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Localized 18 F-fluorodeoxyglucose uptake at the pancreatic head during remission phase of autoimmune pancreatitis: A case report

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ABSTRACT

Autoimmune pancreatitis (AIP) is a unique form of pancreatitis, histopathologically characterized by dense lymphoplasmacytic infiltration and fibrosis of the pancreas with obliterative phlebitis. AIP is associated with a good response to steroid therapy. Differentiation between AIP and pancreatic cancer to determine a preoperative diagnosis is often challenging, despite the use of various diagnostic modalities, including computed tomography (CT), magnetic resonance imaging and endoscopic retrograde cholangiopancreatography. It has been reported that 18F-fluorodeoxyglucose (18F-FDG)-positron emission tomography (PET)/CT may be a useful tool for distinguishing between the two diseases. In the present case report, a 71-year-old male patient presented with a well-circumscribed, solitary, nodular and homogenous 18F-FDG uptake at the pancreatic head, while receiving maintenance steroid therapy in the remission phase of AIP; preoperatively, the patient had been strongly suspected of having pancreatic cancer. Pathological examination revealed post-treatment relapse of AIP. The present case highlights the diagnostic and management difficulties with AIP in the remission phase. In certain cases, it remains challenging to differentiate the two diseases, even using the latest modalities.

No MeSH data available.


Related in: MedlinePlus

Pathological examination revealing diffuse lymphoplasmacytic infiltrate with fibrosis, periductal lymphoplasmacytic infiltrate in the pancreatic head mass: (A) ×40 and (B) ×400 magnification. (C) Elastica-Masson staining showing obliterative phlebitis in this specimen. (D) An abundance of IgG4-positive cells was observed in the lymphoplasmacytic infiltrate (>10 cells/high power field).
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f4-ol-0-0-4815: Pathological examination revealing diffuse lymphoplasmacytic infiltrate with fibrosis, periductal lymphoplasmacytic infiltrate in the pancreatic head mass: (A) ×40 and (B) ×400 magnification. (C) Elastica-Masson staining showing obliterative phlebitis in this specimen. (D) An abundance of IgG4-positive cells was observed in the lymphoplasmacytic infiltrate (>10 cells/high power field).

Mentions: The patient was referred to the Department of Hepatobiliary-Pancreatic and Breast Surgery, Ehime University Hospital with a suspected diagnosis of concomitant pancreatic cancer with AIP, and pancreatoduodenectomy was performed. The formalin-fixed paraffin-embedded 4-µm sections were used for hematoxylin and eosin staining, Elastica-Masson staining and IgG4 immunostaining (mouse anti-human IgG4 monoclonal antibody; dilution, 1:400; catalog no., GTX75819; GeneTex, Irvine, CA, USA). Pathological examination revealed diffuse lymphoplasmacytic infiltrate with fibrosis, periductal lymphoplasmacytic infiltrate and obliterative phlebitis (Fig. 4A-C). The lymphoplasmacytic infiltrate included an abundance of IgG4-positive cells [>10 cells/high power field (HPF)] (Fig. 4D), which forms one of the histological criteria for AIP proposed by the Mayo Clinic (7). No malignant cells were found. Recurrent AIP was therefore diagnosed. Maintenance steroid therapy was resumed following surgery, and, at the time of writing the present study, no recurrent AIP in the pancreatic remnant has been identified for 4 years after surgery.


Localized 18 F-fluorodeoxyglucose uptake at the pancreatic head during remission phase of autoimmune pancreatitis: A case report
Pathological examination revealing diffuse lymphoplasmacytic infiltrate with fibrosis, periductal lymphoplasmacytic infiltrate in the pancreatic head mass: (A) ×40 and (B) ×400 magnification. (C) Elastica-Masson staining showing obliterative phlebitis in this specimen. (D) An abundance of IgG4-positive cells was observed in the lymphoplasmacytic infiltrate (>10 cells/high power field).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4998295&req=5

f4-ol-0-0-4815: Pathological examination revealing diffuse lymphoplasmacytic infiltrate with fibrosis, periductal lymphoplasmacytic infiltrate in the pancreatic head mass: (A) ×40 and (B) ×400 magnification. (C) Elastica-Masson staining showing obliterative phlebitis in this specimen. (D) An abundance of IgG4-positive cells was observed in the lymphoplasmacytic infiltrate (>10 cells/high power field).
Mentions: The patient was referred to the Department of Hepatobiliary-Pancreatic and Breast Surgery, Ehime University Hospital with a suspected diagnosis of concomitant pancreatic cancer with AIP, and pancreatoduodenectomy was performed. The formalin-fixed paraffin-embedded 4-µm sections were used for hematoxylin and eosin staining, Elastica-Masson staining and IgG4 immunostaining (mouse anti-human IgG4 monoclonal antibody; dilution, 1:400; catalog no., GTX75819; GeneTex, Irvine, CA, USA). Pathological examination revealed diffuse lymphoplasmacytic infiltrate with fibrosis, periductal lymphoplasmacytic infiltrate and obliterative phlebitis (Fig. 4A-C). The lymphoplasmacytic infiltrate included an abundance of IgG4-positive cells [>10 cells/high power field (HPF)] (Fig. 4D), which forms one of the histological criteria for AIP proposed by the Mayo Clinic (7). No malignant cells were found. Recurrent AIP was therefore diagnosed. Maintenance steroid therapy was resumed following surgery, and, at the time of writing the present study, no recurrent AIP in the pancreatic remnant has been identified for 4 years after surgery.

View Article: PubMed Central - PubMed

ABSTRACT

Autoimmune pancreatitis (AIP) is a unique form of pancreatitis, histopathologically characterized by dense lymphoplasmacytic infiltration and fibrosis of the pancreas with obliterative phlebitis. AIP is associated with a good response to steroid therapy. Differentiation between AIP and pancreatic cancer to determine a preoperative diagnosis is often challenging, despite the use of various diagnostic modalities, including computed tomography (CT), magnetic resonance imaging and endoscopic retrograde cholangiopancreatography. It has been reported that 18F-fluorodeoxyglucose (18F-FDG)-positron emission tomography (PET)/CT may be a useful tool for distinguishing between the two diseases. In the present case report, a 71-year-old male patient presented with a well-circumscribed, solitary, nodular and homogenous 18F-FDG uptake at the pancreatic head, while receiving maintenance steroid therapy in the remission phase of AIP; preoperatively, the patient had been strongly suspected of having pancreatic cancer. Pathological examination revealed post-treatment relapse of AIP. The present case highlights the diagnostic and management difficulties with AIP in the remission phase. In certain cases, it remains challenging to differentiate the two diseases, even using the latest modalities.

No MeSH data available.


Related in: MedlinePlus