Simultaneous occurrence of autoimmune pancreatitis and pancreatic cancer in patients resected for focal pancreatic mass

Diagnostic Differentiation between Pancreatitis and Pancreatic Cancer: A Scoping Review

Pancreatitis, encompassing acute and chronic forms, and pancreatic cancer pose significant challenges to the exocrine tissue of the pancreas. Recurrence rates and complications following acute pancreatitis episodes can lead to long-term risks, including diabetes mellitus. Chronic pancreatitis can develop in approximately 15% of cases, regardless of the initial episode's severity. Alcohol-induced pancreatitis, idiopathic causes, cigarette smoking, and hereditary pancreatitis contribute to the progression to chronic pancreatitis. Chronic pancreatitis is associated with an increased risk of pancreatic cancer, with older age at onset and smoking identified as risk factors. This scoping review aims to synthesise recent publications (2017-2022) on the diagnostic differentiation between pancreatitis and pancreatic cancer while identifying knowledge gaps in the field. The review focuses on biomarkers and imaging techniques in individuals with pancreatitis and pancreatic cancer. Promising biomarkers such as faecal elastase-1 and specific chemokines offer non-invasive ways to assess pancreatic insufficiency and detect early biomarkers for chronic pancreatitis. Imaging techniques, including computed tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasound (EUS), and positron emission tomography (PET), aid in differentiating between chronic pancreatitis and pancreatic cancer. However, accurately distinguishing between the two conditions remains a challenge, particularly when a mass is present in the head of the pancreas. Several knowledge gaps persist despite advancements in understanding the association between pancreatitis and pancreatic cancer, including the correlation between histopathological grading systems, non-invasive imaging techniques, and biomarkers in chronic pancreatitis to determine the risk of progression to pancreatic cancer, as well as differentiating between the two conditions. Further research is necessary to enhance our understanding of these aspects, which can ultimately improve the diagnosis and management of pancreatitis and pancreatic cancer.

Autoimmune pancreatitis type 2 (idiopathic duct-centric pancreatitis): A comprehensive review

Autoimmune pancreatitis (AIP) is an uncommon fibro-inflammatory disorder precipitated by autoimmune/inflammatory reactions. Currently, there are two clinical subtypes of AIP (type 1 [AIP-1] and type 2 [AIP-2]) that correspond to two histologic descriptors (lymphoplasmacytic sclerosing pancreatitis and idiopathic duct-centric pancreatitis, respectively). While our understanding of AIP-1 has evolved considerably over the years, little is known about AIP-2 due to its rarity, often leading to misdiagnosis, delayed treatment, and even unnecessary surgical resection. Compared to AIP-1, AIP-2 exhibits distinct clinical and histologic features. Because AIP-2 is a pancreas-restricted disease without a specific serum marker, the evaluation of histologic features (e.g., granulocytic epithelial lesions) is essential for an accurate diagnosis. Patients with AIP-2 respond well to glucocorticoids, with anti-tumor necrosis factor-alpha antibodies as a promising alternative therapy. The prognosis of AIP-2 is generally favorable and relapse is uncommon. Here, we provide an overview of our current knowledge on the clinical features, diagnosis, therapeutic regimens, prognosis, and putative mechanisms underlying AIP-2. Notably, the diagnostic differentiation between AIP-2, especially the mass-forming/focal type, and pancreatic cancer is important, but challenging. In this regard, endoscopic ultrasound-guided core biopsy has a key role, but novel diagnostic markers and modalities are clearly needed.

Is Surgery in Autoimmune Pancreatitis Always a Failure?

Autoimmune pancreatitis is a rare form of chronic pancreatitis of presumed autoimmune etiology. Due to significant overlap in clinical and imaging characteristics, misdiagnosis as a pancreatic malignancy is common. As a result, a significant number of patients undergo a major pancreatic resection, associated with considerable morbidity, for a disease process that generally responds well to corticosteroid therapy. In the past ten years, important advances have been made in understanding the disease. Several diagnostic criteria have been developed to aid in diagnosis. Despite this, pancreatic resection may still be required in a subset of patients to reliably exclude pancreatic malignancy and establish a definite diagnosis of autoimmune pancreatitis. This article aimed to define the role of surgery in autoimmune pancreatitis, if any. For this purpose, published case series of patients with a diagnosis of autoimmune pancreatitis, based on the histopathological examination of surgical specimens, were reviewed and patients' clinical, radiological and serological details were assessed. At the end, histopathologic examinations of patients who underwent pancreatic resection at our department in the last 10 years were retrospectively reviewed in order to identify patients with autoimmune pancreatitis and assess their clinical characteristics.

Pancreatitis and Pancreatic Cancer Risk

Purpose: The present retrospective study aimed to explore the relationship between pancreatitis and pancreatic cancer in the population cohort of the UK Biobank (UKB) (https://www.ukbiobank.ac.uk). Methods: From the 500 thousand population cohort of UKB, according to the age and gender of patients with pancreatic cancer 1:10, matching the control without pancreatic cancer, the binary Logistic regression model was used to analyze the relationship between pancreatitis and pancreatic cancer, and subgroup analyses were used to identify potential effect modifiers. Results: A total of 1538 patients with pancreatic cancer were compared with 15 380 controls. In the fully adjusted model, patients with pancreatitis had a significantly increased risk of pancreatic cancer compared with no pancreatitis. The risk of pancreatitis and pancreatic cancer increased with the age of pancreatitis, and the risk of pancreatic cancer was highest in the 61 to 70 age group. In addition, in the first 3 years of acute pancreatitis, the risk of pancreatic cancer increased significantly with the increase in the duration of the disease (odds ratio [OR] 29.13, 95% confidence interval [CI]: 16.34-51.93), after 3 years, the trend of increase decreased. After more than 10 years, there was no significant correlation between the risk of acute pancreatitis and pancreatic cancer. However, patients with chronic pancreatitis were significantly associated with an increased risk of pancreatic cancer only in the first 3 years (OR 28.14, 95% CI: 14.86-53.31). Conclusion: Pancreatitis may associate with an increased risk of pancreatic cancer. The older the age of pancreatitis, the higher the risk of pancreatic cancer. The risk of pancreatic cancer increases significantly in the first 3 years of the course of pancreatitis. This may provide an alternative strategy for the early identification of individuals at high risk of pancreatic cancer.

Helicobacter pylori infection and other bacteria in pancreatic cancer and autoimmune pancreatitis

Helicobacter pylori (H. pylori) is an infectious agent influencing as much as 50% of the world’s population. It is the causative agent for several diseases, most especially gastric and duodenal peptic ulcer, gastric adenocarcinoma and mucosa-associated lymphoid tissue lymphoma of the stomach. A number of other, extragastric manifestations also are associated with H. pylori infection. These include neurological disorders, such as Alzheimer’s disease, demyelinating multiple sclerosis and Parkinson’s disease. There is also evidence for a relationship between H. pylori infection and such dermatological diseases as psoriasis and rosacea as well as a connection with infection and open-angle glaucoma. Generally little is known about the relationship between H. pylori infection and diseases of the pancreas. Most evidence about H. pylori and its potential role in the development of pancreatic diseases concerns pancreatic adenocarcinoma and autoimmune forms of chronic pancreatitis. There is data (albeit not fully consistent) indicating modestly increased pancreatic cancer risk in H. pylori-positive patients. The pathogenetic mechanism of this increase is not yet fully elucidated, but several theories have been proposed. Reduction of antral D-cells in H. pylori-positive patients causes a suppression of somatostatin secretion that, in turn, stimulates increased secretin secretion. That stimulates pancreatic growth and thus increases the risk of carcinogenesis. Alternatively, H. pylori, as a part of microbiome dysbiosis and the so-called oncobiome, is proven to be associated with pancreatic adenocarcinoma development via the promotion of cellular proliferation. The role of H. pylori in the inflammation characteristic of autoimmune pancreatitis seems to be explained by a mechanism of molecular mimicry among several proteins (mostly enzymes) of H. pylori and pancreatic tissue. Patients with autoimmune pancreatitis often show positivity for antibodies against H. pylori proteins. H. pylori, as a part of microbiome dysbiosis, also is viewed as a potential trigger of autoimmune inflammation of the pancreas. It is precisely these relationships (and associated equivocal conclusions) that constitute a center of attention among pancreatologists, immunologists and pathologists. In order to obtain clear and valid results, more studies on sufficiently large cohorts of patients are needed. The topic is itself sufficiently significant to draw the interest of clinicians and inspire further systematic research. Next-generation sequencing could play an important role in investigating the microbiome as a potential diagnostic and prognostic biomarker for pancreatic cancer.

Pancreatic cancer in patients with autoimmune pancreatitis: A scoping review

BACKGROUND

Chronic pancreatitis is a known risk factor of pancreatic cancer (PDAC). A similar association has been suggested but not demonstrated for autoimmune pancreatitis (AIP).

OBJECTIVE

The aim of our study was to identify and analyse all published cases of AIP and PDAC co-occurrence, focusing on the interval between the diagnoses and the cancer site within the pancreas.

METHODS

Relevant studies were identified through automatic searches of the MEDLINE, EMBASE, Scopus, and Web of Science databases, and supplemented by manual checks of reference lists in all retrieved articles. Missing/unpublished data were obtained from the authors of relevant publications in the form of pre-prepared questionnaires.

RESULTS

A total of 45 cases of PDAC in AIP patients were identified, of which 12 were excluded from the analysis due to suspicions of duplicity or lack of sufficient data. Thirty-one patients (94%) had type 1 AIP. Synchronous occurrence of PDAC and AIP was reported in 11 patients (33%), metachronous in 22 patients (67%). In the metachronous group, the median period between diagnoses was 66.5 months (2-186) and a majority of cancers (86%) occurred more than two years after AIP diagnosis. In most patients (70%), the cancer originated in the part of the pancreas affected by AIP.

CONCLUSIONS

In the literature, there are reports on numerous cases of PDAC in AIP patients. PDAC is more frequent in AIP type 1 patients, typically metachronous in character, and generally found in the part of the pancreas affected by AIP.

Systemic IgG4-Related Disease Masquerading as Cholangiocarcinoma: A Case Report Underscoring the Importance of Medical History

BACKGROUND Immunoglobulin (Ig) G4-related disease is a rare disease of unknown pathophysiology, which can affect multiple organs leading to tissue fibrosis and organ failure. The present case report describes a patient with systemic IgG4-related disease (IgG4-RD) that occurred over a 1-year period and affected multiple organs at different times. Imaging studies, interventional procedures, changes in laboratory parameters, and histopathology demonstrate the novel and known aspects of this disease before and during prednisolone monotherapy and in combination with azathioprine. CASE REPORT A 64-year-old man presented with weight loss and painless jaundice, which was highly suspicious for cholangiocarcinoma. A thorough medical history together with laboratory tests, imaging procedures, and endoscopic interventions confirmed that surgery was not needed and led to the final diagnosis of histologically-confirmed, IgG4-related sclerosing cholangitis and autoimmune pancreatitis type 1. Other typical organ manifestations of systemic IgG4-RD were diagnosed through a thorough medical review, which led to immunohistochemical reevaluation of past surgical specimens. Besides the IgG4-related organ manifestations, which can include periorbital xanthelasmas, our patient developed a pulmonary adenocarcinoma 6 years after the initial clinical onset of IgG4-RD. After immunosuppressive treatment with prednisolone alone and subsequently in combination with azathioprine, the patient's IgG4-RD resolved. CONCLUSIONS Interdisciplinary collaboration is required to diagnose IgG4-RD that involves multiple organs. Patient medical history remains crucial for diagnosis and attention should be paid to avoiding unnecessary surgery. Tumors (lung adenocarcinomas) and xanthelasmas can develop because of IgG4-RD. Glucocorticoids and additional azathioprine may be advisable for maintenance treatment.

The role of apparent diffusion coefficient value in the diagnosis of localized type 1 autoimmune pancreatitis: differentiation from pancreatic ductal adenocarcinoma and evaluation of response to steroids

PURPOSE

The aim of this study was to clarify the usefulness of the apparent diffusion coefficient (ADC) value in the differential diagnosis of localized autoimmune pancreatitis (AIP) and pancreatic ductal adenocarcinoma (PDAC) and the evaluation of response to steroids.

METHODS

This study retrospectively analyzed 40 patients with localized AIP and 71 patients with PDAC who underwent abdominal MRI with DWI (b = 0 and 1000 s/mm²). Their ADC values at the lesion sites and five MRI findings useful for diagnosing AIP were evaluated. In addition, ADC values before and after steroid therapy were compared in 28 patients with localized AIP.

RESULTS

The median ADC value was significantly lower for localized AIP than for PDAC (1.057 × 10^-3 vs 1.376 × 10^-3 mm²/s, P < 0.001). In the ROC curve analysis, the area under the curve was 0.957 and optimal cut-off value of ADC for differentiating localized AIP from PDAC was 1.188 × 10^-3 mm²/s. ADC value ≤ 1.188 × 10^-3 mm²/s showed the highest sensitivity and accuracy among the MRI findings (92.6% and 90.7%, respectively), and when combined with one or more other MRI findings, showed 96.3% specificity. The median ADC values before and after steroid therapy (mean 7.9 days) were 1.061 × 10^-3 and 1.340 × 10^-3 mm²/s, respectively, and ADC values were significantly elevated after steroid induction (P < 0.001).

CONCLUSION

The measurement of ADC values was useful for the differential diagnosis of localized AIP and PDAC and for the early determination of the effect of steroid therapy.

Early pancreatic cancer in IgG4-related pancreatic mass: A case report

BACKGROUND

IgG4-related disease can manifest diversely, including autoimmune pancreatitis and IgG4-related cholangiopathy. We are reporting a very unusual cause of pancreatic cancer triggered in a previously unknown IgG4-related disease.

CASE SUMMARY

A 75-year-old man was diagnosed with a 43 mm × 33 mm pancreatic head tumor after consulting for abdominal pain and jaundice. A pancreaticoduodenectomy was carried out uneventfully, and the histopathology report showed an early stage of acinar-cell pancreatic cancer. The patient reconsulted on the 30^th postoperative day with fever, jaundice and asthenia. Magnetic resonance cholangiopancreatography evidenced an extense bile duct stricture. A percutaneous biliary drainage proved to be ineffective, even after exchanging it with larger bore drainage. Reviewing the surgical specimen, features compatible with IgG4-related disease were observed. Consequently, empiric treatment with steroids was initiated achieving excellent results.

CONCLUSION

IgG4-related disease may cause chronic inflammation of the pancreas and can condition pancreatic malignancies.

Recurrence and survival after surgery for pancreatic cancer with or without acute pancreatitis

BACKGROUND

In pancreatic cancer, acute pancreatitis (AP) is a serious morbidity, but its negative effect on long-term outcomes remains to be elucidated.

AIM

To investigate the effects of AP on the tumor recurrence pattern of pancreatic ductal adenocarcinoma (PDAC) and tumor-specific survival.

METHODS

The medical records of 219 patients with curative pancreatectomy for pancreatic cancer at the Pancreatic Surgery Center of West China Hospital from July 2012 to December 2016 were analyzed retrospectively. The severity of acute pancreatitis was classified according to the Atlanta classification of AP. The patient demographics and tumor characteristics were assessed. Early recurrence was defined as a relapse within 12 mo after surgery. Overall and disease-free survival and recurrence patterns were analyzed. Mild acute pancreatitis was excluded because its negative effects can be negligible.

RESULTS

Early recurrence in AP group was significantly higher than in non-AP group (71.4% vs 41.2%; P = 0.009). Multivariate analysis of postoperative early recurrence showed that moderate or severe AP was an independent risk factor for an early recurrence [odds ratio (OR): 4.13; 95% confidence interval (CI): 1.41-12.10; P = 0.01]. The median time to recurrence was shorter in patients with AP than in those without (8.4 vs 12.8 mo; P = 0.003). Multivariate analysis identified AP as an independent prognostic factor for overall survival [relative risk (RR): 2.35; 95%CI: 1.45-3.83] and disease-free survival (RR: 2.24; 95%CI: 1.31-3.85) in patients with PDAC.

CONCLUSION

Patients with moderate or severe acute pancreatitis developed recurrences earlier than those without. Moderate or severe AP is associated with shorter overall and disease-free survival of patients with PDAC.

Pancreatic tumor in type 1 autoimmune pancreatitis: a diagnostic challenge

Background

The co-occurrence of type 1 autoimmune pancreatitis (AIP) and pancreatic tumor (PaT) has been previously reported. Pure AIP cases have favorable prognosis and are primarily treated with steroids, while AIP cases with PaT are associated with poor prognosis where the primary management is pancreatic resection. However, it’s a challenge to timely identify the concurrent PaT in AIP because of their similar clinical and radiological manifestations.

Methods

We retrospectively reviewed the data in two medical centers from January 2010 to April 2019. The inclusion criteria were as follows: 1) completion of abdominal CT imaging before invasive procedures to the pancreas, 2) a final diagnosis of type 1 AIP using the 2011 international consensus diagnostic criteria, 3) follow-up duration of at least one month unless AIP and PaT were identified simultaneously. The presence of PaT in AIP was made based on histopathological confirmation, and the absence of PaT in AIP was defined as no pathological or radiological evidence of concurrent PaT. Clinical and radiological characteristics including gender, age, surveillance period, serum IgG4 and Ca-199 levels, biopsy, extrapancreatic involvement, CT and MR (if performed) imaging characteristics were compared between AIP with and without PaT. The Fisher’s exact test was used for qualitative variables, and nonparametric Mann-Whitney test for quantitative variables. A p value ≤0.05 was considered statistically significant.

Results

A total of 74 patients with type 1 AIP were included, of which 5 (6.7%) had the concurrent PaT. The subtypes were pancreatic ductal adenocarcinoma (3/5), solitary extramedullary plasmacytoma in the pancreas (1/5) and cholangiocarcinoma in the pancreatic segment (1/5), respectively. Gender (p = 0.044), the pattern of pancreatic enlargement (p = 0.003), heterogeneity (p = 0.015), low-density (p = 0.004) on CT and rim enhancement on MRI (p = 0.050) differed significantly between AIP with and without PaT. None of the low-density characteristics on CT or other assessed MRI characteristics could significantly differentiate the two groups (p>0.05).

Conclusions

Female, focal pancreatic enlargement, pancreatic heterogeneity, low-density on CT and rim enhancement on MRI are suggestive of the concurrent PaT in type 1 AIP. The characteristics of low-density on CT or other MRI characteristics did not provide further diagnostic values.

The use of magnetic resonance elastography in differentiating autoimmune pancreatitis from pancreatic ductal adenocarcinoma: A preliminary study

PURPOSE

To assess the value of magnetic resonance elastography (MRE) in patients with autoimmune pancreatitis (AIP) and in the differentiation of AIP from pancreatic ductal adenocarcinoma (PDAC).

METHOD AND MATERIALS

This prospective study included 14 AIP patients, 26 PDAC patients, and 14 healthy volunteers. All participants underwent pancreatic MRE (40-Hz; 3 T scanner) at enrollment, and 7 AIP patients underwent a second MRE after initiation of steroid therapy. Pancreatic stiffness values were obtained by MRE and a new logistic regression model (the calculated Rad score) was used to combine pancreatic stiffness and the distribution and shape of high-stiffness areas for differentiation of AIP and PDAC. The area under the curve (AUC) was calculated for all parameters using receiver operating characteristic (ROC) analysis.

RESULTS

Pancreatic stiffness was significantly higher (2.67 kPa [interquartile range, 2.24-3.56 kPa]) in AIP than in healthy pancreas (1.24 kPa [1.18-1.24 kPa]) and significantly lower in AIP than in PDAC (3.78 kPa [3.22-5.11 kPa]; both P < 0.05). Diffuse (n = 4 vs 1; P = 0.043) and multiple (n = 3 vs 0; P = 0.037) lesions were more common in AIP, while solitary (n = 25 vs 7; P = 0.001) and nodular lesions (n = 18 vs 2; P =  0.002) were more frequent in PDAC. Rad scores outperformed individual imaging parameters in distinguishing AIP from PDAC (AUC, 0.948 vs 0.607 to 0.782; all P < 0.05), with 84.6% specificity and 92.9% sensitivity. Pancreatic stiffness in AIP decreased significantly, from 2.66 kPa [2.29 to 3.05 kPa] to 1.55 kPa [1.43 to 1.67 kPa] (P = 0.016), during treatment.

CONCLUSIONS

MRE shows promise as a quantitative imaging method for differentiating AIP from PDAC and for monitoring the treatment response in AIP.

Diagnosis and treatment of autoimmune pancreatitis

PURPOSE OF REVIEW

Clinical management of autoimmune pancreatitis changed over the last years. The lack of high-quality studies, probably due to the relative rarity of the disease, has not fully clarified many diagnostic and therapeutic aspects. Aim of this review is to overview the literature from a clinical point of view, focusing on diagnostic and therapeutic approach to this complicated disease.

RECENT FINDINGS

They have been focused mainly on the risk of misdiagnosing a cancer. Many significant articles have been published on the treatment strategies of autoimmune pancreatitis, considering both induction and maintenance therapy.

SUMMARY

Diagnosis of autoimmune pancreatitis remains challenging, particularly in focal pancreatic involvement, despite recent advances on imaging modalities. Treatment is based on induction and maintenance phases. Steroid treatment remains the best option to induce remission. Maintenance therapy may be used to prevent disease relapses, and low-dose steroids, azathioprine or rituximab are the therapeutic options. However, it remains unclear which patient needs to be treated.