'Non-tropical idiopathic splenomegaly' ('primary hypersplenism'): a review of ten cases and their relationship to malignant lymphomas

The Diagnostic Utility of Splenectomy in Idiopathic Splenomegaly

INTRODUCTION

With increasing frequency, patients with idiopathic splenomegaly are referred to surgeons for splenectomy. We evaluated the diagnostic utility of splenectomy and feasibility of a minimally invasive approach in the face of idiopathic splenomegaly.

METHODS

We retrospectively reviewed 68 patients who underwent splenectomy for idiopathic splenomegaly. The primary endpoint was the rate of definitive diagnosis based on final surgical pathology of the removed spleen.

RESULTS

Preoperative workup included a bone marrow biopsy and peripheral blood smear in 93% and 100% of patients, respectively, with none having lymphadenopathy warranting biopsy. Splenectomy provided a definitive diagnosis for 44 (64.7%) patients. Of these, 34 (50%) patients had an underlying malignancy, of which more than half were splenic marginal zone lymphoma. There were 33 (48.5%) laparoscopic, 23 (33.8%) open, 10 (14.7%) laparoscopic converted to open, and two (2.9%) laparoscopic hand-assist cases. Conversion to open was due to splenic size [median craniocaudal length 21.8 cm (cm)] in eight and staple line bleeding at the splenic hilum in two patients. Overall, the laparoscopic approach was completed in patients with a smaller splenic size compared to open (median craniocaudal length 15.2 vs. 26.0 cm, p < 0.0001). The open group had one (1.5%) intra-operative mortality due to uncontrollable hemorrhage. Thirty-day complication rates were similar for laparoscopic and open approaches (p = 0.10).

CONCLUSION

Splenectomy is an effective diagnostic modality in determining a pathologic cause for splenomegaly in this patient population. Laparoscopic splenectomy can be performed safely in appropriate cases with craniocaudal splenic size having the largest influence on surgical approach.

Idiopathic splenomegaly: a previously unrecognised cause of anaemia and thrombocytopenia in a dog

Summary

A nine-year-old female neutered Old English sheepdog was referred for investigation and treatment of moderate, non-regenerative anaemia and thrombocytopenia. Aside from the aforementioned changes on complete blood count (CBC), the only abnormality found during diagnostic investigation was marked, generalised splenomegaly. A cause for the anaemia, thrombocytopenia and splenomegaly was not found following initial investigation. Splenectomy was performed and histopathological analysis showed marked, diffuse, subacute-chronic congestion and intraparenchymal haemorrhage. There was no evidence of neoplastic change. The splenic vasculature appeared normal during coeliotomy and torsion was not present. The findings of anaemia and thrombocytopenia, along with the histopathological changes found in the spleen, are similar to those found in people diagnosed with idiopathic splenomegaly. The dog recovered well from anaesthesia and was discharged the following day. Repeat CBCs over 12 months postsurgery showed results within normal limits, and no clinical signs had been reported by the owners.

An inherited disorder with splenomegaly, cytopenias, and vision loss

We describe a novel inherited disorder consisting of idiopathic massive splenomegaly, cytopenias, anhidrosis, chronic optic nerve edema, and vision loss. This disorder involves three affected patients in a single non-consanguineous Caucasian family, a mother and two daughters, who are half-sisters. All three patients have had splenectomies; histopathology revealed congestion of the red pulp, but otherwise no abnormalities. Electron microscopic studies of splenic tissue showed no evidence for a storage disorder or other ultrastructural abnormality. Two of the three patients had bone marrow examinations that were non-diagnostic. All three patients developed progressive vision loss such that the two oldest patients are now blind, possibly due to a cone-rod dystrophy. Characteristics of vision loss in this family include early chronic optic nerve edema, and progressive vision loss, particularly central and color vision. Despite numerous medical and ophthalmic evaluations, no diagnosis has been discovered.

Hepatic cytotoxic T-cell infiltrates in patients with peripheral T-cell proliferative diseases/lymphomas: Clinicopathological and molecular analysis

Seventy patients with various types of peripheral T-cell proliferative disease/lymphoma who manifested with prolonged fever, weight loss, anemia, lymphadenopathy, hepatosplenomegaly and elevated serum levels of alkaline phosphatase and/or lactate dehydrogenase were evaluated. Histopathological examination of the livers revealed T-cell infiltration into the hepatic sinusoids and portal tracts. The morphology of the infiltrated T cells varied from mature small lymphocytes to malignant lymphoid cells. The liver pathology was classified into four groups on the basis of cellular atypia. Group A and group B showed mature lymphoid cell infiltration; however, only group B had multiple large areas of hepatocellular necrosis. Group C showed atypical lymphoid cell infiltration and in group D malignant lymphoid cell infiltrates were demonstrated. The majority of the antigenic phenotypes of these T-cell infiltrates were CD3+, CD4-, CD8+, CD20-, CD45RO+, CD56-, CD57-, TIA-1+ and betaF1-. Epstein-Barr virus RNA in the nuclei of the infiltrated T cells was recorded in 38.6% of the patients and was more common in groups C and D. Patients in groups B, C and D had a very poor prognosis, median survival was only 1 month, whereas median survival in group A patients was 36 months. Chemotherapy was not effective in improving survival. Monoclonal band/s of T-cell receptors (TCR) beta and/or gamma gene rearrangements were detected in 88.6% of patients, and DNA-sequence analysis showed high identity to the human TCR germline gene.

The spleen as a diagnostic specimen: a review of 10 years' experience at two tertiary care institutions

BACKGROUND

Few studies have examined the yield of the diagnostic splenectomy, and the relevance of these studies to the management of patients with unexplained splenomegaly or a splenic mass are limited by low number of cases, the use of selection criteria, and the lack of modern terminology and modern ancillary studies. The current study correlates clinical intent with preoperative clinical and radiologic studies and histologic findings in an assessment of the diagnostic yield of splenectomy.

METHODS

The medical charts, laboratory data, radiologic studies, and pertinent preoperative biopsies on all patients who underwent splenectomy between the years 1986 and 1995 were reviewed, and the clinical intent behind the procedure was correlated with histologic findings.

RESULTS

One hundred twenty-two of the 1280 patients underwent splenectomy for diagnosis, and in 116 patients a specific disease was identified histologically that explained the splenomegaly/splenic mass; malignancy was the most common cause of unexplained splenomegaly or splenic mass, though benign neoplasms and reactive disorders were documented in 25% of the cases. Primary splenic lymphomas were most commonly of large cell B-cell type.

CONCLUSIONS

In the setting of splenomegaly or splenic mass, splenectomy has a high diagnostic yield and usually discloses a malignancy. The clinical category of "primary splenic lymphoma" is biologically heterogeneous, and the diagnosis is usually an intermediate grade (not low grade) lymphoma. The range of conditions associated with splenic masses were quite commonly associated with diseases that are amenable to fine-needle aspiration (FNA) diagnosis, whereas those disorders associated only with splenomegaly included a large fraction of diseases for which FNA may yield either incomplete or misleading results.

Splenectomy in patients with undiagnosed splenomegaly

Of splenectomies performed in the Cork Regional Hospital over an 11 year period, ten were undertaken primarily for diagnostic purposes. A definitive histological diagnosis was established in nine patients, seven of whom had lymphoma, two with Hodgkin's disease and five with non-Hodgkin's lymphoma. The weight of the excised spleen in all patients with lymphoma exceeded 1 kg; in all those with a diagnosis other than lymphoma, the spleen weighed less than 1 kg. A majority of patients also had symptomatic improvement from reversal of hypersplenism and from relief of the mechanical pressure effects of an enlarged spleen. Operative mortality was zero. Diagnostic splenectomy is a worthwhile procedure. Most patients will have lymphoma.

Interstitial 9q deletion. A primary change in a case with splenomegaly of unknown origin

In a case with splenomegaly of unknown origin and features of hypersplenism, an interstitial 9q deletion was identified as a sole clonal abnormality of bone marrow cells. The meaning of 9q deletion as a primary change, as well as its clinical significance, are considered.

Chronic infectious mononucleosis; a case report

A 39-year-old woman had an adenitis colli followed by anaemia, splenomegaly, atypical lymphoid cells in blood with increased B-lymphocytes, reduced T-suppressor/cytotoxic cells, increased polyclonal IgM, high titres of EB VCA IgG, EB EA IgD&R +/- and EBNA IgG-. The disease progressed slowly for 2 years, splenectomy was followed by clinical improvement; spleen morphology was compatible with a benign disease of viral origin.

Malignant lymphoplasmacytic lymphoma with prominent splenomegaly (primary lymphoma of the spleen)

Eleven patients (age range 51-65 years) presenting with primary splenic lymphoma of lymphoplasmacytic type are described, together with detailed histological, immunohistochemical, and ultrastructural findings. The subclassification of this type of lymphoma is considered, and the prognosis discussed.

True idiopathic splenomegaly--a distinct clinical entity

10 asymptomatic young male patients with moderate splenomegaly detected at a routine examination are presented. The history and clinical examination failed to reveal the aetiology of the splenomegaly. Further investigations, including screening for blood dyscrasias, clotting abnormalities and reticuloendothelial abnormalities were likewise unrevealing. Liver biopsies, rectal biopsies for bilharzia and bone marrow aspirates for Gaucher's Disease were found to be normal. Serology for malaria and Ebstein Barr Virus infection was also negative. Positive immunofluorescent tests for IgG antibodies specific for cytomegalovirus were found in 5 patients. We consider that these patients have splenomegaly which is not of a specific nature, but may be associated with a severe antigeneic response to the previous cytomegalovirus infection. In view of the otherwise negative findings these patients should be considered to have 'True Idiopathic Splenomegaly', a term which would indicate the benign nature of the splenic enlargement. This diagnosis should be considered in the differential diagnosis of asymptomatic patients who have splenomegaly of undetermined origin.

Non-tropical idiopathic splenomegaly and chronic T cell lymphocytosis

Non-tropical idiopathic splenomegaly (NTIS) is thought to predispose to the development of lymphoid neoplasia of B-cell type. We report a case of NTIS that evolved into a T-lymphoproliferative disorder. Review of the literature suggests that this type of evolution is not uncommon. The role of splenectomy in this progression is discussed.

Hyperreactive malarious splenomegaly (tropical splenomegaly syndrome)

Hyperreactive malarious splenomegaly (HMS), formerly known as tropical splenomegaly syndrome (TSS), was recognized some 20 years ago as an entity distinct from the splenic enlargement resulting directly from malarial parasitaemia. Its basis appears to be a disturbance in the T-lymphocyte control of the humoral response to recurrent malaria, possibly linked to particular HLA Class II antigens. Gross overproduction of IgM antibodies leads to the formation of high molecular weight immune complexes, persistent gross splenomegaly recurrent episodes of profound anaemia and increased susceptibility to infections. Those with gross disease experience a high mortality, which constitutes a major public health problem in communities where the syndrome affects a majority of adults.

Vertebral and paravertebral sepsis in diabetes: an easily missed cause of backache

Vertebral osteomyelitis and epidural abscess are uncommon causes of backache but may have a prediliction for patients with diabetes. We report four cases seen in a diabetic unit over 2 years to emphasize the importance of making a diagnosis as early as possible. We suggest that when a diabetic patient complains of backache the erythrocyte sedimentation rate should be measured since this is the best clue that backache is due to something other than a mechanical derangement.

Malignant lymphoma presenting with prominent splenomegaly. A clinicopathologic study with special reference to intermediate cell lymphoma

Although non-Hodgkin's lymphoma presenting with prominent splenomegaly is a well-recognized clinical syndrome, previous reports of such cases create confusion today because of the use of outdated pathologic classifications, awkward or inappropriate terms, and imprecise diagnostic criteria. The authors have studied 31 such cases and have classified them according to the modified Rappaport and Lukes-Collins classifications as well as the recently introduced International Working Formulation. Most of our cases (30/31) of malignant lymphoma presenting with prominent splenomegaly were of the small cell type, with morphologic and/or immunologic evidence of B-cell origin. The single largest subtype in our series (19/30) was intermediate lymphocytic lymphoma (IL), a recently described entity in which this mode of presentation has not been previously emphasized. Although such cases have been termed "primary splenic lymphoma," almost all are disseminated diseases that pursue a progressive course and require multiagent chemotherapy and/or radiotherapy.

Primary splenic presentation of malignant lymphoma and related disorders. A study of 49 cases

The diagnosis of malignant lymphoma presenting as an initial splenic manifestation may go unrecognized as such when peripheral lymph nodes are not enlarged and when results of bone marrow biopsies are negative. Tissues from 49 patients, ranging in age from 15 to 78 years, in whom the original diagnosis of malignant lymphoma and related conditions was made at splenectomy, were classified as: diffuse small lymphocytic (20), diffuse large cell (11), diffuse small cleaved (5), diffuse large cell, immunoblastic (5), follicular small cleaved cell (3), and follicular mixed small cell and large cell (2). Two additional spleens, diagnosed as acute blastic leukemia, were initially confused with malignant non-Hodgkin's lymphoma by light microscopy. One patient presented with Hodgkin's disease confined to the spleen. For the non-Hodgkin's lymphoma group, parameters of age, sex, splenic weight (range, 226-4000 g), lymph node, bone marrow, or liver involvement did not adversely influence prognosis. Abdominal lymph nodes were positive in 31 of 37 patients having splenic hilar and/or abdominal lymph nodes available for review. Of 29 patients with adequate follow-up, 7 died of disease, 5 were free of disease at 3 years, 2 were free of disease at 5 years, 2 were alive with disease at 3 years, 4 were alive with disease at 5 years, and 9 died from second malignancies, unknown, or unrelated causes. Six of the 7 patients who died of lymphoma were classified as large cell (four diffuse large cell and two diffuse large cell, immunoblastic), with a mean 2-year survival. One patient died of leukemia. Those lymphomas classified as low grade behaved in an indolent fashion. The morphologic diversity of these cases emphasizes the need for the initial recognition and correct classification of lymphomas which present in the spleen, since survival is best determined according to histologic type.

Splenic siderosis and parenteral iron dextran in maintenance haemodialysis patients

The histological features of 40 spleens surgically removed from maintenance haemodialysis patients are reported. Twenty-four of the 40 (60%) showed massive iron loading and a significant direct correlation was found between iron loading and the amount of intravenous iron dextran administered. Since parenteral iron dextran appears to be a major factor in causing iron overload in haemodialysis patients its use as a method of iron replacement in these patients would appear inappropriate.

Tropical splenomegaly syndrome (T.S.S.) in a European

A case of tropical splenomegaly syndrome in a 66-year-old white man who had lived in Tanzania for 34 years is described. He had taken anti-malarial prophylaxis continuously and regularly. He had had malaria in 1955 but there was no history of alcoholism or jaundice. He was treated with proguanil hydrochloride and, after return to Tanzania, took paludrine as prophylactic. One year later he had no further complaints, the spleen was no longer palpable and the liver only just palpable.

Non-tropical idiopathic splenomegaly (Dacie's syndrome): report of 5 cases

We describe 5 patients, aged 22-69 years, with massive splenomegaly of unknown origin an features of hypersplenism. Splenectomy corrected the cytopenia(s) and abolished the symptoms in each case; the histological features of the spleen were non-specific and included congestive changes and lymphoid hyperplasia. 2 of these patients developed non-Hodgkin's lymphoma (NHL) 2 and 6 years after spenectomy. A total of 46 cases of splenomegaly of unknown origin have been reported from UK, USA, and Australia so far, and in 9, NHL developed 8 to 80 months after splenectomy. The questions relating to the pathogenesis of splenomegaly and the subsequent development of NHL remain to be answered. We propose that this 'entity' be known as Dacie's syndrome, after Sir John Dacie who characterised it in 1969.

Primary splenic hairy cell leukemia--remission for 21 years following splenectomy

A patient with primary splenic hairy cell leukemia is reported. This patient presented with massive splenomegaly and pancytopenia due to hypersplenism. Exploratory laparotomy failed to demonstrate any disease outside the spleen and splenic hilar lymph nodes. Splenectomy was the only form of treatment. During the following 21 years, no recurrent hairy cell leukemia has been found. This case allows speculation that hairy cell leukemia may originate in the spleen and that prolonged survival or cure of the disease after splenectomy alone may be due to removal of stem cells in the spleen.

Splenectomy for undiagnosed splenomegaly

During the 9-year period 1968-76 116 splenectomies were performed at the General Hospital, Nottingham. Of these, 13 (11 per cent) were undertaken for unexplained splenomegaly. In 6 patients a diagnosis was established by the operative procedure (2 with sarcoidosis, 2 splenic cysts, 1 Gaucher's disease and 1 haemangiosarcoma). Histological examination of the excised spleens in the remaining 7 patients showed no specific features. Two of these patients benefited considerably from removal of very large spleens. Another patient died from lymphosarcoma which was diagnosed 21 months after splenectomy. In the remaining 4 patients with mild to moderate splenomegaly, there were no real diagnostic or therapeutic advantages. It is concluded that splenectomy should always be considered in patients with unexplained moderate or gross splenomegaly but it may not be helpful in the patient whose spleen is only midly enlarged.

Non-tropical 'idiopathic splenomegaly': a follow-up study of ten patients described in 1969

The later history is described of four of 10 patients who were reported in 1969 as suffering from non-tropical 'idiopathic splenomegaly'. Two of the four patients developed malignant lymphomas 6 years and 2 years, respectively, after splenectomy but the two other patients have lived for 17 and 15 years, respectively, without developing any signs of a malignant tumour. Thus, four of the original 10 patients have developed malignant's lymphomas. The histology of the patients' spleens has been reviewed in the light of their clinical history, but no criteria have been found which are of clear prognostic value. However, with hindsight it was possible to recognize some cytological abnormality in the spleens in three out of the four patients who developed malignant lymphomas, and it appears that unless the cell population in both the red and white pulp is strictly normal, the patient is likely to develop a malignant lymphoma. The tumours which subsequently developed showed no special or characteristic features. The title 'idiopathic splenomegaly' is clearly unsatisfactory but the alternative 'chronic lymphocytic lymphoma with hypersplenism', although appropriate for the illness of the patients who developed malignant lymphomas, is inappropriate for those in which the pathological process seems not to be neoplastic.