Splenic marginal zone lymphoma presenting as myelofibrosis associated with bone marrow involvement of lymphoma cells which secrete a large amount of TGF-�

We report here on a patient with splenic marginal zone lymphoma presenting diffuse fibrosis of bone marrow and spleen. After splenectomy and chemotherapy, bone marrow biopsy demonstrated an improvement of fibrosis. Plasma concentration of transforming growth factor (TGF)-beta was much higher in this patient than in those of age-matched non-Hodgkin's lymphoma patients ( n=5) at diagnosis, decreasing after resolution of myelofibrosis. Immunostaining with the TGF-beta antibody revealed that the lymphoma cells in bone marrow and spleen were positive for TGF-beta. TGF-beta secreted by tumor cells was thought to stimulate the growth of fibroblasts and synthesize collagen in bone marrow and splenic fibroblasts, and play an important role in the development of marrow and splenic fibrosis in this patient. This is the first report of a patient with splenic marginal zone lymphoma presenting as myelofibrosis associated with bone marrow involvement of lymphoma cells which secrete a large amount of TGF-beta.

Isolated spleen metastatic involvement from a colorectal adenocarcinoma complicated with a gastrosplenic fistula. A case report and literature review

We present the case of a 66-year-old man with a moderately differentiated adenocarcinoma of the left colon and isolated spleen metastases, complicated with a gastrosplenic fistula. The patient underwent a palliative segmental resection of the primitive colic tumour, as no curative treatment could be offered in view of the spleen involvement. Adjuvant chemotherapy was started. After a few chemotherapy treatments, he developed a gastrosplenic fistula which required the resection of the spleen and the greater gastric curvature together. This fistula was, among other things, responsible for bad breath that immediately disappeared postoperatively. At the end of the chemotherapy course, all carcinologic features had also disappeared.

Fulminant liver failure induced by hepatosplenic alphabeta T-cell lymphoma

Since survival rates of fulminant liver failure are low, early consideration of liver transplantation in patients developing hepatic encephalopathy due to progressive liver failure is mandatory. Rapid diagnostic work-up is necessary to identify the underlying disease and to rule out contraindications to liver transplantation. We report the case of a 35-year-old patient presenting with fulminant hepatitis and a four-week history of biopsy-proven autoimmune hepatitis. Despite high-dose steroid-treatment liver function progressively worsened and hepatic encephalopathy rapidly developed. Histopathologic evaluation of a liver biopsy specimen revealed necrotizing hepatitis and rare atypical lymphocytes. Surgical biopsy specimens confirmed the suspicion of an aggressive hepatosplenic alphabeta T-cell lymphoma which represents a contraindication to liver transplantation.

[A case of splenic hemorrhage in the course of malignant mesothelioma]

A 56-year-old man was admitted to our hospital because of mass lesions at the levels of the right upper and lower lung regions on a chest plain radiograph. Chest computed tomography showed tumors which projected from the pleura of the right upper and lower lung fields. One particular point of interest was the complete separation of the tumors from each other. Malignant mesothelioma was diagnosed by biopsy of the pleura via echogram. Both chemotherapy and radiotherapy were administered because of brain metastasis and direct rib invasion. Under this combined therapy, sudden anemia and hypotension appeared due to splenic hemorrhage, which suggested splenic metastasis of the malignant mesothelioma. Multiple metastases in, for example, the spleen, brain, lung, liver, duodenum, small intestine, kidney, adrenal gland, vertebra, thyroid gland, and lymph nodes were confirmed by autopsy. Distant metastasis is rare for malignant mesothelioma, and we report here a case of splenic metastasis with splenic hemorrhage in malignant mesothelioma.

Immune-mediated haemolytic anaemia associated with a sarcoma in a flat-coated retriever

A seven-year-old flat-coated retriever presented with a history of lethargy, dyspnoea and inappetence of several days' duration. Clinical examination revealed pale mucous membranes and tachypnoea, and haematology demonstrated marked autoagglutination. Thoracic radiographs revealed an increased opacity in the perihilar region. The owners declined further evaluation and the dog was treated symptomatically with immunosuppressive doses of prednisolone and azathioprine. The dog's demeanour improved, although it was eventually euthanased seven weeks later because of dysphagia and worsening dyspnoea. Postmortem examination revealed a widespread, poorly differentiated sarcoma involving the lungs, pericardium, thoracic lymph nodes and spleen. Immune-mediated haemolytic anaemia is a well recognised condition in dogs and is occasionally associated with neoplastic conditions. This is the first case report to describe immune-mediated haemolytic anaemia associated with a diffuse, poorly differentiated sarcoma.

Solitary spleen metastasis and amyloidosis in a patient with endometrial cancer

BACKGROUND

In contrast to autopsy findings, solitary splenic metastases from solid tumors are extremely rare. It may occasionally be the first manifestation of recurrent solid cancers, and in particular of gynecologic malignancies. Secondary amyloidosis is also found in malignancy.

CASE

A 52-year-woman originally diagnosed with a Stage IB, grade 2 endometrial carcinoma presented two and a half years later with a paroxysmal non-productive cough, weakness, loss of appetite and daily afternoon fever. On clinical examination wheezing on forced exhalation and painful splenomegaly was found. After an extensive work-up the patient underwent an explorative laparotomy and a splenectomy was performed. Histologic examination showed solitary spleen metastasis with amyloidosis. All symptoms resolved. As the patient had received a full course of postoperative irradiation after a total abdominal hysterectomy, six cycles of combination chemotherapy were administered. The patient remains free of recurrence, 46 months later.

CONCLUSION

A case of solitary spleen metastasis with amyloidosis in a patient with endometrial cancer is presented.

Solitary splenic metastasis of squamous cell carcinoma of the uterine cervix: a case report and review of the literature

A 45-year-old patient presented with complaints of vaginal bleeding and pelvic pain. Fractioned probe curettage was performed and reported as Stage IIa, grade 3, squamous cell carcinoma of the uterine cervix. The patient underwent radical hysterectomy type III, bilateral salpingo-oophorectomy, omentectomy, appendectomy, and pelvic para-aortic lymph node dissection according to our clinical protocol. Adjuvant radiation therapy was planned. A splenic mass of 8 cm in diameter was revealed on computed tomography at the end of the third year of the disease-free follow-up period. Fine needle aspiration biopsy was performed and reported as metastatic carcinoma correlated to the previous cervical cancer. Debulking surgery was performed. The patient died one year after the second surgical operation. Spleen metastasis in patients with squamous cell carcinoma of the uterine cervix is exceedingly rare. Nonetheless we recommend screening of all intra-abdominal organs including the spleen as a rare metastastic site in follow-up examination protocols.

Primary histiocytic sarcoma of the spleen associated with erythrophagocytic histiocytosis

We report an exceptional case of a histiocytic sarcoma presenting as a primary isolated spleen tumor in a 71-year-old woman. The neoplastic cells in the cords and sinuses of the red pulp formed multiple lobulated tumors, which were detected in vivo by ultrasound scan. The medium cells, large cells and the giant cells expressed CD68, a histiocyte-associated marker, lysozyme and S100 protein. All these cells were negative for B- and T-cell markers, cytokeratins, melanosome markers (HMB45) and CD1a (Langerhans' cells). Many tumor cells displayed strong erythrophagocytosis and sometimes lymphocytophagocytosis. In addition, numerous histiocytes with morphology indistinguishable from reactive macrophages also exhibited a strong erythrophagocytosis, and were found in the tumor as well as in the normal splenic parenchyma. Despite multi-agent chemotherapy, the patient suffered from a relapse in the liver, with a rapid fatal outcome. A literature review showed that such a primary splenic presentation with multiple tumors is rare. In contrast, in systemic malignant histiocytosis, secondary spleen involvement occurs more frequently but with diffuse infiltration. The association with a reactive histiocytosis with erythrophagocytosis corresponds to "histiocytic medullary reticulosis", as previously described by Scott and Robb-Smith.

Littoral cell angioma of the spleen in a patient with severe aplastic anaemia

Littoral cell angioma (LCA) is a rare benign tumour of the spleen. We describe a patient with aplastic anaemia who, following multiple treatments with rabbit and horse Anti-Thymocyte Globulin and anabolic steroids developed marked splenomegaly and hypersplenism. LCA was diagnosed post splenectomy. This is the first case of LCA associated with aplastic anaemia and its treatment.

Splenic rupture as a consequence of dual malignant pathology: a case report

A 76 year old woman presented acutely with non-traumatic splenic rupture, which was successfully treated by emergency splenectomy. Histological examination of the spleen revealed the coexistence of metastatic adenocarcinoma cells, together with low grade B cell non-Hodgkin lymphoma. Splenic rupture as a consequence of malignant disease is discussed, together with a brief review of the literature.

Littoral cell angioma of the spleen in a patient with severe aplastic anaemia

Littoral cell angioma (LCA) is a rare benign tumour of the spleen. We describe a patient with aplastic anaemia who, following multiple treatments with rabbit and horse Anti-Thymocyte Globulin and anabolic steroids developed marked splenomegaly and hypersplenism. LCA was diagnosed post splenectomy. This is the first case of LCA associated with aplastic anaemia and its treatment.

Splenic lymphangioma and presentation with frequent urination: a case report

Lymphangioma of the spleen is a rare disorder with a clinical manifestation ranging from incidental findings of an abdominal mass to symptomatic abdominal pain. The authors reported a case of splenic lymphangioma with the presenting symptom of frequent urination in a 9-year-old boy. A large firm mass was found at the left upper quadrant, 12 cm in diameter. The diagnosis was confirmed by ultrasonography and computerized tomographic (CT) scan. The symptoms of frequent urination disappeared after operative splenectomy. No evidence of recurrence occurred over a 3-year follow-up.

General anesthetic management for diagnostic splenectomy in a patient with paraneoplastic pemphigus

Paraneoplastic pemphigus (PNP) is an autoantibody-mediated mucocutaneous blistering disease that often occurs with confirmed or occult malignancy. It is often accompanied by extensive eruption of respiratory mucosa and can lead to respiratory failure. The indications for anesthetic management in patients with PNP are rare due to the high risk of generating further eruption of respiratory mucosa during intubation, with potentially disastrous consequences. We report the anesthetic management in a 43-year-old woman with PNP scheduled for diagnostic splenectomy. The surgery was postponed due to persistent hoarseness, diffuse oral-pharyngeal mucositis, and laryngeal erosion. Methylprednisolone 40 mg 3 times daily was prescribed for controlling the mucosa lesions. Two weeks later, after the improvement of mucosal lesions, direct laryngoscopic intubation and the scheduled splenectomy were performed under general anesthesia. Pathology of the spleen showed low-grade B-cell lymphoma had induced PNP. Flexible fiberoptic bronchoscopic examination revealed neither bleeding nor bullae formation in the trachea either immediately after intubation or before extubation. The tracheal mucosa is highly susceptible to mechanical stimulation with direct laryngoscopic intubation. Cuff inflation and positive pressure ventilation, awareness of the disease characteristics of PNP, a sufficient course of steroid therapy beforehand, and adequate mucosal protection are essential to the uneventful anesthetic management of the patient with PNP involving the respiratory tract mucosa.

Hepatosplenic T-gammadelta lymphoma in a patient with Crohn's disease treated with azathioprine

Hepatosplenic gammadelta T-cell lymphoma (HS-gammadeltaTCL) is an uncommon type of peripheral T-cell lymphoma, which has been associated in some cases with immunosuppression, mainly after solid organ transplants. We describe a case of HSgammadeltaTCL with a leukaemic course in a patient with Crohn's disease who had received azathioprine during the previous 5.5 years. Sinusoidal infiltration by atypical lymphocytes was observed in the liver, spleen and bone marrow and the typical cytogenetic abnormalities (isochromosome 7 and trisomy 8) were found. The patient did not respond to intensive chemotherapy. This case shows the importance of ruling out HSgammadeltaTCL in patients with hepatosplenomegaly, B-symptoms and any immunosuppressive condition.

Burkitt lymphoma following splenic marginal zone lymphoma. evidence for two independent B-cell clones

We report the progression of splenic marginal zone lymphoma (SMZL) with circulating villous lymphocytes to Burkitt lymphoma with the presence of a t(8;14)(q24;q32) followed by a highly aggressive course. While the initial indolent lymphoma had an IgM lambda immunophenotype the Burkitt lymphoma was IgM kappa-positive. Immunoglobulin heavy chain gene (IGH) sequence analysis showed no identity between the two clones. We conclude that Burkitt lymphoma can occur in patients with SMZL, although not necessarily of identical clonal origin.

Splenic marginal-zone lymphoma: a distinct clinical and pathological entity

In the World Health Organization classification system, splenic marginal-zone lymphoma (splenic MZL) is described as an indolent B-cell lymphoma, which generally presents as splenomegaly with involvement of the bone marrow and peripheral blood. Presence of disease in peripheral lymph nodes and extranodal locations is uncommon. Splenic MZL is characterised by micronodular infiltration of the spleen with marginal-zone differentiation; the immunophenotype is usually IgM+ IgD+/- cytoplasmic-Ig-/+ pan B antigens+ CD5- CD10- CD23- CD43-/+ cyclin D1-; and the most common genetic abnormalities are deletions at 7q22-7q32. Most patients with splenic MZL live for a long time but classic prognostic factors cannot distinguish between patients who are likely to have good and poor outcomes. However, immunological events, such as haemolytic anaemia and immune thrombocytopenia, or the presence of a monoclonal component, are significantly associated with shorter survival. Splenectomy is considered the first-line treatment of choice for splenic MZL; it results in only partial remission, but responses are generally sufficient for correcting cytopenia, improving quality of life, and increasing survival.

A case of splenic lymphoma with marked diffuse nodular fibrosis and calcification, complicated with severe autoimmune hemolytic anemia

A splenic lymphoma, possibly of a splenic marginal zone lymphoma, marked by small nodular splenic calcified fibrosis and complicated by intractable autoimmune hemolytic anemia, was studied by immunohistochemical, molecular genetic, and ultrastructural analyses. The patient was a 57-year-old Japanese man who had moderate splenomegaly, and who had undergone splenectomy for improvement of severe autoimmune hemolytic anemia and to rule out malignancy in the spleen. In the resected spleen, proliferative atypical lymphoid cells were observed both in the red and white pulp with diminished germinal centers and irregularly widened marginal zones with peculiar dimorphic pattern. Ultrastructural study revealed no hairy cells or villous lymphocytes. Diffuse nodular hyalinous fibrosis surrounding the small arterioles in the white pulp overlapped with frequent calcification was a unique histologic feature in this case. Degenerative connective tissue, extracellular matrix, or collagen fibers surrounding the arterial sheath in the white pulp caused by some immunological abnormalities associated with this splenic lymphoma could be assumed to be the predisposing factor for this excessive fibrosis and dystrophic calcification in the spleen.

No V(H) somatic hypermutation was detected in B-cells of a patient with macroglobulinemia due to splenic marginal zone lymphoma

B-cell diseases are classified on the basis of the normal differentiation stages. We report here a case of a patient with a long history of leukocytosis, splenomegaly without lymphadenopathy, and hyperviscosity symptoms. Clinically, the patient's diagnosis was leukemic Waldenstrom macroglobulinemia. Chromosomal analysis revealed translocation t(2;7)(p11;q22) along with disease progression. Death occurred from pulmonary infection at 46 months after the initial presentation. At autopsy, malignant lymphocytes were found in the marginal areas of the spleen with spreading to the bone marrow and the liver. The histologic findings were consistent with splenic marginal zone lymphoma. We examined the sequences of the immunoglobulin V(H) gene in cells from the initial peripheral blood and from the spleen at autopsy and found that the sequences were identical and had no somatic hypermutation. Macroglobulinemia can occur in various B-cell disorders, including splenic marginal zone lymphoma, even with the transformation of unmutated B-lymphocytes.