IgG4-related Lung Disease With Recurrent Pulmonary Lesions During Steroid Therapy and Difficulty in Differentiating From Malignancy: Case Report and Literature Review

Background: Immunoglobulin G4-related disease (IgG4-RD) is characterized by the formation of inflammatory lesions with fibrosis and infiltration of IgG4-positive plasma cells and lymphocytes in various organs of the body. Since the first report of IgG4-related autoimmune pancreatitis, IgG4-RD affecting various organs has been reported; however, there are still only a few reports of IgG4-related lung disease (IgG4-RLD). In this report, we describe a case of IgG4-RLD with recurrent pulmonary lesions during steroid therapy that were difficult to differentiate from malignancy.Case presentation: A 61-year-old man was referred to our hospital after an abnormal chest shadow on X-ray was noted during his visit to his previous doctor for asthma treatment. Chest computed tomography (CT) revealed a middle lobe hilar mass with irregular margins and swelling of the right hilar and mediastinal lymph nodes. 18F-fluorodeoxyglucose-positron emission tomography revealed a mass lesion with a maximum diameter of 5.5 cm, maximum standardized uptake value (SUVmax) of 11.0, and areas with high SUV in the hilar and mediastinal lymph nodes. We suspected lung cancer or malignant lymphoma and performed a thoracoscopic lung biopsy to confirm the diagnosis. A total of five tumor sites and an enlarged lymph node (LN#10) were biopsied; histopathological examination revealed no malignant findings, and IgG4-RLD was diagnosed. One month after treatment with prednisolone (PSL), the tumor had shrunk, but a CT scan during the third month of PSL treatment revealed multiple nodular shadows in both lungs. Considering the possibility of malignant complications and multiple lung metastases, we performed thoracoscopic partial lung resection of the new left lung nodules to determine the treatment strategy. Histopathological examination revealed no malignant findings in any of the lesions, and the patient was diagnosed with IgG4-RLD refractory to PSL monotherapy. We are considering the combination of azathioprine and PSL as future treatment.Conclusions: IgG4-RLD refractory to PSL monotherapy showed changes from a solitary large mass (pseudotumor) to multiple nodules on chest CT. It was difficult to distinguish malignancy from IgG4-RLD based on imaging tests and blood samples alone, and performing thoracoscopic lung biopsies and partial lung resection were useful in determining the diagnosis and treatment plan.

Partial lung resection by uniportal video-assisted thoracoscopic surgery: technique and pitfalls

The use of uniportal video-assisted thoracoscopic surgery (VATS) has increased worldwide. The number of facilities introducing this simple and cost-effective surgical procedure in Japan has also increased. Partial lung resection is performed to diagnose or treat various cases and surgeons are required to flexibly deal with it. This report describes the technique and pitfalls of partial lung resection by uniportal VATS.

Thoracoscopic partial lung resection following pneumonectomy: a report of three cases

Background The prognosis of patients who undergo unilateral pneumonectomy and subsequently develop a contralateral pulmonary tumor can be improved by tumor resection. Thus, surgery is a treatment option if the patient’s pulmonary function and performance status are satisfactory. To date, there have been only few cases reporting thoracoscopic lung resection for pulmonary tumor after contralateral pneumonectomy because of the difficulty in respiratory management during surgery. Thoracoscopic surgery requires the maintenance of the operative field to allow the lung to collapse, and in partial lung resection we need to identify tumor localization. The identification of a tumor lesion just inferior to the pleura is easy; however, the identification of a tumor lesion in the deep parts is difficult. The tumor in the deep part of the lung segments can be easily located if the tumor-affected lobe is allowed to completely collapse. Therefore, ventilation technique should be modified according to the tumor localization. Case presentation Here, we report three cases of thoracoscopic partial lung resections for pulmonary tumors that developed after contralateral pneumonectomy. Intermittent manual ventilation using a tracheal tube was performed in two cases with a lesion just inferior of the pleura. The tumors in both patients were resected using automatic suturing devices while arresting manual ventilation. The affected lobe was allowed to collapse using a bronchial blocker in one of the cases with a lesion in the deep part. Furthermore, she had contralateral pneumothorax with bullae on the right upper and lower lobes of the lung. The tumor in the deep part of the lung segment and ruptured bullae were easily located and resected using automatic suturing devices. The hemodynamic status of the patients was stable, and the intra- and postoperative courses were uneventful. Conclusions Our cases demonstrate that thoracoscopic lung resection after contralateral pneumonectomy can be performed if intermittent manual ventilation is utilized when the tumor is located just inferior to the pleura and if selective double ventilation using an intrabronchial blocker is utilized when the tumor is located in the deep part.