Localized autoimmune pancreatitis mimicking pancreatic cancer: Case report and literature review

Abstract

Autoimmune pancreatitis (AP) is a rare autoimmune pancreatic manifestation of systemic immunoglobulin G4 (IgG4)-related sclerosing disease. Distinguishing between AP and pancreatic cancer is crucial because the clinical courses, treatments, and prognoses of these two disease entities are quite different. We herein report a case involving a 52-year-old man with subacute epigastralgia who visited our hospital for evaluation of a suspicious pancreatic mass found during esophagogastroduodenoscopy. Enhanced computed tomography (CT) revealed an enlarged lesion in the pancreatic head with encasement of hepatic vessels. The lesion also exhibited increased ¹⁸F-fluorodeoxyglucose accumulation on positron emission tomography/CT imaging, which was highly suggestive of pancreatic cancer. After open biopsy, morphologic examination showed an inflammatory infiltrate in the pancreas, which was compatible with chronic sclerotic pancreatitis. Further laboratory tests revealed an elevated serum IgG4 level, and the diagnosis of sclerotic pancreatitis was then confirmed. After corticosteroid treatment, the pancreatic lesion showed shrinkage on follow-up CT, and the serum IgG4 titer decreased to the normal range. This case suggests that clinicians should be familiar with the clinical presentations and diagnostic criteria of AP versus pancreatic cancer. An awareness of the differences between these diseases may avoid misdiagnosis and unnecessary surgical intervention.

Keywords: Autoimmune pancreatitis; FDG PET/CT; IgG4-related sclerosing disease; epigastralgia; inflammatory infiltration; pancreatic cancer.

Figure 1.

A sequential axial abdominal computed tomography scan shows a lobulated mass lesion with a cystic component and peripheral enhancement in the head and proximal body of the pancreas with exophytic growth (white arrows in a–c). Encasement of the common hepatic artery and main portal vein is also depicted (white arrowheads in d–ƒ).

Figure 2.

Positron emission tomography/computed tomography (PET/CT) using ¹⁸F-fluorodeoxyglucose shows a hypermetabolic tumor in the head of the pancreas with a maximum standardized uptake value of 8.2 (arrowheads). (a) Maximal intensity projection. (b) PET image. (c, d) Non-enhanced CT and fused PET and CT images at corresponding levels, respectively.

Figure 3.

Representative histological pictures (hematoxylin and eosin stain). (a) 100×, (b) 400×. These images show chronic inflammatory infiltration of lymphocytes and plasma cells around ductules and acini with sclerotic stroma in the pancreas.

Figure 4.

(a–f) Axial abdominal computed tomography scan 3 months after corticosteroid treatment shows marked shrinkage of the previous lobulated mass lesion (arrowheads).