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