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Pezhouh MK, Lam-Himlin D, Zaheer A, Voltaggio L. Systemic diseases affecting the GI tract: A review of clinical and histopathologic manifestations. Ann Diagn Pathol 2024; 73:152351. [PMID: 39004038 DOI: 10.1016/j.anndiagpath.2024.152351] [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: 05/27/2024] [Accepted: 05/31/2024] [Indexed: 07/16/2024]
Abstract
A variety of systemic diseases may affect the gastrointestinal (GI) tract. Since the GI tract responds to injury in limited ways, identifying these processes may be challenging, especially on small endoscopic biopsies. This article reviews the clinicopathologic features of commonly encountered systemic diseases affecting the tubular GI tract: sarcoidosis, graft vs. host disease, mast cell disorders, systemic sclerosis, and IgG-4 related disease. In addition, we offer guidance in differentiating them from their mimics.
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Affiliation(s)
- Maryam K Pezhouh
- University of California San Diego, Department of Pathology, CA, United States of America
| | - Dora Lam-Himlin
- Mayo Clinic, Department of Laboratory Medicine and Pathology, AZ, United States of America
| | - Atif Zaheer
- Johns Hopkins University, Department of Radiology, MD, United States of America
| | - Lysandra Voltaggio
- Johns Hopkins University, Department of Pathology, MD, United States of America.
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2
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Kim D, Lee J, Jung M, Lee SL, Yim K, Chong Y, Alam MR, Seo KJ. Immunoglobulin G4-related disease mimicking an appendiceal neoplasm: a case report. J Int Med Res 2024; 52:3000605241260540. [PMID: 38902205 PMCID: PMC11193344 DOI: 10.1177/03000605241260540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 05/23/2024] [Indexed: 06/22/2024] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory condition characterized by chronic activation of the immune system and a tendency to form tumorous lesions. IgG4-RD is frequently characterized by the presence of tumor-like masses affecting multiple organs and is easily mistaken for a malignant neoplasm. However, IgG4-RD affecting the appendix is extremely rare, with only seven cases reported previously. We report the case of a woman in her early 60s who presented with insidious abdominal pain and radiological findings mimicking appendiceal neoplasms. After diagnosing appendiceal neoplasms, surgery was performed. The patient had a serum IgG4 concentration of <1.35 g/L, which did not satisfy one of the three revised comprehensive diagnostic criteria for IgG4-RD. A pathological examination was conducted, and the patient was diagnosed with appendiceal IgG4-RD. To the best of our knowledge, there have been no previously reported cases of IgG4-RD affecting the appendix in patients with low serum IgG4 concentrations. This report may prove beneficial for the future understanding of IgG4-RD and for the revision of diagnostic and treatment strategies.
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Affiliation(s)
- Dongwoo Kim
- College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jongwon Lee
- College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Minsoo Jung
- College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Su Lim Lee
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwangil Yim
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yosep Chong
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mohammad Rizwan Alam
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyung Jin Seo
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
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3
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Czarnywojtek A, Agaimy A, Pietrończyk K, Nixon IJ, Vander Poorten V, Mäkitie AA, Zafereo M, Florek E, Sawicka-Gutaj N, Ruchała M, Ferlito A. IgG4-related disease: an update on pathology and diagnostic criteria with a focus on salivary gland manifestations. Virchows Arch 2024; 484:381-399. [PMID: 38316669 DOI: 10.1007/s00428-024-03757-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/12/2024] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a multi-organ disorder characterized by a highly variable clinical presentation depending on the affected organ/s, extent of tumefactive fibroinflammatory lesions, and associated functional impairment. The disease pursues a chronic, relapsing, often asymptomatic course and hence may pose a significant diagnostic challenge. Diagnostic delay can lead to progressive fibrosis and irreversible organ damage resulting into significant morbidity and even mortality. Given its broad clinical spectrum, physicians of all specialties may be the first clinicians facing this diagnostic challenge. Outside the pancreatobiliary system, the head and neck represents the major site of IgG4-RD with variable organ-specific diffuse or mass-forming lesions. In up to 75% of cases, elevated serum IgG4 levels are observed, but this figure possibly underestimates the fraction of seronegative cases, as the disease manifestations may present metachronously with significant intervals. Together with negative serology, this can lead to misdiagnosis of seronegative cases. A standardized nomenclature and diagnostic criteria for IgG4-RD were established in 2012 and revised in 2020 facilitating scientific research and expanding the range of diseases associated with IgG4 abnormalities. In addition to orbital pseudotumor, dacryoadenitis, Riedel thyroiditis, sinonasal manifestations, and rare miscellaneous conditions, IgG4-related sialadenitis is one of the most frequent presentations in the head and neck region. However, controversy still exists regarding the relationship between sialadenitis and IgG4-RD. This review focuses on the clinicopathological features of IgG4-related sialadenitis and its contemporary diagnostic criteria.
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Affiliation(s)
- Agata Czarnywojtek
- Department of Pharmacology, Poznan University of Medical Sciences, 60-806, Poznan, Poland
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 60-355, Poznan, Poland
| | - Abbas Agaimy
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), 91054, Erlangen, Germany
| | | | - Iain J Nixon
- Department of Otorhinolaryngology Head and Neck Surgery, NHS Lothian, Edinburgh, EH8 9YL, UK
| | - Vincent Vander Poorten
- Otorhinolaryngology-Head and Neck Surgery, KU Leuven University Hospitals, 3000, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, 3000, Leuven, Belgium
| | - Antti A Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, and the Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, 00014, Helsinki, Finland
| | - Mark Zafereo
- Department of Head & Neck Surgery, MD Anderson Cancer Center, Houston, TX, 77005, USA
| | - Ewa Florek
- Laboratory of Environmental Research, Department of Toxicology, Poznan University of Medical Sciences, 60-806, Poznan, Poland.
| | - Nadia Sawicka-Gutaj
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 60-355, Poznan, Poland
| | - Marek Ruchała
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 60-355, Poznan, Poland
| | - Alfio Ferlito
- International Head and Neck Scientific Group, 35100, Padua, Italy
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Vernia F, Cirella L, Calvisi G, Viscido A, Latella G. Immunoglobulin G4-Related Disease of the Intestine: A Clinicopathological Entity to Be Considered. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:57. [PMID: 38256319 PMCID: PMC10818347 DOI: 10.3390/medicina60010057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Immunoglobulin G4-related disease (IgG4-RD) is a recently recognized immune-mediated, systemic condition of unknown etiology, associated with fibroinflammatory lesions. Diagnosis is set in the presence of IgG4-positive plasma cell infiltration of the involved tissue and elevated serum IgG4 levels. However, approximately 30% of patients have normal serum IgG4 levels. IgG4-RD may affect several organs, including the pancreas, bile ducts, mesentery, retroperitoneum, and salivary glands, but the involvement of the gastrointestinal tract is uncommon. Materials and Methods: The case series of 4 patients with IgG4-RD involving the intestinal tract was observed in the period of 2017-2022. Colorectal and ileal biopsy specimens were stained with hematoxylin and eosin and immunohistochemical techniques using monoclonal antihuman IgG4 primary antibody. Diagnosis of IgG4-RD was based on the presence of >50 cells/ HPF and IgG4/IgG ratio >40 confirmed by two pathologists. Results: IgG4-RD was set in patients previously diagnosed as affected by Crohn's disease. Conclusions: Systematic IgG4 immunohistochemical staining should be considered in the diagnostic workup of patients with gastrointestinal strictures, mimicking Crohn's disease. The exact prevalence of the condition is likely more frequent than reported and should be defined by a large series of consecutive patients.
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Affiliation(s)
- Filippo Vernia
- Department of Life, Health, and Environmental Sciences, Division of Gastroenterology, Hepatology, and Nutrition, University of L’Aquila, Piazza S. Tommasi, 1, Coppito, 67100 L’Aquila, Italy; (F.V.); (A.V.)
| | - Laura Cirella
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100 L’Aquila, Italy; (L.C.); (G.C.)
| | - Giuseppe Calvisi
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100 L’Aquila, Italy; (L.C.); (G.C.)
| | - Angelo Viscido
- Department of Life, Health, and Environmental Sciences, Division of Gastroenterology, Hepatology, and Nutrition, University of L’Aquila, Piazza S. Tommasi, 1, Coppito, 67100 L’Aquila, Italy; (F.V.); (A.V.)
| | - Giovanni Latella
- Department of Life, Health, and Environmental Sciences, Division of Gastroenterology, Hepatology, and Nutrition, University of L’Aquila, Piazza S. Tommasi, 1, Coppito, 67100 L’Aquila, Italy; (F.V.); (A.V.)
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Czarnywojtek A, Pietrończyk K, Thompson LDR, Triantafyllou A, Florek E, Sawicka-Gutaj N, Ruchała M, Płazinska MT, Nixon IJ, Shaha AR, Zafereo M, Randolph GW, Angelos P, Al Ghuzlan A, Agaimy A, Ferlito A. IgG4-related sclerosing thyroiditis (Riedel-Struma): a review of clinicopathological features and management. Virchows Arch 2023; 483:133-144. [PMID: 37204493 PMCID: PMC10412505 DOI: 10.1007/s00428-023-03561-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/03/2023] [Accepted: 05/14/2023] [Indexed: 05/20/2023]
Abstract
We present a thorough review of the literature on Riedel thyroiditis (RT) with emphasis on aetiology, diagnosis and management, using the PubMed, Sinomed, and China National Knowledge Infrastructure databases. Although the exact aetiology of RT remains obscure, the histopathological features are consistent with a localized form of IgG4-related systemic disease (IgG4-RSD). Nevertheless, IgG4-RSD as a systemic fibroinflammatory disorder per se rarely affects the thyroid in the context of multiorgan manifestations. The initial diagnosis of RT is based on clinical history and imaging, but confirmation by histopathological examination is mandatory. In contrast to the historical surgical approach, glucocorticosteroid therapy is currently considered first line therapy, in line with the RT currently being viewed as a manifestation of, or analogous to, IgG4-RSD. For disease relapse, immunomodulatory agents (azathioprine, methotrexate, rituximab) can be used.
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Affiliation(s)
- Agata Czarnywojtek
- Department of Pharmacology, Poznan University of Medical Sciences, 60-806 Poznan, Poland
- Chair and Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | | | | | - Asterios Triantafyllou
- Department of Pathology, Liverpool Clinical Laboratories, School of Dentistry, University of Liverpool, Liverpool, L3 5PS UK
| | - Ewa Florek
- Laboratory of Environmental Research, Department of Toxicology, Poznan University of Medical Sciences, Dojazd 30 Street, 60-631 Poznan, Poland
| | - Nadia Sawicka-Gutaj
- Chair and Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Marek Ruchała
- Chair and Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | | | - Iain J. Nixon
- Department of Otorhinolaryngology Head and Neck Surgery, NHS Lothian, Edinburgh, EH8 9YL UK
| | - Ashok R. Shaha
- Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10065 USA
| | - Mark Zafereo
- Department of Head & Neck Surgery, MD Anderson Cancer Center, Houston, TX 77005 USA
| | - Gregory William Randolph
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, MA 02114 USA
| | - Peter Angelos
- Section of General Surgery and Surgical Oncology, Department of Surgery, The University of Chicago, Chicago, Illinois IL 60637 USA
| | - Abir Al Ghuzlan
- Department of Biology and Pathology, Gustave Roussy Cancer Campus, University Paris-Saclay, 91190 Villejuif, France
| | - Abbas Agaimy
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35100 Padua, Italy
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Sawada H, Czech T, Silangcruz K, Kozai L, Obeidat A, Wien EA, Nishimura MF, Nishikori A, Sato Y, Nishimura Y. Clinicopathological characteristics of gastric IgG4-related disease: Systematic scoping review. J Gastroenterol Hepatol 2022; 37:1865-1872. [PMID: 35949057 DOI: 10.1111/jgh.15980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/01/2022] [Accepted: 08/06/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Gastric IgG4-related disease (IgG4-RD) can mimic malignancy, submucosal tumors (SMT), and ulcers, leading to over-triage and unnecessary medical interventions such as gastrectomy. The variability in the clinicopathological presentation of IgG4-related disease is not yet well defined, posing a diagnostic challenge. METHODS Following the PRISMA Extension for Scoping Reviews, we searched MEDLINE and EMBASE for all peer-reviewed articles using keywords including "gastritis," "stomach," "gastrointestinal stromal tumor," and "IgG4-RD" from their inception to December 28, 2021. RESULTS Thirty-nine articles, including 2 observational studies and 42 cases, were included in the systematic review. While bottom-heavy lymphoplasmacytic mucosal infiltration is a characteristic finding of gastric IgG4-RD, it was only present in less than half of the patients in the observational studies. Patients with gastric IgG4-RD were more likely to be diagnosed with gastrointestinal stromal tumor (GIST), gastric cancer, or peptic ulcer disease and their clinical course involved resection (51.3%) or even gastrectomy. Diagnosis of gastric IgG4-RD was most frequently made by post-operative pathological analysis. CONCLUSION This systematic review summarizes the current understanding of the characteristics of gastric IgG4-RD. Increased awareness of gastric IgG4-RD as a differential diagnosis of gastric SMT or ulcers among clinicians is crucial in order to reduce unnecessary high-risk, invasive interventions.
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Affiliation(s)
- Haruki Sawada
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Torrey Czech
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Krixie Silangcruz
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Landon Kozai
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Adham Obeidat
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Eric Andrew Wien
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Midori Filiz Nishimura
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Asami Nishikori
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Yasuharu Sato
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA.,Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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7
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Abstract
IgG4-related conditions affecting the digestive tract are part of a multi-organ fibro-inflammatory disorder termed IgG4-related disease (IgG4-RD), with autoimmune pancreatitis and IgG4-related cholangitis being the most prominent manifestations. Gastrointestinal symptoms include jaundice, weight loss, abdominal pain, biliary strictures, and pancreatic and hepatic masses that mimic malignant diseases. IgG4-RD manifestations occur less frequently elsewhere in the digestive tract, namely in the oesophagus, retroperitoneum or intestine. Evidence-based European guidelines frame the current state-of-the-art in the diagnosis and management of IgG4-related digestive tract disease. Diagnosis is based on histology (if available), imaging, serology, other organ involvement and response to therapy (HISORt criteria). Few biomarkers beyond serum IgG4 concentrations are reliable. The first-line therapy (glucocorticoids) is swiftly effective but disease flares are common at low doses or after tapering. Second-line therapy might consist of other immunosuppressive drugs such as thiopurines or rituximab. Further trials, for example, of anti-CD19 drugs, are ongoing. Although an association between IgG4-RD and the development of malignancies has been postulated, the true nature of this relationship remains uncertain at this time.
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8
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Agaimy A. [Mesenchymal tumors and tumor-like lesions of the gastrointestinal tract: an overview]. DER PATHOLOGE 2022; 43:31-44. [PMID: 34919183 DOI: 10.1007/s00292-021-01040-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 06/14/2023]
Abstract
Mesenchymal tumors and tumor-like lesions of the gastrointestinal (GI) tract are uncommon. They vary from reactive tumefactive lesions and benign neoplasms to highly aggressive sarcomas. Among them, GI stromal tumors (GISTs) are most common, followed, with less frequency, by smooth muscle and neurogenic tumors. The major challenge resides in correctly identifying GISTs and providing a comprehensive report (including risk assessment and genotyping) that represents the basis for an optimized surgical-oncological treatment and/or adjuvant therapy. On the other hand, the challenge of benign lesions is to find a good name (well understandable and reproducible diagnostic term) that helps avoid diagnostic ambiguity and prognostic uncertainty so that overprognostication and overtreatment can be prevented. Moreover, several recently described genetically defined benign and malignant entities need be correctly diagnosed due to their special "targeted" therapeutic options and to further characterize their clinicopathological and biological properties in the future. These recent entities include aggressive epithelioid inflammatory myofibroblastic sarcoma (ALK-RANBP2-driven), malignant gastrointestinal neuroectodermal tumor (EWSR1-ATF1/CREB-related), NTRK-rearranged neoplasms, and, most recently, colorectal NUTM1-rearranged sarcomas. This review highlights the major clinicopathological features of gastrointestinal mesenchymal lesions in light of recent developments.
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Affiliation(s)
- Abbas Agaimy
- Pathologisches Institut, Universitätsklinikum Erlangen, Krankenhausstraße 8-10, 91054, Erlangen, Deutschland.
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Uchino K, Notohara K, Uehara T, Kuraishi Y, Itakura J, Matsukawa A. Utility of gastric biopsy in diagnosing IgG4-related gastrointestinal disease. Pathol Int 2020; 71:124-134. [PMID: 33378576 DOI: 10.1111/pin.13059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 01/13/2023]
Abstract
The utility of gastric biopsy for diagnosing immunoglobulin (Ig)G4-related gastrointestinal disease (IgG4-GID) remains unclear. Bottom-heavy plasmacytosis (BHP) is a distinct feature of IgG4-GID. To clarify the feasibility of using gastric biopsies to diagnose BHP in IgG4-GID, we analyzed the histological features and immunostaining of gastric biopsy specimens from 31 known IgG4-related disease (IgG4-RD) patients and we assessed the presence of BHP in 1696 consecutive routine gastric biopsies. Cases with both >10 IgG4-positive plasma cells per high-power field and an IgG4/IgG-positive ratio >40% were defined as IgG4-high. Ten of the 31 IgG4-RD patients were concluded to have IgG4-GID, in which IgG4-positive plasma cells were notably detected at the deeper part of the mucosa. Six cases displayed BHP whereas the remaining four cases showed transmural infiltration with concomitant Helicobacter pylori-associated gastritis. In addition to BHP, we identified two unique histologic features for IgG4-GID: plasmacytic aggregation in the muscularis mucosae and permeative plasmacytic infiltration between fundic glands in the non-atrophic mucosa. Six of the routine cases (0.35%) displayed BHP, including a case with IgG4-RD. IgG4-GID can be suspected by the presence of gastric biopsy specimens with characteristic histological features. Such cases are recommended to undergo further examinations to determine whether IgG4-RD is present.
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Affiliation(s)
- Kaori Uchino
- Department of Pathology and Experimental Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Takeshi Uehara
- Department of Laboratory Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Yasuhiro Kuraishi
- Department of Gastroenterology, Shinshu University School of Medicine, Nagano, Japan
| | - Junya Itakura
- Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Akihiro Matsukawa
- Department of Pathology and Experimental Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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Muto O, Tamakawa S, Takahashi K, Yokohama S, Takasoe A, Hirano F, Nishimura H, Saito H. IgG4-related Disease Manifesting as Gastroduodenal Ulcer Diagnosed by an Endoscopic Biopsy. Intern Med 2020; 59:2491-2497. [PMID: 32581158 PMCID: PMC7662039 DOI: 10.2169/internalmedicine.4483-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A 26-year-old man was admitted to our hospital due to upper abdominal pain. He had previously been diagnosed with gastroduodenal ulcer at 23 and 25 years old and had been treated with proton-pump inhibitors. Endoscopic hemostasis and a biopsy were performed on the hemorrhagic gastroduodenal ulcers. Laboratory and pathologic examinations demonstrated elevated serum IgG4 levels and the infiltration of IgG4-positive plasma cells into the gastroduodenal tissues. Based on the clinicopathologic findings and after excluding other causes, he was diagnosed with IgG4-related gastroduodenal ulcer. We herein report a rare case of IgG4-related disease manifesting as a gastroduodenal ulcer diagnosed by an endoscopic biopsy.
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Affiliation(s)
- Osamu Muto
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Susumu Tamakawa
- Department of Pathology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Kenji Takahashi
- Division of Metabolism and Biosystemic Science, Department of Medicine, Asahikawa Medical University, Japan
| | - Shiro Yokohama
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Ai Takasoe
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Fuminori Hirano
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Hideo Nishimura
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Hiroki Saito
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
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11
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Dias AB, Horvat N, Begnami MD, Abe ES, Viana PCC, Machado MCC. Case report of IgG4-related appendiceal disease: A challenging disease. Medicine (Baltimore) 2020; 99:e20588. [PMID: 32569185 PMCID: PMC7310901 DOI: 10.1097/md.0000000000020588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Immunoglobulin G4 (IgG4)-related disease is an increasingly recognized immune-mediated entity that can affect virtually every organ system. Depending on the location of the disease, it can present a wide range of clinical manifestations and even mimic malignancies. Appendiceal involvement in patients with IgG4-related disease is particularly rare and very few cases are reported in the literature. PATIENT CONCERNS We report a case of IgG4-related appendiceal disease in a 42-year-old woman who presents with a subacute onset of right lower quadrant abdominal pain. DIAGNOSIS Abdominal computed tomography showed a markedly enlarged appendix, raising the concern of malignancy. The diagnosis of IgG4 appendiceal disease was confirmed by postoperative histopathologic and immunohistochemical examination. INTERVENTIONS The patient underwent right hemicolectomy. OUTCOMES After the surgery, the patient had an uneventful recovery and reported a resolution of her symptoms. The serum IgG4 was revaluated 5 days after surgery and returned to its normal values. At the 3-year follow up, the patient had no recurrence of symptoms and her imaging exams remain unremarkable. LESSONS This study reports the fifth case of IgG4-related appendiceal disease. Increasing awareness of this condition may influence the management of these patients, once patients with IgG4-related disease should be monitored after treatment, due to the risk of recurrence or involvement of other organs.
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Chetty R. A reappraisal of sclerosing nodular and/or polypoid lesions of the gastrointestinal tract rich in IgG4-positive plasma cells. Histopathology 2020; 76:832-837. [PMID: 31919879 DOI: 10.1111/his.14061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/14/2019] [Accepted: 01/08/2020] [Indexed: 11/30/2022]
Abstract
AIMS To describe additional cases of nodular and polypoid sclerosing lesions of the gastrointestinal tract (GIT) that are associated with numerous IgG4-positive plasma cells, review the pertinent literature to ascertain the relationship with systemic IgG4-related disease, and provide a reporting framework for such lesions. METHODS AND RESULTS Five new cases of sclerosing polyps or nodules were collected over a 10-year period, occurring in four females and one male ranging in age from 32 years to 56 years (mean, 41.6 years). Patients were asymptomatic or had epigastric pain, and one had rectal bleeding. None had autoimmune or other obvious IgG4-related disease, and serum IgG4 levels were normal. All were solitary nodules in the stomach (two cases), ileum, caecum, and rectum. Four lesions were submucosal and one was subserosal; all were well circumscribed, composed of hyalinised, keloidal fibrous tissue with lymphoplasmacytic inflammation. Obliterative phlebitis was not seen. Lineage-specific immunomarkers were negative. In excess of 10 IgG4-positive plasma cells per high-power field were seen, and the IgG4/IgG ratios were >0.4. CONCLUSIONS Very few IgG4-related lesions in the tubular GIT are associated with disease at other sites and/or elevated serum IgG4 levels. The majority may represent a lesion in the spectrum of IgG4-related disease. The use of the term 'IgG4-positive nodule or polyp with probable histological features of IgG4-related disease' is advocated for nodular and/or polypoid lesions in the GIT with ≥10 IgG4-positive plasma cells in a high-power field and an IgG/IgG4 ratio of >0.4.
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Affiliation(s)
- Runjan Chetty
- Division of Anatomical Pathology, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
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13
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Ramakrishna B, Yewale R, Vijayakumar K, Radhakrishna P, Ramakrishna BS. Gastric IgG4-related disease presenting as a mass lesion and masquerading as a gastrointestinal stromal tumor. J Pathol Transl Med 2020; 54:258-262. [PMID: 32126738 PMCID: PMC7253960 DOI: 10.4132/jptm.2020.02.10] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/10/2020] [Indexed: 12/22/2022] Open
Abstract
IgG4-related disease of the stomach is a rare disorder, and only a few cases have been reported. We present two cases that were identified over a 2-month period in our center. Two male patients aged 52 and 48 years presented with mass lesion in the stomach, which were clinically thought to be gastrointestinal stromal tumor, and they underwent excision of the lesion. Microscopic examination revealed marked fibrosis, which was storiform in one case, associated with diffuse lymphoplasmacytic infiltration and an increase in IgG4-positive plasma cells on immunohistochemistry. Serum IgG4 level was markedly elevated. Although rare, IgG4-related disease should be considered in the differential diagnosis of gastric submucosal mass lesions.
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Affiliation(s)
| | - Rohan Yewale
- Department of Medical Gastroenterology, SRM Institutes for Medical Science, Vadapalani, India
| | - Kavita Vijayakumar
- Department of Pathology, SRM Institutes for Medical Science, Vadapalani, India
| | - Patta Radhakrishna
- Department of Surgical Gastroenterology, SRM Institutes for Medical Science, Vadapalani, India
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14
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Chelliah A, Kalimuthu SN, Chetty R. Sclerosing Tumors of the Gastrointestinal Tract: A Systematic Approach. Int J Surg Pathol 2019; 27:468-476. [PMID: 30955389 DOI: 10.1177/1066896919840431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Some lesions in the gastrointestinal tract have a propensity for sclerosis such that it may mask the actual true nature of the lesion. The purpose of this review is to highlight those lesions of the gastrointestinal tract that can be attended by sclerosis. The sclerosis can mask the cellularity of the lesion; hence, knowledge of the key lesions that are known to have sclerosis will be aid the diagnostic pathologist.
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Affiliation(s)
- Adeline Chelliah
- 1 Toronto General Hospital, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
| | - Sangeetha N Kalimuthu
- 1 Toronto General Hospital, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
| | - Runjan Chetty
- 1 Toronto General Hospital, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
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15
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Yorita K, Iwamura S. Can colonic inflammatory polyp with numerous immunoglobulin G4-positive plasma cells represent a colonic manifestation of immunoglobulin G4-related disease? A case report. Clin J Gastroenterol 2019; 12:398-402. [PMID: 30895472 DOI: 10.1007/s12328-019-00966-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/11/2019] [Indexed: 01/13/2023]
Abstract
We present an asymptomatic case of a 79-year-old Japanese man who had a 6 mm colonic inflammatory polyp with numerous immunoglobulin G4 (IgG4)-positive plasma cells. No symptoms or abnormal laboratory data, such as changes in serum IgG4 levels, were found at the time of diagnosis or during the 1 year of follow-up thereafter. Additionally, no diffuse/localized swelling or masses were found in organs, except for colonic polyps, by abdominal computed tomography 1 year prior to the polypectomy. Inflammatory myofibroblastic tumor was unlikely from the lack of spindle cell proliferation and ALK immunoreactivity. This is the first case of this colonic polyp in an asymptomatic person. This polyp could be probable for single organ manifestation of IgG4-related disease (IgG4-RD), according to the comprehensive diagnostic criteria for IgG4-RD published in 2012; however, colonic manifestation of IgG4-RD has not been clarified owing to its rarity, and colon-specific criteria for IgG4-RD have not been proposed. Thus, we could not definitively establish the colonic polyp as IgG4-RD. Therefore, careful clinicopathological evaluation is needed to reveal whether this colonic polyp represents a nonspecific inflammatory response or an early manifestation of IgG4-RD.
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Affiliation(s)
- Kenji Yorita
- Department of Diagnostic Pathology, Japanese Red Cross Kochi Hospital, 2-13-51 Shinhonmachi, Kochi-shi, Kochi-ken, 780-8562, Japan.
| | - Shinichi Iwamura
- Department of Gastroenterology, Japanese Red Cross Kochi Hospital, 2-13-51 Shinhonmachi, Kochi-shi, Kochi-ken, 780-8562, Japan
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16
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Lim DY, Cheng LTE, Tan DMY, Al Jajeh I. Isolated IgG4-related gastric disease presenting as diffuse gastric wall thickening with ulcer. J Radiol Case Rep 2019; 12:9-20. [PMID: 30651919 DOI: 10.3941/jrcr.v12i9.3493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
An 81-year-old male presented with loss of appetite, early satiety and iron deficiency anaemia. A computed tomography (CT) scan of the abdomen and pelvis during initial work-up revealed diffuse gastric mural thickening associated with a large ulcer and adjacent gastro-hepatic lymphadenopathy. The CT appearances, together with the clinical features, were highly suspicious for an infiltrative type of gastric malignancy. Endoscopic biopsy however showed erosive inflammation, IgG4 plasmacytosis and fibrosis, raising the possibility of IgG4-related disease. A serologic assay for IgG showed normal IgG4 and elevated IgG2 serum levels. After appropriate steroid treatment, endoscopy and CT scan showed resolution of the ulcer and gastric wall thickening. This case shows yet another possible appearance of gastric involvement in IgG4-related disease on the current evolving spectrum of this disease presentation. Greater awareness and education of this disease would help in patient care, ensuring earlier diagnosis, prevention of severe organ damage and morbidity, as well as unnecessary surgery.
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Affiliation(s)
- David Yurui Lim
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | | | - Damien Meng Yew Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Issam Al Jajeh
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
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17
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Ileocecal IgG4-Related Disease: A Case Report Mimicking Malignancy. ACG Case Rep J 2018; 5:e84. [PMID: 30568972 PMCID: PMC6277136 DOI: 10.14309/crj.2018.84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/12/2018] [Indexed: 12/24/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a chronic mass-forming inflammatory disease characterized by fibroblastic proliferation and mixed inflammatory cell infiltration. IgG4-RD can involve one or multiple organs, and the most commonly affected organs include the pancreas, salivary glands, and the orbit. We present a case of a 66-year-old man, with a history of sarcoidosis, who presented with an obstructing ileocecal mass highly suspicious for malignancy. After surgical resection and pathological and serological evaluation, a diagnosis of IgG4-RD was rendered. In the absence of other manifestations, preoperative diagnosis is challenging, and IgG4-RD may continue to be a diagnostic pitfall.
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18
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Gastrointestinal manifestation of immunoglobulin G4-related disease: clarification through a multicenter survey. J Gastroenterol 2018; 53:845-853. [PMID: 29222587 DOI: 10.1007/s00535-017-1420-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 11/28/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Several reports on immunoglobulin (Ig)G4-related disease (IgG4-RD) with gastrointestinal involvement (IgG4-related gastrointestinal disease; IgG4-GID) have been published, although this entity has not been fully established clinicopathologically. Thus, we carried out a multicenter survey. METHODS Patients with possible IgG4-GID who underwent resection were collected. Histologic slides were reevaluated, and eight cases with diffuse lymphoplasmacytic infiltration but without numerous neutrophils, granulations or epithelioid granulomas were further analyzed. RESULTS Overall, the IgG4 counts (87-345/high-power field) and IgG4/IgG-positive ratio were high (44-115%). The demographic findings included advanced age among the patients (55-80 years) and male preponderance (six cases). Six lesions (five gastric, one esophageal), consisting of lymphoplasmacytic infiltration with neural involvement in the muscularis propria and/or bottom-heavy plasmacytosis in the gastric mucosa, were histologically regarded as highly suggestive of IgG4-RD. Storiform fibrosis and obliterative phlebitis were found in two cases, and the former gave rise to a 7-cm-sized inflammatory pseudotumor (IPT) in one case. Ulceration and carcinoma co-existed in three and two lesions, respectively. All the patients had other organ involvement (OOI), and serum IgG4 levels were markedly elevated (four of five patients). The remaining two cases with gastric IPTs featuring reactive nodular fibrous pseudotumor or nodular lymphoid hyperplasia were regarded as possible cases of IgG4-RD because of the histologic findings and lack of OOI. CONCLUSIONS IgG4-GID is found in the setting of IgG4-RD, often with ulceration or cancer. Characteristic histologic findings are observed in the muscularis propria and gastric mucosa. Cases with IPT may be heterogeneous, and there may be mimickers of IgG4-GID.
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19
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Ciccone F, Ciccone A, Di Ruscio M, Vernia F, Cipolloni G, Coletti G, Calvisi G, Frieri G, Latella G. IgG4-Related Disease Mimicking Crohn's Disease: A Case Report and Review of Literature. Dig Dis Sci 2018; 63:1072-1086. [PMID: 29417330 DOI: 10.1007/s10620-018-4950-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 01/26/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Fabiana Ciccone
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Antonio Ciccone
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Mirko Di Ruscio
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Filippo Vernia
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Gianluca Cipolloni
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100, L'Aquila, Italy
| | - Gino Coletti
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100, L'Aquila, Italy
| | - Giuseppe Calvisi
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100, L'Aquila, Italy
| | - Giuseppe Frieri
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Giovanni Latella
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy.
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20
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Seo HS, Jung YJ, Park CH, Song KY, Jung ES. IgG4-related Disease in the Stomach which Was Confused with Gastrointestinal Stromal Tumor (GIST): Two Case Reports and Review of the Literature. J Gastric Cancer 2018; 18:99-107. [PMID: 29629225 PMCID: PMC5881015 DOI: 10.5230/jgc.2018.18.e8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 03/12/2018] [Accepted: 03/21/2018] [Indexed: 12/13/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibro-inflammatory disorder characterized by specific pathological findings and elevated serum IgG4 level. IgG4-RD in the stomach is rare, and occasionally diagnosed as gastric subepithelial tumor (SET) by endoscopy or computed tomography scan. Two female patients in the age group of 40–50 years were diagnosed with 4 cm sized gastric SET. One underwent laparoscopic gastric wedge resection. Another one had a history of subtotal gastrectomy for early gastric cancer and idiopathic thrombocytopenic purpura with oral steroids administration. She underwent a completion total gastrectomy with splenectomy for the gastric SET and ITP. The pathology showed storiform fibrosis, and IgG4 was positive in immunohistochemistry (IHC) stain. IgG4-RD is known as a medical disease that could be treated with oral steroids. The difficulty in preoperative diagnosis of the disease occasionally causes unnecessary gastric resection. Thus, preoperative diagnostic methods for IgG4-RD such as deep biopsy with IHC stain or magnetic resonance imaging are needed.
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Affiliation(s)
- Ho Seok Seo
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Yoon Ju Jung
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Cho Hyun Park
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Kyo Young Song
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Eun Sun Jung
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
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21
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Ileocecal IgG4-Related Disease: A Case Report Mimicking Malignancy. ACG Case Rep J 2018. [DOI: 10.14309/02075970-201805110-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Bulanov D, Arabadzhieva E, Bonev S, Yonkov A, Kyoseva D, Dikov T, Dimitrova V. A rare case of IgG4-related disease: a gastric mass, associated with regional lymphadenopathy. BMC Surg 2016; 16:37. [PMID: 27255154 PMCID: PMC4890503 DOI: 10.1186/s12893-016-0151-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 05/19/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND IgG4-related disease (IgG4-RD) is a newly recognized disorder, characterized by massive IgG4+ lymphocyte and plasma cell infiltration, storiform fibrosis, causing enlargement, nodules or thickening of the various organs, simultaneously or metachronously. Involvement of the gastrointestinal tract is very rare and can be presented as a diffuse wall thickening or polyp or mass-like lesion. Up to now, there have been reported only a few cases of isolated gastric IgG4-RD. CASE PRESENTATION We present an unusual case of IgG4-RD of the stomach with involvement of the regional lymph nodes, clinically manifested as a gastric cancer with related pyloric stenosis. The patient underwent distal gastrectomy, omentectomy and lymph node dissection. The postoperative serum IgG4 level was increased. The diagnosis was confirmed by immunohistochemical study. CONCLUSIONS In the most of the reported cases there was not sufficient data about the regional lymph nodal status, although the majority of the patients had been operated with presumptive diagnosis of gastric neoplasm. Our case is rare and valuable because it presents a gastric IgG4-related lesion larger than all previously reported in literature, and IgG4-related lymphadenopathy, confirmed histologically, which contributes to better knowledge of the disease.
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Affiliation(s)
- Dimitar Bulanov
- Department of General and Hepato-pancreatic Surgery, Medical University of Sofia, University Hospital "Alexandrovska", 1 Georgi Sofiiski Str, 1431, Sofia, Bulgaria
| | - Elena Arabadzhieva
- Department of General and Hepato-pancreatic Surgery, Medical University of Sofia, University Hospital "Alexandrovska", 1 Georgi Sofiiski Str, 1431, Sofia, Bulgaria.
| | - Sasho Bonev
- Department of General and Hepato-pancreatic Surgery, Medical University of Sofia, University Hospital "Alexandrovska", 1 Georgi Sofiiski Str, 1431, Sofia, Bulgaria
| | - Atanas Yonkov
- Department of General and Hepato-pancreatic Surgery, Medical University of Sofia, University Hospital "Alexandrovska", 1 Georgi Sofiiski Str, 1431, Sofia, Bulgaria
| | - Diana Kyoseva
- Department of General and Clinical Pathology, Medical University of Sofia, 2 Zdrave Str, 1431, Sofia, Bulgaria
| | - Tihomir Dikov
- Department of General and Clinical Pathology, Medical University of Sofia, 2 Zdrave Str, 1431, Sofia, Bulgaria
| | - Violeta Dimitrova
- Department of General and Hepato-pancreatic Surgery, Medical University of Sofia, University Hospital "Alexandrovska", 1 Georgi Sofiiski Str, 1431, Sofia, Bulgaria
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Cheong HR, Lee BE, Song GA, Kim GH, An SG, Lim W. Immunoglobulin G4-Related Inflammatory Pseudotumor Presenting as a Solitary Mass in the Stomach. Clin Endosc 2016; 49:197-201. [PMID: 26867551 PMCID: PMC4821516 DOI: 10.5946/ce.2015.074] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/26/2015] [Accepted: 07/11/2015] [Indexed: 12/24/2022] Open
Abstract
Immunoglobulin G4 (IgG4)-related disease (IgG4RD) is a relatively recently recognized entity that is histopathologically characterized by an extensive infiltration of lymphocytes and IgG4-positive plasma cells with dense fibrosis. IgG4RD is now known to affect any organ system, and a few cases of gastrointestinal lesions have also been reported. However, solitary IgG4RD of the stomach is still very rare. Furthermore, as it can mimic malignant conditions, it is important to recognize this disease to avoid unnecessary surgery. Herein, we present a case of IgG4RD presenting as an isolated subepithelial mass in the stomach.
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Affiliation(s)
- Hong Ryeol Cheong
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Bong Eun Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Sung Gyu An
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Won Lim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
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Kim HS, Kang WK, Chung DJ. Appendiceal Immunoglobulin G4-Related Disease Mimicking Appendiceal Tumor or Appendicitis: A Case Report. Korean J Radiol 2016; 17:56-8. [PMID: 26798216 PMCID: PMC4720812 DOI: 10.3348/kjr.2016.17.1.56] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 10/29/2015] [Indexed: 12/24/2022] Open
Abstract
Immunoglobulin G4 (IgG4)-related disease is an autoimmune disease that forms tumorous lesions. Several cases involving various organs are reported, however, IgG4-related disease involving appendix has not been reported yet. In this report, we presented a case of IgG4-related disease of appendix, which raised a suspicion of appendiceal tumor or usual appendicitis and, therefore, led to unnecessary surgical resection. IgG4-related disease should be considered in the differential diagnosis for a mass-like swelling of the appendix, in order to avoid unnecessary surgery.
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Affiliation(s)
- Hyun Soo Kim
- Department of Radiology, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul 07345, Korea
| | - Won Kyung Kang
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul 07345, Korea
| | - Dong Jin Chung
- Department of Radiology, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul 07345, Korea
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26
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Sarkar A, Pitchumoni CS. The protean manifestations of IgG4-RD in gastrointestinal disorders. Dis Mon 2015; 61:493-515. [DOI: 10.1016/j.disamonth.2015.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Tsuchiya T, Yagi T, Tsukamoto M, Fukushima Y, Shimada R, Nakamura K, Fujii S, Nozawa K, Matsuda K, Kikuchi Y, Saito K, Hashiguchi Y. A case of IgG4-related disease coexisted with rectal cancer. Surg Case Rep 2015; 1:118. [PMID: 26943442 PMCID: PMC4658344 DOI: 10.1186/s40792-015-0120-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 11/19/2015] [Indexed: 01/12/2023] Open
Abstract
A 67-year-old man was referred to our hospital with suspicion of rectal tumor, hilar tumor, and urinary tumor. Colonoscopic findings were intermittent nodular lesions with redness which were atypical to primary rectal cancer. Endoscopic retrograde cholangiopancreatography showed narrowing of the bilateral intrahepatic bile duct. However, the findings were improved 1 month later. Blood biochemistry showed high level of serum IgG4 up to 1140 mg/dl. The patient matched to comprehensive diagnostic criteria for IgG4-related disease as a possible diagnostic case. Laparoscopic low anterior resection with creation of ileostomy was performed for rectal cancer. Histological findings revealed cancer cells spread horizontally at submucosal layer and subserosal layer. There was marked infiltration of the plasma cells and lymphocytes at tumor stroma, and more than half of the plasma cells were positive for IgG4. After surgery, the level of serum IgG4 was decreased to 597 mg/dl. Although the association with IgG4-related disease and colorectal disease is unclear, the tumor progression was atypical for rectal cancer. Some report that the disease may rise up the risk of a malignant disease. It is necessary to perform systemic examination keeping in mind for concurrence of malignancy.
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Affiliation(s)
- Takeshi Tsuchiya
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Takahiro Yagi
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Mitsuo Tsukamoto
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Yoshihisa Fukushima
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Ryu Shimada
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Keisuke Nakamura
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Shoichi Fujii
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Keijiro Nozawa
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Keiji Matsuda
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Yoshinao Kikuchi
- The Department of Pathology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Koji Saito
- The Department of Pathology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Yojiro Hashiguchi
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
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Kawano H, Ishii A, Kimura T, Takahashi T, Hironaka H, Kawano M, Yamaguchi M, Oishi K, Kubo M, Matsui S, Notohara K, Ikeda E. IgG4-related disease manifesting the gastric wall thickening. Pathol Int 2015; 66:23-8. [DOI: 10.1111/pin.12364] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 10/20/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Hiroo Kawano
- Department of Laboratory Science, Faculty of Health Science; Yamaguchi University Graduate School of Medicine; Ube Japan
| | - Aya Ishii
- Department of Pathology; Yamaguchi University Graduate School of Medicine; Ube Japan
| | - Tokuhiro Kimura
- Department of Pathology; Yamaguchi University Graduate School of Medicine; Ube Japan
| | | | - Hideharu Hironaka
- Department of Surgery; Saiseikai Yamaguchi Hospital; Yamaguchi Japan
| | - Michitaka Kawano
- Department of Internal Medicine; Saiseikai Yamaguchi Hospital; Yamaguchi Japan
| | - Michiya Yamaguchi
- Department of Dermatology; Yamaguchi University Graduate School of Medicine; Ube Japan
| | - Keiji Oishi
- Department of Internal medicine; Ube Medical Center; Ube Japan
| | - Makoto Kubo
- Department of Medicine and Clinical Science; Yamaguchi University Graduate School of Medicine; Ube Japan
| | - Shoko Matsui
- Health Administration Center; Toyama University; Toyama Japan
| | - Kenji Notohara
- Department of Anatomic Pathology; Kurashiki Central Hospital; Kurashiki Japan
| | - Eiji Ikeda
- Department of Pathology; Yamaguchi University Graduate School of Medicine; Ube Japan
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Woo CG, Yook JH, Kim AY, Kim J. IgG4-Related Disease Presented as a Mural Mass in the Stomach. J Pathol Transl Med 2015; 50:67-70. [PMID: 26420251 PMCID: PMC4734962 DOI: 10.4132/jptm.2015.07.28] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/28/2015] [Indexed: 02/07/2023] Open
Abstract
Isolated gastric IgG4-related disease (IgG4-RD) is a very rare tumefactive inflammatory condition, with only a few cases reported to date. A 48-year-old woman was incidentally found to have a subepithelial tumor in the stomach. Given a presumptive diagnosis of gastrointestinal stromal tumor or neuroendocrine tumor, she underwent wedge resection. The lesion was vaguely nodular and mainly involved the submucosa and proper muscle layer. Microscopically, all classical features of type I autoimmune pancreatitis including lymphoplasmacytic infiltration, storiform fibrosis, obliterative phlebitis, and numerous IgG4-positive plasma cells were seen. She had no evidence of IgG4-RD in other organs. Although very rare, IgG4-RD should be considered one of the differential diagnoses in the setting of gastric wall thickening or subepithelial mass-like lesion. Deep biopsy with awareness of this entity might avoid unnecessary surgical intervention.
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Affiliation(s)
- Chang Gok Woo
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hwan Yook
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ah Young Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea ; Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jihun Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Inoue K, Okubo T, Kato T, Shimamura K, Sugita T, Kubota M, Kanaya K, Yamachika D, Sato M, Inoue D, Harada K, Kawano M. IgG4-related stomach muscle lesion with a renal pseudotumor and multiple renal rim-like lesions: A rare manifestation of IgG4-related disease. Mod Rheumatol 2015; 28:188-192. [DOI: 10.3109/14397595.2015.1081743] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Koichi Inoue
- Division of Surgery, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Takehiko Okubo
- Division of Internal Medicine, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Takashi Kato
- Division of Rheumatology, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Kazuo Shimamura
- Division of Pathology, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Teruji Sugita
- Division of Surgery, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Mitsuhiro Kubota
- Division of Surgery, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Kohji Kanaya
- Division of Surgery, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Daisuke Yamachika
- Division of Surgery, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Makoto Sato
- Division of Surgery, Yamachika Memorial Hospital, Odawara, Kanagawa, Japan,
| | - Dai Inoue
- Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa, Japan,
| | - Kenichi Harada
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa, Japan, and
| | - Mitsuhiro Kawano
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa, Japan
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31
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Yan F, Ma Y, Sun J, Zhu P. Reactive nodular fibrous pseudotumor involving the gastrointestinal tract and mesentery: A case report and review of the literature. Oncol Lett 2015; 9:1343-1346. [PMID: 25663910 PMCID: PMC4315131 DOI: 10.3892/ol.2015.2882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 12/12/2014] [Indexed: 12/26/2022] Open
Abstract
Reactive nodular fibrous pseudotumor (RNFP) is a tumor-like lesion that is characterized by reactive fibroblast/myofibroblast proliferation within collagenic hyalinized stroma, due to its association with injury or inflammation. The current study describes the case of a 60-year-old female with a history of abdominal surgery and abdominal pain. Upon laparoscopy, multiple nodules attached to the outer layer of the colon and mesentery were identified, and therefore, complete surgical excision was performed. Macroscopically, the nodules were well-circumscribed, firm, tan-white in color and ranged in size between 2.0–10.0 cm at the greatest dimension. Microscopically, the nodules were composed of spindle and stellate cells in a dense collagenic hyalinized background with sparse lymphocytic infiltration. Immunohistochemical analysis demonstrated positive staining for vimentin, smooth muscle actin and cluster of differentiation (CD) 117, and focally-positive keratin staining with AE1/AE3; however, no staining was observed for gastrointestinal stromal tumor 1, CD34, S-100, anaplastic lymphoma kinase or β-catenin. Therefore, it was proposed that the lesion may be most accurately described as an RNFP. The current study reports a rare case of RNFP, emphasizing its histopathological features and differential diagnoses to promote an improved and broader understanding of this poorly understood condition.
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Affiliation(s)
- Fei Yan
- Department of Oncology, Zhongshan Hospital of Hubei Province, Wuhan, Hubei 430000, P.R. China
| | - Yanli Ma
- Department of Oncology, Zhongshan Hospital of Hubei Province, Wuhan, Hubei 430000, P.R. China
| | - Jianhai Sun
- Department of Oncology, Zhongshan Hospital of Hubei Province, Wuhan, Hubei 430000, P.R. China
| | - Pengcheng Zhu
- Institute of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China
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Huang Y, Li LP, Wang J, Lun ZJ, Li W, Yang Z. Inflammatory pseudotumor of the colon causing intussusception: A case report and literature review. World J Gastroenterol 2015; 21:704-710. [PMID: 25593502 PMCID: PMC4292308 DOI: 10.3748/wjg.v21.i2.704] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 06/18/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023] Open
Abstract
Inflammatory pseudotumor (IPT) is a rare space-occupying lesion of unknown etiology that can mimic malignancy on clinic-radiological and pathological examination. We describe a rare case of ileocecal intussusception from clinically suspected malignancy of the right colon where the patient underwent right hemicolectomy. Histopathology of the resected specimen confirmed IPT of the colon. This patient was observed to have abnormally elevated total leukocyte count and platelets before and after surgery. In an adult with intussusception associated with an abdominal mass, the possibility of IPT of the colon should be considered. Considering the abnormally high total leukocyte and platelet counts and colonic IPT, it is necessary to prevent postoperative adverse effects due to these changes. Although IPT of the colon is usually a benign process, controversy regarding its management still exists. We consider hemicolectomy as a safe treatment approach for colonic IPT and review the existing literature.
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Zhang H, Jin Z, Ding S. Gastric calcifying fibrous tumor: A case of suspected immunoglobulin G4-related gastric disease. Saudi J Gastroenterol 2015; 21:423-6. [PMID: 26655140 PMCID: PMC4707813 DOI: 10.4103/1319-3767.170950] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Gastrointestinal lesions resulting from immunoglobulin G4-related disease are classified into two types: One is a gastrointestinal lesion showing marked thickening of the wall, and the other is an IgG4-related pseudotumor. We report the case of a woman with gastric calcifying fibrous tumor undergoing endoscopic resection that contained 62 IgG4+ plasma cells per high-power field and an IgG4-to-IgG ratio of 41% in lesional plasma cells, which shared clinical and histopathological features associated with gastric IgG4-related pseudotumor. So, we postulate that calcifying fibrous tumor as part of the spectrum of IgG4-related disease might be the unifying concept with IgG4-related pseudotumor. Meanwhile, the patient had coexistent autoimmune diseases, including autoimmune atrophic gastritis, Hashimoto's thyroiditis, and possible primary biliary cirrhosis. The clinical follow-up evaluation was uneventful.
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Affiliation(s)
- Hejun Zhang
- Department of Gastroenterology, Peking University Third Hospital, Beijing, China
| | - Zhu Jin
- Department of Gastroenterology, Peking University Third Hospital, Beijing, China
| | - Shigang Ding
- Department of Gastroenterology, Peking University Third Hospital, Beijing, China,Address for correspondence: Dr. Shigang Ding, No. 49 Road Huayuan North, Haidian District, Beijing - 100191, PR China. E-mail:
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Na KY, Sung JY, Jang JY, Lim SJ, Kim GY, Kim YW, Park YK, Lee JH. Gastric nodular lesion caused by IgG4-related disease. Pathol Int 2014; 62:716-8. [PMID: 23005600 DOI: 10.1111/j.1440-1827.2012.02859.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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35
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Hiyoshi Y, Oki E, Zaitsu Y, Ando K, Ito S, Saeki H, Morita M, Yamamoto H, Baba H, Maehara Y. IgG4-related disease of the ileocecal region mimicking malignancy: A case report. Int J Surg Case Rep 2014; 5:669-72. [PMID: 25194601 PMCID: PMC4189076 DOI: 10.1016/j.ijscr.2014.08.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 08/04/2014] [Accepted: 08/04/2014] [Indexed: 12/24/2022] Open
Abstract
The colonic IgG4-RD is rare. We report the case of a74-year-old female with IgG4-RD of the ileocecal region. The patient was diagnosed asmalignant lymphoma and underwent right-hemi colectomy. Postoperative pathologicalexamination revealed IgG4-RD of the ileocecal region. Surgical resection for IgG4-RDis necessary for cases with concerns of malignancy.
INTRODUCTION Immunoglobulin G4-related disease (IgG4-RD) is a systemic disease characterized by chronic fibrosing inflammation with abundant IgG4-positive plasma cells, and responds well to steroids. Previous reports of IgG4-RD have focused on pancreatic and extrapancreatic including the gastrointestinal tract, however, the colonic IgG4-RD is rare. PRESENTATION OF CASE We herein report the case of a 74-year-old female with edematous wall thickening of the terminal ileum to the lower ascending colon confirmed by several preoperative imaging studies, who underwent right hemi-colectomy for suspected malignant lymphoma. The resected specimen showed an irregular wall thickness with subserosal sclerosis, and the lesion was 10 cm in length from the terminal ileum to the ascending colon. The patient was diagnosed with IgG4-RD by pathological examinations, which demonstrated an increased number of IgG4-positive plasma cells (150/HPF), and an elevated IgG4/IgG ratio (50%). DISCUSSION Gastrointestinal IgG4-RD appears to be difficult to diagnose prior to surgical resection because of its rarity, and the similarity of its features to malignancy. The measurement of the serum IgG4 levels, immunohistochemical examination of biopsy specimens and use of several imaging modalities might help us to diagnose the disease without surgical resection, and this disease can generally be treated with steroid therapy. However, surgical resection for IgG4-RD may still be also necessary for patients with concerns regarding malignancy or with intractable gastrointestinal obstruction caused by this disease. CONCLUSION Gastrointestinal IgG4-RD often mimics malignancy, and we should therefore consider this disease in the differential diagnosis of colonic lesions in order to optimize the treatment.
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Affiliation(s)
- Yukiharu Hiyoshi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan.
| | - Eiji Oki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yoko Zaitsu
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Koji Ando
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Shuhei Ito
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Hiroshi Saeki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masaru Morita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Hidetaka Yamamoto
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
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Uehara T, Hamano H, Suga T, Kawa S, Yoshizawa A, Kobayashi Y, Murata K, Oki K, Sano K, Onodera R, Ota H. Inflammation of colon adenoma in the setting of type 1 autoimmune pancreatitis. Pathol Int 2014; 64:67-74. [DOI: 10.1111/pin.12139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 01/19/2014] [Indexed: 12/24/2022]
Affiliation(s)
- Takeshi Uehara
- Department of Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Hideaki Hamano
- Division of Medical Informatics; Shinshu University Hospital; Matsumoto Japan
| | - Tomoaki Suga
- Gastroenterology, Department of Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Shigeyuki Kawa
- Center for Health, Safety and Environmental Management; Shinshu University; Matsumoto Japan
| | - Akihiko Yoshizawa
- Department of Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Yukihiro Kobayashi
- Department of Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Kazuya Murata
- Department of Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Keiko Oki
- Department of Laboratory Medicine; Shinshu University Hospital; Matsumoto Japan
| | - Kenji Sano
- Department of Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Rie Onodera
- Department of Biomedical Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Hiroyoshi Ota
- Department of Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
- Department of Laboratory Medicine; Iwate Medical University School of Medicine; Morioka Japan
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37
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Lee LH, Shaffer EA, Falck V, Kelly MM. Solitary Lesions With Fibrosis and Increased IgG4+ Plasma Cells. Int J Surg Pathol 2013; 22:105-12. [DOI: 10.1177/1066896913513832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We assessed 6 cases acquired during routine surgical sign-out for IgG4-related disease (IRD) according to criteria from a recent consensus meeting. These cases fulfilled the morphologic criteria—that is, dense lymphoplasmacytic infiltrates, IgG4:IgG ratio greater than or equal to 0.4, and fibrosis (storiform in 4 cases—but were associated with malignancy or did not fulfill the criteria for a new site. These criteria include increased serum IgG4 (normal in the majority of IRD) and a response to glucocorticoids, which is not appropriate treatment for resectable lesions as in our cases. Until more is known about the natural history of the disease, we propose that the possibility of an early, localized, or forme fruste of IRD should be considered and that cases associated with malignancy should at least be documented. Although we acknowledge the value of the consensus criteria, their strict application may result in missed opportunities to study the disease.
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Affiliation(s)
- Lik Hang Lee
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
| | - Eldon A. Shaffer
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Vincent Falck
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
| | - Margaret M. Kelly
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
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Kuwata G, Kamisawa T, Koizumi K, Tabata T, Hara S, Kuruma S, Fujiwara T, Chiba K, Egashira H, Fujiwara J, Arakawa T, Momma K, Horiguchi S. Ulcerative colitis and immunoglobulin G4. Gut Liver 2013; 8:29-34. [PMID: 24516698 PMCID: PMC3916684 DOI: 10.5009/gnl.2014.8.1.29] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 02/20/2013] [Accepted: 04/03/2013] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Ulcerative colitis (UC) is sometimes associated with autoimmune pancreatitis (AIP). Infiltration of immunoglobulin G4 (IgG4)-positive plasma cells is sometimes detected in the colonic mucosa of AIP or UC patients. This study aimed to clarify the relation between UC and IgG4. Methods Associations with UC were reviewed in 85 AIP patients. IgG4 immunostaining was performed on biopsy specimens from the colonic mucosa of 14 AIP and 32 UC patients. Results UC was confirmed in two cases (type 1 AIP, n=1; suspected type 2 AIP, n=1). Abundant infiltration of IgG4-positive plasma cells in the colonic mucosa was detected in the case of suspected type 2 AIP with UC and two cases of type 1 AIP without colitis. Abundant infiltration of IgG4-positive plasma cells was detected in 10 UC cases (IgG4-present, 31%). Although 72% of IgG4-absent UC patients showed mild disease activity, 70% of IgG4-present patients showed moderate to severe disease activity (p<0.05). Conclusions UC is sometimes associated with AIP, but it seems that UC is not a manifestation of IgG4-related disease. Infiltration of IgG4-positive plasma cells is sometimes detectable in the colonic mucosa of UC patients and is associated with disease activity.
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Affiliation(s)
- Go Kuwata
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Koichi Koizumi
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Taku Tabata
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Seiichi Hara
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Sawako Kuruma
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Takashi Fujiwara
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Kazuro Chiba
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Hideto Egashira
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Junko Fujiwara
- Department of Endoscopy, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Takeo Arakawa
- Department of Endoscopy, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Kumiko Momma
- Department of Endoscopy, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
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Koizumi S, Kamisawa T, Kuruma S, Tabata T, Chiba K, Iwasaki S, Endo Y, Kuwata G, Koizumi K, Shimosegawa T, Okazaki K, Chiba T. Immunoglobulin G4-related gastrointestinal diseases, are they immunoglobulin G4-related diseases? World J Gastroenterol 2013; 19:5769-5774. [PMID: 24124321 PMCID: PMC3793131 DOI: 10.3748/wjg.v19.i35.5769] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/30/2013] [Accepted: 07/19/2013] [Indexed: 02/06/2023] Open
Abstract
In immunoglobulin G4 (IgG4)-related disease (RD), organ enlargement or nodular lesions consisting of abundant infiltration of lymphocytes and IgG4-positive plasma cells and fibrosis are seen in various organs. Although infiltration of many IgG4-positive plasma cells is detected in the gastric and colonic mucosa and major duodenal papilla of patients with autoimmune pancreatitis, it cannot be diagnosed as a gastrointestinal lesion involved in IgG4-RD, because none of the following is observed in these lesions: a mass-like formation; dense fibrosis; or obliterative phlebitis. Based on our review of the literature, there appear to be two types of IgG4-related gastrointestinal disease. One is a gastrointestinal lesion showing marked thickening of the wall of the esophagus and stomach, consisting of dense fibrosis with abundant infiltration of IgG4-positive plasma cells, which usually show submucosal spreading. The other is an IgG4-related pseudotumor occurring in gastrointestinal regions such as the stomach, colon, and major duodenal papilla, showing polypoid or mass-like lesions. Most solitary IgG4-related gastrointestinal lesions that are not associated with other IgG4-RD appear to be difficult to diagnose. It is of utmost importance to rule out malignancy. However, these lesions may respond to steroid therapy. To avoid unnecessary resection, IgG4-related gastrointestinal diseases should be considered in the differential diagnosis.
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Shi S, Zhang P, Cheng Q, Wu J, Cui J, Zheng Y, Bai XY, Chen X. Immunohistochemistry of deparaffinised sections using antigen retrieval with microwave combined pressure cooking versus immunofluorescence in the assessment of human renal biopsies. J Clin Pathol 2013; 66:374-80. [PMID: 23476077 DOI: 10.1136/jclinpath-2012-201125] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Immunofluorescence of frozen tissue sections (IF-F) is a traditional technique used in renal biopsy. However, IF-F has certain disadvantages, such as a few or even no glomeruli in the section, and limited long-term preservation of the fluorescently labelled samples. METHODS We compared two-step immunohistochemistry (IHC) staining of deparaffinised sections for antigen retrieval with microwave combined high-pressure cooking to IF-F used to detect antigens of IgG, IgA, IgM, C3, C1q, κ and λ in patient renal biopsy samples. The number of glomeruli detected, sensitivity and specificity of positive staining, tissue structure, and location staining of the antigens were determined using the two methods in 285 patients diagnosed with different renal diseases. RESULTS Concordant observations between IF-F and IHC were 99% for all antigen staining (1969 of 1995 observations) and 100% for IgG, IgA and IgM (all 285 observations). The number of glomeruli in IHC sections was significantly greater compared with IF-F sections (p<0.001). IHC provided clearer images of tissue structure, more precise localisation of positive-staining antigens, and IHC staining allowed simultaneous evaluation of tissue by light microscopy. Correlation between tissue structure and immune deposits are not readily attained by IF-F. CONCLUSIONS IHC is superior to IF-F for immunopathological diagnosis of renal biopsy tissue and is a reliable replacement for the more traditional IF-F method.
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Affiliation(s)
- Suozhu Shi
- Department of Nephrology, State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
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Shi S, Cheng Q, Zhang P, Wang N, Zheng Y, Bai XY, Chen X. Immunofluorescence with dual microwave retrieval of paraffin-embedded sections in the assessment of human renal biopsy specimens. Am J Clin Pathol 2013; 139:71-8. [PMID: 23270901 DOI: 10.1309/ajcprzg8exn7baid] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Immunofluorescence of frozen tissue sections (IF-F) is a classic technique for renal immunopathologic examination. However, it has certain disadvantages, such as diffuse antigen distribution and few or even no glomeruli in the section. We developed a new technique of immunofluorescence staining using dual microwave retrieval in paraffin-embedded renal tissue sections (IF-DMP) and compared IF-DMP with IF-F in 406 renal biopsy samples. IF-DMP detected significantly more glomeruli than did IF-F (P< .001). There was no significant difference for the specificity and sensitivity in the detection of immunoglobulins, complements, κ, and λ between IF-F and IF-DMP. Concordant observations were 98% for all immunofluorescence, complements, κ, and λ staining and 100% for immunoglobulin staining. Both techniques were completely accurate in confirming diagnoses of various glomerular diseases. IF-DMP provided clearer images of tissue structure and more precise localization of antigens, and it is a suitable alternative for traditional IF-F in clinical renal immunopathologic diagnosis.
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Affiliation(s)
- Suozhu Shi
- Department of Nephrology, State Key Lab of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Qingli Cheng
- Department of Geriatric Nephrology, Chinese PLA General Hospital, Beijing, China
| | - Ping Zhang
- Department of Pathology, Wang Jing Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China
| | - Nan Wang
- Department of Nephrology, State Key Lab of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Ying Zheng
- Department of Nephrology, State Key Lab of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Xue-Yuan Bai
- Department of Nephrology, State Key Lab of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Xiangmei Chen
- Department of Nephrology, State Key Lab of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
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Fujita K, Naganuma M, Saito E, Suzuki S, Araki A, Negi M, Kawachi H, Watanabe M. Histologically confirmed IgG4-related small intestinal lesions diagnosed via double balloon enteroscopy. Dig Dis Sci 2012; 57:3303-6. [PMID: 22695887 DOI: 10.1007/s10620-012-2267-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 05/30/2012] [Indexed: 01/27/2023]
Affiliation(s)
- Kyohei Fujita
- Departments of Gastroenterology and Hepatology, School of Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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IgG4-related sclerosing disease of the small bowel presenting as necrotizing mesenteric arteritis and a solitary jejunal ulcer. Am J Surg Pathol 2012; 36:929-34. [PMID: 22367294 DOI: 10.1097/pas.0b013e3182495c96] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Since first described in the mid 1990s, there has been burgeoning literature on IgG4-related sclerosing disease. The number of sites that may be involved is ever increasing, with the pancreas, salivary glands, and lymph nodes being the most commonly affected organs. There are no well-documented cases arising in the gastrointestinal tract. In this report, we present the first case to our knowledge of IgG4-related sclerosing disease involving the small bowel with a distinctly unusual clinicopathologic presentation. A previously well 46-year-old woman presented with a 2-year history of intermittent abdominal pain with recent worsening due to small bowel obstruction. Following imaging, which showed jejunitis with surrounding mesenteric inflammatory changes, she proceeded to a segmental small bowel resection. The resected jejunum revealed an isolated, stenosing chronic ulcer associated with a necrotizing mesenteric arteritis. A transmural inflammatory infiltrate rich in IgG4 plasma cells was seen in the wall of the bowel and mesenteric artery. Abundant IgG4 interfollicular plasma cells were also identified in a mesenteric lymph node. The serum IgG4 level was elevated at >800 mg/dL (reference range 8 to 140 mg/dL). Although phlebitis is an almost constant feature of this disease, arteritis is not described other than in the lung and aorta. In this report, we also discuss the diagnostic pitfalls and the differential diagnoses that should be considered when this condition arises in the gastrointestinal tract.
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Culver EL, Bateman AC. IgG4-related disease: can non-classical histopathological features or the examination of clinically uninvolved tissues be helpful in the diagnosis? J Clin Pathol 2012; 65:963-9. [PMID: 22685258 DOI: 10.1136/jclinpath-2012-200932] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IgG4-related disease (IgG4-RD) is an increasingly recognised inflammatory and fibrosing condition that commonly shows multisystem involvement. The disease may mimic malignancy and other inflammatory or immune-mediated disorders, but usually has a good response to corticosteroid therapy, underlining the requirement for recognition of the condition. Accurate diagnosis requires careful interpretation of varying combinations of serum IgG4 levels, radiological features and characteristic histopathological appearances within an appropriate clinical setting. The presence of 'classical' histopathological features together with an elevated tissue IgG4+ plasma cell count and IgG4 to IgG ratio is often diagnostic and at the very least can strongly support a clinicopathological diagnosis of IgG4-RD. The authors describe the most recent diagnostic criteria for IgG4-RD, especially the histopathological features. The authors then discuss the merits of examining tissues that may be more easily obtainable than those that commonly show the 'classical' histopathological features, but within which not all of these 'diagnostic' features may be present. The authors conclude that while a combination of 'classical' histopathological features and an elevated tissue IgG4+ plasma cell count is the gold standard for diagnosis, examination of tissues that show some but not all of these features can, in the appropriate context, provide useful supporting evidence for a clinicopathological diagnosis of IgG4-RD.
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Affiliation(s)
- Emma L Culver
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Abstract
PURPOSE OF REVIEW Provide an update of the developments in IgG4 related disease within the last year in terms of nomenclature, diagnostic criteria and clinical features. RECENT FINDINGS The number of diseases associated with IgG4 related disease continues to grow. The entities of idiopathic orbital inflammation, idiopathic cervical fibrosis, eosinophilic angiocentric fibrosis, reactive nodular fibrous pseudotumor, sclerosing mesenteritis, and membranous glomerulonephritis should all be added to the list of diseases associated with the IgG4 related disease spectrum. The issues of nomenclature and diagnostic criteria for IgG4 related disease have important recent developments as well. SUMMARY The diagnosis of IgG4 related disease continues to be challenging. Increasing recognition of IgG4 related disease has led to a large body of literature on organ sites of involvement. Understanding how the disease manifests itself is critical to diagnosis and ultimately treatment.
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Strehl JD, Hartmann A, Agaimy A. Numerous IgG4-positive plasma cells are ubiquitous in diverse localised non-specific chronic inflammatory conditions and need to be distinguished from IgG4-related systemic disorders. J Clin Pathol 2011; 64:237-43. [PMID: 21233087 DOI: 10.1136/jcp.2010.085613] [Citation(s) in RCA: 238] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND IgG4-related systemic fibrosclerosis is a recently defined disorder characterised by a diffuse or tumefactive inflammatory reaction rich in IgG4-positive plasma cells associated with sclerosis and obliterative phlebitis. Although characteristic histopathological features are essential for the diagnosis of these disorders, to date there exists no consensus regarding the cut-off values used to define a 'significant IgG4-positive plasma cell count,' and data regarding the distribution of IgG4-positive plasma cells under common (non-specific) inflammatory conditions are lacking. METHODS The authors analysed 121 randomly selected histopathological specimens containing prominent lymphoplasmacytic infiltrates (11 obstructive sialadenitis, 27 inflammatory lesions of the oral cavity, 24 inflammatory gastrointestinal lesions, 15 rheumatoid synovitis, 15 non-specific synovitis, eight non-specific dermatitis and 21 primary carcinomas with a peritumoral inflammatory response). For comparison, seven cases of sclerosing sialadenitis (Küttner tumour) were examined. RESULTS High counts of IgG4 plasma cells were found in sclerosing sialadenitis (mean 40/high-power field (hpf)), contrasting sharply with sialadenitis caused by sialolithiasis (mean 3/hpf). Greatly varied but generally high counts of IgG4-positive plasma cells were also seen in several of the other lesions, particularly in rheumatoid synovitis (mean 55/hpf), oral cavity lesions (mean 79/hpf) and carcinoma-associated inflammatory response (mean 24/hpf). The mean IgG4/IgG ratios for all lesions varied between 0 and 0.4. CONCLUSIONS The results demonstrate the ubiquitous occurrence of variably high numbers of IgG4-positive plasma cells under diverse non-specific inflammatory conditions, indicating that high IgG4-positive plasma cell counts and high IgG4/IgG ratios per se do not reliably distinguish IgG4-associated systemic disease from non-specific conditions, and that the IgG4 counts must be cautiously interpreted in the context of appropriate clinical and histopathological features.
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Affiliation(s)
- Johanna D Strehl
- Institute of Pathology, University of Erlangen, Krankenhausstrasse 12, Erlangen, Germany
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