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A rare case of IgG4-related disease: a gastric mass, associated with regional lymphadenopathy
© The Author(s). 2016
Received: 5 March 2016
Accepted: 19 May 2016
Published: 2 June 2016
IgG4-related disease (IgG4-RD) is a newly recognized disorder, characterized by massive IgG4+ lymphocyte and plasma cell infiltration, storiform fibrosis, causing enlargement, nodules or thickening of the various organs, simultaneously or metachronously. Involvement of the gastrointestinal tract is very rare and can be presented as a diffuse wall thickening or polyp or mass-like lesion. Up to now, there have been reported only a few cases of isolated gastric IgG4-RD.
We present an unusual case of IgG4-RD of the stomach with involvement of the regional lymph nodes, clinically manifested as a gastric cancer with related pyloric stenosis. The patient underwent distal gastrectomy, omentectomy and lymph node dissection. The postoperative serum IgG4 level was increased. The diagnosis was confirmed by immunohistochemical study.
In the most of the reported cases there was not sufficient data about the regional lymph nodal status, although the majority of the patients had been operated with presumptive diagnosis of gastric neoplasm. Our case is rare and valuable because it presents a gastric IgG4-related lesion larger than all previously reported in literature, and IgG4-related lymphadenopathy, confirmed histologically, which contributes to better knowledge of the disease.
IgG4-related disease (IgG4-RD) is a newly recognized disorder, characterized by massive IgG4+ lymphocyte and plasma cell infiltration, storiform fibrosis, causing enlargement, nodules or thickening of the various organs, simultaneously or metachronously [1–4]. Other typical features are obliterative phlebitis, increased IgG4-expressing plasma cells, and often, but not always elevated serum IgG4 level [2, 3]. IgG4-RD frequently might be misinterpreted clinically and radiologically as a neoplasm, resulting in overtreatment [1–4]. The disease usually affects the pancreas, bile ducts, gallbladder, liver, lacrimal glands, salivary glands, retroperitoneum and lymph nodes [1–4]. Involvement of the gastrointestinal tract is very rare and can be presented as a diffuse wall thickening or polyp or mass-like lesion [3, 4]. Up to date, there have been reported only a few cases of isolated gastric IgG4-RD .
We described the case of suspected gastric IgG4-RD and regional lymphadenopathy, misdiagnosed as a gastric cancer. A 62-year-old female presented with symptoms of severe weakness and fatigue. Laboratory tests revealed anemia (hemoglobin 58 g/L). Because of these the patient had been admitted to another hospital where a gastric tumor and related pyloric stenosis were found with gastroscopy and several blood transfusions were performed. The biopsy showed a chronic ulcerative lesion with suspected atypical cells in the bottom. Computer tomography (CT) revealed prepyloric irregular thickening of the gastric wall up to 15 mm which involved its entire circumference. The patient’s co-morbidities included Henoch-Schonlein purpura, allergy to analgesics, arterial hypertension and depressive disorder. Several years ago, the patient had undergone cholecystectomy and plastic of hiatal hernia. The physical examination of the abdomen did not reveal any pathological findings. Given the presumptive diagnosis of gastric cancer, the patient was hospitalized in our department for surgical treatment. A distal gastrectomy, omentectomy and lymph node dissection were performed. The diagnosis was confirmed with histological and immunohistochemical study.
The postoperative period was uneventful. Serum IgG4 level measured postoperatively was 193.1 mg/dL (reference values 23–111 mg/dL).
Summary of the cases with gastric IgG4-RD, reported in the literature and our case
Case № [Ref. №]
Location in stomach
Fundus and body
AIP, IgG4-related sialadenitis
Up to 22
Type 2 diabetes
Hashimoto’s thyroiditis, possible primary biliary cirrhosis
IgG4-RD in lungs, skin and lymph nodes
12 [present case]
Henoch-Schonlein purpura, IgG4-RD in lymph nodes
The most gastric IgG4-RD was detected in middle- aged patients (45 to 75 years) with predominance of women, although the total number of patients is too small to reveal any meaningful data. The body of the stomach was affected mainly. The size was variable (8–56 mm in cases reported in literature) and tumor in our case was considerably larger than the other gastric lesions of IgG4-RD. In most of the cases the gastric lesion was solitary. The two patients with multiple polyps in the stomach also had AIP and autoimmune endocrinopathy, respectively. In 7 of all reported cases, there were associated autoimmune diseases. In four of these patients there was multi-organ involvement of IgG4-RD – one patient with concomitant AIP, one case – with AIP and IgG4-related sialadenitis, one patient with localization of the disease in stomach, lungs, skin and lymph nodes and our patient had lymphonodal involvement, too. The IgG4-related lymphadenopathy, as in our case, can be confirmed only by histological examination. According to criteria, classified by Sato et al. histological changes include: 1/Castleman’s disease-like morphology; 2/reactive follicular hyperplasia, 3/interfollicular plasmacytosis and immunoblastosis, 4/progressive transformation of germinal center-like, and 5/inflammatory pseudotumor-like morphology [1, 14].
In most of the reported cases of gastric IgG4-RD there was not sufficient data about the lymph nodal status, although they were treated surgically with presumptive diagnosis of gastric neoplasm. In our case the accurate lymph nodal dissection was performed and IgG4-related lymphadenopathy was confirmed immunohistochemically. No enlarged lymph nodes had been detected on CT and the dissection was carried out only because we had suspected oncological disease. So if we had not done it, we would have missed the involvement of lymph nodes of IgG4-RD.
The first therapeutic choice for management of IgG4-RD is the steroid treatment [1, 3]. However, most patients with gastric IgG4-RD were treated surgically, except one patient with concomitant AIP who underwent steroid therapy. This is probably because IgG4-RD frequently might be misinterpreted clinically and radiologically as a neoplasm [1–4]. In our case the surgery was necessary not only because of the suspected gastric cancer, but for the relevant pyloric stenosis.
Most gastric IgG4-RD lesions are difficult to diagnose because of their rarity and it is of utmost importance to exclude neoplasm. Unnecessary surgery can be avoided if the IgG4-RD of the stomach is considered in the differential diagnosis. Our case is rare and valuable because it presents a gastric IgG4-related lesion larger than all previously reported in literature, and IgG4-related lymphadenopathy, confirmed histologically, which contributes to the better knowledge of the disease.
AIP, autoimmune pancreatitis; CT, Computer tomography; DG, distal gastrectomy; ESR, endoscopic submucosal resection; F, female; H&E, Hematoxylin and Eosin; IgG4-RD, IgG4-related disease; M, male; NA, not available; WR, wedge resection
The authors appreciate the patient’s approval to present this case and acknowledge all the medical and surgical staff that took care of the patient.
Availability of data and materials
The data sets supporting the conclusions of this article are included within the article.
Elena Arabadzhieva wrote the paper and collected the literature for the review in the report. Sasho Bonev analysed the review. Atanas Yonkov and Dimitar Bulanov performed the operation of the patient described in this report. Tihomir Dikov and Diana Kyoseva performed the histological examination and the immunohistochemical study and confirmed the diagnosis. Violeta Dimitrova revised the manuscript for important intellectual content and technical details. All authors have read and approved the final manuscript.
The authors declare that they have no competing interests.
The patient’s approval has been given for publication of this case report.
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