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Kawasaki T, Ichikawa J, Onohara K, Kanno S, Wako M, Taniguchi N, Ochiai S, Torigoe T, Yazawa Y. IgG4-related disease with subcutaneous involvement and the associated diagnostic challenges with MRI. Skeletal Radiol 2024:10.1007/s00256-024-04768-3. [PMID: 39085476 DOI: 10.1007/s00256-024-04768-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/18/2024] [Accepted: 07/22/2024] [Indexed: 08/02/2024]
Abstract
IgG4-related disease is a rare fibroinflammatory disorder characterized by the infiltration of IgG4-rich plasma cells. Herein, we report a case of IgG4-related disease of the subcutaneous tissue with atypical MRI findings and difficulties in the histopathological examination using needle biopsy. Based on the clinical presentation and MRI findings, the patient was diagnosed with a benign myxoid or cystic tumor. Additionally, histopathological findings from a needle biopsy suggested a myxoma. Therefore, the correct diagnosis of IgG4-related disease was not made preoperatively. The resected specimens confirmed IgG4-related disease with an IgG4/IgG ratio > 80%. Previous reports have shown that the MRI findings of IgG4-related disease mimic both malignancy and inflammation; surprisingly, the features of subcutaneous IgG-related disease, including tail sign, unclear border, and heterogeneous enhancement, were similar to those found in sarcoma. Therefore, histopathological findings are needed for a correct diagnosis. Furthermore, careful examination is essential because the neoplasm and inflammation may overlap with IgG4-related disease, and needle biopsy is not fully reflective of the tumor. As is highlighted in the present case, IgG4-related disease is often misdiagnosed; therefore, clinicians should adequately recognize that even if the histopathological findings in biopsy were consistent with those observed in the MRI, misdiagnosis may occur.
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Affiliation(s)
- Tomonori Kawasaki
- Department of Pathology, Saitama Medical University International Medical Centre, Saitama, Japan
| | - Jiro Ichikawa
- Department of Orthopaedic Surgery, Interdisciplinary Graduate School of Medicine, University of Yamanashi, Yamanashi, Japan.
| | - Kojiro Onohara
- Interdisciplinary Graduate School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Satoshi Kanno
- Department of Pathology, Saitama Medical University International Medical Centre, Saitama, Japan
| | - Masanori Wako
- Department of Orthopaedic Surgery, Interdisciplinary Graduate School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Naofumi Taniguchi
- Department of Orthopaedic Surgery, Interdisciplinary Graduate School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Satoshi Ochiai
- Department of Orthopaedic Surgery, National Hospital Organization (NHO) Kofu National Hospital, Kofu, Yamanashi, Japan
| | - Tomoaki Torigoe
- Orthopaedic Oncology & Surgery, Saitama Medical University International Medical Centre, Saitama, Japan
| | - Yasuo Yazawa
- Orthopaedic Oncology & Surgery, Saitama Medical University International Medical Centre, Saitama, Japan
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Wallace ZS, Katz G, Hernandez-Barco YG, Baker MC. Current and future advances in practice: IgG4-related disease. Rheumatol Adv Pract 2024; 8:rkae020. [PMID: 38601138 PMCID: PMC11003820 DOI: 10.1093/rap/rkae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/28/2023] [Indexed: 04/12/2024] Open
Abstract
IgG4-related disease (IgG4-RD) is an increasingly recognized cause of fibroinflammatory lesions in patients of diverse racial and ethnic backgrounds and is associated with an increased risk of death. The aetiology of IgG4-RD is incompletely understood, but evidence to date suggests that B and T cells are important players in pathogenesis, both of which are key targets of ongoing drug development programmes. The diagnosis of IgG4-RD requires clinicopathological correlation because there is no highly specific or sensitive test. Glucocorticoids are highly effective, but their use is limited by toxicity, highlighting the need for studies investigating the efficacy of glucocorticoid-sparing agents. B cell-targeted therapies, particularly rituximab, have demonstrated benefit, but no randomized clinical trials have evaluated their efficacy. If untreated or under-treated, IgG4-RD can cause irreversible organ damage, hence close monitoring and consideration for long-term immunosuppression is warranted in certain cases.
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Affiliation(s)
- Zachary S Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Guy Katz
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Yasmin G Hernandez-Barco
- Harvard Medical School, Harvard University, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew C Baker
- Division of Immunology and Rheumatology, Stanford University, Palo Alto, CA, USA
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Shanbhogue KP, Ramani N, Surabhi VR, Balasubramanya R, Prasad SR. Tumefactive Nonneoplastic Proliferative Pseudotumors of the Kidneys and Urinary Tract: CT and MRI Findings with Histopathologic Correlation. Radiographics 2023; 43:e230071. [PMID: 37971934 DOI: 10.1148/rg.230071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
A diverse spectrum of pathologically distinct, nonneoplastic, proliferative conditions of the kidneys and urinary tract demonstrate a expansile growth pattern similar to that of neoplasms. The renal pseudotumors include myriad causes of infections as well as rare noninfectious causes such as sarcoidosis, amyloidosis, and immunoglobulin G4-related disease (IgG4-RD). Rare entities such as cystitis cystica, endometriosis, nephrogenic adenoma, and pseudosarcomatous myofibroblastic proliferation and distinct types of prostatitis comprise tumefactive nontumorous disorders that affect specific segments of the urinary tract. The pseudotumors of the kidneys and urinary tract demonstrate characteristic histopathologic and epidemiologic features, as well as protean clinical manifestations, natural history, and imaging findings. Many patients present with genitourinary tract-specific symptoms or systemic disease. Some cases may be incidentally discovered at imaging. Some entities such as perinephric myxoid pseudotumors, IgG4-RD, fibroepithelial polyp, and nephrogenic adenoma display specific anatomic localization and disease distribution. Imaging features of multisystem disorders such as tuberculosis, sarcoidosis, and IgG4-RD provide supportive evidence that may allow precise diagnosis. Fungal pyelonephritis, xanthogranulomatous pyelonephritis, IgG4-RD, actinomycosis, and endometriosis show markedly low signal intensity on T2-weighted MR images. Although some pseudotumors exhibit characteristic imaging findings that permit correct diagnosis, laboratory correlation and histopathologic confirmation are required for definitive characterization in most cases. A high index of suspicion is a prerequisite for diagnosis. Accurate diagnosis is critical for instituting optimal management while preventing use of inappropriate therapies or interventions. Surveillance CT and MRI are frequently used for monitoring the response of pseudotumors to therapy. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Krishna Prasad Shanbhogue
- From the Departments of Radiology (K.P.S., V.R.S., R.B., S.R.P.) and Pathology (N.R.), Michael E. DeBakey VA Medical Center, Houston, Tex; Department of Radiology, NYU Langone Health, New York, NY (K.P.S.); Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pa (R.B.); and Department of Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1473, Houston, TX 77030 (V.R.S., S.R.P.)
| | - Nisha Ramani
- From the Departments of Radiology (K.P.S., V.R.S., R.B., S.R.P.) and Pathology (N.R.), Michael E. DeBakey VA Medical Center, Houston, Tex; Department of Radiology, NYU Langone Health, New York, NY (K.P.S.); Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pa (R.B.); and Department of Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1473, Houston, TX 77030 (V.R.S., S.R.P.)
| | - Venkateswar R Surabhi
- From the Departments of Radiology (K.P.S., V.R.S., R.B., S.R.P.) and Pathology (N.R.), Michael E. DeBakey VA Medical Center, Houston, Tex; Department of Radiology, NYU Langone Health, New York, NY (K.P.S.); Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pa (R.B.); and Department of Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1473, Houston, TX 77030 (V.R.S., S.R.P.)
| | - Rashmi Balasubramanya
- From the Departments of Radiology (K.P.S., V.R.S., R.B., S.R.P.) and Pathology (N.R.), Michael E. DeBakey VA Medical Center, Houston, Tex; Department of Radiology, NYU Langone Health, New York, NY (K.P.S.); Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pa (R.B.); and Department of Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1473, Houston, TX 77030 (V.R.S., S.R.P.)
| | - Srinivasa R Prasad
- From the Departments of Radiology (K.P.S., V.R.S., R.B., S.R.P.) and Pathology (N.R.), Michael E. DeBakey VA Medical Center, Houston, Tex; Department of Radiology, NYU Langone Health, New York, NY (K.P.S.); Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pa (R.B.); and Department of Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1473, Houston, TX 77030 (V.R.S., S.R.P.)
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Kim JO, Lee YS, Park S. Soft tissue pseudotumors of the hand and wrist mimicking malignancy: Two case reports. Medicine (Baltimore) 2023; 102:e34236. [PMID: 37390243 PMCID: PMC10313308 DOI: 10.1097/md.0000000000034236] [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: 04/21/2023] [Accepted: 06/16/2023] [Indexed: 07/02/2023] Open
Abstract
RATIONALE Most soft-tissue lesions in the hand and wrist have a benign etiology, and malignant tumors, such as soft-tissue sarcomas, are rare. Mimickers of soft tissue tumors in the hand and wrist are more common than true neoplastic lesions; however, soft tissue pseudotumors that mimic malignancy are very rare. PATIENT CONCERNS This study describes 2 patients with soft tissue pseudotumors of the hand and wrist. Both patients presented with rapidly growing soft-tissue masses. Magnetic resonance imaging (MRI) revealed ill-defined margins and an aggressive appearance in both cases, leading to a strong suspicion of malignant soft tissue tumors. DIAGNOSIS Both patients underwent incisional biopsies, and the final diagnoses were inflammation due to IgG4-related disease in the first case and chronic granulomatous inflammation in the second case. INTERVENTIONS The first patient was administered oral steroids, while the second patient was treated with anti-inflammatory drugs. OUTCOMES Both patients showed a reduction in swelling of the hand and wrist. LESSONS Although the imaging approach for pseudotumorous lesions is similar to that for true soft tissue tumors, the management of these lesions is different. Biopsies should only be performed when the diagnosis is unclear.
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Affiliation(s)
- Jong Ok Kim
- Department of Pathology, Daejeon St. Mary’s Hospital, The Catholic University of Korea, Chung-gu, Daejeon, Republic of Korea
| | - Yeon Soo Lee
- Department of Radiology, Daejeon St. Mary’s Hospital, The Catholic University of Korea, Chung-gu, Daejeon, Republic of Korea
| | - Sangeun Park
- Department of Orthopedic Surgery, Daejeon St. Mary’s Hospital, The Catholic University of Korea, Chung-gu, Daejeon, Republic of Korea
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Primary biliary cholangitis: review for radiologists. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:127-135. [PMID: 34743232 DOI: 10.1007/s00261-021-03335-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/19/2021] [Accepted: 10/22/2021] [Indexed: 01/21/2023]
Abstract
Primary biliary cholangitis is a rare progressive chronic inflammation of the medium and small bile ducts that abdominal radiologists may encounter, particularly if working in a tertiary setting or at a transplant center. This brief review covers current thinking about the pathophysiology and presentation of the disease, as well as the current diagnostic criteria in use by hepatologists. Imaging strategies for diagnosis will be reviewed as well as current treatment strategies and the use of imaging in monitoring response to treatment, including image-guided elastography.
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Özgül HA, Gezer NS, Özkal S, Tuna EB, Özdemir N, Balcı P. Three cases of immunoglobulin G4-related respiratory disease with uncommon imaging findings. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2021; 38:e2021019. [PMID: 34316259 PMCID: PMC8288200 DOI: 10.36141/svdld.v38i2.10302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 03/16/2021] [Indexed: 11/04/2022]
Abstract
Background: Immunoglobulin G4-related disease (IgG4-RD) is a rare multisystemic idiopathic fibroinflammatory disorder. The rare form of IgG4-RD with isolated thorax involvement is called immunoglobulin G4-related respiratory disease (IgG4-RRD). IgG4-RRD, which is reported in a limited number of cases in the literature, can be categorized into four types on the prevalent chest computed tomography (CCT) findings: solid nodular, round-shaped ground-glass opacity, alveolar interstitial, and bronchovascular. Solid nodular form of IgG4-RRD with mass-like lesions is sporadic and described in the literature with a small number of case reports. Objectives/Methods: We aim to present the radiologic, pathologic, and clinical findings of three cases of IgG4-RRD mimicking lung cancer. Results: In all three patients, IgG4-RRD occurred with mass-like lesions in the thorax. In case-1 and 2, CCT showed multiple, nodular lesions and multiple mediastinal lymph nodes. On positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro- D-glucose integrated with computed tomography (18F-FDG PET/CT), the masses showed increased 18F-FDG uptake in case-2 and 3. The gold standard histopathological verification for IgG4-RRD was provided for all cases. Conclusions: IgG4-RD is an immune-mediated condition comprised of a collection of disorders that share particular pathologic, radiologic, serologic, and clinical features. Isolated IgG4-RRD is rarely seen and is available in the literature as case reports. IgG4-RRD, which can make lung involvement in different patterns, rarely appears with mass-like lesions. Still, IgG4-RRD must be considered in the differential diagnosis of mass lesions detected in CCT. Laboratory, radiological, and histopathological findings of the disease should be evaluated together for an accurate diagnosis.
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Affiliation(s)
- Hakan Abdullah Özgül
- Department of Radiology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Naciye Sinem Gezer
- Department of Radiology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Sermin Özkal
- Department of Pathology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Emine Burçin Tuna
- Department of Pathology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Nezih Özdemir
- Department of Thoracic Surgery, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Pınar Balcı
- Department of Radiology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
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Sousa CP, Fonseca E, Viamonte B, Lobo JC, Madureira A. Kimura's disease: a rare cause of facial mass in a caucasian male patient. BJR Case Rep 2020; 6:20200099. [PMID: 33299599 PMCID: PMC7709070 DOI: 10.1259/bjrcr.20200099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/05/2022] Open
Abstract
Kimura's disease is an uncommon inflammatory disorder of unclear aetiology, mainly affecting young Asian descent males among their second and fourth decades of life. The disease typically emerges as a long-standing and painless subcutaneous mass lesion in the head and neck region, frequently associated with swelling of major salivary glands, particularly the parotid gland, and regional lymphadenopathy. Peripheral eosinophilia and high serum immunoglobulin E are also characteristic findings. We report a case and describe the imaging and pathological features of the disease in a 19-year-old Caucasian male, with review of the literature.
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Affiliation(s)
- Célia Peixoto Sousa
- Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Elsa Fonseca
- Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Bárbara Viamonte
- Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - João Calheiros Lobo
- Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - António Madureira
- Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
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Xu C, Han Y. Immunoglobulin G4-related sclerosing cholangitis mimicking cholangiocarcinoma: a case report and literature review. J Int Med Res 2020; 48:300060520959214. [PMID: 33025818 PMCID: PMC7545771 DOI: 10.1177/0300060520959214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a novel clinical disease that is characterized by elevated serum IgG4 concentrations and tumefaction or tissue infiltrated by IgG4+ plasma cells. The clinical manifestations of IgG4-RD depend on the type of tissues affected. IgG4-related sclerosing cholangitis is a type of IgG4-RD. We report a patient who initially visited a local hospital with a 5-month history of jaundice. He was found to have a mass in the upper part of the common bile duct that mimicked cholangiocarcinoma. He underwent surgery in our hospital and was later diagnosed with IgG4-related sclerosing cholangitis. We administered prednisolone 40 mg once a day for treatment. Taking into account the possible side effects of moderate-dose hormone therapy, we also administered teprenone, potassium chloride, and calcium carbonate. The patient did not have any recurrence of symptoms or adverse drug reactions during follow-up.
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Affiliation(s)
- Cheng Xu
- Department of Rheumatology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou City, Zhejiang Province, China
| | - Yongmei Han
- Department of Rheumatology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou City, Zhejiang Province, China
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Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibro-inflammatory condition that often causes the formation of tumefactive lesions. The discovery of IgG4-RD linked many well-known isolated conditions as a distinct multi-organ disease, and started an era of promoting investigation and treatment in relevant fields. In the thyroid gland, a subcategory of Hashimoto thyroiditis (HT) with IgG4-rich inflammation was first discovered and named IgG4 thyroiditis by our group. This subtype of HT presents with rapidly progressive clinical manifestations and destructive histopathological features underlying thyroid dysfunction, which are significantly different from the common type of HT. Moreover, other IgG4-rich thyroid conditions in patients with Graves' disease and systemic IgG4-RD have been described. These observations are most frequently reported in the Asian population for unknown reasons. Although recent studies demonstrated that IgG4 thyroiditis is a specific entity independent from IgG4-RD, recognition of this unique subset of thyroid disease has yielded important insights into understanding its pathogenesis and the development of novel therapeutic approaches.
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Affiliation(s)
- Yaqiong Li
- Department of Pathology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Keiko Inomata
- Department of Clinical and Laboratory Medicine, Yamashita Thyroid Hospital, Fukuoka, Japan
| | | | - Kennichi Kakudo
- Department of Pathology and Thyroid Disease Center, Izumi City General Hospital, Izumi, Japan
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Oh JW, Rha SE, Choi MH, Oh SN, Youn SY, Choi JI. Immunoglobulin G4-related Disease of the Genitourinary System: Spectrum of Imaging Findings and Clinical-Pathologic Features. Radiographics 2020; 40:1265-1283. [PMID: 32870766 DOI: 10.1148/rg.2020200043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disease characterized by focal or diffuse organ infiltration of IgG4-bearing plasma cells. The diagnosis of IgG4-RD is based on a combination of clinical, serologic, radiologic, and histopathologic findings. IgG4-RD has been reported to affect almost all organ systems. The kidney is the most frequently involved of the genitourinary organs. The most common renal manifestation of IgG4-RD is IgG4-RD tubulointerstitial nephritis, followed by membranous glomerulonephropathy and, less frequently, obstructive nephropathy involving the renal pelvis, ureter, or retroperitoneum. Renal parenchymal lesions may appear as multiple nodular lesions, diffuse patchy infiltrative lesions, or a single nodular lesion. Multiple small nodular cortical lesions are the most common imaging findings of IgG4-RD involving the kidney. Renal pelvic, sinus, or perinephric lesions can also occur. IgG4-RD involvement of other genitourinary organs including the ureter, bladder, urethra, and male and female reproductive organs is rare compared with kidney involvement but may show variable imaging findings such as a localized mass within or surrounding the involved organ or diffuse enlargement of the involved organ. Imaging findings of IgG4-RD involving the genitourinary system are nonspecific but should be differentiated from inflammatory and neoplastic lesions that mimic IgG4-RD. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2020.
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Affiliation(s)
- Ji Woon Oh
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Sung Eun Rha
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Moon Hyung Choi
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Soon Nam Oh
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Seo Yeon Youn
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Joon-Il Choi
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
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Abstract
Multidetector computed tomography (MDCT) is a widely used cross-sectional imaging modality for initial evaluation of patients with suspected pancreatic ductal adenocarcinoma (PDAC). However, diagnosis of PDAC can be challenging due to numerous pitfalls associated with image acquisition and interpretation, including technical factors, imaging features, and cognitive errors. Accurate diagnosis requires familiarity with these pitfalls, as these can be minimized using systematic strategies. Suboptimal acquisition protocols and other technical errors such as motion artifacts and incomplete anatomical coverage increase the risk of misdiagnosis. Interpretation of images can be challenging due to intrinsic tumor features (including small and isoenhancing masses, exophytic masses, subtle pancreatic duct irregularities, and diffuse tumor infiltration), presence of coexisting pathology (including chronic pancreatitis and intraductal papillary mucinous neoplasm), mimickers of PDAC (including focal fatty infiltration and focal pancreatitis), distracting findings, and satisfaction of search. Awareness of pitfalls associated with the diagnosis of PDAC along with the strategies to avoid them will help radiologists to minimize technical and interpretation errors. Cognizance and mitigation of these errors can lead to earlier PDAC diagnosis and ultimately improve patient prognosis.
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IgG4-related disease: rare presentation as a soft-tissue mass in the thigh of an adolescent. Skeletal Radiol 2020; 49:155-160. [PMID: 31165193 DOI: 10.1007/s00256-019-03250-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/05/2019] [Accepted: 05/16/2019] [Indexed: 02/02/2023]
Abstract
We report a case of a 16-year-old boy who presented a soft-tissue mass in the anterior compartment of the right thigh discovered by positron emission tomography/computed tomography within the work-up of unexplained prolonged inflammatory syndrome. The mass has no calcification. Subsequently, magnetic resonance imaging of the femoral triangle was carried out. Axial short tau inversion recovery images showed a 3.5-cm ill-defined mass in the femoral triangle with focal areas of hypointensity, which suggests that there might be fibrosis or hemosiderin within the tumor. Axial T1-weighted images showed a slight hyperintense mass involving the iliopsoas muscle. Contrast-enhanced fat-suppressed T1-weighted imaging showed a heterogeneous solid enhancement. Adjacent thick fascia enhancement of the vastus intermedius and the vastus lateralis muscles extending from the mass as a tail-like margin suggested the infiltrative spread of the tumor along the fascial plane. The mass and the lymphadenopathy were excised. Immunohistochemically, tumor cells were staining for muscle actin and desmin. Many plasma cells were IgG4+ (175per high-power field) with a ratio IgG4+/IgG+ of 50%. The diagnosis of IgG4-related disease (IgG4-RD) was made. Although a diffuse array of musculoskeletal symptoms has been observed in IgG4-related disease, reports of biopsy-proven musculoskeletal involvement of the limb are rare. We showed the radiological features of IgG4-RD presenting as a soft-tissue mass of the thigh. Musculoskeletal involvement, clinical significance, and treatment of IgG4-RD are also discussed.
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Abstract
Magnetic resonance imaging of the upper tract (pyelocalyces and ureters) or MR Urography (MRU) is technically possible and when performed correctly offers similar visualization of the upper tracts and for detection of non-calculous diseases of the collecting system similar specificity but with lower sensitivity compared to CTU. MRU provides the ability to simultaneously image the kidneys and urinary bladder with improved soft tissue resolution, better tissue characterization and when combined with assessment of the upper tract, a comprehensive examination of the urinary system. MRU requires meticulous attention to technical details and is a longer more demanding examination compared to CTU. Advances in MR imaging techniques including: parallel imaging, free-breathing motion compensation techniques and compressed sensing can dramatically shorten examination times and improve image quality and patient tolerance for the exam. This review article discusses updates in the MRU technique, summarizes clinical indications and opportunities for MRU in clinical practice and reviews advantages and disadvantages of MRU compared to CTU.
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Review of IgG4-related disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:638-647. [PMID: 31722794 DOI: 10.1016/j.gastrohep.2019.08.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/24/2019] [Accepted: 08/18/2019] [Indexed: 12/12/2022]
Abstract
IgG4-related disease is a fibrous-inflammatory process related to immunomodulation. The most commonly affected organs are: the pancreas, bile duct, major salivary glands, lacrimal glands, retroperitoneum and lymphatic ducts. In recent decades, this disease has been recognised as a systemic disorder that includes many single organ disorders, previously unrelated and known as independent entities. The common characteristics shared by the different entities that make up the IgG4-related disease are: raised serum IgG4 levels, alterations in the imaging tests with neoplastic-like swelling of the affected organs, specific histopathological characteristics and in immunostaining, as well as good response to treatment with glucocorticoids. In this work, we will review this pathology with a special emphasis on the characteristics of autoimmune pancreatitis, sclerosing cholangitis related to IgG4 and the involvement of the retroperitoneum, mesenterium and the digestive tract.
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Swensson J, Tirkes T, Tann M, Cui E, Sandrasegaran K. Differentiating IgG4-related sclerosing cholangiopathy from cholangiocarcinoma using CT and MRI: experience from a tertiary referring center. Abdom Radiol (NY) 2019; 44:2111-2115. [PMID: 30783729 DOI: 10.1007/s00261-019-01944-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To compare the cross-sectional imaging findings of immunoglobulin G4-related sclerosing cholangiopathy (IgG4-SC) and cholangiocarcinoma (CCA). METHODS Retrospective search of radiology and pathology databases identified 24 patients with IgG4-SC and over 500 patients with CCA from January 2009 to December 2016. Patients with no pre-treatment imaging studies available on PACS, non-contrasted imaging only, presence of mass lesions, metastatic disease or biliary stents were excluded. 17 patients with IgG4-SC and a selected group of 20 (age and gender matched) patients with CCA were obtained. Images were blinded and independently reviewed by two radiologists. Differences in proportions and means between groups were analyzed using Fishers and Mann-Whitney tests, respectively. RESULTS Both readers identified a statistically significant difference in the presence of abrupt common bile duct narrowing between IgG4-SC and CCA (6.7% vs. 68.4%, p < 0.001; 33.3% vs. 75%, p = 0.019). No difference was seen in biliary wall thickening, wall enhancement, extrahepatic exclusive location of disease, or pancreatic duct dilation. Inter-observer variability was κ = 0.52. Total bilirubin and CA 19-9 were unable to differentiate between IgG4-SC and CCA. Serum IgG4 was positive in two of six IgG4-SC patients who were tested. CONCLUSION IgG4-SC and CCA share many clinical and imaging findings on CT and MRI. Abrupt bile duct cut sign strongly favors CCA. In the absence of this finding, IgG4-SC should be considered in the differential diagnosis in all cases of suspected extrahepatic CCA.
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Affiliation(s)
- Jordan Swensson
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd Room 0663, Indianapolis, IN, 46202, USA.
| | - Temel Tirkes
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd Room 0663, Indianapolis, IN, 46202, USA
| | - Mark Tann
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd Room 0663, Indianapolis, IN, 46202, USA
| | - Enming Cui
- Department of Radiology, Jiangmen Central Hospital, 23 Haibang Street, Pengjiang District, Jiangmen, 529030, Guangdong, People's Republic of China
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Lee HW, Moon SH, Kim MH, Cho DH, Jun JH, Nam K, Song TJ, Park DH, Lee SS, Seo DW, Lee SK. Relapse rate and predictors of relapse in a large single center cohort of type 1 autoimmune pancreatitis: long-term follow-up results after steroid therapy with short-duration maintenance treatment. J Gastroenterol 2018; 53:967-977. [PMID: 29362937 DOI: 10.1007/s00535-018-1434-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/15/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Type 1 autoimmune pancreatitis (AIP), as a pancreatic manifestation of IgG4-related disease, shows a favorable prognosis in the short term. However, disease relapse is common in long-term follow-up, despite a successful initial treatment response. This study aimed to identify the predictors of relapse and long-term outcomes in patients with type 1 AIP. METHODS Patients with more than 2 years of follow-up who met the International Consensus Diagnostic Criteria for type 1 AIP were included. Patients who had undergone pancreatic operations associated with AIP or who lacked sufficient clinical data were excluded. RESULTS All 138 patients achieved clinical remission with initial steroid therapy, and 66 (47.8%) experienced relapse during a median 60 (range 24-197) months follow-up. Among the relapsed patients, about 74% (49/66) relapsed within 3 years. About 60% (82/138) had other organ involvement (OOI), most commonly in the proximal bile duct (26.8%). At first diagnosis, OOI, and especially OOI of the proximal bile duct, was a significant independent predictor of relapse (hazard ratio 2.65; 95% confidence interval 1.44-4.89; p = 0.002), according to multivariate analysis. During the follow-up period, 16 (11.6%) patients experienced endocrine/exocrine dysfunction and 32 (23.2%) patients developed de novo pancreatic calcifications/stones. No pancreatic cancer occurred in any patients. CONCLUSIONS Type 1 AIP has common relapses, and patients with OOI, especially OOI of the proximal bile duct, appear to be at increased risk for relapse. Long-term sequelae, including pancreatic insufficiency and pancreatic calcifications/stones, are common in patients with relapse. To reduce the relapse, longer maintenance treatment may be needed especially for patients at high risk for relapse.
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Affiliation(s)
- Hyun Woo Lee
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon, South Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Myung-Hwan Kim
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Dong Hui Cho
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jae Hyuck Jun
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Kwangwoo Nam
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, South Korea
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Dong-Wan Seo
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505, Republic of Korea
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Ugga L, Ravanelli M, Pallottino AA, Farina D, Maroldi R. Diagnostic work-up in obstructive and inflammatory salivary gland disorders. ACTA OTORHINOLARYNGOLOGICA ITALICA 2018; 37:83-93. [PMID: 28516970 PMCID: PMC5463527 DOI: 10.14639/0392-100x-1597] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/12/2016] [Indexed: 02/07/2023]
Abstract
Inflammatory and obstructive disorders of the salivary glands are caused by very different pathological conditions affecting the gland tissue and/or the excretory system. The clinical setting is essential to address the appropriate diagnostic imaging work-up. According to history and physical examination, four main clinical scenarios can be recognised: (1) acute generalised swelling of major salivary glands; (2) acute swelling of a single major salivary gland; (3) chronic generalised swelling of major salivary glands, associated or not with "dry mouth"; (4) chronic or prolonged swelling of a single major salivary gland. The algorithm for imaging salivary glands depends on the scenario with which the patient presents to the clinician. Imaging is essential to confirm clinical diagnosis, define the extent of the disease and identify complications. Imaging techniques include ultrasound (US), computed tomography (CT) and magnetic resonance (MR) with MR sialography.
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Affiliation(s)
- L Ugga
- Department of Advanced Biomedical Sciences, "Federico II" University, Naples, Italy
| | - M Ravanelli
- Department of Radiology, University of Brescia, Brescia, Italy
| | - A A Pallottino
- Department of Radiology, Campus Biomedico University, Rome, Italy
| | - D Farina
- Department of Radiology, University of Brescia, Brescia, Italy
| | - R Maroldi
- Department of Radiology, University of Brescia, Brescia, Italy
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Euch ME, Hddad S, Mahfoudhi M, Maktouf H, Ben Hamida F, Jaziri F, Ben Abdelghani K, Turki S, Ben Abdallah T. A Case of Type 1 Autoimmune Pancreatitis (AIP), a Form of IgG4-Related Disease (IgG4-RD). AMERICAN JOURNAL OF CASE REPORTS 2017; 18:822-825. [PMID: 28736430 PMCID: PMC5539804 DOI: 10.12659/ajcr.904263] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 04/28/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Type 1 autoimmune pancreatitis (AIP), also known as lymphoplasmacytic sclerosing pancreatitis (LPSP), is a rare cause of chronic pancreatitis, characterized by a fibro-inflammatory process. However, patients with AIP may have a good response to corticosteroid therapy. We describe a Tunisian patient with AIP that was confirmed to be an IgG4-related disease (IgG4-RD). CASE REPORT We describe a case of a 70-year-old man who was admitted to hospital for obstructive jaundice and abdominal pain. Serum liver function tests were abnormal and upper abdominal computed tomography (CT) imaging showed diffuse pancreatic swelling and strictures of the main pancreatic duct without any focal lesion. Pancreatico-biliary magnetic resonance imaging (MRI) showed a thickened rim surrounding the pancreatic duct Serum IgG4 levels were elevated, resulting in a diagnosis of IgG4-related AIP. The patient showed a good clinical, biochemical, and radiological response following steroid therapy in combination with azathioprine. CONCLUSIONS The diagnostic workup of IgG4-RD is complex and usually requires a combination of clinical examination, imaging, and serological analysis. As this case report has demonstrated, IgG4-RD should be considered in patients who present with pancreatitis or AIP, because of the favorable response to steroid therapy, particularly when treatment is initiated early.
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Affiliation(s)
- Mounira El Euch
- Department of Internal Medicine ‘A’, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis Manar, Tunis, Tunisia
| | - Souha Hddad
- Department of Internal Medicine ‘A’, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis Manar, Tunis, Tunisia
| | - Madiha Mahfoudhi
- Department of Internal Medicine ‘A’, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis Manar, Tunis, Tunisia
- Research Laboratory of Kidney Diseases (LR00SP01), Charles Nicolle Hospital, Tunis, Tunisia
| | - Hela Maktouf
- Department of Internal Medicine ‘A’, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis Manar, Tunis, Tunisia
| | - Fethi Ben Hamida
- Department of Internal Medicine ‘A’, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis Manar, Tunis, Tunisia
- Research Laboratory of Kidney Diseases (LR00SP01), Charles Nicolle Hospital, Tunis, Tunisia
| | - Fatima Jaziri
- Department of Internal Medicine ‘A’, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis Manar, Tunis, Tunisia
| | - Khaoula Ben Abdelghani
- Department of Internal Medicine ‘A’, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis Manar, Tunis, Tunisia
| | - Sami Turki
- Department of Internal Medicine ‘A’, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis Manar, Tunis, Tunisia
| | - Taïeb Ben Abdallah
- Department of Internal Medicine ‘A’, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis Manar, Tunis, Tunisia
- Research Laboratory of Kidney Diseases (LR00SP01), Charles Nicolle Hospital, Tunis, Tunisia
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