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Bateman AC, Culver EL. Challenges and pitfalls in the diagnosis of IgG4-related disease. Semin Diagn Pathol 2024; 41:45-53. [PMID: 38000975 DOI: 10.1053/j.semdp.2023.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023]
Abstract
IgG4-related disease (IgG4-RD) is a relatively novel fibroinflammatory condition characterized typically by dense lymphoplasmacytic inflammation, storiform fibrosis and obliterative venulitis, together with prominent IgG4+ plasma cells and an IgG4+/IgG+ plasma cell ratio of >40 %. The diagnosis is usually made on a combination of clinical and serological features together with characteristic radiological and histological appearances. The condition may be limited to a single tissue/organ (e.g., autoimmune pancreatitis) or may be multicentric in nature - four clinical 'patterns' of disease distribution have recently been described. The diagnosis of IgG4-RD can be challenging, particularly when the clinical presentation is unusual and/or when the histological features are not typical. A diagnosis of IgG4-RD may still be achieved in these situations, after careful clinicopathological discussion e.g., at a specialist multidisciplinary team meeting. However, a wide range of other conditions (neoplastic and non-neoplastic) can mimic IgG4-RD, clinically and/or on histological examination. The relationship between IgG4-RD and non-IgG4-RD associated conditions in some clinical situations is particularly complex. This review describes the role of histological examination in the diagnosis of IgG4-RD, discusses some of the practical difficulties that may be encountered and provides an insight into the range of non-IgG4-RD associated conditions that can mimic IgG4-RD on clinical and/or histological grounds. The requirement for interpretation of histological features in the context of the global clinical picture of the patient is highlighted and emphasized.
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Affiliation(s)
- Adrian C Bateman
- Department of Cellular Pathology, Southampton General Hospital, MP002, Level E, South Block, Tremona Road, Southampton SO16 6YD, UK.
| | - Emma L Culver
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
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2
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Abou Saleh M, Alkhayyat M, Habash A, Almomani A, Qayyum F, Kim W, Bena J, Martin C, Regueiro M, Rieder F, Simons-Linares CR, Chahal P. The Natural Course of Pancreatic Cysts in Inflammatory Bowel Disease: Results of a Long-term Follow-up. Pancreas 2022; 51:814-820. [PMID: 36395408 PMCID: PMC10921864 DOI: 10.1097/mpa.0000000000002102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The natural course of pancreatic cysts in inflammatory bowel disease (IBD) is unknown. We aim to describe the natural course of pancreatic cysts in IBD and evaluate long-term outcomes. METHODS A database of patients with abdominal imaging diagnosis of pancreatic cysts (2008-2019) was reviewed. Patients with IBD and pancreatic cysts (study group) and pancreatic cysts without IBD (controls) were selected. Outcomes were measured at 1, 3, 5, and 10 years. Several logistic regression models were used for analysis. RESULTS Of the 1789 patients evaluated, 1690 had pancreatic cysts without IBD, and 78 had IBD and pancreatic cysts. Majority of cysts were intraductal papillary mucinous neoplasms. Patients with IBD and pancreatic cysts were more likely to be diagnosed with pancreatic cysts at a younger age (P < 0.001) and were more likely to undergo surgical intervention at a younger age (P < 0.001). CONCLUSIONS This is the first study to evaluate the natural course of pancreatic cysts in IBD patients. Patients with IBD were more likely to have pancreatic cysts detected at a younger age. Despite the early presentation, there were no differences in long-term outcomes. Patients with IBD with pancreatic cysts should be managed similarly to those without IBD.
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Affiliation(s)
- Mohannad Abou Saleh
- From the Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Notohara K. Histological features of autoimmune pancreatitis and IgG4-related sclerosing cholangitis with a correlation with imaging findings. J Med Ultrason (2001) 2021; 48:581-594. [PMID: 34669070 DOI: 10.1007/s10396-021-01148-5] [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: 07/06/2021] [Accepted: 09/03/2021] [Indexed: 12/12/2022]
Abstract
Autoimmune pancreatitis (AIP) is characterized by a tumefactive inflammatory lesion resembling pancreatic carcinoma. Type 1 AIP is a pancreatic manifestation of IgG4-related disease characterized by unique histological features that can be identified on imaging. The capsule-like rim, which is a collar of hypertrophic lesion surrounding the pancreas, consists of lymphoplasmacytic infiltration and fibrosis, and storiform fibrosis is often identified. Hypertrophic lesions of various microscopic architectures such as the ducts, veins (obliterative phlebitis), arteries (periarteritis), and nerves are observed without parenchymal damage. The pancreatic lobules keep their contours, but the acinar cells are diminished and replaced by numerous inflammatory cells. These features provide clues to arrive at a diagnosis of type 1 AIP and to distinguish it from pancreatic carcinoma on imaging. In contrast, type 2 AIP is an epithelium-centered inflammation involving the ducts and lobules. Neutrophilic infiltration in the epithelium and/or lumens (granulocytic epithelial lesion) is a characteristic finding. Lobular swelling due to inflammation is the cause of pancreatic enlargement. IgG4-related sclerosing cholangitis is histologically similar to the hypertrophic ductal lesion in type 1 AIP and characterized by wall thickening due to inflammation and luminal stenosis. The epithelium is intact, which is different from bile duct carcinomas and primary sclerosing cholangitis, the latter of which is characterized by inflammation targeting the epithelium. Although the histological features of type 1 AIP and IgG4-related sclerosing cholangitis are unique, the biopsy diagnosis of these diseases has limitations, which should be recognized by clinicians.
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Affiliation(s)
- Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan.
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Hirano K, Itoi T, Sasahira N, Koyama H, Ihara F. Coexisting Type 1 Autoimmune Pancreatitis and Mixed-type Intraductal Papillary Mucinous Neoplasm. Intern Med 2021; 60:2793-2797. [PMID: 33746160 PMCID: PMC8479204 DOI: 10.2169/internalmedicine.6514-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An 84-year-old man was referred to our hospital for a cystic lesion of the pancreatic head, swelling of the pancreatic tail and hilar biliary stricture, resulting in elevated liver enzyme levels. We suspected branch duct-type intraductal papillary mucinous neoplasm (IPMN) and type I autoimmune pancreatitis (AIP) associated with sclerosing cholangitis because of the high serum IgG4 levels. The main pancreatic duct on the tail side of the AIP lesion was moderately dilated. Although the biliary stricture and pancreatic swelling improved after prednisolone treatment, the pancreatic enzyme levels increased rapidly. The entire main pancreatic duct exhibited remarkable dilatation, which led to the diagnosis of mixed-type IPMN. The clinical characteristics of IPMN in the main pancreatic duct appear to have been initially masked by AIP.
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Affiliation(s)
- Kenji Hirano
- Department of Internal Medicine, Japan Community Healthcare Organization Tokyo Takanawa Hospital, Japan
| | - Takanobu Itoi
- Department of Internal Medicine, Japan Community Healthcare Organization Tokyo Takanawa Hospital, Japan
| | - Naoki Sasahira
- Department of Internal Medicine, Japan Community Healthcare Organization Tokyo Takanawa Hospital, Japan
| | - Hiroto Koyama
- Department of Surgery, Japan Community Healthcare Organization Tokyo Takanawa Hospital, Japan
| | - Fumie Ihara
- Department of Pathology, Japan Community Healthcare Organization Tokyo Takanawa Hospital, Japan
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5
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Suzuki R, Okada R, Muto M, Takagi T, Sugimoto M, Irie H, Nakamura J, Takasumi M, Kato T, Hashimoto M, Notohara K, Suzuki O, Hashimoto Y, Hikichi T, Marubashi S, Ohira H. Rare coincidence of intraductal papillary mucinous neoplasm and type 1 autoimmune pancreatitis. Clin J Gastroenterol 2020; 13:1315-1321. [PMID: 32594422 DOI: 10.1007/s12328-020-01162-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/18/2020] [Indexed: 01/06/2023]
Abstract
The present case involved a 60-year-old man with autoimmune pancreatitis (AIP). While his AIP was in remission for 6 years, a follow-up CE-CT revealed a dilated main pancreatic duct (MPD) and an enhanced mural nodule. Fluorodeoxyglucose uptake was positive on positron emission tomography. Endoscopic retrograde pancreatography showed a filling defect of the MPD, and pancreatoscopy revealed a nodule partially covered with papillary lesions. Although a repeat biopsy revealed no evidence of malignancy, we speculated that there was a high likelihood of main-duct-type intraductal papillary mucinous neoplasm (IPMN)-derived carcinoma concomitant with AIP. Subsequently, the patient underwent subtotal stomach-preserving pancreaticoduodenectomy. A surgical specimen showed a 35 mm protuberant papillary lesion with abundant stroma, located in the main duct of the pancreas. Further histological evaluation revealed that the nodule was predominantly composed of IPMN with low-grade dysplasia, which was accompanied by abundant IgG4-positive lymphoplasmacytic infiltration, and fibrosis existed predominantly around the IPMN. The epithelium of the cyst showed mucinous hyperplasia with focal papillary structures of gastric phenotype (MUC5A+, MUC6+, MUC1-, MUC2-, CDX-). After surgical resection, we did not find any imaging evidence suggesting a recurrent tumor and AIP relapse in the remnant pancreas. In conclusion, we report a case of IPMN coincidentally found in a patient with type 1 AIP. Active AIP may exaggerate the morphology of IPMN, and careful evaluation should be performed to select appropriate management.
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Affiliation(s)
- Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Ryo Okada
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University School of Medicine, Fukushima, 960-1295, Japan
| | - Makoto Muto
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University School of Medicine, Fukushima, 960-1295, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Hiroki Irie
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University School of Medicine, Fukushima, 960-1295, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Tsunetaka Kato
- Department of Endoscopy, Fukushima Medical University School of Medicine, Fukushima, 960-1295, Japan
| | - Minami Hashimoto
- Department of Endoscopy, Fukushima Medical University School of Medicine, Fukushima, 960-1295, Japan
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Kurashiki, 710-8602, Japan
| | - Osamu Suzuki
- Department of Pathology, Fukushima Medical University School of Medicine, Fukushima, 960-1295, Japan
| | - Yuko Hashimoto
- Department of Pathology, Fukushima Medical University School of Medicine, Fukushima, 960-1295, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University School of Medicine, Fukushima, 960-1295, Japan
| | - Shigeru Marubashi
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University School of Medicine, Fukushima, 960-1295, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
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Löhr JM, Beuers U, Vujasinovic M, Alvaro D, Frøkjær JB, Buttgereit F, Capurso G, Culver EL, de-Madaria E, Della-Torre E, Detlefsen S, Dominguez-Muñoz E, Czubkowski P, Ewald N, Frulloni L, Gubergrits N, Duman DG, Hackert T, Iglesias-Garcia J, Kartalis N, Laghi A, Lammert F, Lindgren F, Okhlobystin A, Oracz G, Parniczky A, Mucelli RMP, Rebours V, Rosendahl J, Schleinitz N, Schneider A, van Bommel EF, Verbeke CS, Vullierme MP, Witt H. European Guideline on IgG4-related digestive disease - UEG and SGF evidence-based recommendations. United European Gastroenterol J 2020; 8:637-666. [PMID: 32552502 DOI: 10.1177/2050640620934911] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The overall objective of these guidelines is to provide evidence-based recommendations for the diagnosis and management of immunoglobulin G4 (IgG4)-related digestive disease in adults and children. IgG4-related digestive disease can be diagnosed only with a comprehensive work-up that includes histology, organ morphology at imaging, serology, search for other organ involvement, and response to glucocorticoid treatment. Indications for treatment are symptomatic patients with obstructive jaundice, abdominal pain, posterior pancreatic pain, and involvement of extra-pancreatic digestive organs, including IgG4-related cholangitis. Treatment with glucocorticoids should be weight-based and initiated at a dose of 0.6-0.8 mg/kg body weight/day orally (typical starting dose 30-40 mg/day prednisone equivalent) for 1 month to induce remission and then be tapered within two additional months. Response to initial treatment should be assessed at week 2-4 with clinical, biochemical and morphological markers. Maintenance treatment with glucocorticoids should be considered in multi-organ disease or history of relapse. If there is no change in disease activity and burden within 3 months, the diagnosis should be reconsidered. If the disease relapsed during the 3 months of treatment, immunosuppressive drugs should be added.
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Affiliation(s)
- J-Matthias Löhr
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden and Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Miroslav Vujasinovic
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden and Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité University Medicine Berlin, Berlin, Germany
| | - Gabriele Capurso
- PancreatoBiliary Endoscopy and EUS Division Pancreas Translational and Clinical Research Center IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emma L Culver
- Translational Gastroenterology Unit, John Radcliffe Hospital and Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, ISABIAL, Alicante, Spain
| | - Emanuel Della-Torre
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Disease (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sönke Detlefsen
- Department of Pathology, Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
| | - Enrique Dominguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Nils Ewald
- Institute of Endocrinology, Diabetology and Metabolism, Johannes Wesling University hospital, Minden, Germany and Justus Liebig University Giessen, Giessen, Germany
| | - Luca Frulloni
- Department of Medicine, Pancreas Institute, University of Verona, Verona, Italy
| | - Natalya Gubergrits
- Department of Internal Medicine, Donetsk National Medical University, Lyman, Ukraine
| | - Deniz Guney Duman
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Nikolaos Kartalis
- Department of Abdominal Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Andrea Laghi
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Fredrik Lindgren
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Karolinska University Hospital, Stockholm, Sweden
| | | | - Grzegorz Oracz
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Andrea Parniczky
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Heim Pál National Insitute of Pediatrics, Budapest, Hungary
| | | | - Vinciane Rebours
- Pancreatology Department, Beaujon Hospital, Clichy, Université de Paris, France
| | - Jonas Rosendahl
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
| | - Nicolas Schleinitz
- Département de Médicine Interne Timone, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Alexander Schneider
- Department of Gastroenterology and Hepatology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany
| | - Eric Fh van Bommel
- Department of Internal Medicine, Dutch National Center of Expertise Retroperitoneal Fibrosis, Albert Schweitzer hospital, Dordrecht, the Netherlands
| | | | | | - Heiko Witt
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin, Paediatric Nutritional Medicine, Technische Universität München, Freising, Germany
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- See list at the end of this article
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7
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Kaneko J, Matsubayashi H, Satoh T, Sato J, Takinami M, Ishiwatari H, Uesaka K, Abe M, Sasaki K, Ono H. Multilocular Cyst of Type 1 Autoimmune Pancreatitis Masquerading as Cancerization of Intraductal Papillary Mucinous Neoplasm. Intern Med 2020; 59:199-204. [PMID: 31484912 PMCID: PMC7008053 DOI: 10.2169/internalmedicine.3561-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A small proportion of intraductal papillary mucinous neoplasms (IPMNs) are accompanied by type 1 autoimmune pancreatitis (AIP); however their clinical courses and image characteristics have not been fully reported. A 65-year-old woman was referred to our hospital for the examination of a pancreatic head cyst that had shown exacerbation for two years. Several images demonstrated a multilocular cyst with a symmetrically thickened, enhanced, cyst wall. Cancerization of IPMN was suspected, and pancreatoduodenectomy was performed. The resected specimens showed a multilocular cyst with solid areas. The solid areas demonstrated pathological findings that corresponded with type 1 AIP. Papillary epithelia suggestive of IPMN was recognized in some parts of the cystic wall.
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Affiliation(s)
| | | | | | - Junya Sato
- Division of Endoscopy, Shizuoka Cancer Center, Japan
| | | | | | - Katsuhiko Uesaka
- Division of Hepato-pancreaticobiliary Surgery, Shizuoka Cancer Center, Japan
| | - Masato Abe
- Division of Pathology, Shizuoka Cancer Center, Japan
| | - Keiko Sasaki
- Division of Pathology, Shizuoka Cancer Center, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Japan
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Gowing K, Schaeffer DF, Yang HM. Mucinous cystic neoplasm of the pancreas with type-1 autoimmune pancreatitis-like lesion. HUMAN PATHOLOGY: CASE REPORTS 2019. [DOI: 10.1016/j.ehpc.2019.200339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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9
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Hedayat AA, Lisovsky M, Suriawinata AA, Longnecker DS. Association of IgG4 response and autoimmune pancreatitis with intraductal papillary-mucinous neoplasms. Pancreatology 2017; 17:263-266. [PMID: 28215485 DOI: 10.1016/j.pan.2017.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/14/2017] [Accepted: 02/06/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Concurrent intraductal papillary-mucinous neoplasm (IPMN) and autoimmune pancreatitis (AIP) was observed in a patient (index case) at our institution. Cases of coincidental IPMN and type 1 AIP and concurrent ductal adenocarcinoma (PDAC) and AIP have been previously reported. In this study we evaluate the hypothesis that IPMN elicits an IgG4 response. METHODS Twenty-one pancreases (including the index case) with IPMN resected at our institution were studied. H&E stained slides were reviewed and blocks of peritumoral pancreas were immunostained with IgG4 to look for IgG4-positive plasma cells. RESULTS We found evidence of variable IgG4 overexpression in 4/21 (19%) of IPMN. These included the index case and three others without stigmata of AIP. CONCLUSION A small subset of pancreatic neoplasms including intraductal papillary-mucinous neoplasms (IPMN) is associated with an IgG4 autoimmune response that sometimes progresses to peritumoral type 1 AIP and less often to diffuse AIP and IgG4-related systemic disease.
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Affiliation(s)
- Amin A Hedayat
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, United States.
| | - Mikhail Lisovsky
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, United States
| | - Arief A Suriawinata
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, United States
| | - Daniel S Longnecker
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, United States
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10
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Bateman AC, Culver EL. IgG4-related disease-experience of 100 consecutive cases from a specialist centre. Histopathology 2017; 70:798-813. [DOI: 10.1111/his.13136] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/21/2016] [Accepted: 11/24/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Adrian C Bateman
- Department of Cellular Pathology; University Hospital Southampton NHS Foundation Trust; Southampton UK
| | - Emma L Culver
- Translational Gastroenterology Department; John Radcliffe Hospital; Oxford UK
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11
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Hatano Y, Kawashima K, Iwashita T, Kimura M, Shimizu M, Hara A. A Solid Pseudopapillary Neoplasm of the Pancreas Associated With IgG4-Related Pancreatitis: A Case Report. Int J Surg Pathol 2017; 25:271-275. [PMID: 28107092 PMCID: PMC5405824 DOI: 10.1177/1066896916677289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A solid and cystic pancreatic lesion was incidentally found in a 62-year-old woman on abdominal computed tomography. The lesion was diagnosed as a solid pseudopapillary neoplasm by using endoscopic ultrasound-guided fine needle aspiration, and the tumor was resected. Histologically, the tumor cells had relatively small, round nuclei and papillary-like architecture in a hemorrhagic background. On immunohistochemical examination, the tumor cells were diffusely positive for nuclear β-catenin and cytoplasmic CD10. In addition, typical histological findings of IgG4-related pancreatitis (obstructive phlebitis, storiform-type fibrosis, and abundant IgG4-positive plasma cell infiltration) were found in the surrounding stroma of the solid pseudopapillary neoplasm. Postoperative workup failed to detect any other sclerotic lesions or serum IgG4 elevation, suggesting that the patient had no evidence of IgG4-related disease. To avoid misdiagnosis of a combined pancreatic neoplasm and fibro-inflammatory lesion, pathologists should consider such situations and make a definitive diagnosis after careful observation of all pancreatic lesions.
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Affiliation(s)
- Yuichiro Hatano
- 1 Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Keisuke Kawashima
- 2 Department of Pathology and Translational Research, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takuji Iwashita
- 3 First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Masaki Kimura
- 4 Department of General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masahito Shimizu
- 3 First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Akira Hara
- 1 Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
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Intraductal Papillary Neoplasm of the Bile Duct With Invasive Adenocarcinoma Complicating IgG4-related Sclerosing Cholangitis: Report of a Case. Int Surg 2017. [DOI: 10.9738/intsurg-d-15-00023.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Although there have been many previous studies of IgG4-related SC focusing on the differential diagnosis from cholangiocarcinoma, only a few patients with cholangiocarcinoma against a background of IgG4-related SC have been reported. We herein present a case of intraductal papillary neoplasm of the bile duct (IPNB) associated with invasive carcinoma complicating IgG4-related sclerosing cholangitis. A 71-year-old female with icterus was admitted to a local hospital, where stricture of the extrahepatic bile duct were detected, and subsequently referred to our hospital for possible surgery. Abdominal multidetector-row computed tomography demonstrated marked wall thickening along the entire extrahepatic bile duct. The left lateral superior bile duct (B2) and left lateral inferior duct (B3) were individually obstructed, and percutaneous transhepatic biliary drainage catheters were placed in B2 and B3 separately. The patient was diagnosed to have diffusely spread cholangiocarcinoma and underwent right hepatic trisectionectomy with caudate lobectomy and pancreatoduodenectomy. A histological examination revealed intraductal papillary tumors composed of fibrovascular stalks covered by neoplastic epithelium. Carcinomatous invasion of the papillary tumors was observed in the fibromuscular layer, and there was abundant infiltration of inflammatory cells with fibrosis outside of the cancerous tissue. The inflammatory cells were primarily composed of plasma cells, a majority of which were positive for IgG4 (>30 cells/high-power field); the postoperative serum IgG4 level was 890 mg/dL. Therefore, a diagnosis of coexisting IPNB associated with invasive carcinoma and IgG4-related sclerosing cholangitis was made. To the best of our knowledge, this is the first report of IPNB complicating IgG4-related sclerosing cholangitis.
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13
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Matsubayashi H, Iwai T, Matsui T, Wada T, Kawata N, Ito H, Sasaki K, Uesaka K, Ono H. Pancreatic cystic lesions with atypical steroid response should be carefully managed in cases of autoimmune pancreatitis. J Gastroenterol Hepatol 2016. [PMID: 26207936 DOI: 10.1111/jgh.13051] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM Pancreatic cysts have been reported in cases with autoimmune pancreatitis (AIP) and are often treated by corticosteroid; however, their response to steroid has not been determined fully. We aimed to see the incidence and steroid response of pancreatic cysts and the features of cysts without proper response in cases with AIP. METHODS Fifty-eight AIP cases were analyzed for the incidence and associated factors of pancreatic cystic lesions (≥ 10 mm). Of these, 47 cases, determined for steroid response, were retrospectively investigated for the factors associated with cyst change by corticosteroid therapy. RESULTS At initial diagnosis, 17 pancreatic cystic lesions were recognized in 13 cases (22.4%) of AIP, with an average size of 30 mm (range: 11-130 mm), associated with higher incidence of elevated serum amylase (38.5% vs 11.1%, P = 0.02). Of these 13 cases, nine cases with 10 cystic lesions underwent steroid therapy in our hospital. All of seven unilocular cysts were dramatically shrunken or vanished in a few months; meanwhile, three cases with multilocular cysts showed scarcely any steroid response (P = 0.008). Of these three cases, two cases were revealed to accompany pancreatic ductal carcinoma, in contrast to null of seven unilocular cysts (P = 0.07). CONCLUSIONS Pancreatic cystic lesions are sometimes recognized in cases with AIP, and most unilocular cysts can be minimized by corticosteroids. However, clinicians must be alert for atypical pancreatic cysts, such as multilocular cysts or cysts without obvious steroid response.
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Affiliation(s)
| | - Tomohiro Iwai
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Toru Matsui
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takuya Wada
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroaki Ito
- Division of Diagnostic Radiology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Keiko Sasaki
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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14
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Roch AM, Rosati CM, Cioffi JL, Ceppa EP, DeWitt JM, Al-Haddad MA, House MG, Zyromski NJ, Nakeeb A, Schmidt CM. Intraductal papillary mucinous neoplasm of the pancreas, one manifestation of a more systemic disease? Am J Surg 2015; 211:512-8. [PMID: 26830712 DOI: 10.1016/j.amjsurg.2015.12.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 12/21/2015] [Accepted: 12/21/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Several studies have demonstrated a high prevalence of extrapancreatic malignancies, and an association with autoimmune pancreatitis in patients with intraductal papillary mucinous neoplasm (IPMN). We hypothesized that IPMNs were associated with an increase rate of systemic diseases. METHODS From 1996 to 2013, a retrospective analysis of a prospectively collected database was performed and supplemented with electronic medical charts review. RESULTS Two hundred twenty extrapancreatic malignancies were found in 185 patients (22%) compared with expected 5% in the general population. Colorectal, lung, and renal cell carcinoma had significant observed/expected ratios (P < .0001). One hundred ten synchronous autoimmune diseases were found in 96 patients (11%). Systemic lupus erythematosus, rheumatoid arthritis, and inflammatory bowel disease showed statistically significant observed/expected ratios (P < .0001, .01, and <.0001, respectively). There was no impact of immunosuppressive treatment on the IPMN subtype and malignancy rate. CONCLUSIONS IPMN are associated with surprisingly high rates of autoimmune diseases suggesting that IPMN might be 1 manifestation of a more systemic disease.
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Affiliation(s)
- Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - Carlo Maria Rosati
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - Jessica L Cioffi
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - John M DeWitt
- Division of Gastroenterology, Department of Medicine, Indiana University Hospital, Indianapolis, IN, USA
| | - Mohammad A Al-Haddad
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA.
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15
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Saavedra-Perez D, Vaquero EC, Ayuso JR, Fernandez-Cruz L. Pancreatitis autoinmune: un dilema quirúrgico. Cir Esp 2014; 92:645-53. [DOI: 10.1016/j.ciresp.2014.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 01/25/2014] [Indexed: 01/06/2023]
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16
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Vaquero EC, Salcedo MT, Cuatrecasas M, De León H, Merino X, Navarro S, Ginès A, Abu-Suboh M, Balsells J, Fernández-Cruz L, Molero X. Autoimmune pancreatitis type-1 associated with intraduct papillary mucinous neoplasm: report of two cases. Pancreatology 2014; 14:316-8. [PMID: 25062884 DOI: 10.1016/j.pan.2014.04.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 03/31/2014] [Accepted: 04/28/2014] [Indexed: 12/11/2022]
Abstract
Chronic pancreatitis lesions usually embrace both intraduct papillary mucinous neoplasm (IPMN) and pancreatic ductal adenocarcinoma (PDAC). Patients at genetically-determined high risk of PDAC often harbor IPMN and/or chronic pancreatitis, suggesting IPMN, chronic pancreatitis and PDAC may share pathogenetic mechanisms. Chronic autoimmune pancreatitis (AIP) may also herald PDAC. Concurrent IPMN and AIP have been reported in few patients. Here we describe two patients with IPMN who developed type-1 AIP fulfilling the Honolulu and Boston diagnostic criteria. AIP diffusively affected the whole pancreas, as well as peripancreatic lymph nodes and the gallbladder. Previous pancreatic resection of focal IPMN did not show features of AIP. One of the patients carried a CFTR class-I mutation. Of notice, serum IgG4 levels gradually decreased to normal values after IPMN excision. Common risk factors to IPMN and AIP may facilitate its coincidental generation.
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Affiliation(s)
- Eva C Vaquero
- Department of Gastroenterology, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, CIBEREHD, IDIBAPS, Barcelona, Spain
| | - Maria T Salcedo
- Department of Pathology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Míriam Cuatrecasas
- Department of Pathology, Centre de Diagnòstic Biomèdic (CDB), Hospital Clínic, University of Barcelona and Banc de Tumors-Biobanc Clinic-IDIBAPS-XBTC, Barcelona, Spain
| | - Hannah De León
- Exocrine Pancreatic Diseases Research Group, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, CIBEREHD, Barcelona, Spain
| | - Xavier Merino
- Department of Radiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Salvador Navarro
- Department of Gastroenterology, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, CIBEREHD, IDIBAPS, Barcelona, Spain
| | - Angels Ginès
- Department of Gastroenterology, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, CIBEREHD, IDIBAPS, Barcelona, Spain
| | - Monder Abu-Suboh
- Department of Endoscopy, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joaquim Balsells
- Department of Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laureano Fernández-Cruz
- Department of Surgery, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, CIBEREHD, IDIBAPS, Barcelona, Spain
| | - Xavier Molero
- Exocrine Pancreatic Diseases Research Group, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, CIBEREHD, Barcelona, Spain.
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