi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
| | - Taira Kuroda
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
| | - Hirofumi Yamanishi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
| | - Yoshinori Ohno
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
| | - Yoshiki Imamura
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
| | - Eiji Takeshita
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
| | | | | | - Morikazu Onji
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
| | - Yoichi Hiasa
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
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Khangura T, Uddin G, Davies A, Keating J. A Rare Variant of Pancreatic Sarcoidosis: Diagnostic Challenge. Euroasian J Hepatogastroenterol 2016; 5:118-121. [PMID: 29201707 PMCID: PMC5578541 DOI: 10.5005/jp-journals-10018-1149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 03/04/2015] [Indexed: 11/23/2022] Open
Abstract
Pancreatic sarcoidosis is one of the variant of systemic sarcoidosis which is extremely rare in literature and opined as an enigma. Hence, its diagnosis is very challenging as its presentation mimics pancreatic carcinoma. In view of a better understanding, we are presenting a case of pancreatic sarcoidosis to emphasize the above. To clearly distinguish sarcoidosis from malignancy, repeated computed tomography scans, Positron emission tomography scans, fine needle aspiration cytology, endoscopic retrograde cholangio-pancreatography supplemented with histology and relevant blood tests proved it to be a pancreatic sarcoidosis then a malignancy. Over the course, concrete evidence was divulged from lymph node biopsy and histology in clinching the diagnosis which later transformed into a malignancy. Therefore, we concluded it is a rare variant of pancreatic sarcoidosis and careful serial investigations include repeated imaging, histology and blood tests are essential to establish and most importantly differentiate the diagnosis. How to cite this article Khangura T, Uddin G, Davies A, Keating J. A Rare Variant of Pancreatic Sarcoidosis: Diagnostic Challenge. Euroasian J Hepato-Gastroenterol 2015;5(2):118-121.
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Affiliation(s)
- Taran Khangura
- Department of Gastroenterology and Hepatology, Furness General Hospital, University Hospitals of Morecambe Bay NHS Foundation Trust, Barrow in Furness, Cumbria, LA14 4LF, United Kingdom
| | - Gias Uddin
- Department of Gastroenterology and Hepatology, Furness General Hospital, University Hospitals of Morecambe Bay NHS Foundation Trust, Barrow in Furness, Cumbria, LA14 4LF, United Kingdom
| | - Albert Davies
- Department of Gastroenterology and Hepatology, Furness General Hospital, University Hospitals of Morecambe Bay NHS Foundation Trust, Barrow in Furness, Cumbria, LA14 4LF, United Kingdom
| | - John Keating
- Department of Gastroenterology and Hepatology, Furness General Hospital, University Hospitals of Morecambe Bay NHS Foundation Trust, Barrow in Furness, Cumbria, LA14 4LF, United Kingdom
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Mayne AIW, Ahmad J, Loughrey M, Taylor MA. Sarcoidosis of the pancreas mimicking adenocarcinoma. BMJ Case Rep 2013; 2013:bcr-2013-009118. [PMID: 23784760 DOI: 10.1136/bcr-2013-009118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Primary sarcoidosis of the pancreas is extremely rare. Clinical presentation is often identical to that of pancreatic adenocarcinoma. Preoperative diagnosis of primary pancreatic sarcoidosis is always challenging. We present a 52-year-old man who developed weight loss and obstructive jaundice. Abdomino-pelvic CT scan showed a mass in the pancreatic head. After hepatopancreaticobiliary MDT discussion, a Whipple's procedure was attempted but the mass was deemed unresectable due to invasion of the superior mesenteric vein. Upon completion of palliative chemotherapy, repeat imaging showed significant mass shrinkage. A reattempt Whipple's procedure was successfully undertaken. Histology showed changes of chronic pancreatitis and peripancreatic granulomatous inflammation with no evidence of malignancy and a diagnosis of sarcoidosis was made. Owing to the devastating nature of pancreatic adenocarcinoma, any mass in the pancreas must be thoroughly investigated before a definitive diagnosis is made.
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Pezzilli R, Vecchiarelli S, Di Marco MC, Serra C, Santini D, Calculli L, Fabbri D, Rojas Mena B, Imbrogno A. Pancreatic ductal adenocarcinoma associated with autoimmune pancreatitis. Case Rep Gastroenterol 2011; 5:378-85. [PMID: 21769291 PMCID: PMC3134062 DOI: 10.1159/000330291] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Autoimmune pancreatitis (AIP), in contrast to other benign chronic pancreatic diseases, can be cured with immunosuppressant drugs, thus the differentiation of AIP from pancreatic cancer is of particular interest in clinical practice. There is the possibility that some patients with AIP may develop pancreatic cancer, and this possibility contributes to increasing our difficulties in differentiating AIP from pancreatic cancer. We herein report the case of a 70-year-old man in whom pancreatic adenocarcinoma and AIP were detected simultaneously. We must carefully monitor AIP patients for the simultaneous presence of pancreatic cancer, even when a diagnosis of AIP is confirmed.
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Affiliation(s)
- Raffaele Pezzilli
- Pancreas Unit, Department of Digestive Diseases and Internal Medicine, University of Bologna, Bologna, Italy
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Abstract
Sarcoidosis is an inflammatory disease characterized by non-caseating granulomas in the absence of other autoimmune processes, infectious diseases, or foreign agents. The etiology of sarcoidosis is not completely understood. Several organ systems can be affected, of which the most frequently involved include the lungs and lymph nodes. Intra-abdominal sarcoidosis is less common, but can be found in the absence of pulmonary or lymphatic disease. Intra-abdominal sarcoidosis is most often asymptomatic. However, long-standing unrecognized disease can result in life-threatening complications. The identification, monitoring and prevention of these complications will be discussed, with emphasis on both clinical and histological presentations of intra-abdominal sarcoidosis.
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Wijkstrom M, Bechara RI, Sarmiento JM. A Rare Nonmalignant Mass of the Pancreas: Case Report and Review of Pancreatic Sarcoidosis. Am Surg 2010. [DOI: 10.1177/000313481007600116] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Sarcoidosis is a systemic granulomatous disease of unknown etiology affecting patients from all genetic backgrounds. Pancreatic involvement is rare; the first case was described on autopsy in 1937. We present a case of pancreatic sarcoidosis without a history of the disease presenting as biliary obstruction mimicking pancreatic malignancy. We also review the literature with respect to management and outcomes of similar cases. The patient described here presented with all the signs and symptoms of a pancreatic malignancy, which was confirmed on a CT scan; the positron emission tomography scan and the CA 19-9 level were also confirmatory of the suspected diagnosis. In this setting, if the mass looks resectable, a Whipple procedure would be the next logical step. However, such strategy would be aggressive management for a benign condition that could be palliated with diverting rather than resective procedures without changing the outlook of the disease. We suggest keeping a high index of suspicion in patients with a history of the disease if demographic concordance exists.
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Affiliation(s)
- Martin Wijkstrom
- Departments of Surgery and Emory University School of Medicine, Atlanta, Georgia
| | - Rabih I. Bechara
- Departments of Pulmonary Medicine and Critical Care, Emory University School of Medicine, Atlanta, Georgia
| | - Juan M. Sarmiento
- Departments of Surgery and Emory University School of Medicine, Atlanta, Georgia
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Morselli-Labate AM, Pezzilli R. Usefulness of serum IgG4 in the diagnosis and follow up of autoimmune pancreatitis: A systematic literature review and meta-analysis. J Gastroenterol Hepatol 2009; 24:15-36. [PMID: 19067780 DOI: 10.1111/j.1440-1746.2008.05676.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
High circulating serum immunoglobulin G4 (IgG4) levels have been proposed as a marker of autoimmune pancreatitis (AIP). The aim of the present study was to review the data existing in the English literature on the usefulness of the IgG4 serum levels in the diagnosis and follow up of patients with AIP. A total of 159 patients with AIP and 1099 controls were described in seven selected papers reporting the usefulness of serum IgG4 in diagnosing AIP. In total, 304 controls had pancreatic cancer, 96 had autoimmune diseases, and the remaining 699 had other conditions. The summary receiver-operating characteristic curve analysis was carried out by means of Meta-DiSc open-access software. Serum IgG4 showed good accuracy in distinguishing between AIP and the overall controls, pancreatic cancer and other autoimmune diseases (area under the curve [+/- SE]: 0.920 +/- 0.073, 0.914 +/- 0.191, and 0.949 +/- 0.024, respectively). The studies analyzed showed significantly heterogeneous specificity values in each of the three analyses performed. The analysis of the four studies comparing AIP and pancreatic cancers also showed significantly heterogeneous values of sensitivities and odds ratios. Regarding the usefulness of IgG4 as a marker of efficacy of steroid treatment, a decrease in the serum concentrations of IgG4 was found in the four available studies. The serum IgG4 subclass is a good marker of AIP, and its determination should be included in the diagnostic workup of this disease. However, the heterogeneity of the studies published until now means that more studies are necessary in order to better evaluate the true accuracy of IgG4 in discriminating AIP versus other autoimmune diseases.
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Ebert EC, Kierson M, Hagspiel KD. Gastrointestinal and hepatic manifestations of sarcoidosis. Am J Gastroenterol 2008; 103:3184-92; quiz 3193. [PMID: 18853979 DOI: 10.1111/j.1572-0241.2008.02202.x] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sarcoidosis is a multisystem disease characterized by noncaseating granulomas in the affected organs, including skin, heart, nervous system, and joints. Diagnosis of sarcoidosis is generally based upon a compatible history, demonstration of granulomas in at least two different organs, negative staining and culture for acid fast bacilli, absence of occupational or domestic exposure to toxins, and lack of drug-induced disease. Involvement of the hollow organs is rare. Rather than being due to sarcoidosis, some reported mucosal lesions may simply have incidental granulomas. Extrinsic compression from lymphadenopathy can occur throughout the gastrointestinal tract. The stomach, particularly the antrum, is the most common extrahepatic organ to be involved, while the small bowel is the least common. Liver involvement frequently occurs and ranges from asymptomatic incidental granulomas to portal hypertension from granulomas in the portal triad, usually with relatively preserved liver function. CT scans show hepatosplenomegaly and adenopathy, followed in frequency by focal low-attenuation lesions of the liver and spleen. Ascites is usually a transudate from right heart failure (because of pulmonary hypertension) or portal hypertension (because of biliary cirrhosis). Rarely, an exudative ascites may occur from studding of the peritoneum with nodules. Pancreatic involvement presents as a mass, usually in the head or a diffusely firm, nodular organ. Corticosteroids should be instituted when organ function is threatened, usually lungs, eyes, and central nervous system. Their role in the treatment of hepatic sarcoidosis is unclear. The overall prognosis is good although most patients will have some permanent organ impairment. Cardiac and pulmonary diseases are the main causes of death.
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Affiliation(s)
- Ellen C Ebert
- Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey 08903, USA
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Bouvry D, Uzunhan Y, Naccache JM, Nunes H, Brillet PY, Valeyre D. [Atypical sarcoidosis]. Rev Med Interne 2007; 29:46-53. [PMID: 18054125 DOI: 10.1016/j.revmed.2007.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 10/03/2007] [Indexed: 11/30/2022]
Abstract
PURPOSE Sarcoidosis is a granulomatous disease of unknown etiology. Lung and lymphatic system are the principal localisations. Clinical presentations are various depending on involved organs. Some presentations, which are easily diagnosed, are typical and frequent. Atypical forms have unusual presentations and/or are rare. Beside, in a multisystemic sarcoidosis, the affection of only one organ can be unusual. Rigorous diagnosis procedure could avoid errors. CURRENT KNOWLEDGE AND KEY POINTS Twenty percent of sarcoidosis have atypical presentation. However, each of them are infrequent. Atypical features are wide and can concern pulmonary or extrapulmonary manifestations, general manifestations, blood testing or pathological pattern. FUTURE PROSPECTS AND PROJECTS Describing atypical forms are necessary for their diagnosis. The diagnosis of atypical sarcoidosis is found on the knowledge of atypical forms previously described, presence of granulomas on specimen biopsy and excluding other granulomatous disease.
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Affiliation(s)
- D Bouvry
- AP-HP, service de pneumologie, hôpital Avicenne, 125 route de Stalingrad, Bobigny, France
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Harder H, Büchler MW, Fröhlich B, Ströbel P, Bergmann F, Neff W, Singer MV. Extrapulmonary sarcoidosis of liver and pancreas: A case report and review of literature. World J Gastroenterol 2007; 13:2504-9. [PMID: 17552036 PMCID: PMC4146771 DOI: 10.3748/wjg.v13.i17.2504] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Sarcoidosis is a chronic multisystemic granulomatous disease of unknown origin, which can involve nearly all organs. In the case of an infrequent gastrointestinal tract involvement in systemic sarcoidosis, granulomas of the liver are most commonly described while isolated pancreatic sarcoid lesions are rarely seen. We report a case of systemic sarcoidosis with exclusive extrapulmonal involvement of the liver and the pancreas in a 71-year-old white man. The diagnosis of liver involvement was confirmed by biopsy. Pancreatic surgery was needed because preoperative evaluation could not exclude pancreatic cancer and for biliary decompression. An extensive literature review of systemic sarcoidosis, focusing on reported cases with unusual presentation of sarcoidosis in the liver and the pancreas, its diagnosis, treatment, and prognosis was made.
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Affiliation(s)
- Hermann Harder
- Department of Medicine II (Gastroenterology, Hepatology and Infectious Diseases), University Hospital of Heidelberg at Mannheim, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany
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