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, 3 (2), 157-163
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IgG4-related Sclerosing Cholangitis Mimicking Hilar Cholangiocarcinoma (Klatskin Tumor): A Case Report of a Challenging Disease and Review of the Literature

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Case Reports

IgG4-related Sclerosing Cholangitis Mimicking Hilar Cholangiocarcinoma (Klatskin Tumor): A Case Report of a Challenging Disease and Review of the Literature

Anke Mittelstaedt et al. Innov Surg Sci.

Abstract

Background: Even though IgG4-related disease has gained increased attention worldwide, the diagnosis remains challenging. IgG4-related sclerosing cholangitis (IgG4-SC) is not well described in the western hemisphere and may mimic cholangiocarcinoma (CC), especially when occurring without other symptoms such as, e.g. concurrent pancreatitis or retroperitoneal fibrosis. We present a case to add further information to the diagnosis and treatment of this challenging disease.

Case report: A 60-year-old male patient presented with painless jaundice. Prior medical history showed diabetes mellitus type I, high blood pressure, and deep vein thrombosis. Diagnostic investigations were strongly suspicious of a Klatskin tumor, although biopsies were inconclusive. The tumor marker Carbohydrate Antigen 19-9 (CA 19-9) was elevated. Prior to the recommended surgery, the patient had two second opinions in two different university hospitals, both arguing for surgery as well. The patient received hilar resection with right hemihepatectomy. During the postoperative course, some major complications occurred, i.e. recurrent pleural effusion, abscess in the liver resection area, sepsis, ileus, and restricted liver metabolism. Treatment with prednisolone did not show any improvement. Approximately 3 months after surgery, the patient died in consequence of acute respiratory failure. Histology showed no signs of CC, but IgG4-SC could be diagnosed.

Conclusion: In the case of preoperative signs of CC, differential diagnosis of IgG4-SC needs to be considered, in particular, in cases with missing histologic proof of malignant disease.

Keywords: IgG4; IgG4-related disease; autoimmune biliary disease; cholangiocarcinoma; sclerosing cholangitis.

Figures

Figure 1:
Figure 1:
(A) ERCP; (B) (transversal), (C, D) (both frontal): MRI. Cholangiographic findings show intrahepatic PSC-like lesions and extended intrahepatic bile ducts but are also strongly suspicious of a Klatskin tumor type IV of Bismuth. The arrows show a soft tissue thickening leading to a stenosis of the hilar bile duct region. There are also prestenotic dilatations of the bile duct. These findings correlate with type 4 of the cholangiographic classification of IgG4-SC.
Figure 2:
Figure 2:
Cut section of the patients’ liver: tumor-like prestenotic wall thickening of the right hepatic bile duct.
Figure 3:
Figure 3:
Histopathological sample of the patient. (A) Hematoxylin and eosin. (B) Elastica van Gieson: small artery (short arrow) next to an inflammatory occluded vein (long arrow). (C) Immunostaining: IgG4-positive plasma cells. (D) Elastica van Gieson: IgG4-sclerosing cholangitis: Accessory gland in the wall of a bile duct with periductal lymphoplasma cellular infiltrate.

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