Thoracoabdominal splenosis

Barrio, Elvira; Ramon, María del Carmen; Valcárcel, Andrea

doi:10.1016/j.medcle.2020.02.017

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As a history of interest, she reported a splenectomy due to abdominal trauma in a traffic accident at the age of 15.Physical examination, electrocardiogram, venous blood gases and blood tests were normal. A chest X-ray was performed, showing a minimal left pleural effusion. Subsequently, a chest CT angiography was requested in which the presence of pulmonary thromboembolism was ruled out, but it showed multiple pleural lesions, the largest of 4 cm in diameter, with intense uptake in the arterial phase, over the entire left pleural surface, as well as multiple bilateral and mediastinal hilar lymphadenopathies. There was also a solution of continuity in the diaphragm, compatible with a partial traumatic rupture of this muscle. These findings were considered to be of probable malignant aetiology, so admission to internal medicine was decided to continue the study.Once on the ward, mammography and abdominal ultrasound were performed, which showed no abnormalities. Thoracentesis was ruled out due to the small amount of pleural effusion. It was decided to repeat the chest CT in arterial and portal phases, detecting several lesions with the same characteristics previously described in the theoretical region of the spleen and between the thorax and abdomen in the region of the diaphragmatic disruption. These findings were considered compatible with foci of thoracic, diaphragmatic, and left subphrenic splenosis. In addition, a prominent splenic artery was observed leading to the area of the apparent subdiaphragmatic splenic implants, making the proposed diagnosis even more likely. A 99mTc-labeled red blood cell SPECT/CT scintigraphy was requested, which was not conclusive due to the non-specificity of the radiotracer.To obtain an established diagnosis, a video-assisted thoracoscopy (VATS) with biopsy of one of the lesions was performed, the result of which confirmed the splenic nature of the lesions. The patient remained asymptomatic in subsequent outpatient controls.Splenosis is an entity whose actual incidence is unknown since its course is generally asymptomatic. It is thought to be much more common than what is suggested by the few published cases. A study in which patients with post-traumatic splenectomy underwent ultrasound follow-up concluded that splenosis as a presumptive diagnosis (without histological confirmation) reached one third of the patients studied.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>The most common route of implantation is by direct displacement of splenic fragments nesting in highly vascularised serosal surfaces. Cases have been reported without diaphragmatic rupture, which is probably attributed to the passage of small splenic tissue into the thoracic cavity through pores in the diaphragm.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>The most common location is the left upper quadrant of the abdomen, the natural region of the spleen that is absent in these patients. Other locations described are the thoracic cavity, liver, stomach, pericardium, testicle, vagina, adrenal gland, subcutaneous implants in the laparotomy scar, and even intracranial ones.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>It is usually diagnosed accidentally during imaging studies or surgery for other reasons. However, it can occasionally cause symptoms due to bleeding, compression, or recurrence of haematological processes treated with splenectomy.Diagnostic imaging is of limited value due to its low specificity, and it can easily be confused with other entities, usually malignancies. The diagnostic technique of choice is scintigraphy. 99mTc-sulfur colloid (SC), 99mTc-HD or indium-labelled platelets (111In) can be used.When non-invasive studies are not sufficient to reach the diagnosis, a CT-guided fine needle aspiration can be performed.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> However, the size or location of the lesion may prevent the procedure from reaching the target site. Laparoscopy provides a minimally invasive access for visualisation and biopsy. Resection of masses is only recommended if they produce symptomatology or in case of haematological disease benefiting from splenectomy.In conclusion, as our case illustrates, a thorough medical history and a high index of suspicion are necessary to reach the diagnosis of splenosis." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Barrio E, Ramon MC, Valcárcel A. Esplenosis toracoabdominal. Med Clin (Barc). 2021;156:581–582." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Milzneubildungen nach traumatisch bedingter splenektomie- diagnostik und function" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "U. Muller" 1 => "M. 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Ravn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2019.01.083" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2019" "volumen" => "108" "paginaInicial" => "e221" "paginaFinal" => "e222" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30878459" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A unique case of cerebral Spleen" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Rickert ChH" 1 => "U. Maasjosthusmann" 2 => "S. Probst-Cousin" 3 => "C.H. August" 4 => "F. Gullotta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00000478-199807000-00011" "Revista" => array:6 [ "tituloSerie" => "Am J Surg Pathol" "fecha" => "1998" "volumen" => "22" "paginaInicial" => "894" "paginaFinal" => "896" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9669351" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic imaging of abnormalities in the number and location of the spleen" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Rodríguez Vargas" 1 => "M.J. Parada Blázquez" 2 => "B. Vargas Serrano" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Radiología" "fecha" => "2019" "volumen" => "61" "paginaInicial" => "26" "paginaFinal" => "34" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015600000011/v1_202106060546/S2387020621002217/v1_202106060546/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015600000011/v1_202106060546/S2387020621002217/v1_202106060546/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621002217?idApp=UINPBA00004N"]

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Vol. 156. Issue 11.

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