Coexistence of lung cancer and immunoglobulin G4-related lung disease in a nodule: a case report

Abstract

Background: Immunoglobulin G4-related disease is characterized by infiltration of immunoglobulin G4-positive plasmacytes in various organs. The radiological findings of lung involvement of immunoglobulin G4-related disease include hilar and mediastinal lymphadenopathies, thickness of bronchovascular bundles, peribronchovascular consolidation, and lung nodules. Although a pathological approach is needed to diagnose immunoglobulin G4-related disease, it is ordinarily diagnosed by biopsy from one lesion even if there are multiple lesions. We reported a rare case of the coexistence of immunoglobulin G4-related disease and lung cancer in the same lung nodule.

Case presentation: A 72-year-old Japanese man visited our hospital for evaluation of a nodular shadow in the middle lobe of his right lung that was seen on chest radiograph and computed tomography scan. An abdominal computed tomography scan showed a tumefactive lesion in his anterior sacral spine. Blood examinations revealed high serum immunoglobulin G4 concentration at 346 mg/dl, renal dysfunction, and anemia. He underwent right upper lobectomy and regional lymph node dissection. Pathologic findings of the lung nodule showed lepidic pattern adenocarcinoma with infiltration of immunoglobulin G4-positive plasma cells and obliterative phlebitis.

Conclusions: To date, there have been only few reports on the coexistence of immunoglobulin G4-related disease and lung cancer; here, we report such a rare case. Histologic examination should be considered in cases of suspicious immunoglobulin G4-related disease appearing in a lung nodule.

Keywords: IgG4-related disease; Lung cancer; Lung nodule.

Fig. 1

The findings of a chest radiograph and computed tomography. a Chest radiograph shows a nodular shadow in the middle lobe of his right lung. b Chest computed tomography revealed a 20-mm spiculated part-solid nodule with pleural indentation in segment 3 on the right

Fig. 2

Positron emission tomography-computed tomography examination in a 72-year-old man with coexisting lung cancer and immunoglobulin G4-related disease. There is high accumulation of ¹⁸F-fluorodeoxyglucose in his a lung nodule, hilar, and mediastinal lymph node and in his b retroperitoneum

Fig. 3

Pathological findings of the resected lung nodule and hilar lymph node in a 72-year-old man with coexisting lung cancer and immunoglobulin G4-related disease. In the lung nodule, a lepidic pattern of adenocarcinoma coexisted with lymphocytes and plasma cells (hematoxylin and eosin, ×400). The infiltrating lymphocytes and plasma cells are positive for b immunoglobulin G and c immunoglobulin G4 staining (×400), with an immunoglobulin G4 to immunoglobulin G ratio of more than 40 %. d Obliterative phlebitis findings ("arrows") in the lung nodule (Elastica van Gieson, ×200). In the hilar lymph node, e the infiltration of plasma cells are seen with storiform fibrosis (×100) and f these cells were positive for immunoglobulin G4 staining (×400)