1
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Sawada H, Czech T, Silangcruz K, Kozai L, Obeidat A, Wien EA, Nishimura MF, Nishikori A, Sato Y, Nishimura Y. Clinicopathological characteristics of gastric IgG4-related disease: Systematic scoping review. J Gastroenterol Hepatol 2022; 37:1865-1872. [PMID: 35949057 DOI: 10.1111/jgh.15980] [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: 05/23/2022] [Revised: 08/01/2022] [Accepted: 08/06/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Gastric IgG4-related disease (IgG4-RD) can mimic malignancy, submucosal tumors (SMT), and ulcers, leading to over-triage and unnecessary medical interventions such as gastrectomy. The variability in the clinicopathological presentation of IgG4-related disease is not yet well defined, posing a diagnostic challenge. METHODS Following the PRISMA Extension for Scoping Reviews, we searched MEDLINE and EMBASE for all peer-reviewed articles using keywords including "gastritis," "stomach," "gastrointestinal stromal tumor," and "IgG4-RD" from their inception to December 28, 2021. RESULTS Thirty-nine articles, including 2 observational studies and 42 cases, were included in the systematic review. While bottom-heavy lymphoplasmacytic mucosal infiltration is a characteristic finding of gastric IgG4-RD, it was only present in less than half of the patients in the observational studies. Patients with gastric IgG4-RD were more likely to be diagnosed with gastrointestinal stromal tumor (GIST), gastric cancer, or peptic ulcer disease and their clinical course involved resection (51.3%) or even gastrectomy. Diagnosis of gastric IgG4-RD was most frequently made by post-operative pathological analysis. CONCLUSION This systematic review summarizes the current understanding of the characteristics of gastric IgG4-RD. Increased awareness of gastric IgG4-RD as a differential diagnosis of gastric SMT or ulcers among clinicians is crucial in order to reduce unnecessary high-risk, invasive interventions.
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Affiliation(s)
- Haruki Sawada
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Torrey Czech
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Krixie Silangcruz
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Landon Kozai
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Adham Obeidat
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Eric Andrew Wien
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Midori Filiz Nishimura
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Asami Nishikori
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Yasuharu Sato
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA.,Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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2
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Uchino K, Notohara K, Uehara T, Kuraishi Y, Itakura J, Matsukawa A. Utility of gastric biopsy in diagnosing IgG4-related gastrointestinal disease. Pathol Int 2020; 71:124-134. [PMID: 33378576 DOI: 10.1111/pin.13059] [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: 10/09/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 01/13/2023]
Abstract
The utility of gastric biopsy for diagnosing immunoglobulin (Ig)G4-related gastrointestinal disease (IgG4-GID) remains unclear. Bottom-heavy plasmacytosis (BHP) is a distinct feature of IgG4-GID. To clarify the feasibility of using gastric biopsies to diagnose BHP in IgG4-GID, we analyzed the histological features and immunostaining of gastric biopsy specimens from 31 known IgG4-related disease (IgG4-RD) patients and we assessed the presence of BHP in 1696 consecutive routine gastric biopsies. Cases with both >10 IgG4-positive plasma cells per high-power field and an IgG4/IgG-positive ratio >40% were defined as IgG4-high. Ten of the 31 IgG4-RD patients were concluded to have IgG4-GID, in which IgG4-positive plasma cells were notably detected at the deeper part of the mucosa. Six cases displayed BHP whereas the remaining four cases showed transmural infiltration with concomitant Helicobacter pylori-associated gastritis. In addition to BHP, we identified two unique histologic features for IgG4-GID: plasmacytic aggregation in the muscularis mucosae and permeative plasmacytic infiltration between fundic glands in the non-atrophic mucosa. Six of the routine cases (0.35%) displayed BHP, including a case with IgG4-RD. IgG4-GID can be suspected by the presence of gastric biopsy specimens with characteristic histological features. Such cases are recommended to undergo further examinations to determine whether IgG4-RD is present.
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Affiliation(s)
- Kaori Uchino
- Department of Pathology and Experimental Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Takeshi Uehara
- Department of Laboratory Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Yasuhiro Kuraishi
- Department of Gastroenterology, Shinshu University School of Medicine, Nagano, Japan
| | - Junya Itakura
- Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Akihiro Matsukawa
- Department of Pathology and Experimental Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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Muto O, Tamakawa S, Takahashi K, Yokohama S, Takasoe A, Hirano F, Nishimura H, Saito H. IgG4-related Disease Manifesting as Gastroduodenal Ulcer Diagnosed by an Endoscopic Biopsy. Intern Med 2020; 59:2491-2497. [PMID: 32581158 PMCID: PMC7662039 DOI: 10.2169/internalmedicine.4483-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A 26-year-old man was admitted to our hospital due to upper abdominal pain. He had previously been diagnosed with gastroduodenal ulcer at 23 and 25 years old and had been treated with proton-pump inhibitors. Endoscopic hemostasis and a biopsy were performed on the hemorrhagic gastroduodenal ulcers. Laboratory and pathologic examinations demonstrated elevated serum IgG4 levels and the infiltration of IgG4-positive plasma cells into the gastroduodenal tissues. Based on the clinicopathologic findings and after excluding other causes, he was diagnosed with IgG4-related gastroduodenal ulcer. We herein report a rare case of IgG4-related disease manifesting as a gastroduodenal ulcer diagnosed by an endoscopic biopsy.
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Affiliation(s)
- Osamu Muto
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Susumu Tamakawa
- Department of Pathology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Kenji Takahashi
- Division of Metabolism and Biosystemic Science, Department of Medicine, Asahikawa Medical University, Japan
| | - Shiro Yokohama
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Ai Takasoe
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Fuminori Hirano
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Hideo Nishimura
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Hiroki Saito
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
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4
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Chetty R. A reappraisal of sclerosing nodular and/or polypoid lesions of the gastrointestinal tract rich in IgG4-positive plasma cells. Histopathology 2020; 76:832-837. [PMID: 31919879 DOI: 10.1111/his.14061] [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: 11/04/2019] [Revised: 12/14/2019] [Accepted: 01/08/2020] [Indexed: 11/30/2022]
Abstract
AIMS To describe additional cases of nodular and polypoid sclerosing lesions of the gastrointestinal tract (GIT) that are associated with numerous IgG4-positive plasma cells, review the pertinent literature to ascertain the relationship with systemic IgG4-related disease, and provide a reporting framework for such lesions. METHODS AND RESULTS Five new cases of sclerosing polyps or nodules were collected over a 10-year period, occurring in four females and one male ranging in age from 32 years to 56 years (mean, 41.6 years). Patients were asymptomatic or had epigastric pain, and one had rectal bleeding. None had autoimmune or other obvious IgG4-related disease, and serum IgG4 levels were normal. All were solitary nodules in the stomach (two cases), ileum, caecum, and rectum. Four lesions were submucosal and one was subserosal; all were well circumscribed, composed of hyalinised, keloidal fibrous tissue with lymphoplasmacytic inflammation. Obliterative phlebitis was not seen. Lineage-specific immunomarkers were negative. In excess of 10 IgG4-positive plasma cells per high-power field were seen, and the IgG4/IgG ratios were >0.4. CONCLUSIONS Very few IgG4-related lesions in the tubular GIT are associated with disease at other sites and/or elevated serum IgG4 levels. The majority may represent a lesion in the spectrum of IgG4-related disease. The use of the term 'IgG4-positive nodule or polyp with probable histological features of IgG4-related disease' is advocated for nodular and/or polypoid lesions in the GIT with ≥10 IgG4-positive plasma cells in a high-power field and an IgG/IgG4 ratio of >0.4.
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Affiliation(s)
- Runjan Chetty
- Division of Anatomical Pathology, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
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5
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Lim DY, Cheng LTE, Tan DMY, Al Jajeh I. Isolated IgG4-related gastric disease presenting as diffuse gastric wall thickening with ulcer. J Radiol Case Rep 2019; 12:9-20. [PMID: 30651919 DOI: 10.3941/jrcr.v12i9.3493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
An 81-year-old male presented with loss of appetite, early satiety and iron deficiency anaemia. A computed tomography (CT) scan of the abdomen and pelvis during initial work-up revealed diffuse gastric mural thickening associated with a large ulcer and adjacent gastro-hepatic lymphadenopathy. The CT appearances, together with the clinical features, were highly suspicious for an infiltrative type of gastric malignancy. Endoscopic biopsy however showed erosive inflammation, IgG4 plasmacytosis and fibrosis, raising the possibility of IgG4-related disease. A serologic assay for IgG showed normal IgG4 and elevated IgG2 serum levels. After appropriate steroid treatment, endoscopy and CT scan showed resolution of the ulcer and gastric wall thickening. This case shows yet another possible appearance of gastric involvement in IgG4-related disease on the current evolving spectrum of this disease presentation. Greater awareness and education of this disease would help in patient care, ensuring earlier diagnosis, prevention of severe organ damage and morbidity, as well as unnecessary surgery.
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Affiliation(s)
- David Yurui Lim
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | | | - Damien Meng Yew Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Issam Al Jajeh
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
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6
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Gastrointestinal manifestation of immunoglobulin G4-related disease: clarification through a multicenter survey. J Gastroenterol 2018; 53:845-853. [PMID: 29222587 DOI: 10.1007/s00535-017-1420-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 11/28/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Several reports on immunoglobulin (Ig)G4-related disease (IgG4-RD) with gastrointestinal involvement (IgG4-related gastrointestinal disease; IgG4-GID) have been published, although this entity has not been fully established clinicopathologically. Thus, we carried out a multicenter survey. METHODS Patients with possible IgG4-GID who underwent resection were collected. Histologic slides were reevaluated, and eight cases with diffuse lymphoplasmacytic infiltration but without numerous neutrophils, granulations or epithelioid granulomas were further analyzed. RESULTS Overall, the IgG4 counts (87-345/high-power field) and IgG4/IgG-positive ratio were high (44-115%). The demographic findings included advanced age among the patients (55-80 years) and male preponderance (six cases). Six lesions (five gastric, one esophageal), consisting of lymphoplasmacytic infiltration with neural involvement in the muscularis propria and/or bottom-heavy plasmacytosis in the gastric mucosa, were histologically regarded as highly suggestive of IgG4-RD. Storiform fibrosis and obliterative phlebitis were found in two cases, and the former gave rise to a 7-cm-sized inflammatory pseudotumor (IPT) in one case. Ulceration and carcinoma co-existed in three and two lesions, respectively. All the patients had other organ involvement (OOI), and serum IgG4 levels were markedly elevated (four of five patients). The remaining two cases with gastric IPTs featuring reactive nodular fibrous pseudotumor or nodular lymphoid hyperplasia were regarded as possible cases of IgG4-RD because of the histologic findings and lack of OOI. CONCLUSIONS IgG4-GID is found in the setting of IgG4-RD, often with ulceration or cancer. Characteristic histologic findings are observed in the muscularis propria and gastric mucosa. Cases with IPT may be heterogeneous, and there may be mimickers of IgG4-GID.
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7
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Ciccone F, Ciccone A, Di Ruscio M, Vernia F, Cipolloni G, Coletti G, Calvisi G, Frieri G, Latella G. IgG4-Related Disease Mimicking Crohn's Disease: A Case Report and Review of Literature. Dig Dis Sci 2018; 63:1072-1086. [PMID: 29417330 DOI: 10.1007/s10620-018-4950-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 01/26/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Fabiana Ciccone
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Antonio Ciccone
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Mirko Di Ruscio
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Filippo Vernia
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Gianluca Cipolloni
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100, L'Aquila, Italy
| | - Gino Coletti
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100, L'Aquila, Italy
| | - Giuseppe Calvisi
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100, L'Aquila, Italy
| | - Giuseppe Frieri
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Giovanni Latella
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy.
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8
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Seo HS, Jung YJ, Park CH, Song KY, Jung ES. IgG4-related Disease in the Stomach which Was Confused with Gastrointestinal Stromal Tumor (GIST): Two Case Reports and Review of the Literature. J Gastric Cancer 2018; 18:99-107. [PMID: 29629225 PMCID: PMC5881015 DOI: 10.5230/jgc.2018.18.e8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 03/12/2018] [Accepted: 03/21/2018] [Indexed: 12/13/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibro-inflammatory disorder characterized by specific pathological findings and elevated serum IgG4 level. IgG4-RD in the stomach is rare, and occasionally diagnosed as gastric subepithelial tumor (SET) by endoscopy or computed tomography scan. Two female patients in the age group of 40–50 years were diagnosed with 4 cm sized gastric SET. One underwent laparoscopic gastric wedge resection. Another one had a history of subtotal gastrectomy for early gastric cancer and idiopathic thrombocytopenic purpura with oral steroids administration. She underwent a completion total gastrectomy with splenectomy for the gastric SET and ITP. The pathology showed storiform fibrosis, and IgG4 was positive in immunohistochemistry (IHC) stain. IgG4-RD is known as a medical disease that could be treated with oral steroids. The difficulty in preoperative diagnosis of the disease occasionally causes unnecessary gastric resection. Thus, preoperative diagnostic methods for IgG4-RD such as deep biopsy with IHC stain or magnetic resonance imaging are needed.
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Affiliation(s)
- Ho Seok Seo
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Yoon Ju Jung
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Cho Hyun Park
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Kyo Young Song
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Eun Sun Jung
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
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9
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Mori S, Tahashi Y, Uchida K, Ikeura T, Danbara N, Wakamatsu T, Kusuda T, Takahashi Y, Yanagawa M, Matsushita M, Ohe C, Michiura T, Inoue K, Kon M, Okazaki K. Sclerosing Esophagitis with IgG4-positive Plasma Cell Infiltration. Intern Med 2017; 56:3023-3026. [PMID: 29021429 PMCID: PMC5725855 DOI: 10.2169/internalmedicine.8095-16] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The patient was a 76-year-old woman who had noticed slight difficulty in swallowing in the 3 years prior to this presentation. Her dysphagia progressed while she was hospitalized following cervical cancer surgery. Esophagogastroduodenoscopy and an esophagram showed circumferential erosion and a stricture of the thoracic esophagus. Esophageal resection was performed; the resected specimens showed a stricture and wall thickening. Histologically, transmural hyperplasia, which consisted of inflammatory granulation tissue with the abundant infiltration of IgG4-positive plasma cells and lymphocytes, was observed. The patient was diagnosed with probable IgG4-related disease. IgG4-related esophageal disease presenting as esophageal lesions alone is a very rare condition.
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Affiliation(s)
- Shigeo Mori
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | - Yoshiya Tahashi
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | - Kazushige Uchida
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | - Tsukasa Ikeura
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | - Naoyuki Danbara
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | | | - Takeo Kusuda
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | - Yu Takahashi
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | - Masato Yanagawa
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | | | - Chisato Ohe
- Department of Pathology and Laboratory Medicine, Kansai Medical University, Japan
| | - Taku Michiura
- Department of Surgery, Kansai Medical University, Japan
| | - Kentaro Inoue
- Department of Surgery, Kansai Medical University, Japan
| | - Masanori Kon
- Department of Surgery, Kansai Medical University, Japan
| | - Kazuichi Okazaki
- Third Department of Internal Medicine, Kansai Medical University, Japan
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10
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Park S, Ahn S, Hong M, Ko YH. Increased plasmacytic differentiation in gastric mucosa–associated lymphoid tissue lymphomas: Helicobacter pylori eradication response and IgG4+ plasma cell association. Hum Pathol 2017; 59:113-119. [DOI: 10.1016/j.humpath.2016.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/22/2016] [Accepted: 09/16/2016] [Indexed: 01/29/2023]
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11
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Inoue D, Yoneda N, Yoshida K, Nuka H, Kinoshita J, Fushida S, Toshima F, Minami T, Takahira M, Hamaoka S, Ikeda H, Gabata T, Kawano M. Imaging and pathological features of gastric lesion of immunoglobulin G4-related disease: A case report and review of the recent literature. Mod Rheumatol 2016; 29:377-382. [DOI: 10.1080/14397595.2016.1209819] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Dai Inoue
- Department of Radiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan,
| | - Norihide Yoneda
- Department of Radiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan,
| | - Kotaro Yoshida
- Department of Radiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan,
| | - Hiromi Nuka
- Division of Rheumatology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan,
| | - Jun Kinoshita
- Department of Gastroenterological Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan,
| | - Sachio Fushida
- Department of Gastroenterological Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan,
| | - Fumihito Toshima
- Department of Radiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan,
| | - Tetsuya Minami
- Department of Radiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan,
| | - Masayuki Takahira
- Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan, and
| | - Shoko Hamaoka
- Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan, and
| | - Hiroko Ikeda
- Division of Pathology, Kanazawa University Hospital, Kanazawa, Japan
| | - Toshifumi Gabata
- Department of Radiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan,
| | - Mitsuhiro Kawano
- Division of Rheumatology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan,
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12
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Bulanov D, Arabadzhieva E, Bonev S, Yonkov A, Kyoseva D, Dikov T, Dimitrova V. A rare case of IgG4-related disease: a gastric mass, associated with regional lymphadenopathy. BMC Surg 2016; 16:37. [PMID: 27255154 PMCID: PMC4890503 DOI: 10.1186/s12893-016-0151-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 05/19/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND IgG4-related disease (IgG4-RD) is a newly recognized disorder, characterized by massive IgG4+ lymphocyte and plasma cell infiltration, storiform fibrosis, causing enlargement, nodules or thickening of the various organs, simultaneously or metachronously. Involvement of the gastrointestinal tract is very rare and can be presented as a diffuse wall thickening or polyp or mass-like lesion. Up to now, there have been reported only a few cases of isolated gastric IgG4-RD. CASE PRESENTATION We present an unusual case of IgG4-RD of the stomach with involvement of the regional lymph nodes, clinically manifested as a gastric cancer with related pyloric stenosis. The patient underwent distal gastrectomy, omentectomy and lymph node dissection. The postoperative serum IgG4 level was increased. The diagnosis was confirmed by immunohistochemical study. CONCLUSIONS In the most of the reported cases there was not sufficient data about the regional lymph nodal status, although the majority of the patients had been operated with presumptive diagnosis of gastric neoplasm. Our case is rare and valuable because it presents a gastric IgG4-related lesion larger than all previously reported in literature, and IgG4-related lymphadenopathy, confirmed histologically, which contributes to better knowledge of the disease.
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Affiliation(s)
- Dimitar Bulanov
- Department of General and Hepato-pancreatic Surgery, Medical University of Sofia, University Hospital "Alexandrovska", 1 Georgi Sofiiski Str, 1431, Sofia, Bulgaria
| | - Elena Arabadzhieva
- Department of General and Hepato-pancreatic Surgery, Medical University of Sofia, University Hospital "Alexandrovska", 1 Georgi Sofiiski Str, 1431, Sofia, Bulgaria.
| | - Sasho Bonev
- Department of General and Hepato-pancreatic Surgery, Medical University of Sofia, University Hospital "Alexandrovska", 1 Georgi Sofiiski Str, 1431, Sofia, Bulgaria
| | - Atanas Yonkov
- Department of General and Hepato-pancreatic Surgery, Medical University of Sofia, University Hospital "Alexandrovska", 1 Georgi Sofiiski Str, 1431, Sofia, Bulgaria
| | - Diana Kyoseva
- Department of General and Clinical Pathology, Medical University of Sofia, 2 Zdrave Str, 1431, Sofia, Bulgaria
| | - Tihomir Dikov
- Department of General and Clinical Pathology, Medical University of Sofia, 2 Zdrave Str, 1431, Sofia, Bulgaria
| | - Violeta Dimitrova
- Department of General and Hepato-pancreatic Surgery, Medical University of Sofia, University Hospital "Alexandrovska", 1 Georgi Sofiiski Str, 1431, Sofia, Bulgaria
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13
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Tsuchiya T, Yagi T, Tsukamoto M, Fukushima Y, Shimada R, Nakamura K, Fujii S, Nozawa K, Matsuda K, Kikuchi Y, Saito K, Hashiguchi Y. A case of IgG4-related disease coexisted with rectal cancer. Surg Case Rep 2015; 1:118. [PMID: 26943442 PMCID: PMC4658344 DOI: 10.1186/s40792-015-0120-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 11/19/2015] [Indexed: 01/12/2023] Open
Abstract
A 67-year-old man was referred to our hospital with suspicion of rectal tumor, hilar tumor, and urinary tumor. Colonoscopic findings were intermittent nodular lesions with redness which were atypical to primary rectal cancer. Endoscopic retrograde cholangiopancreatography showed narrowing of the bilateral intrahepatic bile duct. However, the findings were improved 1 month later. Blood biochemistry showed high level of serum IgG4 up to 1140 mg/dl. The patient matched to comprehensive diagnostic criteria for IgG4-related disease as a possible diagnostic case. Laparoscopic low anterior resection with creation of ileostomy was performed for rectal cancer. Histological findings revealed cancer cells spread horizontally at submucosal layer and subserosal layer. There was marked infiltration of the plasma cells and lymphocytes at tumor stroma, and more than half of the plasma cells were positive for IgG4. After surgery, the level of serum IgG4 was decreased to 597 mg/dl. Although the association with IgG4-related disease and colorectal disease is unclear, the tumor progression was atypical for rectal cancer. Some report that the disease may rise up the risk of a malignant disease. It is necessary to perform systemic examination keeping in mind for concurrence of malignancy.
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Affiliation(s)
- Takeshi Tsuchiya
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Takahiro Yagi
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Mitsuo Tsukamoto
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Yoshihisa Fukushima
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Ryu Shimada
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Keisuke Nakamura
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Shoichi Fujii
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Keijiro Nozawa
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Keiji Matsuda
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Yoshinao Kikuchi
- The Department of Pathology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Koji Saito
- The Department of Pathology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Yojiro Hashiguchi
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
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Kawano H, Ishii A, Kimura T, Takahashi T, Hironaka H, Kawano M, Yamaguchi M, Oishi K, Kubo M, Matsui S, Notohara K, Ikeda E. IgG4-related disease manifesting the gastric wall thickening. Pathol Int 2015; 66:23-8. [DOI: 10.1111/pin.12364] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 10/20/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Hiroo Kawano
- Department of Laboratory Science, Faculty of Health Science; Yamaguchi University Graduate School of Medicine; Ube Japan
| | - Aya Ishii
- Department of Pathology; Yamaguchi University Graduate School of Medicine; Ube Japan
| | - Tokuhiro Kimura
- Department of Pathology; Yamaguchi University Graduate School of Medicine; Ube Japan
| | | | - Hideharu Hironaka
- Department of Surgery; Saiseikai Yamaguchi Hospital; Yamaguchi Japan
| | - Michitaka Kawano
- Department of Internal Medicine; Saiseikai Yamaguchi Hospital; Yamaguchi Japan
| | - Michiya Yamaguchi
- Department of Dermatology; Yamaguchi University Graduate School of Medicine; Ube Japan
| | - Keiji Oishi
- Department of Internal medicine; Ube Medical Center; Ube Japan
| | - Makoto Kubo
- Department of Medicine and Clinical Science; Yamaguchi University Graduate School of Medicine; Ube Japan
| | - Shoko Matsui
- Health Administration Center; Toyama University; Toyama Japan
| | - Kenji Notohara
- Department of Anatomic Pathology; Kurashiki Central Hospital; Kurashiki Japan
| | - Eiji Ikeda
- Department of Pathology; Yamaguchi University Graduate School of Medicine; Ube Japan
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15
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Woo CG, Yook JH, Kim AY, Kim J. IgG4-Related Disease Presented as a Mural Mass in the Stomach. J Pathol Transl Med 2015; 50:67-70. [PMID: 26420251 PMCID: PMC4734962 DOI: 10.4132/jptm.2015.07.28] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/28/2015] [Indexed: 02/07/2023] Open
Abstract
Isolated gastric IgG4-related disease (IgG4-RD) is a very rare tumefactive inflammatory condition, with only a few cases reported to date. A 48-year-old woman was incidentally found to have a subepithelial tumor in the stomach. Given a presumptive diagnosis of gastrointestinal stromal tumor or neuroendocrine tumor, she underwent wedge resection. The lesion was vaguely nodular and mainly involved the submucosa and proper muscle layer. Microscopically, all classical features of type I autoimmune pancreatitis including lymphoplasmacytic infiltration, storiform fibrosis, obliterative phlebitis, and numerous IgG4-positive plasma cells were seen. She had no evidence of IgG4-RD in other organs. Although very rare, IgG4-RD should be considered one of the differential diagnoses in the setting of gastric wall thickening or subepithelial mass-like lesion. Deep biopsy with awareness of this entity might avoid unnecessary surgical intervention.
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Affiliation(s)
- Chang Gok Woo
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hwan Yook
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ah Young Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea ; Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jihun Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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16
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Inoue K, Okubo T, Kato T, Shimamura K, Sugita T, Kubota M, Kanaya K, Yamachika D, Sato M, Inoue D, Harada K, Kawano M. IgG4-related stomach muscle lesion with a renal pseudotumor and multiple renal rim-like lesions: A rare manifestation of IgG4-related disease. Mod Rheumatol 2015; 28:188-192. [DOI: 10.3109/14397595.2015.1081743] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Koichi Inoue
- Division of Surgery, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Takehiko Okubo
- Division of Internal Medicine, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Takashi Kato
- Division of Rheumatology, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Kazuo Shimamura
- Division of Pathology, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Teruji Sugita
- Division of Surgery, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Mitsuhiro Kubota
- Division of Surgery, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Kohji Kanaya
- Division of Surgery, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Daisuke Yamachika
- Division of Surgery, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Makoto Sato
- Division of Surgery, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Dai Inoue
- Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa, Japan,
| | - Kenichi Harada
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa, Japan, and
| | - Mitsuhiro Kawano
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa, Japan
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17
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Frydman J, Grunner S, Kluger Y. IgG4-related disease manifesting as an acute gastric-pericardial fistula. World J Gastroenterol 2014; 20:16782-16785. [PMID: 25469052 PMCID: PMC4248227 DOI: 10.3748/wjg.v20.i44.16782] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 05/10/2014] [Accepted: 07/25/2014] [Indexed: 02/06/2023] Open
Abstract
IgG4-related disease is a recently recognized entity linked initially to autoimmune pancreatitis and has been subsequently described in nearly every organ system. Men over the age of 50 represent the most affected demographic group and a comprehensive set of diagnostic criteria has been developed to aid treating clinicians. Though elevated levels of IgG4 in the serum are suggestive of the disease, definitive diagnosis is made on histopathology. Treatment is tailored to the clinical presentation with corticosteroid therapy known to have proven efficacy. Gastric manifestations of the IgG4-related disease primarily come in two varieties, notably chronic ulceration or pseudotumor formation. Autoimmune pancreatitis conveys increased risk for IgG4-related disease of the stomach, which is independent of Helicobacter pylori status. In this case report, we present an acute gastric-pericardial fistula secondary to IgG4-related disease that required urgent operative management. To our knowledge, this is the first report in the medical literature describing this complication of IgG4-related disease.
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Koizumi S, Kamisawa T, Kuruma S, Tabata T, Chiba K, Iwasaki S, Endo Y, Kuwata G, Koizumi K, Shimosegawa T, Okazaki K, Chiba T. Immunoglobulin G4-related gastrointestinal diseases, are they immunoglobulin G4-related diseases? World J Gastroenterol 2013; 19:5769-5774. [PMID: 24124321 PMCID: PMC3793131 DOI: 10.3748/wjg.v19.i35.5769] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/30/2013] [Accepted: 07/19/2013] [Indexed: 02/06/2023] Open
Abstract
In immunoglobulin G4 (IgG4)-related disease (RD), organ enlargement or nodular lesions consisting of abundant infiltration of lymphocytes and IgG4-positive plasma cells and fibrosis are seen in various organs. Although infiltration of many IgG4-positive plasma cells is detected in the gastric and colonic mucosa and major duodenal papilla of patients with autoimmune pancreatitis, it cannot be diagnosed as a gastrointestinal lesion involved in IgG4-RD, because none of the following is observed in these lesions: a mass-like formation; dense fibrosis; or obliterative phlebitis. Based on our review of the literature, there appear to be two types of IgG4-related gastrointestinal disease. One is a gastrointestinal lesion showing marked thickening of the wall of the esophagus and stomach, consisting of dense fibrosis with abundant infiltration of IgG4-positive plasma cells, which usually show submucosal spreading. The other is an IgG4-related pseudotumor occurring in gastrointestinal regions such as the stomach, colon, and major duodenal papilla, showing polypoid or mass-like lesions. Most solitary IgG4-related gastrointestinal lesions that are not associated with other IgG4-RD appear to be difficult to diagnose. It is of utmost importance to rule out malignancy. However, these lesions may respond to steroid therapy. To avoid unnecessary resection, IgG4-related gastrointestinal diseases should be considered in the differential diagnosis.
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19
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Kim DH, Kim J, Park DH, Lee JH, Choi KD, Lee GH, Jung HY, Kim JH. Immunoglobulin G4-related inflammatory pseudotumor of the stomach. Gastrointest Endosc 2012; 76:451-2. [PMID: 21981816 DOI: 10.1016/j.gie.2011.07.061] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 07/27/2011] [Indexed: 02/08/2023]
Affiliation(s)
- Do Hoon Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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20
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Distinguishing autoimmune pancreatitis from pancreaticobiliary cancers: current strategy. Ann Surg 2012; 255:248-58. [PMID: 21997803 DOI: 10.1097/sla.0b013e3182324549] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE A review of the literature to identify current modalities for the diagnosis of autoimmune pancreatitis (AIP) with the objective of establishing a strategy to distinguish it from pancreaticobiliary cancers. BACKGROUND Pancreatic and biliary manifestations of AIP mimic pancreaticobiliary cancers. Misdiagnosis of AIP can result in major surgery for a steroid-responsive disease. METHODS A review of the literature was performed to identify recent advances in the diagnosis of AIP and evaluate outcomes with various diagnostic strategies to minimize operative intervention for an autoimmune disease. RESULTS Diagnostic criteria for AIP are based on histology, imaging, serology, extrapancreatic organ involvement, and response to steroid therapy. The most commonly involved extrapancreatic sites are bile duct, kidney, and retroperitoneum. The Mayo Clinic diagnostic strategy utilizes core biopsy of the pancreas and the Japanese strategy depends on a characteristic pancreatogram. The rate of operative intervention was similar with both strategies and none of the patients with cancer received steroid therapy. Immunoglobulin G subtype 4 (IgG4)-associated cholangitis mimics cholangiocarcinoma and presence of more than 10 IgG4-positive plasma cells/high power field on endoscopic biopsy of the bile duct was diagnostic for AIP in 88% patients. Biliary complications and early relapse are common after surgical resection and immunomodulatory drugs can maintain long-term remission. CONCLUSION Criteria based on histology, imaging, endoscopy, serology, extrapancreatic organ involvement, and response to steroid therapy improve the diagnostic yield for AIP. Application of diagnostic and therapeutic protocols by a multidisciplinary team will optimize outcomes with a decline in the rate of operative intervention for AIP, a steroid-responsive disease with propensity for relapse.
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21
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IgG4-related sclerosing esophagitis: a case report. Gastrointest Endosc 2011; 73:834-7. [PMID: 21067736 DOI: 10.1016/j.gie.2010.08.043] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 08/11/2010] [Indexed: 02/08/2023]
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22
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Current world literature. Curr Opin Rheumatol 2010; 23:125-30. [PMID: 21124095 DOI: 10.1097/bor.0b013e3283422cce] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Prasad Shanbhogue AK, Prasad SR, Jagirdar J, Takahashi N, Sandrasegaran K, Fazzio RT, Fidler JL. Comprehensive Update on Select Immune-Mediated Gastroenterocolitis Syndromes: Implications for Diagnosis and Management. Radiographics 2010; 30:1465-87. [DOI: 10.1148/rg.306105520] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Kamisawa T, Takuma K, Egawa N, Tsuruta K, Sasaki T. Autoimmune pancreatitis and IgG4-related sclerosing disease. Nat Rev Gastroenterol Hepatol 2010; 7:401-9. [PMID: 20548323 DOI: 10.1038/nrgastro.2010.81] [Citation(s) in RCA: 145] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Autoimmune pancreatitis (AIP) is a unique form of pancreatitis in which the pathogenesis is suspected to involve autoimmune mechanisms. AIP sometimes mimics pancreatic cancer in its presentation, but as AIP responds dramatically to steroid therapy, accurate diagnosis is necessary. AIP is currently diagnosed on the basis of a combination of characteristic clinical, serological, morphological and histopathological features. However, its diagnosis remains a clinical challenge and there are no internationally agreed diagnostic criteria. Another type of AIP called 'idiopathic duct-centric chronic pancreatitis' or 'AIP with granulocytic epithelial lesion' has been reported in Western countries. IgG4-related sclerosing disease is a systemic disease in which IgG4-positive plasma cells and T lymphocytes extensively infiltrate various organs. Organs with tissue fibrosis and obliterative phlebitis, such as the pancreas, salivary gland and retroperitoneum, show clinical manifestations; AIP seems to represent one manifestation of IgG4-related sclerosing disease. As a mass is formed in most cases of IgG4-related sclerosing disease, a malignant tumor is frequently suspected on initial presentation. Clinicians should consider IgG4-related sclerosing disease in the differential diagnosis to avoid unnecessary surgery.
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Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan.
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