PMC9381340_01
Abdominal arterial phase-enhanced computed tomography (CT) performed at the time of the visit to our department. The axial image (A) and coronal image (B) showing enlargement of the pancreas with a capsule-like low-density rim (arrows).
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Although contrast-enhanced computed tomography (CT) showed no enlarged lymph nodes or distant metastases, diffuse enlargement of the pancreas and a capsule-like rim that appeared as a band-like area around the whole pancreas were incidentally detected (Fig. 1).
Magnetic resonance cholangiopancreatography (MRCP) showing stenosis of the main pancreatic duct with partial obscurity.
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On magnetic resonance cholangiopancreatography (MRCP), the main pancreatic duct was stenotic and partially obscured, and there was no stenosis of the common bile duct (Fig. 2).
Esophagogastroduodenoscopy performed in our department showing a flat, depressed lesion at the lesser curvature of the gastric body (arrows).
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We performed endoscopic submucosal dissection of the gastric cancer, as we determined that there was no evidence of submucosal invasion on endoscopic findings (Fig. 3).
A histological examination of the resected specimen by endoscopic submucosal dissection showing a well-differentiated adenocarcinoma. (A) Loupe image of the gastric lesion stained with Hematoxylin and Eosin staining (Scale bar=5 mm). (B) Higher magnification of the boxed area shown in (A) (Scale bar=200 mum). (C) Immunohistochemical staining for IgG4 with the boxed area shown enlarged in (D) showing >30 IgG4-positive plasma cells per high-power field (Scale bar=100 mum).
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The postoperative pathological diagnosis was early gastric cancer (type 0-IIa+IIc), 80 mm, tub1, pT1a (M), Ly0, V0, pHM0, pVM0 according to the 15th edition of Japanese Classification of Gastric Carcinoma (Fig. 4A, B). In addition, the cancer lesion showed the infiltration of plasma cells, with marked infiltration of IgG4-positive plasma cells on immunostaining (Fig. 4C, D).
Serum IgG4 levels over three years. At 10 months after endoscopic submucosal dissection (ESD) for early gastric cancer, the serum IgG4 levels normalized and have remained normal since then. One year after ESD, computed tomography (CT) was performed.
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Ten months after the endoscopic treatment, the serum IgG4 levels normalized and were maintained at normal levels for the next 30 months (Fig. 5).
Arterial phase-enhanced computed tomography (CT) performed one year after endoscopic submucosal dissection (ESD) showing the disappearance of pancreatic enlargement and a capsule-like low-density rim.
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One year after the endoscopic treatment, diffuse enlargement of the pancreas with a capsule-like rim had disappeared on CT, and there has been no relapse to date (Fig. 6).