Management of intrahepatic splenosis:a case report and review of the literature

Hepatic Splenosis: A Rare Entity and Great Mimicker

Splenosis is a benign and rare condition that is usually caused by trauma or splenectomy or other procedures involving splenic tissue. The patient is usually asymptomatic and often diagnosed incidentally especially when presents as intrahepatic lesion, can be misdiagnosed as neoplasm. Here, we present case report of a 56-year-old male patient, who was incidentally detected to have focal liver lesion on routine ultrasound check up. He was further evaluated with computed tomography (CT) and magnetic resonance imaging (MRI) and the lesion was indistinguishable from neoplastic lesions and misdiagnosed to be hepatic adenoma. Retrospectively analyzing, the patient had history of splenectomy following road traffic accident 10 years before the present presentation. Following laparotomy, the liver lesion was resected and histopathology confirmed the diagnosis of hepatic splenosis. In this case report and review, we present the diagnostic features and the criteria that help in the diagnosis of splenosis which is a great mimicker.

Application of multimodal imaging in the diagnosis of intrahepatic splenosis: Two case reports and a literature review

Intrahepatic splenosis is quite rare and is often misdiagnosed as other lesions. We present two cases of intrahepatic splenosis examined with hepatobiliary contrast agents, intravoxel incoherent motion diffusion-weighted imaging and magnetic resonance elastography. We discuss various imaging modalities and the roles of various magnetic resonance imaging methods in diagnosis. We also discuss the differentiating features that allow the correct diagnosis to be made and provide a brief review of the literature.

Splenosis masquerading as gastric stromal tumor: A case report

BACKGROUND

Splenosis is a rare benign disease that often disguises itself as a malignant tumor. There are few articles providing a comprehensive description of splenosis, especially cases located in the stomach being treated by laparoscopic surgery.

CASE SUMMARY

A 44-year-old man presented with recurrent upper abdominal pain for more than half a year. The patient had splenic rupture caused by trauma more than 10 years ago and underwent splenectomy. An abdominal contrast-enhanced computed tomography scan revealed an irregular soft tissue density. Gastroscopy revealed an approximately 3.0 cm × 3.0 cm mucosal eminence at the posterior wall of the upper segment of the gastric body. Biopsy was not performed since the lesion was found under the mucosa and the gastric mucosa appeared normal. According to these findings, a diagnosis of gastric stromal tumor was made, although a definitive differential diagnosis was not known before surgery. When laparoscopic resection of the gastric stromal tumor was performed, an astonishing finding was made when postoperative pathology showed that the lesion comprised typical spleen tissue.

CONCLUSION

This case highlights the strong similarities between splenosis and malignant tumors. A detailed medical history combined with various effective auxiliary examinations can help improve differential diagnosis.

A case of hepatic splenosis in the setting of iron overload; multimodal and literature review

Hepatic splenosis, a rare entity, is the ectopic implantation of splenic tissue into the hepatic parenchyma, most often incidentally seen in patients with a history of splenic trauma and splenectomy. We present a unique case of hepatic splenosis in a patient with hemosiderosis and splenectomy following the incidental finding of hepatic masses on pretransplant imaging. Final diagnosis was made based on cross-sectional imaging characteristics matching that of the left upper quadrant splenules alone. We discuss common characteristics of hepatic splenosis on multiple modalities, the effect of iron deposition on the imaging characteristics of hepatic and splenic tissue and how that impacts the differential and diagnosis. This case highlights the unique imaging characteristics hepatic splenosis can have particularly in the setting of hemosiderosis. Hepatic splenosis imaging diagnosis has a significant advantage over tissue diagnosis in terms of decreased risk, time and cost.

Coincidence of Intra-Abdominal Splenosis in a Patient with Advanced Ovarian Cancer: Case Report and Review of the Literature

Splenosis is a rare disease, which is often discovered incidentally years after surgical procedures on the spleen or traumatic splenic lesions. Through injury of the splenic capsule, splenic cells are able to spread and autoimplant in a fashion similar to the process of metastatic cancer. Here we present the case of a 62-year-old female patient with a palpable tumor of the lower abdomen. Her medical history was unremarkable, except for splenectomy after traumatic splenic lesion in her childhood. Clinical examination and diagnostic imaging raised the suspicion of advanced ovarian cancer, which was further substantiated by the typical presentation of adnexal masses and disseminated peritoneal metastases during the following staging laparotomy. Surprisingly, we also found peritoneal implants macroscopically similar to splenic tissue. Microscopic examination of tissue specimens by intrasurgical frozen section confirmed the diagnosis of intra-abdominal splenosis. The patient then underwent cytoreductive surgery with complete resection of all cancer manifestations, sparing the remaining foci of splenosis to avoid further morbidity. This case demonstrates the rare coincidence of intra-abdominal carcinoma and splenosis, which could lead to intraoperative difficulties by misinterpreting benign splenic tissue. Therefore, splenosis should be considered in patients with medical history of splenic lesions and further diagnostic imaging like Tc-99m-tagged heat-damaged RBC scan could be used for presurgical distinguishing between tumor spread in the abdominal cavity and disseminated splenosis. The presented case report should not only raise awareness for the rare disease splenosis, but also emphasize the need to consider the possibility of simultaneous incidence of benign and malignant intra-abdominal lesions, as to our knowledge this is the first published case of simultaneous peritoneal carcinomatosis and splenosis.

Perirectal intraperitoneal splenosis: A case report of MRI with laparoscopic correlation

Splenosis is a benign acquired condition, which appears after rupture of the spleen and heterotopic auto-transplantation. Mostly found as an incidental finding on cross-sectional imaging, definitive diagnosis is frequently made histologically after resection or tissue sampling. We report a case of a 36-year-old male patient who presented with increased susceptibility to infections, chronic fatigue, and a history of traumatic splenic rupture. Cross-sectional imaging showed perirectal formations within the mesorectal fascia, and extraperitoneal splenosis was suspected. Due to the radiologically unclear entity of the masses, diagnostic laparoscopy with tissue sampling was performed. Intraoperatively the masses turned out to be intraperitoneal. Histological workup showed splenic tissue, consistent with intraperitoneal splenosis after splenic rupture. In this article we want to discuss important imaging findings and their differentials, as well as clinical implications for this rare entity.

Hepatic Arterial Buffer Response in Liver Radioembolization and Potential Use for Improved Cancer Therapy

Simple Summary

Radioembolization of hepatic tumors is performed by injecting ⁹⁰Y or ¹⁶⁶Ho loaded spheres into the hepatic artery. A twofold tumor to normal liver absorbed dose ratio is commonly obtained. In order to improve tumoral cell killing while preserving lobule function, co-injection of arterial vasoconstrictor has been proposed, but without success: the hepatic arterial buffer response quickly inhibits the arterioles vasoconstriction. The aim of the study is to investigate whether it is possible to take benefit from this buffer response, by co-infusing a mesenteric arterial vasodilator in order to dump the hepatic lobules arterial flow. Animal studies evidencing such mechanism are reviewed. Some potential mesenteric vasodilators are identified and their safety profile discussed. A four to sixfold improvement of the tumoral to normal tissue dose ratio is expected, pushing the therapy towards a real curative intention, especially in hepatocellular carcinoma (HCC), more frequent in obese subjects, and where ultra-selective spheres delivery is often not possible.

Abstract

Liver radioembolization is a treatment option for unresectable liver cancers, performed by infusion of ⁹⁰Y or ¹⁶⁶Ho loaded spheres in the hepatic artery. As tumoral cells are mainly perfused via the liver artery unlike hepatic lobules, a twofold tumor to normal liver dose ratio is commonly obtained. To improve tumoral cell killing while preserving lobules, co-infusion of arterial vasoconstrictor has been proposed but with limited success: the hepatic arterial buffer response (HABR) and hepatic vascular escape mechanism hamper the arterioles vasoconstriction. The proposed project aims to take benefit from the HABR by co-infusing a mesenteric arterial vasodilator: the portal flow enhancement inducing the vasoconstriction of the intra sinusoids arterioles barely impacts liver tumors that are mainly fed by novel and anarchic external arterioles. Animal studies were reviewed and dopexamine was identified as a promising safe candidate, reducing by four the hepatic lobules arterial flow. A clinical trial design is proposed. A four to sixfold improvement of the tumoral to normal tissue dose ratio is expected, pushing the therapy towards a real curative intention, especially in HCC where ultra-selective spheres delivery is often not possible.

Intrahepatic splenosis: a world review

Splenosis is defined as the autotransplantation of viable splenic tissue throughout various anatomic compartments. Intrahepatic splenosis (IHS) is rare and diagnosis is often challenging. This study aims to provide a comprehensive review on IHS. A literature review was performed on PubMed database. Fifty-six articles with 59 reported cases were included. The majority of the patients were male (n = 49, 83.1%). Median age was 51 years. Risk factors for hepatocellular carcinoma (HCC) included hepatitis B (n = 8, 13.6%) and cirrhosis (n = 12, 20.3%). The majority of the patients were asymptomatic (62.7%) and did not have risk factors for HCC (55.9%). We report a diagnostic triad for IHS: 1) previous history of abdominal trauma or splenectomy, 2) absence of risk factors for liver malignancy and 3) typical imaging features. Non-invasive diagnostic tests such as technetium-99m-tagged heat-damaged red blood cell scintigraphy are useful in diagnosis. Malignancy should be ruled out in the presence of risk factors for HCC.

A case of intrahepatic splenosis: usefulness of splenic scintigraphy

We report a 39-year-old male with intrahepatic and peritoneal splenosis, focusing on scintigraphic findings. Dynamic computed tomography (CT) showed a 3 cm lesion in the posterior right lobe of the liver with strong early phase enhancement that was homogenous to the liver enhancement in the late phase. A few enhancing nodules were also found in the peritoneum. On gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced dynamic magnetic resonance imaging (MRI), the hepatic lesion had abnormal signal on diffusion-weighted imaging, high signal intensity on T2-weighted imaging, and early enhancement with accumulation decline in the hepatocyte phase. CT and MRI findings of the hepatic lesion were similar to normal spleen. To rule out hepatic neuroendocrine tumor and peritoneal metastases, somatostatin receptor scintigraphy was performed and showed tracer accumulation in the hepatic lesion, which we considered a false positive. Splenic scintigraphy using Tc-99 m-phytate showed accumulation in the hepatic lesion and peritoneal nodules. Given the patient's history of splenic injury and splenectomy 15 years prior and the current imaging findings, we highly suspected splenosis. After surgical treatment, the patient was pathologically diagnosed with intrahepatic and peritoneal splenosis. Splenosis should be suspected when a patient has a history of trauma or abdominal surgery. Since intrahepatic splenosis presents as a nonspecific hypervascular lesion on CT and MRI, splenic scintigraphy should be considered in these patients. In addition Tc-99 m-phytate scintigraphy is easy to use and cost-effective.

Incidental finding of abdominal splenosis with mononucleated cell infiltration leading to a diagnosis of acute myeloid leukemia

Splenosis refers to ectopic splenic implants that are often found incidentally years after splenic rupture/splenectomy, and the nodules of splenosis are usually small, less than 3 cm for the majority. We report a case of splenosis with a 5-centimeter large mass in the anterior abdomen in a 79 year-old male with a remote history of splenic rupture/splenectomy. Unexpectedly, needle core biopsy of the abdominal mass demonstrated splenic tissue with a mononucleated cell infiltrate blurring the splenic architecture that was highlighted only by CD8 stain. This finding prompted a bone marrow examination resulting in the diagnosis of acute myeloid leukemia in the patient. Retrospectively, enlargement of this ectopic spleen may have been caused by this leukemic infiltrate. This case underscores the importance of being aware of this rare pathological condition and its retained vulnerability for involvement by hematolymphoid neoplasms, as well as significance of identifying splenic architecture highlighted by CD8 stain to reach a correct diagnosis.

Intrahepatic and intra-abdominal splenosis: A case report and review of literature

BACKGROUND

Splenosis is defined as the process by which tissue from the spleen disseminates through the body and grows in an ectopic location following trauma or a splenectomy. Visceral sites of splenosis are rare.

CASE SUMMARY

We report a case of intrahepatic splenosis in a 57-year-old man with a history of trauma over 40 years ago who initially presented with chest pain. Findings initially mimicked malignancy but a diagnosis of intrahepatic splenosis was confirmed using computed tomography and scintigraphy with technetium-99m heat-denatured red blood cells (Tc-99 DRBC).

CONCLUSION

Scintigraphy with Tc-99 DRBC is a reliable technique to diagnose splenosis and should be performed before using more invasive procedures are carried out. Splenosis should be considered as a possible differential diagnosis for a hepatic nodule in any patient with a history of abdominal trauma, previous splenectomy or atypical radiological features on imaging.