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Weekly Chest CasesArchive of Old Cases

Case No : 1490 Date 2026-05-11

  • Courtesy of Jinwoo Son, Young Joo Suh / Severance hospital
  • Age/Sex 65 / F
  • Chief ComplaintWorkup for suspected pancreatic cancer
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
  • Figure 7

Diagnosis With Brief Discussion

Diagnosis
IgG4-related disease
Radiologic Findings
Fig 1. Plain radiograph shows multiple nodular opacities in both lungs.
Fig 2-4. Chest CT images show multiple variably sized, poorly defined nodules and masses with peribronchovascular and subpleural distribution in both lungs.
Fig 5. Multiple mediastinal lymph nodes are also noted.
Fig 6. F-18 FDG PET-CT reveals FDG uptake in the lung lesions and mediastinal lymph nodes.
Fig 7. Contrast-enhanced abdominal CT shows a hypoenhancing ovoid mass in the pancreatic tail.
Brief Review
The patient was referred to the oncology department of our institution from an outside hospital with suspected pancreatic cancer. Biopsies of the pancreas and lung nodules were performed, and histopathologic examination confirmed the diagnosis of immunoglobulin G4–related disease (IgG4-RD).
IgG4-RD is a systemic immune-mediated inflammatory disorder that can involve virtually any organ. It most commonly affects the pancreas, bile ducts, salivary glands, lacrimal glands, lungs, kidneys, and retroperitoneum. Thoracic involvement occurs in approximately 40% of patients with IgG4-RD.
The most common imaging findings of thoracic IgG4-RD are mediastinal lymphadenopathy and perilymphangitic interstitial thickening of the lungs.
Pulmonary involvement can be radiologically classified into four major patterns: (1) peribronchovascular and interlobular septal thickening, (2) nodules or mass-like lesions, (3) ground-glass opacities, and (4) alveolar interstitial thickening manifested as diffuse ground-glass opacities, bronchiectasis, and honeycombing.
IgG4-RD may also present as pleuritis with unilateral or bilateral pleural effusion and can involve large- to medium-sized vessels, the coronary arteries, and the pericardium.
IgG4-related pancreatic disease, also known as autoimmune pancreatitis (AIP), typically demonstrates diffuse pancreatic enlargement with loss of the normal lobulated contour (“sausage-shaped” appearance) and minimal adjacent fat stranding on CT. However, approximately 25–40% of patients may show focal enlargement or a mass-like lesion in the pancreas that is iso- to hypoattenuating, making it nearly indistinguishable from pancreatic carcinoma on imaging.
References
1. Kim Y, Choi HY. Immunoglobulin G4-Related Disease in the Thorax: Imaging Findings and Differential Diagnosis. J Korean Soc Radiol. 2021;82(4):826-837.
2. Zheng, Y., Elsayes, K.M., Waranch, C. et al. IgG4-related disease in the abdomen and pelvis: atypical findings, pitfalls, and mimics. Abdom Radiol 2020;45:2485–2499.
Keywords

No. of Applicants : 81

▶ Correct Answer : 47/81,  58.0%
  • - Kyeongpook National University Hospital , Korea (South) JOHN BAEK
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - medical scanning , Japan HIROAKI ARAKAWA
  • - Teikyo University Hospital , Japan ISSEI FUKUDA
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - Kyoto University , Japan AKIHIKO SAKATA
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - Oita university , Japan AYUMI KAMEI
  • - Kyoto University Hospital , Japan YUSUKE UTSUNOMIYA
  • - Chonnam National University Hospital , Korea (South) HYUNJIN KIM
  • - , Italy PAOLO BALDASSARI
  • - , France CHARLES DAMIEN
  • - , China FANG YING GEN
  • - Secomedic Hospital , Japan FUMINORI MIYOSHI
  • - Oita University, Faculty of Medicine , Japan FUMITO OKADA
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - University of Yamanashi , Japan TAKAAKI HASHIMOTO
  • - Osaka University , Japan AKINORI HATA
  • - University of Yamanashi , Japan HIROYUKI MORISAKA
  • - Ajou University Hospital , Korea (South) HYUNSEUNG LEE
  • - Teikyo University Hospital, Mizonokuchi , Japan TOSHIHIRO FURUTA
  • - Nara Medical University , Japan AYA YAMADA
  • - University of Yamanashi , Japan HIROAKI WATANABE
  • - Chonbuk National University Hospital , Korea (South) JUNGHOON OH
  • - Japanese Red Cross Otsu Hospital , Japan JUN YOSHIDA
  • - , Korea (South) HYOUNG YEOB KIM
  • - , Korea (South) KYUNG-HWA CHUNG
  • - The Catholic University of Korea Yoeuido St. Mary , Korea (South) OHMIN KWON
  • - Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
  • - , Japan SHUNJIRO NOGUCHI
  • - Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Osaka metropolitan university Hospital , Japan TATSUSHI OURA
  • - Dokkyo Medical University , Japan HIROAKI ARAKAWA
  • - Seoul Medical Center , Korea (South) HANSEUL CHO
  • - Chonnam National University Hospital , Korea (South) GYERYEONG PARK
  • - Kyoto University , Japan SHO KOYASU
  • - Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
  • - Kantou Rousai Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Matsunami General Hospital , Japan TARO TAKEDA
  • - Ehime University , Japan TOMOHISA OKADA
  • - , Japan YUMI MAEHARA
  • - Chonbuk National University Hospital , Korea (South) HYEONG RYUN CHO
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - University of Yamanashi , Japan KOJIRO ONOHARA
  • - , Japan YUJI OHIZUMI
▶ Correct Answer as Differential Diagnosis : 17/81,  21.0%
  • - , Japan HIROKI SAKURADA
  • - Other , Korea (South) SEONGSU KANG
  • - Seoul Medical Center , Korea (South) HATAEK JEONG
  • - Chiba University Hospital , Japan HIROKI MIYAZAKI
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - Chonbuk National University Hospital , Korea (South) SEUNG HO LEE
  • - , Japan TOMOHIRO KAWAJI
  • - TB centre kasaragod. , India rikhy krishnan
  • - Kobe Children , Japan SHUHEI NORIMOTO
  • - URN , Japan PROTON SPIN CHAN
  • - Kyung Hee University Medical Hospital , Korea (South) JEONG TAEK YOON
  • - Fukuoka university , Japan KEISUKE SATO
  • - , Korea (South) LEE HYE IN
  • - Ehime University , Japan KOTARO MATSUMOTO
  • - , Korea (South) JIYUN KIM
  • - Fukuoka Central Hospital , Japan YUKIHISA TAKAYAMA
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Semi-Correct Answer : 2/81,  2.5%
  • - Affilitated Hospital of Jining Medical college , China JIANG SHENG HUA
  • - IRSA/SIMAGO LA ROCHELLE , France JEAN LUC BIGOT
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