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Metelli F, Manfredi G, Pagano N, Buscarini E, Crinò SF, Armellini E. The Role of Endoscopic Ultrasound and Ancillary Techniques in the Diagnosis of Autoimmune Pancreatitis: A Comprehensive Review. Diagnostics (Basel) 2024; 14:1233. [PMID: 38928649 PMCID: PMC11202526 DOI: 10.3390/diagnostics14121233] [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: 04/09/2024] [Revised: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024] Open
Abstract
Autoimmune pancreatitis (AIP) is a unique form of chronic pancreatitis with a multifactorial pathogenesis. Historically, it has been classified as type 1 and type 2, according to its clinical and histological features. The diagnosis of AIP is challenging and relies on a combination of clinical, histopathologic, serologic, and imaging characteristics. In the available guidelines, the imaging hallmarks of AIP are based on cross-sectional imaging and cholangiopancreatography retrograde endoscopic findings. Endoscopic ultrasound (EUS) is generally used for pancreatic tissue acquisition to rule out pancreatic cancer and diagnose AIP with limited accuracy. Several papers reported the reliability of EUS for providing informative morphologic features of AIP. Nowadays, the improvement in the resolution of EUS conventional images and the development of new ancillary technologies have further increased the diagnostic yield of EUS: contrast-enhanced EUS and EUS elastography are non-invasive and real-time techniques that strongly support the diagnosis and management of pancreatic diseases. In this review article, we will present the role of conventional EUS and ancillary diagnostic techniques in the diagnosis of AIP to support clinicians and endosonographers in managing this condition.
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Affiliation(s)
- Flavio Metelli
- Gastroenterology and Endoscopy Department, ASST Maggiore Hospital Crema, 26013 Crema, Italy; (F.M.); (G.M.); (E.B.)
| | - Guido Manfredi
- Gastroenterology and Endoscopy Department, ASST Maggiore Hospital Crema, 26013 Crema, Italy; (F.M.); (G.M.); (E.B.)
| | - Nico Pagano
- Gastroenterology Unit, Department of Oncological and Specialty Medicine, University Hospital Maggiore della Carità, 28100 Novara, Italy;
| | - Elisabetta Buscarini
- Gastroenterology and Endoscopy Department, ASST Maggiore Hospital Crema, 26013 Crema, Italy; (F.M.); (G.M.); (E.B.)
| | - Stefano Francesco Crinò
- Diagnostic and Interventional Endoscopy of Pancreas, Pancreas Institute, University of Verona, 37134 Verona, Italy;
| | - Elia Armellini
- Gastroenterology and Endoscopy Unit, ASST-Bergamoest, 24068 Seriate, Italy
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Tornel-Avelar AI, Velarde Ruiz-Velasco JA, Pelaez-Luna M. Pancreatic cancer, autoimmune or chronic pancreatitis, beyond tissue diagnosis: Collateral imaging and clinical characteristics may differentiate them. World J Gastrointest Oncol 2023; 15:925-942. [PMID: 37389107 PMCID: PMC10302998 DOI: 10.4251/wjgo.v15.i6.925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/21/2023] [Accepted: 04/28/2023] [Indexed: 06/14/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies and is developing into the 2nd leading cause of cancer-related death. Often, the clinical and radiological presentation of PDAC may be mirrored by other inflammatory pancreatic masses, such as autoimmune pancreatitis (AIP) and mass-forming chronic pancreatitis (MFCP), making its diagnosis challenging. Differentiating AIP and MFCP from PDAC is vital due to significant therapeutic and prognostic implications. Current diagnostic criteria and tools allow the precise differentiation of benign from malignant masses; however, the diagnostic accuracy is imperfect. Major pancreatic resections have been performed in AIP cases under initial suspicion of PDAC after a diagnostic approach failed to provide an accurate diagnosis. It is not unusual that after a thorough diagnostic evaluation, the clinician is confronted with a pancreatic mass with uncertain diagnosis. In those cases, a re-evaluation must be entertained, preferably by an experienced multispecialty team including radiologists, pathologists, gastroenterologists, and surgeons, looking for disease-specific clinical, imaging, and histological hallmarks or collateral evidence that could favor a specific diagnosis. Our aim is to describe current diagnostic limitations that hinder our ability to reach an accurate diagnosis among AIP, PDAC, and MFCP and to highlight those disease-specific clinical, radiological, serological, and histological characteristics that could support the presence of any of these three disorders when facing a pancreatic mass with uncertain diagnosis after an initial diagnostic approach has been unsuccessful.
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Affiliation(s)
- Ana I Tornel-Avelar
- Department of Gastroenterology, Hospital Civil of Guadalajara “Fray Antonio Alcalde”, Guadalajara 44340, Jalisco, Mexico
| | | | - Mario Pelaez-Luna
- Research Division School of Medicine/Department of Gastroenterology, Universidad Nacional Autonoma de México/National Institute of Medical Sciences and Nutrition “Salvador Zubiran”, Tlalpan 14000, Mexico City, Mexico
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Moradi A, Sadeghi A, Asadzadeh Aghdaei H, Mollasharifi T, Ahadi M, Jamali E, Taghavi A, Foroozandeh Shahraki N, Moradi A. An Investigation on the Results of Cytopathologic Tests of Pancreatobiliary System Performed in the Pathology Department in Iran. IRANIAN JOURNAL OF PATHOLOGY 2021; 16:325-331. [PMID: 34306121 PMCID: PMC8298047 DOI: 10.30699/ijp.2021.131467.2462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/05/2021] [Indexed: 11/06/2022]
Abstract
Background & Objective Pancreatobiliary system disorders commonly include inflammatory diseases and tumors. Diagnosis of pancreatic cancer is challenging and is mostly achieved when the disease has extensively progressed, and metastasis has occurred. Therefore, this study was performed to evaluate cytopathology in the diagnosis of Pancreatobiliary malignancies, which can improve diagnostic adequacy and accuracy. Methods A total of 116 cytopathologic results of the Pancreatobiliary system, performed in the Pathology Department of Taleghani Hospital, Tehran, Iran during 2017-2018 were selected and examined in this observational study. The frequency of different results was determined and compared with other variables. Results The most common location of the lesions was the pancreas (47%). The lesions were categorized as malignant, benign, negative, suspicious for malignancy (SFM), and atypical in 28%, 10%, 24%, 14%, and 9% of the cases, respectively. In other cases, lesions were considered non-diagnostic. Rapid on-site evaluation (ROSE) was conducted in 25% of patients. Compatibility of the initial and final diagnoses was 100%, 50%, and 60% in cases with "malignant", "benign", and "negative" diagnoses, respectively. The sensitivity, specificity, as well as positive and negative predictive values of cytopathology in the diagnosis of Pancreatobiliary lesions were 75.8%, 92.3%, 95.9%, and 61.5%, respectively. Conclusion Our findings indicated that half of the lesions of the Pancreatobiliary system were positive, SFM, and atypical. Fine-needle aspiration (FNA) and endoscopic ultrasound-guided FNA (EUS-FNA) were effective modalities in diagnosing Pancreatobiliary malignancies. The most important point in our experience is the increase in diagnostic sensitivity in the presence of ROSE. Therefore, the simultaneous use of ROSE and EUS-FNA can reduce the need for re-sampling.
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Affiliation(s)
- Afshin Moradi
- Department of Pathology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Sadeghi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Asadzadeh Aghdaei
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Tahmineh Mollasharifi
- Department of Pathology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahsa Ahadi
- Department of Pathology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elena Jamali
- Department of Pathology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Afsoon Taghavi
- Department of Pathology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasim Foroozandeh Shahraki
- Department of Pathology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arsham Moradi
- University of Toronto, Department of Biology, Toronto, Canada
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Jung YJ, Moon SH, Kim MH. Role of Endoscopic Procedures in the Diagnosis of IgG4-Related Pancreatobiliary Disease. Chonnam Med J 2021; 57:44-50. [PMID: 33537218 PMCID: PMC7840337 DOI: 10.4068/cmj.2021.57.1.44] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 12/16/2022] Open
Abstract
The emergence of the disease entity of glucocorticoid-responsive systemic immunoglobulin G4 (IgG4)-related pancreatobiliary disease has generated substantial attention among the international gastroenterology society. IgG4-related pancreatobiliary disease includes type 1 autoimmune pancreatitis (AIP) and IgG4-related sclerosing cholangitis (IgG4-SC). The typical manifestations of IgG4-related pancreatobiliary disease are cholestatic liver dysfunction, obstructive jaundice, and weight loss, although it may present with no clinical symptoms. Since it mimics tumors on imaging, AIP/IgG4-SC may often be misdiagnosed as pancreatic or biliary cancer. The endoscopic armamentarium for the diagnosis of IgG4-related pancreatobiliary disease includes endoscopic ultrasonography, intraductal ultrasonography, endoscopic retrograde cholangiopancreatography, and cholangioscopy. The role of endoscopic tissue acquisition is two-fold in the diagnosis of IgG4-related pancreatobiliary disease: exclusion of cancer and procurement of histopathological proof for diagnosis of AIP/IgG4-SC, which can also be achieved by adding the immunohistochemistry for IgG4. Our review article addresses the role of various endoscopic examinations in diagnosing IgG4-related pancreatobiliary disease, focusing on the differentiation of this condition from pancreatobiliary malingnancies.
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Affiliation(s)
- Ye-Ji Jung
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea.,Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Focal Autoimmune Pancreatitis: A Simple Flow Chart for a Challenging Diagnosis. Ultrasound Int Open 2021; 6:E67-E75. [PMID: 33490857 PMCID: PMC7815440 DOI: 10.1055/a-1323-4906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/25/2020] [Indexed: 12/11/2022] Open
Abstract
Autoimmune pancreatitis is a chronic fibroinflammatory autoimmune mediated
disease of the pancreas. Clinically, obstructive painless jaundice and upper
abdominal pain are the main symptoms. Focal AIP is characterized by
segmental involvement of pancreatic parenchyma and it is often
radiologically represented by a pancreatic mass. In these cases, the
diagnosis can be very challenging, since it may be easily confused with
pancreatic cancer. Therefore, we suggest a combined approach of imaging
tests as the diagnostic workup. EUS study combined with CEUS and
elastography, if available, increases the accuracy of the method to rule out
cancer. Moreover, the lesion should always be sampled under EUS guidance to
obtain a cyto/histological diagnosis. The diagnostic workup should
also include the use of diagnostic clinical criteria (extrapancreatic
lesions, steroid response) and laboratory findings (CA 19.9 and IgG4
evaluations).
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Hedegaard Jensen G, Mortensen MB, Klöppel G, Nielsen MFB, Nielsen O, Detlefsen S. Utility of pVHL, maspin, IMP3, S100P and Ki67 in the distinction of autoimmune pancreatitis from pancreatic ductal adenocarcinoma. Pathol Res Pract 2020; 216:152925. [PMID: 32273198 DOI: 10.1016/j.prp.2020.152925] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 03/12/2020] [Accepted: 03/14/2020] [Indexed: 01/07/2023]
Abstract
Morphology plays an important role in the distinction of autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC). However, we aimed to determine the utility of immunohistochemical tumor markers to contribute in the distinction of these entities. In surgical specimens with AIP (n = 20), PDAC (n = 20) and normal pancreas (n = 20), the expression of pVHL, maspin, IMP3, S100P and Ki67 was examined. We evaluated intralobular reactive ducts / acinoductal metaplasia (ILDs) and extralobular ducts (ELDs) in AIP, neoplastic glands in PDAC, and ductal epithelium in the normal pancreas, using a five-tiered scoring system. The Ki67 hot spot index (Ki67-HSPI) was determined manually and using automated digital imaging analysis of virtual double stains of Ki67 and CK8. Besides, sequential dual-immunohistochemical staining of maspin/pVHL, maspin/IMP3 and Ki67/maspin was performed in a subset of the specimens. Strong overexpression of IMP3, maspin, S100P and Ki67 and loss of pVHL was observed in PDAC compared to AIP and normal pancreas. In AIP however, focal and weak aberrant expression was observed with the following proportions in ILDs/ELDs: pVHL in 45 %/85 %, maspin in 30 %/70 %, IMP3 in 55 %/5%, S100P in 10 %/35 % and Ki67-HSPI >20 % in 15 %/70 %. At least two markers were aberrantly expressed in ILDs/ELDs in 45 %/60 %. The aberrant expression was more pronounced in type 2 AIP compared to type 1. In conclusion, our data indicate that pVHL, maspin, IMP3, S100P and Ki67 can be focal and weak aberrantly expressed in AIP. However, when used as a panel, these markers seem to be useful for the differentiation of AIP from PC.
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Affiliation(s)
| | - Michael Bau Mortensen
- HPB Section, Department of Surgery, Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Günter Klöppel
- Department of Pathology, Consultation Center of Pancreatic and Endocrine Tumors, Technical University Munich, Munich, Germany
| | | | - Ole Nielsen
- Department of Pathology, Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Department of Pathology, Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark.
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Cho MK, Moon SH, Song TJ, Kim RE, Oh DW, Park DH, Lee SS, Seo DW, Lee SK, Kim MH. Contrast-Enhanced Endoscopic Ultrasound for Differentially Diagnosing Autoimmune Pancreatitis and Pancreatic Cancer. Gut Liver 2019; 12:591-596. [PMID: 29699060 PMCID: PMC6143455 DOI: 10.5009/gnl17391] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/12/2017] [Accepted: 12/26/2017] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Differentially diagnosing focal-type autoimmune pancreatitis (f-AIP) and pancreatic cancer (PC) is challenging. Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) may provide information for differentiating pancreatic masses. In this study, we evaluated the usefulness of CEH-EUS in differentiating f-AIP from PC. Methods Data were collected prospectively and analyzed on patients who underwent CEH-EUS between May 2014 and May 2015. Eighty consecutive patients were diagnosed with f-AIP or PC. PC and f-AIP were compared for enhancement intensity, contrast agent distribution, and internal vasculature. Results The study group comprised 53 PC patients and 27 f-AIP patients (17 with type-1 AIP [15 definite and two probable], two with probable type-2 AIP, and eight with AIP, not otherwise specified). Hyper- to iso-enhancement in the arterial phase (f-AIP, 89% vs PC, 13%; p<0.05), homogeneous contrast agent distribution (f-AIP, 81% vs PC, 17%; p<0.05), and absent irregular internal vessels (f-AIP, 85% vs PC, 30%; p<0.05) were observed more frequently in the f-AIP group. The combination of CEH-EUS and enhancement intensity, absent irregular internal vessels improved the specificity (94%) in differentiating f-AIP from PC. Conclusions CEH-EUS may be a useful noninvasive modality for differentially diagnosing f-AIP and PC. Combined CEH-EUS findings could improve the specificity of CEH-EUS in differentiating f-AIP from PC.
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Affiliation(s)
- Min Keun Cho
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Tae Jun Song
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Raymond E Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Dong Wook Oh
- Division of Gastroenterology, Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University College of Medicine, Seoul, Korea
| | - Do Hyun Park
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Soo Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Wan Seo
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Koo Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Cao L, Wang Y, Wang J, Guo Q, Chen Q, Wu X, Tang SJ, Cheng B. The role of EUS-guided fine needle aspiration in autoimmune pancreatitis: a single center prospective study. Scand J Gastroenterol 2018; 53:1604-1610. [PMID: 30422724 DOI: 10.1080/00365521.2018.1534137] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Histopathological examination is pivotal in diagnosing autoimmune pancreatitis (AIP). The usefulness of EUS-guided fine needle aspiration (EUS-FNA) in diagnosing AIP remains controversial worldwide. The authors conducted this study to evaluate the efficacy of EUS-FNA for AIP diagnosis using a 22-gauge needle. METHODS Between January 2013 and May 2017, 37 patients had imaging studies suggestive of AIP at Tongji Hospital, and 27 patients of them were enrolled in this study. Tissue specimens acquired through EUS-FNA were analyzed for periductal lymphoplasmacytic infiltrate (LPI), storiform fibrosis (SF), obliterative phlebitis (OP) and immunoglobulin G4 (IgG4)-positive plasma cell counts. Clinical Trials.gov no: TJ-C20121220. RESULTS LPI and SF were present in 18 (66.67%) and 18 (66.67%) of 27 patients, respectively. Abundant IgG4-positive plasmacyte infiltration >10/high-power field (HPF) was detected in 8 of 27 patients (29.63%). OP and the characteristic findings of idiopathic duct-centric chronic pancreatitis (IDCP) and granulocytic epithelial lesion (GEL) were not detected in this study. According to the International Consensus Diagnostic Criteria (ICDC) for AIP, 5 and 12 of 27 patients were assessed as having level 1 and level 2 histological findings, respectively, suggesting that 17 of 27 patients (62.96%) had lymphoplasmacytic sclerosing pancreatitis (LPSP) based on the ICDC. CONCLUSIONS In 92.6% of patients, pancreatic tissues with >5 HPFs were obtained by EUS-FNA using a 22-G needle. In 63% of patients, histology was evaluated to be ≥ level 2 according to the ICDC. The study indicates that EUS-FNA with a 22-G needle is valuable in the histopathological diagnosis of AIP.
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Affiliation(s)
- Li Cao
- a Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Yun Wang
- a Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Jinlin Wang
- a Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Qiaozhen Guo
- a Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Qian Chen
- a Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Xiaoli Wu
- a Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Shou-Jiang Tang
- b Division of Digestive Diseases, Department of Medicine , University of Mississippi Medical Center , Jackson , MS , USA
| | - Bin Cheng
- a Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
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Rodriguez EA, Williams FK. A mass in the junction of the body and tail of the pancreas with negative IgG4 serology: IgG4-related disease with negative serology. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:305-9. [PMID: 26001036 PMCID: PMC4447198 DOI: 10.12659/ajcr.893300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patient:Female, 55 Final Diagnosis: Autoimmune pancreatitis Symptoms: Abdominal pain • weight loss Medication: Prednisone Clinical Procedure: Admitted to the hospital Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Eduardo A Rodriguez
- Department of Internal Medicine, University of Miami Palm Beach Regional Campus, Atlantis, FL, USA
| | - Frederick K Williams
- Department of Internal Medicine, University of Miami Palm Beach Regional Campus, Atlantis, FL, USA
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Furuhashi N, Suzuki K, Sakurai Y, Ikeda M, Kawai Y, Naganawa S. Differentiation of focal-type autoimmune pancreatitis from pancreatic carcinoma: assessment by multiphase contrast-enhanced CT. Eur Radiol 2015; 25:1366-74. [PMID: 25433412 DOI: 10.1007/s00330-014-3512-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 09/30/2014] [Accepted: 11/17/2014] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To evaluate the utility of multiphase contrast-enhanced computed tomography (CT) findings alone and in combination for differentiating focal-type autoimmune pancreatitis (f-AIP) from pancreatic carcinoma (PC). METHODS The study group comprised 22 f-AIP lesions and 61 PC lesions. Two radiologists independently evaluated CT findings. Frequencies of findings were compared between f-AIP and PC. Statistical, univariate and multivariate analyses were performed. RESULTS Homogeneous enhancement during the portal phase (AIP, 59 % vs. PC, 3 %; P < 0.001), dotted enhancement during the pancreatic phase (50 % vs. 7 %; P < 0.001), duct-penetrating sign (46 % vs. 2 %; P < 0.001), enhanced duct sign (36 % vs. 2 %; P < 0.001) and capsule-like rim (46 % vs. 3 %; P < 0.001) were more frequently observed in AIP. Ring-like enhancement during the delayed phase (5 % vs. 46 %; P < 0.001) and peripancreatic strands with a length of at least 10 mm (5 % vs. 39 %; P = 0.001) were more frequently observed in PC. AIP was identified with 82 % sensitivity and 98 % specificity using four of these seven findings. Multivariate analysis revealed significant differences in dotted enhancement (P = 0.004), duct-penetrating sign (P < 0.001) and capsule-like rim (P = 0.007). CONCLUSIONS The combination of CT findings may allow improvements in differentiating f-AIP from PC. KEY POINTS • f-AIP can mimic PC on imaging findings. • The differentiation of f-AIP from PC is important in patient management. • Some CT findings can be used to identify AIP. • The combination of CT findings will improve differentiation from PC.
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Affiliation(s)
- Naohiro Furuhashi
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan,
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Senosiain Lalastra C, Foruny Olcina JR. [Autoimmune pancreatitis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:549-55. [PMID: 25799073 DOI: 10.1016/j.gastrohep.2015.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/20/2015] [Accepted: 01/23/2015] [Indexed: 01/06/2023]
Abstract
Autoimmune pancreatitis is a benign fibroinflammatory disease of the pancreas of probable autoimmune origin, which includes 2 different phenotypes: type 1 (lymphoplasmacytic sclerosing pancreatitis) and type 2 (idiopathic duct-centric pancreatitis). Its clinical presentation as obstructive jaundice in patients with a pancreatic mass is common and therefore it must be included in the differential diagnosis of pancreatic neoplasia. Many diagnostic criteria have been described throughout history. The most famous are the HISORT criteria of the Mayo Clinic and the international consensus criteria of 2011. One of the main features of autoimmune pancreatitis is its dramatic response to steroid therapy, without the need for surgical treatment. Knowledge of this disease can dramatically change the management of patients with obstructive jaundice, who would otherwise be subjected to a pancreaticoduodenectomy.
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Affiliation(s)
- Carla Senosiain Lalastra
- Servicio de Aparato Digestivo, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España.
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12
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Chang MC, Jan IS, Liang PC, Jeng YM, Yang CY, Tien YW, Wong JM, Chang YT. Human cationic trypsinogen but not serine peptidase inhibitor, Kazal type 1 variants increase the risk of type 1 autoimmune pancreatitis. J Gastroenterol Hepatol 2014; 29:2038-42. [PMID: 24909264 DOI: 10.1111/jgh.12649] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Autoimmune pancreatitis (AIP) is a distinct disease entity. Whether the genes involved in pancreatic acinar cell injury, cationic trypsinogen gene (protease, serine, 1 [trypsin 1] [PRSS1]) and the pancreatic secretory trypsin inhibitor gene (serine peptidase inhibitor, Kazal type 1 [SPINK1]), are associated with AIP remains to be explored. METHODS Genetic analyses of PRSS1 variants (exon 2 and 3) and SPINK1 variants (exon 1, 2, and 3) including the intronic areas in 118 patients with AIP and 200 control subjects were performed by direct DNA sequencing. Clinical features including imaging, histology, serology, response to steroid, and extra-pancreatic organ involvement in AIP patients with and without variants were compared. RESULTS A total of 19 PRSS1 variants and one SPINK1 variant were identified in 20 (16.9%) out of 118 AIP patients. They included one K92N, nine R116C, seven T137M, one C139S, and one C139F of PRSS1 and one 2(IVS3 + 2) of SPINK1. No PRSS1 or SPINK1 variant was identified in the control group. Patients with PRSS1 variants had an increased risk of AIP with odds ratio 22.37 (95% confidence interval: 2.96-168.8, P = 0.003) and higher frequency of serum IgG4 above 280 mg/dL. Using immunosuppressive agent and PRSS1 variant were predictors of less disease relapse in univariate analysis. Presence of PRSS1 variants was the only negative predictor for disease relapse in multivariate analysis. CONCLUSIONS We found a significantly higher frequency of PRSS1 variants in AIP patients than in geographically and ethnically matched control subjects. PRSS1 variants are associated with less disease relapse in AIP.
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Affiliation(s)
- Ming-Chu Chang
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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13
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Unno J, Kanno A, Masamune A, Kasajima A, Fujishima F, Ishida K, Hamada S, Kume K, Kikuta K, Hirota M, Motoi F, Unno M, Shimosegawa T. The usefulness of endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of pancreatic neuroendocrine tumors based on the World Health Organization classification. Scand J Gastroenterol 2014; 49:1367-74. [PMID: 25180490 DOI: 10.3109/00365521.2014.934909] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND We assessed the controversial topic of using 22-gauge needles in endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for the diagnosis and evaluation of Ki67 labeling indices (Ki67LI) of pancreatic neuroendocrine tumors (pNET). METHODS Thirty-eight patients with pNET who underwent EUS-FNA between January 1, 2008 and December 31, 2012 were enrolled in this study. When available, the Ki67LI and WHO classifications obtained by EUS-FNA and surgical resection were compared. RESULTS EUS-FNA with a 22-gauge needle acquired sufficient histological sample to correctly diagnose pNET in 35 cases (92.1%). Both EUS-FNA and surgical histological specimens were available for 19 cases, and grading classes of the 2 procedures were consistent in 17 cases (89.5%) according to the WHO classification based on the Ki67LI. Tumor size was associated with a difference in the Ki67LI between the 2 procedures, although the Ki67LI was almost completely consistent for tumors less than 18 mm in size. CONCLUSIONS EUS-FNA with a 22-gauge needle is a safe and highly accurate technique for the diagnosis of pNET. There was a clear correlation between the Ki67LI of histological specimens acquired by EUS-FNA and surgery. EUS-FNA with a 22-gauge needle is useful to predict the WHO classification of pNET.
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Affiliation(s)
- Jun Unno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine , Sendai , Japan
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Kamisawa T, Ohara H, Kim MH, Kanno A, Okazaki K, Fujita N. Role of endoscopy in the diagnosis of autoimmune pancreatitis and immunoglobulin G4-related sclerosing cholangitis. Dig Endosc 2014; 26:627-35. [PMID: 24712522 DOI: 10.1111/den.12289] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 02/19/2014] [Indexed: 12/13/2022]
Abstract
Autoimmune pancreatitis (AIP) must be differentiated from pancreatic carcinoma, and immunoglobulin (Ig)G4-related sclerosing cholangitis (SC) from cholangiocarcinoma and primary sclerosing cholangitis (PSC). Pancreatographic findings such as a long narrowing of the main pancreatic duct, lack of upstream dilatation, skipped narrowed lesions, and side branches arising from the narrowed portion suggest AIP rather than pancreatic carcinoma. Cholangiographic findings for PSC, including band-like stricture, beaded or pruned-tree appearance, or diverticulum-like outpouching are rarely observed in IgG4-SC patients, whereas dilatation after a long stricture of the bile duct is common in IgG4-SC. Transpapillary biopsy for bile duct stricture is useful to rule out cholangiocarcinoma and to support the diagnosis of IgG4-SC with IgG4-immunostaining. IgG4-immunostaining of biopsy specimens from the major papilla advances a diagnosis of AIP. Contrast-enhanced endoscopic ultrasonography (EUS) and EUS elastography have the potential to predict the histological nature of the lesions. Intraductal ultrasonographic finding of wall thickening in the non-stenotic bile duct on cholangiography is useful for distinguishing IgG4-SC from cholangiocarcinoma. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is widely used to exclude pancreatic carcinoma. To obtain adequate tissue samples for the histological diagnosis of AIP, EUS-Tru-cut biopsy or EUS-FNA using a 19-gauge needle is recommended, but EUS-FNA with a 22-gauge needle can also provide sufficient histological samples with careful sample processing after collection and rapid motion of the FNA needles within the pancreas. Validation of endoscopic imaging criteria and new techniques or devices to increase the diagnostic yield of endoscopic tissue sampling should be developed.
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Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
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15
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Iglesias-Garcia J, Lariño-Noia J, Domínguez-Muñoz JE. When to puncture, when not to puncture: Pancreatic masses. Endosc Ultrasound 2014; 3:91-7. [PMID: 24955338 PMCID: PMC4064167 DOI: 10.4103/2303-9027.123007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 11/18/2013] [Indexed: 12/16/2022] Open
Abstract
Endoscopic ultrasound (EUS) has evolved to become a crucial tool for the evaluation of pancreatic diseases, among them solid pancreatic lesions. However, its ability to determine whether a lesion is malignant or not is difficult to establish based only in the endosonographic image. EUS-guided fine needle aspiration (EUS-FNA) allows obtaining a cytological and/or histological sample from pancreatic lesions, with a high overall accuracy and low complication rates. Although the clinical usefulness of EUS-FNA for pancreatic diseases is widely accepted, the indications for tissue diagnosis of pancreatic lesions suspected to be malignant is still controversial. This review highlights the diagnostic accuracy and complications of EUS-FNA, focusing on its current indications.
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Affiliation(s)
- Julio Iglesias-Garcia
- Gastroenterology Department, Foundation for Research in Digestive Diseases (FIENAD), University Hospital of Santiago de Compostela, Spain
| | - Jose Lariño-Noia
- Gastroenterology Department, Foundation for Research in Digestive Diseases (FIENAD), University Hospital of Santiago de Compostela, Spain
| | - J Enrique Domínguez-Muñoz
- Gastroenterology Department, Foundation for Research in Digestive Diseases (FIENAD), University Hospital of Santiago de Compostela, Spain
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Miyabe K, Notohara K, Nakazawa T, Hayashi K, Naitoh I, Okumura F, Shimizu S, Yoshida M, Yamashita H, Takahashi S, Ohara H, Joh T. Histological evaluation of obliterative phlebitis for the diagnosis of autoimmune pancreatitis. J Gastroenterol 2014; 49:715-26. [PMID: 23645070 DOI: 10.1007/s00535-013-0818-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 04/15/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Obliterative phlebitis is a useful pathological finding for the diagnosis of lymphoplasmacytic sclerosing pancreatitis (LPSP), or type 1 autoimmune pancreatitis. The present study evaluated histological findings of obliterative phlebitis, including the significance of adding Elastica van Gieson stain (EVG) in comparison with other pancreatic conditions. METHODS Specimens of LPSP (n = 18), chronic pancreatitis (CP; n = 24), and pancreatic ductal adenocarcinoma (PDA; n = 45) were enrolled. Obliterative venous lesions (OVLs), defined as the presence of inflammatory cells and/or fibrosis inside the tunica adventitia, were counted and compared between hematoxylin and eosin stain (H&E) and EVG. OVLs were classified into three types: OVL-1, lymphoplasmacytic infiltration and fibrosis against a loose textured background; OVL-2, dense fibrosis with minimal or no lymphoplasmacytic infiltration; and OVL-3, densely packed lymphoplasmacytic infiltration without fibrosis. OVL type and OVL size were compared between disease groups. RESULTS OVL counts in LPSP, CP, and PDA were significantly higher with EVG than with H&E (p < 0.001). OVL-1 was most common in LPSP (H&E 92.4 %, EVG 79.8 %), and was identified in almost all cases of LPSP, but was less common in CP and PDA. Maximum diameter and OVL count in 1 cm(2) of OVL-1 were high for LPSP. Maximum diameter of OVL-1 ≥150 μm was observed in 17 LPSP, 0 CP, and 1 PDA cases (sensitivity 94.4 %, specificity 98.6 %). CONCLUSIONS Additional EVG is useful for excluding conditions mimicking OVL-1 or detecting OVL in small specimens. The presence of OVL-1 with diameter ≥150 μm is highly diagnostic for LPSP.
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Affiliation(s)
- Katsuyuki Miyabe
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
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Graziani R, Mautone S, Ambrosetti MC, Manfredi R, Re TJ, Calculli L, Frulloni L, Pozzi Mucelli R. Autoimmune pancreatitis: multidetector-row computed tomography (MDCT) and magnetic resonance (MR) findings in the Italian experience. Radiol Med 2014; 119:558-71. [PMID: 24638911 DOI: 10.1007/s11547-013-0373-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 07/30/2013] [Indexed: 12/17/2022]
Abstract
Multidetector-row computed tomography (MDCT) and magnetic resonance (MR) imaging are currently the most frequently performed imaging modalities for the study of pancreatic disease. In cases of suspected autoimmune pancreatitis (AIP), a dynamic quadriphasic (precontrast, contrast-enhanced pancreatic, venous and late phases) study is recommended in both techniques. In the diffuse form of autoimmune pancreatitis (DAIP), the pancreatic parenchyma shows diffuse enlargement and appears, during the MDCT and MR contrast-enhanced pancreatic phase, diffusely hypodense and hypointense, respectively, compared to the spleen because of lymphoplasmacytic infiltration and pancreatic fibrosis. During the venous phase of MDCT and MR imaging, the parenchyma appears hyperdense and hyperintense, respectively, in comparison to the pancreatic phase. In the delayed phase of both imaging modalities, it shows retention of contrast media. A "capsule-like rim" may be recognised as a peripancreatic MDCT hyperdense and MR hypointense halo in the T2-weighted images, compared to the parenchyma. DAIP must be differentiated from non-necrotizing acute pancreatitis (NNAP) and lymphoma since both diseases show diffuse enlargement of the pancreatic parenchyma. The differential diagnosis is clinically difficult, and dynamic contrast-enhanced MDCT has an important role. In the focal form of autoimmune pancreatitis (FAIP), the parenchyma shows segmental enlargement involving the head, the body-tail or the tail, with the same contrast pattern as the diffuse form on both modalities. FAIP needs to be differentiated from pancreatic adenocarcinoma to avoid unnecessary surgical procedures, since both diseases have similar clinical and imaging presentation. The differential diagnosis is clinically difficult, and dynamic contrast-enhanced MDCT and MR imaging both have an important role. MR cholangiopancreatography helps in the differential diagnosis. Furthermore, MDCT and MR imaging can identify the extrapancreatic manifestations of AIP, most commonly biliary, renal and retroperitoneal. Finally, in all cases of uncertain diagnosis, MDCT and/or MR follow-up after short-term treatment (2-3 weeks) with high-dose steroids can identify a significant reduction in size of the pancreatic parenchyma and, in FAIP, normalisation of the calibre of the upstream main pancreatic duct.
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Affiliation(s)
- Rossella Graziani
- Department of Radiology, "G.B. Rossi" Hospital, University of Verona, P.le L.A. Scuro 11, 37134, Verona, Italy,
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Zhang X, Liu X, Joseph L, Zhao L, Hart J, Xiao SY. Pancreatic ductal adenocarcinoma with autoimmune pancreatitis-like histologic and immunohistochemical features. Hum Pathol 2014; 45:621-7. [DOI: 10.1016/j.humpath.2013.08.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 08/07/2013] [Accepted: 08/09/2013] [Indexed: 01/06/2023]
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Moon SH, Kim MH. Autoimmune pancreatitis: role of endoscopy in diagnosis and treatment. Gastrointest Endosc Clin N Am 2013; 23:893-915. [PMID: 24079796 DOI: 10.1016/j.giec.2013.06.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This review addresses the role of endoscopy in the diagnosis and treatment of autoimmune pancreatitis (AIP) and provides a diagnostic process for patients with suspected AIP. When should AIP be suspected? When can it be diagnosed without endoscopic examination? Which endoscopic approaches are appropriate in suspected AIP, and when? What are the roles of diagnostic endoscopic retrograde pancreatography, endoscopic biopsies, and IgG4 immunostaining? What is the proper use of the steroid trial in the diagnosis of AIP in patients with indeterminate computed tomography imaging? Should biliary stenting be performed in patients with AIP with obstructive jaundice?
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Affiliation(s)
- Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 896 Pyeongchon-dong, Dongan-gu, Anyang 431-070, South Korea
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20
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Kongkam P, Ang TL, Vu CKF, Dy FT, Yasuda K, Rerknimitr R, Varadarajulu S, Dhir V, Chong VH, Zhen DJ, Wong JYY, Ho KY. Current status on the diagnosis and evaluation of pancreatic tumor in Asia with particular emphasis on the role of endoscopic ultrasound. J Gastroenterol Hepatol 2013; 28:924-30. [PMID: 23488477 DOI: 10.1111/jgh.12198] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2013] [Indexed: 12/16/2022]
Abstract
In Asia, the incidence of pancreatic cancer in some countries has been increasing. Owing to most cases being diagnosed late, prognosis for pancreatic cancer remains dismal. It is clear that the future for pancreatic cancer lies in early detection. While the possible presence of pancreatic masses is often first raised by non-invasive abdominal imaging, such as computerized tomography and magnetic resonance imaging, smaller lesions and locoregional lymph node metastases are often not detectable by these means. Endoscopic ultrasonography (EUS) offers a higher sensitivity (93-100%) for detection of small potentially curable pancreatic masses than other existing imaging modalities. It is also recommended for the evaluation of portal vein confluence, portal vein, celiac axis, and superior mesentric artery origin, and exclusion of resectability. Due to the closer proximity of EUS to the target structure, and lower rate of needle tract seeding, EUS-guided fine-needle aspiration of pancreatic mass is considered the most suitable tissue acquisition technique. Lastly, EUS also enables the performance of endoscopic interventions. Its performance can be further enhanced with newer techniques, including contrast-enhanced ultrasound and elastrography. It is anticipated that in the near future, molecular technologies may make it possible to detect microscopic amounts of cancer in tissue or blood, predict relapse and survival after therapy, as well as determine optimal therapy.
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Affiliation(s)
- Pradermchai Kongkam
- Endoscopic Ultrasound Research Unit, Chulalongkorn University, Bangkok, Thailand
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Yoneda M, Inada H, Kanayama K, Shiraishi T. A case of pancreatic ductal adenocarcinoma with marked infiltration with IgG4-positive cells. J Cytol 2013; 30:46-8. [PMID: 23661941 PMCID: PMC3643362 DOI: 10.4103/0970-9371.107513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
A 75-year-old man was diagnosed as having pancreatic ductal carcinoma containing remarkable lymphocytic and plasma cell infiltration, as revealed by the cytological examination of endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) specimen. The EUS-FNA specimen showed small amounts of atypical epithelium with noticeable lymphocytes and plasma cells. A pancreatic resection was performed, and the histopathological features showed an invasive pancreatic ductal carcinoma with autoimmune pancreatitis (AIP) lymphoplasmacytic sclerosing pancreatitis (LPSP)-like lesions. Most of the plasma cells were immunoreactive to anti-IgG4 antibody. EUS-FNA may be necessary for the differential diagnosis of AIP and pancreatic cancer, and close attention should be given to the presence of marked lymphoplasmacytic cells in EUS-FNA specimens while making the diagnosis.
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Affiliation(s)
- M Yoneda
- Department of Pathologic Oncology, Institute of Molecular and Experimental Medicine, Faculty of Medicine, Mie University Graduate School of Medicine, Japan
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22
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Moon SH, Kim MH. The role of endoscopy in the diagnosis of autoimmune pancreatitis. Gastrointest Endosc 2012; 76:645-56. [PMID: 22898422 DOI: 10.1016/j.gie.2012.04.458] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/17/2012] [Indexed: 02/08/2023]
Affiliation(s)
- Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea
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Kanno A, Ishida K, Hamada S, Fujishima F, Unno J, Kume K, Kikuta K, Hirota M, Masamune A, Satoh K, Notohara K, Shimosegawa T. Diagnosis of autoimmune pancreatitis by EUS-FNA by using a 22-gauge needle based on the International Consensus Diagnostic Criteria. Gastrointest Endosc 2012; 76:594-602. [PMID: 22898417 DOI: 10.1016/j.gie.2012.05.014] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 05/09/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND It is controversial whether EUS-guided FNA by using 22-gauge (G) needles is useful for the diagnosis or evaluation of autoimmune pancreatitis (AIP). OBJECTIVE To evaluate the usefulness of EUS-FNA by 22-G needles for the histopathological diagnosis of AIP. DESIGN A retrospective study. SETTING Single academic center. PATIENTS A total of 273 patients, including 25 with AIP, underwent EUS-FNA and histological examinations. RESULTS EUS-FNA by using 22-G needles provided adequate tissue samples for histopathological evaluation because more than 10 high-power fields were available for evaluation in 20 of 25 patients (80%). The mean immunoglobulin G4-positive plasma cell count was 13.7/high-power field. Obliterative phlebitis was observed in 10 of 25 patients (40%). In the context of the International Consensus Diagnostic Criteria for AIP, 14 and 6 of 25 patients were judged to have level 1 (positive for 3 or 4 items) and level 2 (positive for 2 items) histological findings, respectively, meaning that 20 of 25 patients were suggested to have lymphoplasmacytic sclerosing pancreatitis based on the International Consensus Diagnostic Criteria. The diagnosis in 1 patient was type 2 AIP because a granulocytic epithelial lesion was identified in this patient. LIMITATIONS A retrospective study with a small number of patients. CONCLUSIONS The results of this study suggest that EUS-FNA by using 22-G needles provides tissue samples adequate for histopathological evaluation and greatly contributes to the histological diagnosis of AIP.
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Affiliation(s)
- Atsushi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Histopathologic Overlap between Fibrosing Mediastinitis and IgG4-Related Disease. Int J Rheumatol 2012; 2012:207056. [PMID: 22654916 PMCID: PMC3357960 DOI: 10.1155/2012/207056] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 02/16/2012] [Accepted: 02/20/2012] [Indexed: 12/21/2022] Open
Abstract
Fibrosing mediastinitis (FM) and IgG4-related disease (IgG4-RD) are two fibroinflammatory disorders with potentially overlapping clinical and radiological features. In this paper, we looked for histopathologic features of IgG4-RD and enumerated infiltrating IgG4-positive plasma cells within mediastinal tissue biopsies from FM patients. We identified 15 consecutive FM surgical mediastinal tissue biopsies between 1985 and 2006. All patients satisfied the clinical and radiological diagnostic criteria for FM. All patients had either serological or radiological evidence of prior histoplasmosis or granulomatous disease, respectively. Formalin-fixed paraffin-embedded tissue sections of all patients were stained for H&E, IgG, and IgG4. Three samples met the predefined diagnostic criteria for IgG4-RD. In addition, characteristic histopathologic changes of IgG4-RD in the absence of diagnostic numbers of tissue infiltrating IgG4-positive plasma cells were seen in a number of additional cases (storiform cell-rich fibrosis in 11 cases, lymphoplasmacytic infiltrate in 7 cases, and obliterative phlebitis/arteritis in 2 cases). We conclude that up to one-third of histoplasmosis or granulomatous-disease-associated FM cases demonstrate histopathological features of IgG4-RD spectrum. Whether these changes occur as the host immune response against Histoplasma or represent a manifestation of IgG4-RD remains to be determined. Studies to prospectively identify these cases and evaluate their therapeutic responses to glucocorticoids and/or other immunosuppressive agents such as rituximab are warranted.
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Iwashita T, Yasuda I, Doi S, Ando N, Nakashima M, Adachi S, Hirose Y, Mukai T, Iwata K, Tomita E, Itoi T, Moriwaki H. Use of samples from endoscopic ultrasound-guided 19-gauge fine-needle aspiration in diagnosis of autoimmune pancreatitis. Clin Gastroenterol Hepatol 2012; 10:316-22. [PMID: 22019795 DOI: 10.1016/j.cgh.2011.09.032] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 09/11/2011] [Accepted: 09/28/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Histologic techniques are used to distinguish autoimmune pancreatitis (AIP) from pancreatic malignancies and to confirm the etiology of pancreatitis. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a well-established technique used in the diagnosis of pancreatic cancer. However, it is unclear whether specimens obtained from pancreatic lesions by EUS-FNA are adequate for the histologic diagnosis of AIP, because the evaluation of tissue architecture and immunostaining assays usually require larger samples. METHODS We evaluated samples collected by EUS-FNA with a conventional 19-gauge needle by histologic analysis, looking for features of AIP. We analyzed data from 44 patients who were diagnosed with AIP and underwent EUS-FNA with a 19-gauge needle from January 2004 to September 2010. The FNA specimens were reviewed by histologic analysis; AIP was diagnosed based on the presence of lymphoplasmacytic sclerosing pancreatitis or immunoglobulin (Ig)G4-positive plasma cells in the infiltrate. RESULTS The specimen amount was inadequate from 3 patients. Among the remaining 41 patients, histopathologic analysis revealed lymphoplasmacytic sclerosing pancreatitis in 17 samples and IgG4-positive plasma cells in 5 (3 samples were positive for both); no samples had granulocytic epithelial lesions. Therefore, 19 patients (43%) were diagnosed with AIP based on histologic analysis. One patient had temporary abdominal pain. CONCLUSIONS EUS-FNA, with a 19-gauge needle, is a safe and reliable procedure for obtaining pancreatic samples for the histologic analysis of AIP. Although it does not have a high diagnostic yield, it might be useful in patients without typical features of AIP because it would allow patients to avoid surgery.
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Affiliation(s)
- Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
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Affiliation(s)
- John H Stone
- Harvard Medical School and Department of Medicine (Division of Rheumatology, Allergy, and Immunology), Massachusetts General Hospital, Boston, MA 02114, USA.
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Watson RR, Brugge WR. The role of endoscopy in the management of autoimmune pancreatitis. Expert Rev Gastroenterol Hepatol 2012; 6:5-8. [PMID: 22149574 DOI: 10.1586/egh.11.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Imai K, Matsubayashi H, Fukutomi A, Uesaka K, Sasaki K, Ono H. Endoscopic ultrasonography-guided fine needle aspiration biopsy using 22-gauge needle in diagnosis of autoimmune pancreatitis. Dig Liver Dis 2011; 43:869-74. [PMID: 21733766 DOI: 10.1016/j.dld.2011.05.021] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 05/23/2011] [Accepted: 05/29/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUNDS The effectiveness of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has not been fully evaluated in the diagnosis of autoimmune pancreatitis (AIP). AIM To evaluate the effectiveness of EUS-FNA using 22-gauge needles in the diagnosis of AIP. METHODS EUS-FNA was examined in 85 patients with pancreatic mass, including 64 patients with pancreatic cancer and 21 patients with AIP. We investigated ability of EUS-FNA using 22-gauge needle for the differential diagnosis between AIP and pancreatic cancer. We also compared the factors concerning FNA procedures (number of needle passes, size of lesion, device, and amount of obtained pancreatic tissue) between two diseases. RESULTS Tissues obtained from 21 patients with AIP, although none of them demonstrated histology suspicious for malignancy, did not show histological evidence definitive for AIP. The amount of obtained pancreatic tissue was almost equal between two diseases in each pancreatic location. Sensitivity, specificity, overall accuracy, and negative predictive value of histological diagnosis of pancreatic cancer were 92.2%, 100%, 94.1%, and 80.8%, respectively. CONCLUSION EUS-FNA using 22-gauge needle distinguished benign from malignant pancreatic mass with >90% of accuracy, regardless of the location. Hence, it was helpful for the clinical diagnosis of AIP, however not providing satisfactory samples for the histological diagnosis of AIP.
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Affiliation(s)
- Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Suntogun, Shizuoka 411-8777, Japan
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Kamisawa T, Takuma K, Hara S, Tabata T, Kuruma S, Inaba Y, Gopalakrishna R, Egawa N, Itokawa F, Itoi T. Management strategies for autoimmune pancreatitis. Expert Opin Pharmacother 2011; 12:2149-59. [PMID: 21711086 DOI: 10.1517/14656566.2011.595710] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Autoimmune pancreatitis (AIP) is a newly developed concept for a peculiar type of pancreatitis, and at present is recognized as a pancreatic lesion reflecting IgG4-related systemic disease. It is of utmost importance to differentiate AIP from pancreatic cancer to avoid unnecessary surgery. AREAS COVERED The current management strategies for AIP, including its clinical features, diagnostic criteria, clinical subtypes, steroid therapy and prognosis are discussed, based on our 66 AIP cases and papers searched in PubMed from 1992 to March 2011, using the term 'autoimmune pancreatitis'. A new clinicopathological entity, an 'IgG4-related sclerosing disease' is also mentioned. EXPERT OPINION AIP should be considered in the differential diagnosis in elderly male patients presented with obstructive jaundice and pancreatic mass. Steroids are a standard therapy for AIP, but their regimen including maintenance therapy should be evaluated in prospective trials.
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Affiliation(s)
- Terumi Kamisawa
- Tokyo Metropolitan Komagome Hospital, Department of Internal Medicine, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan.
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Giday SA, Khashab MA, Buscaglia JM, Krishnamurty DM, Chen T, Kalloo AN, Canto MI, Okolo PI, Hruban RH, Jagannath SB. Autoimmune pancreatitis: current diagnostic criteria are suboptimal. J Gastroenterol Hepatol 2011; 26:970-3. [PMID: 21299615 DOI: 10.1111/j.1440-1746.2011.06683.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIMS The preoperative diagnosis of autoimmune pancreatitis (AIP) is difficult, given its similar clinical presentation to pancreatic cancer. The aims of the study are to describe our center's experience with AIP and apply the Japanese AIP diagnostic criteria to a cohort of patients with histologically-proven AIP in order to assess their performance characteristics. METHODS A prospective pathology database was queried for AIP patients who were evaluated and/or treated at Johns Hopkins Hospital from 2002 to 2009. AIP histology was defined by the presence of lymphoplasmacytic infiltration, periductal inflammation, fibrosis, and periphlebitis. Imaging, clinical, and biochemical data were analyzed. RESULTS Thirty patients had pancreatic resection with pathological confirmation of AIP. Imaging revealed pancreatic mass (45%), focal prominence without mass lesion (24%), diffuse enlargement (17%), and normal pancreas (14%). Twenty-four patients underwent an endoscopic retrograde cholangiopancreatography and/or magnetic resonance cholangiopancreatography, and 4/24 (17%) had pancreatic ductal narrowing or irregularity. Extrapancreaticobiliary organ involvement was found in 6% (n = 2) of patients. Biliary strictures were present in 87% of patients. Of 16 patients who underwent preoperative tissue biopsy, 10 had non-diagnostic pathology, five had cellular atypia, and one had AIP. Serum immunoglobulin G4 (IgG4) levels were elevated in 12 of 29 (41%) patients. Three (10%) patients had evidence of extrapancreatic manifestations of AIP. When applying the Japanese criteria to the 27 patients who had serum IgG4 measurement, preoperative biopsy, and cross-sectional abdominal imaging, only 44% of the patients would have been diagnosed accurately. CONCLUSIONS When applied to a highly-selected single-center referral population in the USA, current Japanese guidelines for the diagnosis of AIP are found to have suboptimal sensitivity.
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Affiliation(s)
- Samuel A Giday
- Department of Medicine and Division of Gastroenterology and Hepatology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
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Gerstenmaier JF, Malone DE. RE: Mass lesions in chronic pancreatitis: benign or malignant? An "evidence-based practice" approach. A caveat regarding autoimmune pancreatitis. ACTA ACUST UNITED AC 2011; 37:151-2. [PMID: 21567269 DOI: 10.1007/s00261-011-9746-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Swan MP, Bourke MJ, Hopper AD, Kwan V, Williams SJ. Autoimmune pancreatitis: an important diagnostic consideration in obstructive jaundice due to a pancreatic mass lesion. Intern Med J 2010; 40:720-5. [DOI: 10.1111/j.1445-5994.2010.02300.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Neuzillet C, Lepère C, Hajjam ME, Palazzo L, Fabre M, Turki H, Hammel P, Rougier P, Mitry E. Autoimmune pancreatitis with atypical imaging findings that mimicked an endocrine tumor. World J Gastroenterol 2010; 16:2954-8. [PMID: 20556844 PMCID: PMC2887594 DOI: 10.3748/wjg.v16.i23.2954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Autoimmune pancreatitis (AIP) is a rare cause of recurrent acute pancreatitis or chronic pancreatitis in middle-aged patients, and is characterised by a marked infiltration of lymphocytes and plasma cells in pancreatic tissue. Diagnosis of focal forms can be difficult as AIP may mimic pancreatic adenocarcinoma. Pediatric cases of AIP are exceptional. We report the case of a 15-year-old girl who had a focal AIP and associated cholangitis, with a very unusual vascularized mass that mimicked a pancreatic endocrine tumor. The diagnosis was obtained by a pancreatic biopsy, thus avoiding surgical resection, and all the clinical, biological and radiological abnormalities resolved after steroid therapy with 6 mo of follow-up.
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IgG4 immunostaining of duodenal papillary biopsy specimens may be useful for supporting a diagnosis of autoimmune pancreatitis. Gastrointest Endosc 2010; 71:960-6. [PMID: 20304394 DOI: 10.1016/j.gie.2009.12.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2009] [Accepted: 12/03/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Autoimmune pancreatitis (AIP) is now considered to be part of an immunoglobulin G4 (IgG4)-related systemic fibroinflammatory disease. OBJECTIVE We evaluated whether IgG4 immunostaining of duodenal papillary biopsy specimens is useful for supporting a diagnosis of AIP. DESIGN A prospective study. SETTING A tertiary academic center. PATIENTS/INTERVENTIONS We obtained 2 forceps biopsy specimens from the major duodenal papilla (MDP) of 19 symptomatic AIP patients during ERCP before steroid administration. As a control, biopsy specimens were obtained from the MDP of patients with pancreatic cancer (n = 35), cholangiocarcinoma (n = 20), ampullary cancer (n = 11), ordinary chronic pancreatitis (n = 18), and AIP in remission (n = 16) and immunohistochemically examined. MAIN OUTCOME MEASUREMENTS Specimens were considered positive for IgG4 immunostaining if there were more than 10 IgG4-positive plasma cells per high-power field. RESULTS Positive IgG4 immunostaining of the MDP was found in 10 (53%) of 19 symptomatic AIP patients, but was absent in the control groups. Among symptomatic AIP patients (n = 19), 5 (83%) of 6 AIP patients with elevated serum IgG4 levels exhibited positive IgG4 staining of the MDP, whereas 5 (38%) of 13 AIP patients with normal serum IgG4 levels showed positive IgG4 staining of the MDP. Nine of 19 symptomatic AIP patients also underwent pancreatic biopsy, and positive IgG4 immunostaining of the MDP was observed in patients with positive pancreas IgG4 staining (4/6, 67%), but not in patients with negative pancreas IgG4 staining (0/3). LIMITATIONS Small symptomatic AIP patient population. CONCLUSIONS Positive IgG4 immunostaining of the MDP was an extremely specific and moderately sensitive tool for the diagnosis of AIP. IgG4 immunostaining of the MDP may be useful for supporting a diagnosis of AIP, especially when AIP is suspected clinically but serum IgG4 levels are normal or pancreatic tissue is not available.
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Abstract
BACKGROUND Autoimmune pancreatitis (AIP) is a relatively newly recognized type of pancreatitis that is characterized by diffuse or focal swelling of the pancreas due to lymphoplasmacytic infiltration and fibrosis of the pancreatic parenchyma. MATERIAL AND METHODS A PubMed literature search was performed using the keywords "autoimmune pancreatitis". Sometimes, bibliographies were cross-referenced and related article searches were performed once an article of interest was identified. RESULTS Pathologically, AIP shows narrowing of the pancreatic ducts and the intrapancreatic portion of the common bile duct. Obstructive jaundice is a common symptom at presentation, and pancreatic cancer represents an important clinical differential diagnosis. In late stages of the disease, the normal pancreatic parenchyma is often replaced by large amounts of fibrosis. Histologically, there seem to be two subtypes of the disease-one showing infiltration with IgG4-positive plasma cells but lacking granulocytic epithelial lesions (GELs), the other showing GELs but lacking strong IgG4 positivity. AIP is in at least some instances the pancreatic manifestation of a clinicopathological entity of IgG4-related systemic sclerosing disease. On the basis of pancreatic imaging, together with serological measurement of IgG4 and evaluation of other organ involvement, many AIP patients can be identified. The remaining patients require further diagnostic work-up. In these patients, pancreatic core needle biopsy and, as AIP responds to steroid treatment, also a trial with steroids, can help to differentiate AIP from pancreatic cancer. OUTLOOK AND DISCUSSION: This review presents the pathological, radiologic and laboratory findings of AIP. Moreover, the treatment and pathogenesis are discussed.
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Affiliation(s)
- Sönke Detlefsen
- Department of Pathology, Odense University Hospital, Odense, Denmark.
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Kamisawa T, Anjiki H, Takuma K, Egawa N, Itoi T, Itokawa F. Endoscopic approach for diagnosing autoimmune pancreatitis. World J Gastrointest Endosc 2010; 2:20-4. [PMID: 21160674 PMCID: PMC2999079 DOI: 10.4253/wjge.v2.i1.20] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 08/26/2009] [Accepted: 09/02/2009] [Indexed: 02/05/2023] Open
Abstract
It is of utmost importance to differentiate autoimmune pancreatitis (AIP) from pancreatic cancer (PC). Segmental AIP cases are sometimes difficult to differentiate from PC. On endoscopic retrograde cholangiopancreatography, long or skipped irregular narrowing of the main pancreatic duct (MPD), less upstream dilatation of the distal MPD, side branches derived from the narrowed portion of the MPD, absence of obstruction of the MPD, and stenosis of the intrahepatic bile duct suggest AIP rather than PC. Abundant infiltration of IgG4-positive plasma cells is frequently and rather specifically detected in the major duodenal papilla of AIP patients. IgG4-immunostaining of biopsy specimens obtained from the major duodenal papilla is useful for supporting a diagnosis of AIP with pancreatic head involvement. On endoscopic ultrasonography (EUS), hyperechoic spots in the hypoechoic mass and the duct-penetrating sign suggest AIP rather than PC. EUS and intraductal ultrasonography sometimes show wall thickening of the common bile duct even in the segment in which abnormalities are not clearly observed with cholangiography in AIP patients. EUS-guided fine needle aspiration, especially EUS-guided Tru-Cut biopsy, is useful to diagnose AIP, as well as to exclude PC.
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Affiliation(s)
- Terumi Kamisawa
- Terumi Kamisawa, Hajime Anjiki, Kensuku Takuma, Naoto Egawa, Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo 113-8677, Japan
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Diagnostic utility of biopsy specimens for autoimmune pancreatitis. J Gastroenterol 2009; 44:765-73. [PMID: 19430718 DOI: 10.1007/s00535-009-0052-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Accepted: 03/15/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Infiltration of IgG4-positive plasma cells in the pancreas and other organs is characteristic of autoimmune pancreatitis (AIP). However, it is undetermined whether needle or forceps biopsy of pancreas or other organs is indeed useful for the diagnosis of AIP. We aimed to clarify this point. METHODS Among 39 AIP patients, tissue sampling without laparotomy was performed in 27. Biopsy of pancreas, gastric mucosa, liver, bile duct, and duodenal papilla was performed in 15, 17, 11, 5 and 7, respectively. The obtained specimens were examined for IgG4-positive plasma cells. We also examined gastric mucosa of 18 patients with pancreatic cancer as controls. When the number of IgG4-positive plasma cells was more than 10 per high-power field, we regarded it as diagnostic. RESULTS Diagnostic sensitivity in pancreas, gastric mucosa, liver, bile duct, and duodenal papilla was 47% (7/15), 47% (8/17), 36% (4/11), 0% (0/5), and 57% (4/7), respectively. CONCLUSIONS Sensitivity of IgG4 immunostaining was unsatisfactory when tissue sampling was performed by needle or forceps biopsy. Biopsy of gastric mucosa might be a good subsidiary diagnostic tool.
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The clinical and radiological characteristics of focal mass-forming autoimmune pancreatitis: comparison with chronic pancreatitis and pancreatic cancer. Pancreas 2009; 38:401-8. [PMID: 18981953 DOI: 10.1097/mpa.0b013e31818d92c0] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We investigated the clinical and radiological features of focal mass-forming autoimmune pancreatitis (FMF AIP) to help physicians avoid performing unnecessary surgery because of an improper diagnosis. METHODS We evaluated 23 patients with chronic inflammatory pancreatic masses and who underwent pancreatectomy for presumed pancreatic cancer from April 1995 to December 2005. These patients were distinguished into 8 FMF AIP patients and 15 ordinary chronic pancreatitis patients through a histological review, along with considering the immunoglobulin G4 staining. Twenty-six randomly selected pancreatic cancer patients were also evaluated as a control group. RESULTS On the portal venous phase of computed tomography, 6 (85.7%) of 7 FMF AIP patients showed homogeneous enhancement, whereas only 3 chronic pancreatitis patients (25%) and none of the pancreatic cancer patients showed homogeneous enhancement (P < 0.001). None of the FMF AIP patients showed upstream main pancreatic duct dilatation greater than 5 mm or proximal pancreatic atrophy. CONCLUSIONS For patients with a pancreatic mass, if their radiological images show homogeneous enhancement on the portal venous phase, the absence of significant upstream main pancreatic duct dilatation greater than 5 mm, and the absence of proximal pancreatic atrophy, then conducting further evaluations should be considered to avoid performing unnecessary surgery.
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Yamao K, Bhatia V, Mizuno N, Sawaki A, Shimizu Y, Irisawa A. Interventional endoscopic ultrasonography. J Gastroenterol Hepatol 2009; 24:509-19. [PMID: 19220671 DOI: 10.1111/j.1440-1746.2009.05783.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Endoscopic ultrasonography (EUS) is the combination of endoscopy and intraluminal ultrasonography. This allows use of a high frequency transducer, which, due to the short distance to the target lesion, enables ultrasonographic images of high resolution to be obtained. Endoscopic ultrasonography is now a widely accepted modality for the diagnosis of pancreatobiliary diseases. It can be used to determine the depth of invasion of gastrointestinal malignancies, and often for visualizing lesions more precisely than other imaging modalities. The most important early limitation of EUS was the lack of specificity in the differentiation between benign and malignant changes. In 1992, EUS-guided fine needle aspiration (EUS-FNA) of lesions in the pancreas head has been made possible using a curved linear array echoendoscope. Since then, many researchers have expanded the indication of EUS-FNA to various kinds of lesions and also for a variety of therapeutic purposes. In this review, we particularly focus on the present and future roles of interventional EUS, including EUS-FNA and therapeutic EUS.
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Affiliation(s)
- Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan.
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Abstract
Autoimmune pancreatitis (AIP) is the pancreatic manifestation of a systemic fibroinflammatory disorder. It has been recognized as a distinct clinical entity, only recently. Multiple organs, such bile ducts, salivary glands, kidneys and lymph nodes, can be involved either synchronously or metachronously. It is one of the few autoimmune conditions that predominantly affects male subjects in the fifth and sixth decades of life. Obstructive jaundice is the most common presenting symptom but the presentation can be quite nonspecific. There are established diagnostic criteria to diagnose AIP, most of which rely on a combination of clinical presentation, imaging of the pancreas and other organs (by CT scan, MRI and endoscopic retrograde pancreatography), serology, pancreatic histology and response to steroids to make the diagnosis. It is imperative to differentiate AIP from pancreatic cancer owing to the vastly different prognostic and therapeutic implications. AIP responds dramatically to steroid treatment but relapses are common. Relapse of AIP can often be retreated with steroids. As the collective experience with this condition increases, a better understanding of the natural history of this disease is emerging.
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Affiliation(s)
- Aravind Sugumar
- Mayo Clinic College of Medicine, Division of Gastroenterology and Hepatology, 200 First St SW, Rochester, MN, USA.
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Diagnosis of autoimmune pancreatitis by core needle biopsy: application of six microscopic criteria. Virchows Arch 2009; 454:531-9. [PMID: 19238431 DOI: 10.1007/s00428-009-0747-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Revised: 02/10/2009] [Accepted: 02/11/2009] [Indexed: 12/13/2022]
Abstract
Autoimmune pancreatitis (AIP) has been established as a special entity of chronic pancreatitis (CP). However, its clinical distinction from pancreatic cancer and other types of CP is still difficult. The aim of this study was to evaluate the efficacy of pancreatic core needle biopsy for the diagnosis of AIP. In 44 core needle biopsy specimens, we assessed the following microscopic features: granulocytic epithelial lesions (GELs), more than ten IgG4-positive plasma cells/HPF, more than ten eosinophilic granulocytes/HPF, cellular fibrosis with inflammation, lymphoplasmacytic infiltration, and venulitis. All biopsies that showed four or more of the six features (22 of 44) were obtained from 21 of 26 patients whose clinical diagnosis and follow-up were consistent with AIP. All non-AIP CP patients (n = 14) showed three or less than three of the features in their biopsies. GELs were only observed in biopsy specimens from AIP patients. In conclusion, our data indicate that the six criteria we applied were able to recognize AIP in 76% of biopsy specimens using a cut-off level of four. When the specimens that revealed only three features but showed GELs were added, the sensitivity rose to 86%. Pancreatic core needle biopsy can therefore make a significant contribution to the diagnosis of AIP.
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Affiliation(s)
- Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
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Hartwig W, Schneider L, Diener MK, Bergmann F, Büchler MW, Werner J. Preoperative tissue diagnosis for tumours of the pancreas. Br J Surg 2009; 96:5-20. [PMID: 19016272 DOI: 10.1002/bjs.6407] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Preoperative biopsy of pancreatic lesions suspected of malignancy is controversial. METHODS A systematic Medline literature search was carried out. Diagnostic studies reporting quantitative preoperative pancreatic biopsy data were evaluated. RESULTS The analysis included 53 studies, mostly of a retrospective nature. Despite acceptable rates for sensitivity and specificity, the negative predictive value of percutaneous and endoscopic ultrasonography-guided biopsies was 60-70 per cent. Biopsy results were considered to be essential for directing non-surgical therapy in advanced disease. However, they were of limited value in planning the treatment of resectable solid or cystic tumours, or focal lesions in the setting of chronic pancreatitis. CONCLUSIONS Biopsy of suspected pancreatic malignancies with systemic spread or local irresectability is indicated for planning palliative or neoadjuvant therapy. Preoperative biopsy of potentially resectable pancreatic tumours is not generally advisable, as malignancy cannot be ruled out with adequate reliability.
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Affiliation(s)
- W Hartwig
- Department of General Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, Germany
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45
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Gincoul R, Pujol B, Dumortier J, Scoazec JY, Hervieu V, Crombe-Ternamian A, Pilleul F, Napoléon B, Ponchon T. [Bile duct involvement in autoimmune pancreatitis: classification and treatment]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2008; 32:914-921. [PMID: 18472376 DOI: 10.1016/j.gcb.2007.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Autoimmune pancreatitis is a rare disease characterized by inflammation of the pancreatic parenchyma, irregular narrowing of the pancreatic duct, periductal lymphoplasmacytic infiltration and fibrosis at histological examination, the presence of autoantibodies and hypergammaglobulinemia, as well as the possible association of cholangitis and other autoimmune diseases. There is a favorable response to steroid therapy. We report the case of a patient with autoimmune pancreatitis with bile duct involvement and peripheral eosinophilia, requiring long-term immunosuppressant treatment. The diagnosis of a diffuse form of AIP was made without direct histological evidence and based on indirect imaging, clinical and laboratory findings in an autoimmune context. The histological and imaging studies of bile duct involvement and the favourable response to steroids were additional arguments.
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Affiliation(s)
- R Gincoul
- Service d'hépatogastroentérologie, pavillon H, hôpital Edouard-Herriot, Lyon cedex 03, France.
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Abstract
OBJECTIVES The ideal diagnostic criteria of autoimmune pancreatitis (AIP) are still challenging. Therefore, we investigated the clinical features of AIP in Korea and assessed the clinical use of new Korean diagnostic criteria. METHODS We reviewed 67 patients with AIP enrolled in 16 hospitals via a multicenter study. The diagnosis was confirmed according to the Korean diagnostic criteria that included pancreatic imaging, laboratory findings, histopathology, and response to steroid. RESULTS Mean age of the patients was 56 years, and 73% were men. Obstructive jaundice (52%) was the most common symptom, and 14 patients (21%) had other organ involvement. Fifty-four patients (81%) revealed diffuse swelling of the pancreas. Either immunoglobulin (Ig)G or IgG4 was elevated in 76%. According to the Korean criteria, 65 patients had definite diagnostic criteria, and 2 patients had probable criteria. Fifteen patients were fulfilled with image, serological, and histopathologic criteria, and 4 patients could be diagnosed with image and steroid responsiveness. Ten patients experienced recurrent attacks of AIP during the mean 20-month follow-up. CONCLUSIONS Among 67 cases of AIP, either IgG or IgG4 was elevated in 76% of patients, and 14 patients (21%) had other organ involvement. New Korean diagnostic criteria are useful for diagnosis of AIP.
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Alexander S, Bourke MJ, Williams SJ, Bailey A, Gill A, Kench JG. Diagnosis of autoimmune pancreatitis with intraductal biliary biopsy and treatment of stricture with serial placement of multiple biliary stents. Gastrointest Endosc 2008; 68:396-9. [PMID: 18279859 DOI: 10.1016/j.gie.2007.11.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Accepted: 11/28/2007] [Indexed: 02/08/2023]
Affiliation(s)
- Sina Alexander
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
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Abstract
Autoimmune pancreatitis is the pancreatic manifestation of a systemic disorder that affects various organs, including the bile duct, retroperitoneum, kidney, and parotid and lacrimal glands. It represents a recently described subset of chronic pancreatitis that is immune mediated and has unique histologic, morphologic, and clinical characteristics. A hallmark of the disease is its rapid response to corticosteroid treatment. Although still a rare disease, autoimmune pancreatitis is increasingly becoming recognized clinically, leading to evolution in the understanding of its prognosis, clinical characteristics, and treatment.
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Affiliation(s)
- Timothy B Gardner
- Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, Rochester, MN 55905, USA
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Kakar S, Smyrk TC. Autoimmune pancreatitis: negotiating the labyrinth of terminology, diagnosis and differential diagnosis. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.mpdhp.2008.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Ghazale AH, Chari ST, Vege SS. Update on the diagnosis and treatment of autoimmune pancreatitis. Curr Gastroenterol Rep 2008; 10:115-121. [PMID: 18462596 DOI: 10.1007/s11894-008-0031-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Autoimmune pancreatitis (AIP) is the pancreatic manifestation of a systemic fibroinflammatory disease (IgG4-related systemic disease) in which affected organs demonstrate dense lymphoplasmacytic infiltration with abundant IgG4-positive cells. The diagnosis of AIP and its differentiation from pancreatic cancer, its main differential diagnosis, remains a clinical challenge. The five cardinal features of AIP are characteristic histology, imaging, and serology; other organ involvement; and response to steroid therapy. Recent advances in our understanding of these features have resulted in enhanced recognition and diagnosis of this benign disease. This in turn has resulted in the avoidance of unnecessary surgical procedures for suspected malignancy. This article reviews recent updates in the diagnosis and treatment of autoimmune pancreatitis.
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Affiliation(s)
- Amaar H Ghazale
- Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
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