Abdominal Sarcoidosis Mimicking Pancreatic Adenocarcinoma

Sarcoidosis is a chronic, granulomatous, autoinflammatory disease that affects different parts of the body. Pulmonary manifestations are described in the majority of cases, with pancreatic involvement being <1-5%. The initial reports of pancreatic sarcoidosis were detected on autopsy. A review of the literature revealed that the majority of patients with pancreatic sarcoidosis initially presented with a clinical presentation identical to pancreatic malignancy. We describe the case of a male with a history of chronic pancreatitis and alcoholism who underwent pancreaticoduodenectomy given the concern for pancreatic denocarcinoma, and was found to have isolated pancreatic sarcoidosis. This case illustrates the difficulty in diagnosing the etiology of pancreatic masses pre-operatively leading to the majority of cases getting definitive diagnosis after operative exploration. We suggest that there needs to be further delineation of this disease process in order to determine the best treatment options for patients presenting with pancreatic disease.

Comparison between sarcoidosis and IgG4-related disease by whole-body 67Ga scintigraphy

PURPOSE

The aim of this study was to compare uptake lesions in sarcoidosis and IgG4-related disease through gallium-67 ((67)Ga) scintigraphy to differentiate between the two diseases.

MATERIALS AND METHODS

Whole-body (67)Ga scintigraphy findings of 27 patients with sarcoidosis and 16 with IgG4-related disease were reviewed between 2005 and 2011 at our hospital.

RESULTS

In the case of patients with sarcoidosis, significant accumulation of (67)Ga was observed in the lacrimal gland in the case of 26 patients (96%), in mediastinal lymph nodes (LNs) in 23 (85%), in pulmonary hilar LNs in 21 (78%), in the parotid gland in 10 (38%), in supraclavicular LNs in eight (30%), in muscles in seven (26%), in the lung in five (18%), in inguinal LNs in four (15%), in submandibular LNs in two (7%), and in the heart, spleen, kidney and para-aorta in one patient (4%). In patients with IgG4-related disease, abnormal uptake was detected in the pulmonary hilar LNs in 12 patients (75%), in the lacrimal gland in 10 (62%), in the pancreas in 10 (62%), in the parotid gland in six (37%), in the submandibular gland in six (37%), in the para-aorta in three (19%), in the lung in three (19%), in mediastinal LNs in two (12%), and in the kidney in the case of two patients (12%). Asymmetrical accumulation in the submandibular gland was observed in three of six patients (50%) with IgG4-related disease and in none of the two patients (0%) with sarcoidosis. Significant differences were observed in the uptake ratio of the lacrimal gland, the submandibular gland, supraclavicular LNs, mediastinal LNs, pancreas, and muscle between the two groups (P<0.05).

CONCLUSION

(67)Ga scintigraphy was useful in differentiating between the two diseases. Uptake in mediastinal LNs, in supraclavicular LNs, and in the muscle was specific to sarcoidosis, whereas uptake in the pancreas and in the submandibular gland indicated IgG4-related disease.

Multimodality imaging of neoplastic and nonneoplastic solid lesions of the pancreas

Solid lesions of the pancreas represent a heterogeneous group of entities that can be broadly classified as either neoplastic or nonneoplastic. Neoplastic lesions include pancreatic adenocarcinoma, pancreatic neuroendocrine tumor, solid pseudopapillary tumor, pancreatoblastoma, pancreatic lymphoma, metastases to the pancreas, and rare miscellaneous neoplasms. Nonneoplastic lesions include focal pancreatitis, fatty infiltration-replacement, intrapancreatic accessory spleen, congenital anomalies such as prominent pancreatic lobulation and bifid pancreatic tail (pancreatic bifidum), and rare miscellaneous lesions (eg, pancreatic sarcoidosis, Castleman disease of the pancreas). A variety of imaging modalities are available for assessing these solid lesions, including ultrasonography (US), computed tomography (CT), magnetic resonance imaging, endoscopic US, and hybrid nuclear imaging techniques such as single photon emission computed tomography-CT and positron emission tomography-CT, each of which has its own strengths and limitations. Accurate diagnosis can be challenging, and use of a multimodality imaging approach is often helpful in equivocal or complex cases. Knowledge of relevant clinical information and key radiologic features is essential for confident lesion characterization and differentiation.

[A rare tumor-like lesion of the pancreatic head with bile duct obstruction]

Tumors of the pancreatic head commonly consist of carcinomas whereas other entities are rare exceptions. Extrapulmonary sarcoidosis is well-known but is extremely rare when detected as a mass in the pancreatic head. In general the diagnosis of sarcoidosis requires histologic examination with verification of non-caseous, epithelioid cell-like granulomas. Systemic therapy consists of steroids when the patient exhibits symptoms or in the case of progression of the disease. However, in some cases extended abdominal resections are also required to confirm the diagnosis and/or to treat symptoms.