Acute, complete splenic infarction in cancer patient is associated with a fatal outcome

[The causes of splenic infarction: An almost systematic review of the literature]

INTRODUCTION

Splenic infarction is a rare event in clinical practice, diagnosed by CT scan. There are many causes. They often determine the treatment given. However, there is no consensus on etiological investigations.

METHODS

We present here an almost systematic review of the literature, based on data available on Pubmed from 1991 to 2022. Using the keywords "splenic infarct", from 1893 references, 11 cohort studies and 867 clinical cases were included in this review. Articles written in languages using alphabets other than Latin were excluded.

RESULTS AND CONCLUSIONS

Analysis of these various studies has enabled us to draw up a list that is intended to be as exhaustive as possible of the causes of splenic infarction. The most frequent are emboligenic heart disease, hematological malignancies, solid neoplasia and certain infections. The descriptions available in the literature were mainly based on isolated clinical cases, not always making it possible to establish a causal link with the disease described, especially as around 20% of reported cases of splenic infarction were asymptomatic and potentially of incidental discovery. Based on the findings of this literature review, we propose a protocol for the etiological assessment of splenic infarcts.

Clinical characteristics and outcomes of splenic infarction in cancer patients: a retrospective, single center report of 206 cases

Cancer patients have a high risk of thromboembolic events including splenic infarct (SI). However, risk factors for SI in cancer patients are poorly understood, and the utility of systemic anticoagulation in such patients is uncertain. We performed a retrospective cohort study of all cancer patients with SI treated at Yale New Haven Hospital from 2008 to 2017. Central review of radiology imaging was performed to confirm the diagnosis of SI. Baseline differences in variables among patients with and without recurrent SI were compared using Fisher's exact test, Pearson's χ² test, and t-test. Multivariable regression models were conducted to identify factors associated with recurrent SI. Of 206 patients with cancer and SI, 42 had a prior venous thromboembolic event, while 29 had atrial fibrillation/flutter. At a median follow-up of 11.4 months (range: 0-142.3 months), 152 patients underwent follow-up imaging, with only 6 having recurrent SI. The use of anticoagulation after initial SI was associated with a nonsignificant increase in recurrent SI (p = 0.054) and was not associated with development of venous thromboembolism after SI (p = 0.414). In bivariate analyses, the risk of recurrent SI showed a significant association with lower platelet counts (p < 0.001) and with atrial fibrillation/flutter (p = 0.036). In a multivariable logistic regression model, no variables were identified that were associated with a higher risk of recurrent SI. SI in cancer patients is typically an isolated event with low recurrence risk. Anticoagulation use should be guided by other thromboembolic risk factors.

Splenic and Pancreatic Abscesses Associated with In Situ Thrombosis of Splenic Artery

Splenic infarction is rare and occurs when the splenic artery or its branches become occluded, either by an embolus or by in situ thrombosis. In situ thrombosis of splenic artery leading to splenic and pancreatic abscess formation after infarction is rare. We here present a case of a 65-year-old man who was found to have acute complete splenic and distal pancreatic infarction and abscess formation attributable to in situ thrombosis of splenic artery.

Solitary splenic metastasis from nasopharyngeal carcinoma: a case report and systematic review of the literature

Background

Solitary splenic metastases are a rare occurrence, and the nasopharyngeal carcinoma represents one of the most uncommon primary sources. The present study aimed to describe a rare case of a solitary single splenic metastasis from nasopharyngeal carcinoma and to assess the number of cases of isolated nasopharyngeal carcinoma metastases to the spleen reported in the literature.

Main body

We describe the case of a 56-year-old man with a history of nasopharyngeal carcinoma and complete remission after chemo-radiotherapy. Three months after complete remission, positron emission tomography/computed tomography scan revealed a hypermetabolic splenic lesion without increased metabolic activity in other areas. After laparoscopic splenectomy, the pathology report confirmed a single splenic metastasis from undifferentiated carcinoma of the nasopharyngeal type. The postoperative period was uneventful. We also performed a systematic review of the literature using MEDLINE and Google Scholar databases. All articles reporting cases of splenic metastases from nasopharyngeal carcinoma, with or without histologic confirmation, were evaluated. The literature search yielded 15 relevant articles, which were very heterogeneous in their aims and methods and described only 25 cases of splenic metastases from nasopharyngeal carcinoma.

Conclusion

The present review shows that solitary splenic metastases from nasopharyngeal carcinoma are a rare event, but it should be considered in patients presenting with splenic lesions at imaging and a history of primary or recurrent nasopharyngeal carcinoma. No evidence supports a negative impact of splenectomy in patients with solitary splenic metastasis from nasopharyngeal carcinoma.

Hypoplasia of the Spleen: Review of Pathogenesis, Diagnosis, and Potential Clinical Implications

Context:

Splenic aplasia is seen when the spleen is congenitally absent, has been surgically removed, or becomes atrophic secondary to episodes of arterial/venous occlusion, which result in splenic infarction. This rare condition is caused by a heterogenous group of diseases, which may present a wide spectrum of clinical manifestations. Splenic hypoplasia is defined as reduction in splenic mass and or functions caused by incomplete splenic development or secondary parenchymal involution. Splenic infarction may be clinically silent and only discovered incidentally during abdominal exploration for other conditions.

Case Report:

We present an unusual case of hypoplastic spleen with calcifications, which was preoperatively found during radiologic workup for gastric carcinoma. An 88-year-old woman presented with coffee-ground emesis. Her past medical history was only significant for atrial fibrillation. Esophagogastroduodenoscopy demonstrated gastric carcinoma, for which a subtotal gastrectomy was planned. Preoperative computed tomography scan showed a hypoplastic spleen with calcifications in the left upper quadrant. Symptoms of immunologic deficiency were not present. During laparotomy, an atrophied and calcified spleen was identified and left in situ. The patient made an uneventful postoperative recovery. Splenic hypoplasia is an unique entity, which may be seen in the setting of atrial fibrillation and abdominal malignancy.

Conclusion:

Splenic hypoplasia may be detected incidentally during radiologic workup or abdominal exploration. Abdominal symptoms or immunologic deficiency are not always present.

Identification of splenic infarction by emergency department ultrasound

BACKGROUND

Splenic rupture or infarction can occur secondary to acute infectious mononucleosis. Patients with abdominal pain and known or suspected infectious mononucleosis mandate evaluation for these complications, which can have significant morbidity or mortality.

CASE REPORT

An 18-year old man presented to the emergency department (ED) with a 2-day history of left upper quadrant abdominal pain. He had been diagnosed with mononucleosis 4 days before his ED presentation. Physical examination was notable for focal left upper quadrant tenderness. The treating physician's principal diagnostic considerations were splenic rupture or infarction secondary to mononucleosis. Point-of-care ultrasound was performed by the emergency physician, demonstrating multiple hypoechoic areas in the splenic parenchyma with absent Doppler flow, consistent with multiple splenic infarcts. The patient was admitted for observation, managed conservatively, and had an uneventful course.

CONCLUSION

Emergency ultrasound of the spleen can allow rapid diagnosis of splenic infarction and exclusion of splenic rupture in a patient at risk for splenic pathology.

[Splenic vascular disturbances]

Splenic vascular disturbances mainly affect the red pulp and can involve the venous or arterial blood flow. The venous blood flow may be impaired by congestion and morphologically shows dilated splenic sinuses. Disturbances of the arterial blood flow may occur in connection with anomalies of the erythrocyte membrane or in immune haemolysis and usually are characterized by narrow splenic sinuses. Infarction of the spleen is usually caused by arterial embolism.

Splenic metastases in a large unselected autopsy series

We analyzed the files of all autopsies performed at the Institute of Pathology of the Philipps-University Marburg between 1980 and 1999 with respect to the presence of splenic metastasis. The total number of autopsies within the study period was 8,563. In 1,898 cases, a solid malignant tumor (1,774 carcinomas, 36 sarcomas, 27 malignant melanomas) was diagnosed. Metastasis to the spleen occurred in 57 cases (3.0%). Compared to the whole study population, patients with splenic metastasis were significantly younger (59 years vs. 67 years, p<0.05) and had significantly more metastastic sites (median: 6 vs. median:1, p<0.05). This underlines the assumption that splenic metastasis is associated with a worse prognosis. Lung cancer, cutaneous malignant melanoma, and breast cancer were the most frequent primary tumors, accounting for 24.6%, 15.8%, and 12.3% of all spleen metastases, respectively. Patients with testicular germ cell tumors (patients: 9, spleen metastasis: 4), malignant melanoma (patients: 27, spleen metastasis: 9, 33%), and small cell lung cancer (patients: 106, spleen metastasis: 8, 7.5%) had the highest frequency of splenic involvement. Most (n=48) metastases were detected macroscopically, the remaining ones were micrometastases (n=2), small tumor cell clusters, and single tumor cells within sinusoids (n=7). The present study underlines the importance of spleen metastasis as an indicator of poor prognosis. There are, however, various aspects as to the detection and morphology of spleen metastasism, which merit further scrutiny.

Recovery of splenic infarction with anti-platelet treatments and platelet-apheresis in polycythemia vera

Thrombo-embolic events in coronary and peripheral arteries, and cerebral, pulmonary, portal, hepatic, and deep veins are seen in 27-45% of patients with polycythemia vera (PV). A 79-year-old man was admitted with complaints of pruritus increasing after bath and left upper abdominal pain radiating to left shoulder for two months. On physical examination, ruddy and hyperemic appearances of his face and conjunctiva, tenderness on the left upper quadrant, and splenomegaly were noted. Hemoglobin level was 16.6g/dl, hematocrit 53.8%, white blood cell count 26x10(9)/l, and platelet count 1.032x10(9)/l. Bone marrow aspiration and biopsy revealed hypercellularity, megakaryocytic hyperplasia and dysplasia. The leukocyte alkaline phosphatase score was 190. The levels of serum vitamin B12 and D-dimer were 316 pg/ml and 744 ng/ml, respectively. Arterial O2 saturation was 96%. Red cell mass was measured as 43 ml/kg using radionuclide 51Cr labelled erythrocyte scintigraphy. On cytogenetic analysis, deletion of 20q was found. Computed tomography of whole abdomen showed diffuse splenomegaly and two hypodense areas indicating splenic infarction in 2.5x2 and 3.5x3 cm diameters in subcapsular localization of the spleen. The patient was treated with therapeutic platelet-apheresis, 40 mg/day aspirin, analgesic drugs, and 3g/day hydroxyurea. After 1.5 months, platelet counts dropped to less than 500x10(9)/l and splenic infarcts were not detected on computed tomography. Splenic infarction may be the first evidence of thrombosis in PV. The reduction of platelet counts with platelet-apheresis, anti-platelet drugs, and careful clinical observation may be satisfactory in the treatment of splenic infarction.