Splenic anomalies of shape, size, and location: pictorial essay

Spleen anomalies and lesions in CT and MRI: essentials for radiologists and clinicians-a pictorial review

The precise evaluation of splenic lesions using cross-sectional imaging presents a complex challenge due to the overlapping imaging characteristics of most splenic diseases and the absence of specific symptoms, complicating the diagnosis process. This pictorial review highlights the essential elements that should be included in a radiology report to interpret cross-sectional imaging studies of splenic lesions. To augment the diagnostic accuracy, we propose the implementation of a stepwise algorithmic approach. This approach offers a comprehensive analysis of splenic anomalies and lesions, providing an invaluable tool for radiologists and clinicians.

Rupture of an accessory spleen caused by blunt trauma

PURPOSE

The accessory spleen is quite a common abdominal anomaly. However, the traumatic accessory spleen rupture is an extremely rare condition requiring surgical intervention, even laparotomy. 9 cases of traumatic accessory spleen were found published between 1962 and 2022. The study aims to evaluate traumatic accessory spleen rupture cases regarding their causes, clinical course, and possible diagnosis without surgery and treatment.

METHODS

Desk research method using available online databases. Descriptive methods were employed to analyze the collected data. The results are summarized in the Table concerning gender, age, injury details, accessory spleen injury characteristics, treatment, and others such as previous splenectomy or primary spleen involvement in injury or accompanying abdominal injuries.

RESULTS

In total, there were 9 cases of traumatic accessory spleen, of which 2 were managed conservatively and the remaining 7 were treated operatively. All the patients survived. One-third of all included patients already had their primary spleen removed, which facilitated the diagnosis of traumatic rupture of an accessory spleen. The proper diagnosis of an accessory spleen rupture was concluded in 2 cases and confirmed in surgery.

CONCLUSION

The recognition of the traumatic rupture of an accessory spleen before surgery is challenging but can be made easier if the patient underwent splenectomy before. The traumatic accessory spleen rupture does not coexist with an injury of a primary spleen.

Atypically located accessory splenic hemangiosarcoma in a Dog: Diagnostic value of triple-phase computed tomography

A 10-year-old Cocker spaniel presented with lethargy. Triple-phase computed tomography was obtained with a contrast test bolus at the level of porta hepatis, which revealed a right lower abdominal mass. The mass was not connected to other abdominal organs; however, a linear structure was observed connecting the splenic hilum to the mass, which was suspected to be the feeding vessel. The arterial phase image was obtained again with a contrast bolus at the level of the celiac artery. A prominent contrast-enhanced feeding artery originating from the splenic artery to the mass was observed. Histopathology confirmed an accessory splenic hemangiosarcoma.

Intrapancreatic accessory spleens in African swine fever infection of wild boar (Sus scrofa)

Intrapancreatic accessory spleen (IPAS) is one of the most frequent congenital splenic anomalies in humans; however, studies in veterinary medicine are scarce. This study aimed to describe the macroscopic, histopathological and immunohistochemical features of 11 suspected cases of IPAS in wild boar piglets of 3-4 months old. Seven of the 11 animals were immunised with a low virulence isolate of African swine fever virus (ASFV) and subsequently challenged with a highly virulent ASFV isolate (LVI-HVI group). The remaining four animals were exclusively infected with a highly virulent isolate of ASFV (HVI group). Grossly, lesions comprised focal or multifocal reddish areas of variable shape, located on the surface of the pancreatic tail or within the parenchyma. Histological and immunohistochemical studies (anti-CD79 and CD3) confirmed the presence of IPAS in eight of the 11 cases. IPAS shared the same histological structure and alterations as those observed in the original spleen. The immunohistochemical study against ASFV revealed the presence of VP72+ cells in both the spleen and IPAS of seven of the eight piglets. The results of this study describe for the first time the presence of IPAS in ASFV infection of wild boar (Sus scrofa) regardless the isolate and suggest that the infection may induce the development of ectopic splenic tissue due to an increased demand for phagocytic cells from the reticuloendothelial system. However, further studies are needed to understand the immunological mechanisms that trigger the formation of these accessory organs.

Three-dimensional morphological analysis of the human spleen and its surrounding organs during the early fetal period

The spleen has variations in its morphology and is considered to acquire a defined shape in the third month of gestation. However, few studies have investigated spleen development during the first 3 months of fetal life. This study aimed to determine the three-dimensional (3D) morphogenesis of the spleen during the third month of gestation. In this study, 30 fetal specimens (crown-rump length [CRL]: 22-103 mm) were subjected to magnetic resonance imaging analysis. We manually segmented the spleen, stomach, and adrenal gland, reconstructed 3D models, and analyzed the volume and shape of these organs. The results showed that the variation in spleen size was large compared to that in other organs. Spleen morphology was classified into six types based on the number of splenic surfaces as follows: two-faced, three-faced, four-faced, five-faced, ovoid, and irregular. Two-faced spleens were only observed in small specimens, whereas three- and four-faced spleens were observed in larger specimens. We also revealed that the number of fetal splenic surfaces increased as CRL enlarged. Additionally, 3D models indicated that some specimens formed their splenic surfaces without contact with the adjacent organs. This suggested that the splenic surface may be caused not only by pressure from the faced organs but also by an intrinsic program. This study may provide a better understanding of the normal development of the spleen during the early fetal period, and may potentially assist future studies in investigating congenital morphological anomalies of the spleen.

Accessory Spleen Mimicking an Intrahepatic Neoplasm: A Rare Case Report

Accessory spleen and splenosis are two types of ectopic spleen. An accessory spleen can be found in various sites in the abdomen, but an intrahepatic accessory spleen is very rare though many case reports of intrahepatic splenosis are available. This case report presents the incidental diagnosis of accessory spleen in the liver of a 57-year-old male while undergoing laparoscopic diaphragmatic repair. The patient had a history of splenectomy 27 years ago for hereditary spherocytosis, but his routine haemogram did not show any features of the ectopic splenic function. Intraoperatively, a mass was suspected in the liver and was resected. Histopathology revealed an accessory spleen with well-preserved red and white pulp architecture. Though a history of splenectomy suggested a diagnosis of splenosis, a well-encapsulated and preserved splenic architecture confirmed the diagnosis of accessory spleen. Accessory spleen or splenosis can be diagnosed radiologically using Tc-99m-labeled heat-denatured red blood cells (HRBC) and Tc-99m sulfur colloid scans, but the gold standard is histopathological examination. Ectopic spleen is mostly asymptomatic but usually results in unnecessary surgeries as it is difficult to differentiate from benign or malignant tumors. Thus, a high degree of suspicion and awareness is necessary for early and prompt diagnosis.

Morphological variations of the human spleen: no evidence for a multifocal or lobulated developmental origin

OBJECTIVES

Adult spleens show extensive morphological variation, with a reported prevalence of 40-98% clefts (also called notches or fissures) on the splenic surface and 10-30% accessory spleens at autopsy. It is hypothesised that both anatomical variants result from a complete or partial failure of multiple splenic primordia to fuse to the main body. According to this hypothesis, fusion of the spleen primordia is completed after birth and spleen morphological variations are often explained as stagnation of spleen development at the foetal stage. We tested this hypothesis by studying early spleen development in embryos, and compared foetal and adult spleen morphology.

METHODS AND MATERIALS

We assessed 22 embryonic, 17 foetal and 90 adult spleens on the presence of clefts using histology, micro-CT and conventional post-mortem CT-scans, respectively.

RESULTS

The spleen primordium was observed as a single mesenchymal condensation in all embryonic specimens. The number of clefts varied from 0 to 6 in foetuses, compared to 0-5 in adults. We found no correlation between foetal age and number of clefts (R² = 0.004). The independent samples Kolmogorov-Smirnov test showed no significant difference in the total number of clefts between adult and foetal spleens (p = 0.068).

CONCLUSION

We found no morphological evidence for a multifocal origin or a lobulated developmental stage of the human spleen.

ADVANCES IN KNOWLEDGE

Our findings show that splenic morphology is highly variable, independent of developmental stage and age. We suggest to abandon the term "persistent foetal lobulation" and to regard splenic clefts, regardless of their number or location, as normal variants.

Pancreatic Cystic Lesions: A Focused Review on Cyst Clinicopathological Features and Advanced Diagnostics

Macroscopic, endomicroscopic, and histologic findings and correlation are an integral part of the diagnostic evaluation of pancreatic cystic lesions (PCLs), as complementing morphologic features seen by different specialties are combined to contribute to a final diagnosis. However, malignancy risk stratification of PCLs with worrisome features can still be challenging even after endoscopic ultrasound guided-fine needle aspiration (EUS-FNA) with cytological evaluation. This review aims to summarize cyst clinicopathological features from the pathologists' perspective, coupled with knowledge from advanced diagnostics-confocal laser endomicroscopy and cyst fluid molecular analysis, to demonstrate the state-of-art risk stratification of PCLs. This review includes illustrative photos of surgical specimens, endomicroscopic and histologic images, and a summary of cyst fluid molecular markers.

Splenunculus mimicking splenomegaly in a patient with synchronous herpes simplex 1 viremia and myelosuppression

Splenunculus, or congenital accessory spleen, is a benign anatomical variation, and is rarely of clinical consideration in routine clinical practice. We describe a patient who presented with synchronous herpes simplex 1 viraemia and myelosuppression, with a splenunculus mimicking splenomegaly, and we discuss the implications on clinical practice, investigations, and management.

Case report: Misdiagnosis of accessory spleen in the left adrenal region as an adrenal tumour after splenectomy

Background

Adrenal tumours are common in urology and endocrinology, and the diagnosis of adrenal tumours were mainly depends on imaging diagnosis. Howerver, misdiagnosis can still occur for some adrenal space-occupying lesions without specific manifestations or abnormal biochemical indexes.

Methods

We report the case of a 55-year-old patient with a soft-tissue mass in the left adrenal region, and have no specific manifestations or abnormalities in biochemical indexes. The patient had undergone open splenectomy 20 years ago for splenic rupture caused by traffic-accident trauma, and had a 10-year special history of hypertension. Because of the uncertain nature of the mass, surgical treatment was recommended.

Results

The surgeon managed to remove the left adrenal region mass. During the surgery, the adrenal source was excluded. In the histological examination, the splenic corpuscle and splenic medullary structure were seen under the microscope, and an accessory spleen was diagnosed.

Conclusions

The accessory spleen was located in the adrenal region rarely, and can easily be misdiagnosed as an adrenal tumour. When the cases show abnormal adrenal space-occupying lesions in imaging examinations, non-adrenal diseases should be considered. we need to combine different imaging techniques for analysis, and think more about it, avoid misdiagnosis leading to unnecessary surgery.

Accessory spleen presenting with an episode of acute appendicitis; a case report of a very rare case

Introduction

The accessory spleen (AS) is a condition that results from improper placement of spleen cells. About 95 % of ASs are located in the splenic hilum proximal to the tail of the pancreas. Here we present a 23-year-old male diagnosed with AS in the appendix, following an episode of acute appendicitis.

Case presentation

A 23-year-old male patient who presented with typical symptoms of appendicitis and the examination and paraclinical findings were in favor of appendicitis. Intraoperative findings showed an inflamed appendix and a 2 cm solid mass in the mesoappendix. The pathology report showed acute appendicitis and normal spleen tissue.

Conclusion

The current study indicated an abnormal location of AS placed in the mesoappendix, which was presented with an episode of acute appendicitis.

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The accessory spleen (AS) is a condition that results from improper placement of spleen cells.

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About 95% of ASs are located in the splenic hilum proximal to the tail of the pancreas.

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The remaining 5% are formed in the gastrosplenic ligament, wall of the stomach, wall of the intestine, and the mesentery or pelvic cavity

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The current study indicated an abnormal location of AS placed in the mesoappendix, which was presented with an episode of acute appendicitis

Ectopic lesions in the abdomen and pelvis: a multimodality pictorial review

Various ectopic lesions occur in the abdomen and pelvis and affect multiple organs including liver, gallbladder, pancreas, spleen, and organs of the genitourinary system. Ectopic organs may be present outside their normal positions, or ectopic tissues may develop while the original organ exists in its normal position. Both benign and malignant lesions can occur in ectopic organs and tissues. Owing to their unusual location, they can often be misdiagnosed as other lesions or even malignant lesions, such as metastasis or seeding. This multimodality pictorial review provides various cases of ectopic lesions in the abdomen and pelvis, which will help narrow the differential diagnosis and guide clinical decision-making.

Abdominal and pelvic splenosis: atypical findings, pitfalls, and mimics

Splenosis is an acquired form of ectopic splenic tissue that typically arises after trauma or splenectomy. It is often an incidental image finding in an otherwise asymptomatic patient, but the spectrum of symptoms varies based on the site of implantation. Radiologists should be familiar with the imaging features of splenosis to avoid mistaking it for malignancy. Splenosis has identical imaging features to that of the native spleen on US, CT, MRI, and nuclear medicine examinations. Therefore, when the radiologic findings support the diagnosis of splenosis, the patient can be spared invasive procedures for tissue sampling.

Chronic splenic torsion in a dog with an accessory spleen

A 4-year-old, neutered male, mixed breed Old English sheepdog was presented for evaluation and treatment of anorexia, vomiting, and diarrhea. Presumptive severe pancreatitis was diagnosed based on the referral bloodwork. Abdominal ultrasonography identified a suspected liver lobe torsion based on the presence of a normal spleen. However, an exploratory laparotomy identified a splenic torsion in addition to a grossly normal spleen. Key clinical message: This case demonstrates that a second, potentially large area of splenic tissue (ectopic or accessory) can be present in the dog; therefore, the presence of a normal appearing spleen on abdominal ultrasonography does not rule out splenic torsion.

Acute Abdominal Pain due to Accessory Splenic Infarction in an Adult: A Case Report

Accessory spleens are common congenital anatomic variations that are usually asymptomatic. On the other hand, they can be clinically significant if complicated by hemorrhage, torsion, or infarction. This paper describes a case of an infarcted accessory spleen in a 30-year-old male who presented with abdominal pain. Abdominal CT and MRI revealed an isolated mass, 4.5 cm in size, in the perisplenic area. An infarcted accessory spleen was suspected. The patient underwent laparoscopic accessory splenectomy. Histopathology identified the mass as splenic tissue that had undergone ischemic necrosis. A definitive diagnosis of an infarcted accessory spleen was made, and the patient was discharged on day 5 after surgery symptom-free.

Intraperitoneal splenosis mimics peritoneal carcinomatosis of leiomyosarcoma and ovarian cancer

OBJECTIVE

Leiomyosarcoma and ovarian cancer are often diagnosed late due to the absence of initial symptoms. Patients seek help when abdominal distension occurs; this is associated with pelvic tumor and carcinomatosis. Initial imaging often reveals pelvic tumors with diffuse abdominal nodules; however, this imaging could be misleading, such as in the cases of splenosis.

CASE REPORT

A female presented with vaginal bleeding at our outpatient department. Serum CA125 level was elevated. Abdominal and pelvic CT showed multiple uterine masses and left adnexal cysts with peritoneal nodules. Leiomyosarcoma or ovarian cancer with carcinomatosis was suspected. Exploratory laparotomy was performed. Multiple purple spots spreading over peritoneal cavity were noted during the surgery. Pathological examination revealed adenomyosis with multiple uterine myomas and left ovarian endometrioma. Splenic tissues peritoneal implants were observed.

CONCLUSION

In patients with a history of spleen rupture or splenectomy, splenosis should be considered in the differential diagnosis, especially in young patients.

Intrapancreatic Accessory Spleen Diagnosed As Neuroendocrine Tumor: The Dangers of False Positives and Their Implications in Subsequent Management

This case serves as a reminder to consider ectopic splenic tissue in the differential diagnosis of pancreatic masses. The literature shows a lack of awareness and overtreatment of this condition due to clinical and radiologic concern for malignancy, namely neuroendocrine tumors (NETs) identified on positron emission tomography (PET)-CT NETSPOT. Given the vast difference in management and prognosis of ectopic splenic anomalies and malignant neoplasms involving the pancreas, accurate diagnosis is imperative to avoid unnecessary invasive procedures such as Whipple or distal pancreatectomy and splenectomy, which are associated with increased morbidity and mortality.

Accessory spleen originating from the intrinsic muscularis of the stomach misdiagnosed as gastrointestinal stromal tumor: a case report

A 34-year-old man presented to our hospital with a 2-month history of repeated dull upper abdominal pain. Gastroscopy and endoscopic ultrasonography indicated a hemispherical mass at the junction of the greater curvature and the gastric fundus, with hypoechogenicity originating from the intrinsic muscular layer. He was diagnosed with a gastric body submucosal lesion and gastrointestinal stromal tumor, and underwent endoscopic full-thickness resection. However, postoperative pathological examination of the mass unexpectedly revealed heterotopic spleen tissue (accessory spleen). Intragastric ectopic spleen tissue originating from the intrinsic muscular layer of the stomach is a rare clinical condition, with no specific clinical symptoms. This finding is of great clinical significance for the identification of gastric submucosal tumors.

A plea for extension of the anatomical nomenclature: Vessels

This article is the fourth and last part of a series aimed at extending and correcting the anatomical nomenclature. Because of the rapid development of internet and the use of electronic formats in communication in anatomy, embryology, histology, medical education, and clinical medicine, an appropriate, precise, and concise anatomical nomenclature is required. Such tool enables to avoid any potential confusion and possible scientific/medical mistakes. The up-to-date official anatomical terminology, Terminologia Anatomica, is available longer than 20 years and needs to be refined and extended. The authors have collected and listed 210 terms and completed them with definitions and/or explanations. We aimed to start a discussion about their potential incorporation into the new revised version of the Terminologia Anatomica. This article is primarily focused on the vessels of the human body (arteries, veins, and lymphatic system).

Revisiting the Spleen—An Imaging Review of the Common and Uncommon Splenic Pathology

The spleen is the largest lymphatic organ and is responsible for both hematological and immunological functions. Several common etiologies such as trauma, developmental variants, infectious/inflammatory conditions, and benign and malignant lesions can occur in the spleen. The role of imaging modalities such as ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) in diagnosing these conditions continues to evolve. The main objective of this review article is to illustrate the role of imaging in identifying the common and uncommon pathology of the spleen.

Impact of PET data driven respiratory motion correction and BSREM reconstruction of 68Ga-DOTATATE PET/CT for differentiating neuroendocrine tumors (NET) and intrapancreatic accessory spleens (IPAS)

To evaluate whether quantitative PET parameters of motion-corrected ⁶⁸Ga-DOTATATE PET/CT can differentiate between intrapancreatic accessory spleens (IPAS) and pancreatic neuroendocrine tumor (pNET). A total of 498 consecutive patients with neuroendocrine tumors (NET) who underwent ⁶⁸Ga-DOTATATE PET/CT between March 2017 and July 2019 were retrospectively analyzed. Subjects with accessory spleens (n = 43, thereof 7 IPAS) and pNET (n = 9) were included, resulting in a total of 45 scans. PET images were reconstructed using ordered-subsets expectation maximization (OSEM) and a fully convergent iterative image reconstruction algorithm with β-values of 1000 (BSREM₁₀₀₀). A data-driven gating (DDG) technique (MOTIONFREE, GE Healthcare) was applied to extract respiratory triggers and use them for PET motion correction within both reconstructions. PET parameters among different samples were compared using non-parametric tests. Receiver operating characteristics (ROC) analyzed the ability of PET parameters to differentiate IPAS and pNETs. SUVmax was able to distinguish pNET from accessory spleens and IPAs in BSREM₁₀₀₀ reconstructions (p < 0.05). This result was more reliable using DDG-based motion correction (p < 0.003) and was achieved in both OSEM and BSREM₁₀₀₀ reconstructions. For differentiating accessory spleens and pNETs with specificity 100%, the ROC analysis yielded an AUC of 0.742 (sensitivity 56%)/0.765 (sensitivity 56%)/0.846 (sensitivity 62%)/0.840 (sensitivity 63%) for SUVmax 36.7/41.9/36.9/41.7 in OSEM/BSREM₁₀₀₀/OSEM + DDG/BSREM₁₀₀₀ + DDG, respectively. BSREM₁₀₀₀ + DDG can accurately differentiate pNET from accessory spleen. Both BSREM₁₀₀₀ and DDG lead to a significant SUV increase compared to OSEM and non-motion-corrected data.

Surgical Approach of Wandering Spleen in Infants and Children: A Systematic Review

Introduction: Splenopexy has been proposed as the treatment of choice in case of wandering spleen (WS). We report our experience and review the current literature focusing on surgical management and outcomes of children affected by WS. Materials and Methods: Data regarding demographics, clinical manifestations, diagnosis, and treatment of children treated for WS at our Institution were analyzed. Systematic review was registered on Prospero (CRD42018089971). Scientific databases were searched using defined keywords. Articles were selected using predefined exclusion and inclusion criteria. Analysis was conducted adding our center's cases. Results: One hundred sixty-six articles were included in the review, 197 cases were analyzed, 3 of which unpublished. Female/male ratio was 1.5:1 and median age at diagnosis was 8 years. Most frequent clinical manifestation was isolated abdominal pain (42.6%). Torsion of splenic pedicle was diagnosed in 56.3%. Among surgical procedures, 39% underwent splenopexy and 54.8% underwent splenectomy. In case of splenopexy, the most commonly used techniques were using of a mesh (45.5%) or creation of a retroperitoneal pouch (30.9%). In 48.2% of splenopexies, minimally invasive surgery (MIS) was used. Splenopexy was effective in 94.8% (88% considering only cases with a spleen torsion). Conclusion: WS is a rare condition potentially leading to torsion of the spleen. This entity has to be kept in mind as a differential diagnosis in case of abdominal pain. Splenopexy should be the treatment of choice; its success rate in terms of preserved spleens can be affected by the presence of a torted organ. Retroperitoneal pouch or mesh fixation are the most preferred techniques. Authors recommend MIS approach.

A Cadaveric Study of Splenic Fissures and Bilobed Spleen

Objectives

Anatomical knowledge regarding the external morphology of the spleen is essential for surgical intervention and radiological diagnosis. A characteristic feature of the spleen is the presence of splenic notches at the superior border; however, such notches rarely extend deep enough to be considered fissures or to separate the spleen into multiple lobes. To date, there are very few cadaveric reports of splenic fissures. This study aimed to examine the anatomy and morphological structure of spleens collected from cadavers in order to identify the prevalence and clinical significance of splenic notches, fissures and lobation.

Methods

This study was conducted at the Department of Anatomy, Katuri Medical College and Hospital, Guntur, Andhra Pradesh, India. A total of 50 spleens were collected from cadavers over a period of seven years from 2012-2019 and examined to determine the presence of splenic notches or fissures.

Results

Of the 50 spleens, 40% had notches at the superior border, 10% had notches at the inferior border and 50% had no notches at either border. Fissures were present in five spleens (10%); of these, three showed incomplete fissures and the remaining two had complete fissures that divided the spleen into two lobes.

Conclusion

The findings of this study provide valuable information regarding the anatomy and prevalence of splenic fissures and bilobed spleens. A bilobed spleen is a rare congenital malformation which should be considered distinct from other known splenic anomalies. The presence of splenic fissures in bilobed spleens can serve as a guide for surgeons during conservatory splenectomy procedures.

Spleno-adrenal fusion mimicking an adrenal metastasis of a renal cell carcinoma: A case report and embryological background

Foci of splenic tissue separated from the spleen can occur as a congenital anomaly. Isolated nodules of splenic tissue are called accessory spleens or spleniculli. However, nodules of splenic tissue can merge with other organs during embryonic development, in which case we speak of spleno-visceral fusions: most often, they merge with the tail of the pancreas (thus forming spleno-pancreatic fusion or an intrapancreatic accessory spleen), with the reproductive gland (i.e., spleno-gonadal fusion), or with the kidney (i.e., spleno-renal fusion). Our case report describes the fusion of heterotopic splenic tissue with the right adrenal gland, which was misinterpreted as a metastasis of a renal cell carcinoma. To the best of our knowledge, this is the first reported case of spleno-adrenal fusion. Spleno-visceral fusions usually represent asymptomatic conditions; their main clinical significance lies in the confusion they cause and its misinterpretation as tumors of other organs. We believe that the cause of retroperitoneal spleno-visceral fusions is the anomalous migration of splenic cells along the dorsal mesentery to the urogenital ridge, together with primitive germ cells, at the end of the fifth week and during the sixth week of embryonic age. This theory explains the possible origin of spleno-visceral fusions, their different frequency of occurrence, and the predominance of findings on the left side.

Spleen in the thorax: A case report on traumatic diaphragmatic rupture

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Diaphragmatic rupture is a rare complication of abdominal trauma.

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Herniation of abdominal contents can occur following diaphragmatic rupture.

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Spleen was present in the thorax in a case following blunt abdominal trauma.

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Care should be taken when inserting a chest tube in suspected cases.

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Treatment is surgical via Laparotomy or Thoracotomy.

Introduction

Most of the cases of diaphragmatic rupture occur following abdominal trauma and herniation of abdominal organs into the thorax can occur.

Presentation of case

Twenty three years old male presented after a blunt abdominal trauma following a road traffic accident. Investigations revealed a left sided diaphragmatic rupture with herniation of spleen and stomach into the left hemithorax. Surgical repair of the defect was done and splenectomy had to be done due to extensive splenic laceration. Two third of the spleen was found in the left hemithorax.

Discussion

Diagnosis of diaphragmatic rupture can be missed in cases of polytrauma. High clinical suspicion with aids from imaging modalities help in the diagnosis. In suspicion of herniation of abdominal contents into the thorax, one should be careful in insertion of chest tube in view of damaging the herniated organs. Treatment is surgical repair and reduction of herniated contents.

Conclusion

Although a rare entity, diaphragmatic rupture can occur in cases of abdominal trauma. High clinical suspicion with imaging helps in the diagnosis.

Splenic volvulus of a wandering spleen

BACKGROUND

Wandering spleen is a rare condition in which the spleen is not anchored properly, due to congenital or acquired weakness of the splenic ligaments. This allows the spleen to migrate to any portion of the abdomen or pelvis, and can cause complications, including a splenic volvulus. The presentation of splenic volvulus of a wandering spleen ranges from mild pain to a surgical emergency. Splenic volvulus of a wandering spleen can cause significant morbidity and mortality, and often warrants surgical intervention. Cases of splenic volvulus of a wandering spleen have been reported in radiology and surgery literature, however there are no reports in emergency medicine literature in North America.

CASE REPORT

A 37-year-old female presented to the ED with seven days of mild left upper quadrant abdominal pain that acutely worsened. She underwent laboratory studies which were near her baseline values. A CT abdomen pelvis demonstrated findings consistent with splenic volvulus of a wandering spleen. She was taken emergently to the operating room for exploratory laparotomy, detorsion of spleen, and splenectomy. Her postoperative course was uneventful and she was discharged on hospital day six. Splenic volvulus of a wandering spleen is rare, though carries significant morbidity and mortality, especially if unrecognized. The presentation of splenic volvulus is variable, ranging from minor symptoms to an acute abdomen. Early diagnosis can prevent downstream complications, including development of vascular congestion, ischemia or infarcted intra-abdominal organs. Emergency Physicians should consider splenic volvulus in the differential diagnosis as an etiology of left-sided abdominal pain.

SPECT/CT with 99mTc labelled heat-denatured erythrocyte to detect thoracic and abdominal splenosis

Scintigraphy with ^99mTc labelled heat-denatured erythrocyte (DRBC) allows non invasive diagnosis of heterotopic splenic tissue implantation (splenosis) following splenic trauma or surgery. Single-photon emission computed tomography (SPECT) combined with computed tomography (CT) improves diagnostic accuracy of planar imaging through a more precise localization of functional findings. We report about two cases of splenosis occurring many years after splenectomy. ^99MTc-DCRBC scintigraphy was used for differential diagnosis of metastatic disease in one case and to assess an incidental finding at bone scan in the second one. SPECT/CT increased specificity of planar imaging, expecially revealing combined (thoracic and abdominal) splenosis. (www.actabiomedica.it)

Splenomegaly Negatively Impacts Neutrophil Engraftment in Cord Blood Transplantation

Delayed neutrophil engraftment (NE) has been reported in cord blood transplantation (CBT) compared with other stem cell transplantation methods. The numbers of total nucleated cells (TNCs), CD34⁺ cells (generally ≥ 1 × 10⁵/kg), and granulocyte/macrophage colony-forming units (CFU-GM) significantly impact NE. Splenomegaly exerts negative effects on NE, but the appropriate cell dose for the patients with splenomegaly has not yet been determined, especially in CBT. We retrospectively investigated the effect of splenomegaly and number of CD34⁺ cells infused on NE through the analysis of outcomes of 502 consecutive patients who underwent single CBT for the first time at Toranomon Hospital between 2011 and 2018. Spleen index, L_max × H_vert (SI L_max × H_vert), was defined as maximal length at any transverse section, (L_max) × vertical height (H_vert), and splenomegaly was defined as SI L_max × H_vert ≥ 115 cm². Our results show that splenomegaly (hazard ratio [HR], .60; P < .01) and low dose of infused CD34⁺ cells (HR, .58; P < .01) had significant negative impact on NE, whereas neither CFU-GM dose nor TNC dose had any impact on NE in multivariate analysis. Other factors with a significant negative impact on NE in multivariate analysis were myeloid disease (HR, .62; P < .01), nonremission status at CBT (HR, .71; P < .01), low Eastern Cooperative Oncology Group Performance Status (HR, .68; P < .01), and graft-versus-host disease prophylaxis (other than tacrolimus alone) (HR, .76; P < .01). Without splenomegaly, even patients infused with < .8 × 10⁵/kg CD34⁺ cells achieved up to 94.3% NE, with the median value observed at 21 days post-CBT. This study shows that splenomegaly has a significant negative impact on NE after CBT. Cord blood units with < .8 × 10⁵/kg CD34⁺ cells may still be a suitable choice for patients without splenomegaly.

Torsion of an Accessory Spleen in a Child With Biliary Atresia Splenic Malformation Syndrome

Torsion of an accessory spleen is an exceedingly rare cause of abdominal pain in pediatric patients. The diagnosis is frequently challenging as presentation is variable and diagnostic imaging can be aspecific. The current case describes an unusual presentation of a torted accessory spleen in a 5-year-old girl with biliary atresia splenic malformation syndrome who initially presented with non-specific abdominal symptoms and fever. The diagnosis was made following fine-needle aspiration of a suspected intraabdominal abscess. The case highlights the diagnostic challenge of accessory splenic torsion and stresses the importance of its inclusion on the differential diagnosis of pediatric patients, especially those with known splenic or laterality abnormalities, presenting with both acute and sub-acute abdominal symptoms.

Reappraisal of the classical abdominal anatomical landmarks using in vivo computerized tomography imaging

INTRODUCTION

With expanding scope of interventions it becomes mandatory to have correct and evidence-based knowledge of surface anatomy of internal abdominal structures. Information available in text books is derived from work done on cadaveric studies. Current study was designed to provide data of key abdominal surface anatomical landmarks and their variations in living subjects using CT imaging of adult population.

MATERIALS AND METHODS

Cross-sectional study was conducted using 100 abdominopelvic CT scans of patients of Indian origin.

RESULTS

Vertebral levels of origin of celiac trunk varied from T11 to L1/2 intervertebral disc, superior mesenteric artery from T12 to L2, inferior mesenteric artery from L2 to L4 and aortic bifurcation from L3 to L5. Origin of both renal arteries varied between T12 and L2 and the formation of inferior vena cava varied from L3 to L5. Vertebral levels of upper pole of both kidneys ranged from T11 to upper L3. Spleen was related to 9th to 11th ribs in 36% and 10th to 12th ribs in 34% scans. Most common vertebral levels of subcostal plane, planum supracristale and planum intertuberculare noticed were lower L2, L4 and lower L5, respectively.

CONCLUSIONS

Data derived from imaging investigations of living subjects and variations from the conventional descriptions observed in the current study might be helpful for clinicians.

A Multinodular Mass of Abdominal Splenosis: Case Report of Uncommon Images of a Rare Disease

Splenosis is a rare disease which typically forms single or multiple round masses. A 45-year-old male was referred for investigation of an abdominal mass. He had a history of splenic injury from a traffic accident at age 19. Contrast-enhanced computed tomography showed a well-enhanced, multi-nodular mass lesion, 3.5 cm in size, located below the stomach. An endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) for the mass was inconclusive. A surgery was performed, and pathology of the resected mass confirmed splenosis. Clinicians must bear in mind the possibility of occurrence of splenosis after splenic trauma and its image variations.

A Rare Case of Spontaneous Hemorrhage in a Giant Accessory Spleen in a Child

Accessory spleen (AS) is a condition found in about 20% of patients and is most commonly located in the hilar region of the spleen. It is more often asymptomatic, single, and smaller than 2 cm. In the present study, we report the rare case of a 13-year-old boy with giant accessory spleen underwent spontaneous intrasplenic hemorrhage who presented with recurrent abdominal pain. Contrast-enhanced MRI was mandatory for the diagnosis before surgical procedure.

Ultrasonography of the pediatric spleen: a pictorial essay

In infants and children, the spleen is involved in many pathological processes, whether those processes are isolated or related to systemic diseases. Pathology of the pediatric spleen includes congenital anomalies, splenomegaly, trauma, focal lesions, infarction, and tumors. Ultrasonography (US) is a widely available, fast, noninvasive imaging technique to assess the size, shape, and position of the spleen, as well as to define splenic echotexture. US is capable of screening for splenic disorders without the risk of ionizing radiation; it is the initial imaging examination performed to evaluate suspected splenic pathology, providing clinicians with helpful decisional support. US plays an important role in the detection of even very small amounts of hemoperitoneum, a herald of significant abdominal organ injury, in pediatric blunt abdominal trauma. Moreover, contrast-enhanced US may allow early detection of splenic injuries, ideally minimizing children's risk from radiation exposure. This pictorial essay illustrates the normal ultrasound appearance of the pediatric spleen and the sonographic findings which may guide clinicians to a correct diagnosis of pathologic conditions.

Infarcted accessory spleen masquerading as a mesenteric cyst

An accessory spleen is a rare entity which is usually asymptomatic. When symptomatic, it presents as an acute abdomen, with either torsion, rupture or haemorrhage. We present the case of a 20-year-old man who presented with chronic lower abdominal pain since 3 months and a lump in the left lower quadrant. On clinical examination and investigations, the lump was diagnosed as a mesenteric cyst, and an uncomplicated laparoscopic excision was performed. The postoperative histopathological examination reported it as an infarcted accessory spleen.

Intrapancreatic accessory spleen in a harbor porpoise (Phocoena phocoena)

The occurrence of accessory spleens in cetacean species is high yet confirmed reports of intrapancreatic accessory spleen, a congenital malformation, remain undescribed. The current study provides the gross, microscopical, histochemical and immunohistochemical features of an intrapancreatic accessory spleen in a harbor porpoise (Phocoena phocoena). Grossly, a 17 × 18 × 9 mm well-demarcated, dark brown to red mass expanded the left pancreatic lobe. Microscopically, this mass consisted of mature splenic tissue interspersed with exocrine pancreatic acini. Intrapancreatic accessory spleens should be considered in the list of differential diagnoses for intrapancreatic nodular lesions in cetaceans.

Renal Pseudo-tumor Related to Renal Splenosis: Imaging Features

OBJECTIVE

To report the case of a 29-year-old patient presenting with renal splenosis along with a complete review of literature on this condition. Splenosis is a frequent condition following abdominal trauma or splenectomy, described as splenic tissue that autotransplants into a heterotopic location. However, renal splenosis is rare and often mistaken with renal carcinoma.

MATERIALS AND METHODS

The patient was initially referred to our department for a renal mass incidentally discovered on ultrasound. Further investigation included with computed tomography and magnetic resonance imaging.

RESULTS

Imaging features revealed a well circumscribed solid renal mass, exhibiting an isosignal on T1- and T2-weighted sequences in comparison with the renal cortex. The mass exhibited a heterogeneous enhancement on the arterial and portal phases, homogeneous patterns during the delayed phases, and high signal intensity on diffusion-weighted images. A partial nephrectomy was performed and pathological examination revealed the final diagnosis of renal splenosis.

CONCLUSION

Imaging features alone do not provide a definitive diagnosis of splenosis but suggestive past history associated with imaging findings consistent with splenic tissue should lead to ^99m technetium-sulfur colloid scanning or ferumoxid-enhanced MRI to avoid useless surgery.

A unique case of bilateral ovarian splenosis and review of the literature

Splenosis is an acquired anomaly related to heterotopic auto-transplantation of splenic tissue following abdominal trauma or splenectomy. We report the first definitive bilateral ovarian case in a 65-year-old woman who underwent splenectomy following a motor vehicle accident 44 years prior to presentation. We review the literature and discuss the main differential diagnoses. Gross examination revealed a 1-cm well-circumscribed dark nodule on the surface of each ovary. Paraffin-embedded, formalin-fixed blocks were sectioned and stained with hematoxylin-eosin and immunostains (CK5/6, Calretinin, WT1, Vimentin). The histological presence of both red and white splenic pulp, delimitation from ovarian tissue and ovarian origin of blood supply, as well as medical history, led us to the correct diagnosis. The outer nodular surface was covered by mesothelium (WT1+, CK5/6+, Calretinin+, Vimentin+), which was in continuity with the ovarian surface epithelium. To our knowledge, only six previous cases of ovarian splenosis are reported. Our patient is the oldest, with a very long interval from splenectomy to presentation. Clinically, splenosis may mimic malignancy, and a correct diagnosis avoids unnecessary overtreatment. The differential diagnosis includes an accessory spleen, spleno-gonadal fusion, and splenic hamartoma: they should be excluded to come to the correct diagnosis.

Accessory Spleen in the Splenic Hilum: a Cadaveric Study with Clinical Significance

Aim:

An accessory spleen is an additional tissue of the spleen that may be found near the spleen. It is a congenital anomaly of the spleen that its incidence has been reported 10-30% of the population. Hence, the objective of this study was evaluation the incidence of accessory spleen in Iranian cadavers.

Method:

Sixty hundred and ninety three spleens (541 males, 152 females) were excised from cadavers in the dissection hall of Mashhad Forensic Medicine Organization cadavers. Inclusion criteria were as follows: Fresh Iranian cadavers with no history of alcohol, poisoning or drug abuse, and no evidence of pathologic abnormality or injury to the spleen. The presence of accessory spleens, its dimension and weight investigated in cadavers.

Results:

During routine postmortem examination, five cases with an accessory spleen were found in the autopsy laboratory of Mashhad legal Medicine Organization between June 2014 and July 2015. Of the cases, 3 were male and 2 were female. The accessory spleens were observed at the splenic hilum. The length of the accessory spleens ranged from 2-3.5 cm, while the range of width was between 0.5 and 2.5 cm. The accessory spleens were confirmed by histological examination.

Conclusion:

An accessory spleen has clinical importance in some locations. When an accessory spleen is situated in another site, it may mimic some tumors such as pancreatic tumor and adrenal tumor. In addition, accessory spleen may cause hyperplasia after splenectomy and be responsible for a recurrence of the hematological disorders.

MR imaging findings of a patient with isolated intrahepatic splenosis mistaken for hepatocellular carcinoma

Splenosis refers to the autotransplantation of splenic tissue throughout different anatomic compartments secondary to trauma or splenic surgery. The liver is an uncommon location for splenic implants and imaging findings are often described as non-specific. We report MRI findings of a patient with a large liver mass that was first diagnosed as a malignant tumour but histopathology revealed that it was actually intrahepatic splenosis. The signal characteristics of this mass were low intensity on T₁ and high intensity on T₂ weighted images; arterial enhancement, which became more homogeneous in the later phases; and a relative hypointensity on the delayed phase images. Because a high level of awareness is necessary for making a correct diagnosis of this condition, one should consider the possibility of intrahepatic splenosis in a patient with a history of abdominal trauma or splenic surgery.

Laparoscopic transperitoneal left adrenalectomy and wandering spleen risk

Background and Objectives:

Laparoscopic transperitoneal left adrenalectomy (LTLA) has become the standard treatment for adrenal masses <6 cm. LTLA involves the dissection of splenic suspensory ligaments, which replicates their congenital absence or weakening, present in cases of wandering spleen (WS). WS is a rare condition in which the spleen migrates from the left upper quadrant to a more caudal location in the abdomen. A unique case of WS after LTLA was described by Corcione et al. In this prospective study, we investigated the possibility of WS as a consequence of LTLA.

Methods:

Twenty-four patients, 8 men and 16 women, who underwent LTLA with the dissection of splenoparietal and splenorenal ligaments were selected.

Results:

Clinical and ultrasonographic follow-up showed no evidence of postoperative WS.

Conclusions:

In the literature, WS is not commonly reported as a postoperative complication of LTLA. In effect, especially in the case of small adrenal masses, the spleen's repositioning in its seat is autonomous. However, the alarming possibility of WS should not be ignored, especially in the case of extensive dissection of the left colic flexure. It would be useful for other authors to signal this complication, so that different approaches and consequent results may be compared.