Giant splenic cyst with high serum concentration of CA 19-9. Failure of treatment with percutaneous transcatheter drainage and injection of tetracycline

Laparoscopic fenestration for a large ruptured splenic cyst combined with an elevated serum carbohydrate antigen 19-9 level: a case report

Background

Non-parasitic splenic cysts are associated with elevated serum carbohydrate antigen (CA) 19–9 levels. We report a case in which a 23-year-old female exhibited a large ruptured splenic cyst and an elevated serum CA19–9 level.

Case presentation

The patient, who experienced postprandial abdominal pain and vomiting, was transferred to our hospital and was found to have a large splenic cyst during an abdominal computed tomography (CT) scan. On physical examination, her vital signs were stable, and she demonstrated rebound tenderness in the epigastric region. An abdominal CT scan revealed abdominal fluid and a low-density region (12 × 12 × 8 cm) with enhanced margins in the spleen. The patient’s serum levels of CA19–9 and CA125 were elevated to 17,580 U/mL and 909 U/mL, respectively. A cytological examination of the ascitic fluid resulted in it being categorized as class II. Finally, we made a diagnosis of a ruptured splenic epidermoid cyst and performed laparoscopic splenic fenestration. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 5. The cystic lesion was histopathologically diagnosed as a true cyst, and the epithelial cells were positive for CA19–9. Follow-up laboratory tests performed at 4 postoperative months showed normal CA19–9 (24.6 U/L) and CA125 (26.8 U/L) levels. No recurrence of the splenic cyst was detected during the 6 months after surgery.

Conclusion

Laparoscopic fenestration of a ruptured splenic cyst was performed to preserve the spleen, after the results of abdominal fluid cytology and MRI were negative for malignancy.

Percutaneous Treatment of Non-parasitic Splenic Cysts: Long-Term Results for Single- Versus Multiple-Session Treatment

PURPOSE

The aim of this study was to investigate the efficacy and safety of percutaneous sclerotherapy for non-parasitic splenic cysts (NPSCs). The secondary aims were to introduce puncture-aspiration-injection-reaspiration (PAIR) technique in the treatment of NPSCs and to compare multiple- and single-session techniques.

MATERIALS AND METHODS

This retrospective study included 24 (17 females, 7 males) patients, treated between the years 1997 and 2015. Three techniques were used. Group A (n = 8), Group B (n = 6) and Group C (n = 10) were treated by PAIR, single-session catheterization and multiple-session catheterization, respectively. Since both PAIR and single-session catheterization techniques are carried out in a single session, Group A and Group B were evaluated in one group (Group A + B). Group A + B was compared with Group C in terms of patient demographics, the initial volume of the cysts, follow-up periods, complication and hospitalization rates and follow-up results. Recurrence and reduction rates were evaluated for two groups.

RESULTS

Technical success rate was 100%. The mean follow-up period was 68.9 months. Recurrence detected in 7 (29.1%) patients. Final reduction rate was between 40.7 and 100% (median 96.4%) with a significant difference in cyst volume (p < 0.05). There was no significant difference regarding recurrence rates (p = 1) and the final reduction rates (p = 0.51) between the two groups.

CONCLUSION

Percutaneous sclerotherapy is a minimally invasive technique, preserving maximum tissue while effectively treating NPSCs. Single-session sclerotherapy which reduces hospitalization days and increases patient comfort is as effective as multi-session sclerotherapy as the initial procedure. This study supports that single-session sclerotherapy should be a valid treatment option.

Ultrasound-guided percutaneous ethanol ablation for primary non-parasitic splenic cysts in 15 patients

PURPOSE

This study aimed to evaluate the feasibility, safety, and efficacy of ultrasound (US)-guided percutaneous ethanol ablation (PEA) for primary non-parasitic splenic cysts.

MATERIALS AND METHODS

Between February 2006 and February 2015, 15 patients (4 men and 11 women; mean age, 33 ± 15.3 years; age range, 17-65 years) with primary non-parasitic splenic cysts were treated with US-guided PEA. 99.5% absolute ethanol in an amount of approximately 50%-100% of the aspirated volume was injected into each cyst and no more than 240 mL. Standard laboratory tests (hemogram, coagulation, serum, and biochemical tumor marker levels) were performed before and after PEA.

RESULTS

The median follow-up time was 18.7 months (range 2.8-59.2 months). During follow-up, seven cysts after treatment had disappeared completely, while the other eight cysts had decreased significantly in size. The 3-, 6-, 12-, and 24-month volume reduction rates were 49.7%, 87.6%, 94.3%, and 96.7%. Serum tumor marker CA19-9 levels significantly decreased. Mild adverse reactions included moderate pain in four (26.7%), unbearable pain in one (6.67%), fever in two (13.3%) and slight intracystic bleeding in one (6.67%). There were no serious complications.

CONCLUSION

US-guided PEA appears to be a safe and effective minimally invasive technique for management of primary non-parasitic splenic cysts.

Ectopic splenic tissues mimicking gastro-intestinal stromal tumour in a patient after splenectomy for a giant epithelial cyst of spleen: A case report

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Giant epithelial splenic cyst is rare and splenectomy is the treatment.

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Auto-transplantation of ectopic splenic tissues during splenectomy may create diagnostic confusion when subsequent endoscopy or CT scan is performed years after the operation.

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^99mTechnetium sulfur colloid scintigraphy is a useful adjunct and should be considered in doubtful cases.

Introduction

Ectopic splenic tissues left after a previous splenectomy can masquerade as a gastro-intestinal stromal tumour (GIST).

Presentation of case

Splenectomy was carried out for a 17-year-old girl with a giant epithelial cyst of spleen. Four years later, an upper endoscopy carried out for dyspepsia revealed two sub-mucosal lesions at the posterior wall of the gastric fundus. Computed tomography diagnosed a GIST. At operation, a dump-bell shaped extragastric mass was excised. Histology showed normal splenic tissues.

Discussion

Giant epithelial cyst of spleen is rare. It is even rarer for ectopic splenic tissues left after splenectomy to masquerade as a GIST.

Conclusion

Ectopic splenic tissues should be included as a differential diagnosis in a patient who has a history of splenectomy presenting with a sub-mucosal gastric tumour.

Primary non-parasitic splenic cyst: a case report

Cystic disease of the spleen is a relatively rare disease. It is classified either as a true primary cyst or as a secondary pseudocyst. Most splenic cysts are pseudocysts, which have non-epithelial lining, and are caused by previous abdominal blunt trauma. Conversely, primary splenic cysts have epithelial lining and are subdivided into parasitic and non-parasitic cyst. Non-parasitic primary splenic cyst is considered congenital and comprises about 10% of all splenic cysts. Total or partial splenectomy is the treatment of choice, but parasitic infection must be excluded prior to an operation. In this present report, we described a symptomatic, large primary non-parasitic splenic cyst, which was surgically treated with partial splenectomy.

Post-traumatic splenic cysts treated with laparoscopy: two case reports

Introduction

Today, laparoscopy tends to become a useful alternative to open procedure for the surgical treatment of spleen disorders, offering at the same time a conservative approach for the management of selected spleen lesions such as posttraumatic cysts.

Case presentation

This article describes two cases of posttraumatic splenic cysts, one of which was treated with laparoscopic total splenectomy and the second with laparoscopic cystectomy. The procedure was carried out successfully with no complications in both cases, and the patients were discharged a few days after the operation.

Conclusion

Laparoscopy with preservation of functional splenic parenchyma, when feasible, should be the procedure of choice in cases of posttraumatic splenic cysts, as it provides safe and definite treatment with all of the other advantages of minimally invasive surgery.

[Epidermoid splenic cysts in children and adolescents]

Epidermoid cysts of the spleen are a rare lesion comprising less than 10% benign non-parasitic splenic cysts. Two boys and three girls, aged 13 to 24 years (mean 18.0 years) were diagnosed over a 4-year period. Presenting symptoms were dull, acute left hypochondrium pain and diffuse abdominal pain. Hemogram and routine analyses, as well as radiography were performed for the diagnosis. Ultrasound and CT confirmed the cystic nature of the lesion. Definitive diagnosis is made by pathological findings. Was performed splenectomy on one patient, and was performed a partial splenectomy on the other patients, in order to eliminate the symptoms produced by the cyst and prevent potential complications (postspleenectomiam sepsis). Patients were examined postoperatively. They were asymptomatic and with a normal spleen remnant detected by ultrasound and CT. Routine hematological data, blood clotting factors, and immunoglobulins were normal.

Percutaneous treatment of congenital splenic cysts: drainage and sclerotherapy with polidocanol

Congenital "true" splenic cysts are rare lesions. Therapeutic methods for the management of these lesions have been based on preserving splenic function due to the immunologic role of spleen. We report three different cases of congenital splenic cysts treated by percutaneous drainage and polidocanol sclerotherapy. This less invasive treatment appears to be safe and effective after 6 to 36 months of follow-up.

Nonelevation of Serum CA 19-9 Level in a True NonParasitic Splenic Cyst

The diagnosis and management of true nonparasitic splenic cysts has markedly changed in recent years. The use of serum CA 19-9 has been increasingly advocated for diagnosis, while the advent of minimally invasive surgery has radically altered surgical management. We present the first case of a true nonparasitic splenic cyst in which serum CA 19-9 was not elevated. Treatment was by laparoscopic cyst decapsulation utilising the endoscopic Ligasure.

Congenital Splenic Cyst Treated with Percutaneous Sclerosis Using Alcohol

We report a case of successful percutaneous treatment of a congenital splenic cyst using alcohol as the sclerosing agent. A 14-year-old female adolescent presented with a nonsymptomatic cystic mass located in the spleen that was believed to be congenital. After ultrasonography, a drainage catheter was placed in the cavity. About 250 ml of serous liquid was extracted and sent for microbiologic and pathologic studies to rule out an infectious or malignant origin. Immediately afterwards, complete drainage and local sclerotherapy with alcohol was performed. This therapy was repeated 8 days later, after having observed 60 ml of fluid in the drainage bag. One year after treatment the cyst has practically disappeared. We believe that treatment of splenic cyst with percutaneous puncture, ethanolization, and drainage is a valid option and it does not rule out surgery if the conservative treatment fails.

Pure alcohol injection of a congenital splenic cyst: a valid alternative?

Congenital splenic cysts are a rare entity. They are more frequent in children and young adults. They are true cysts, lined by epithelium with a typical trabeculation. Aspiration and injection with antibiotics (minocycline-tetracycline) or pure alcohol has been reported sparsely with variable results. The purpose of this case study is to report our experience with ultrasound (US)-guided aspiration and injection of a congenital splenic cyst, which, in our case, did not prove a viable alternative to surgical defenestration.

Normal interleukin-10 serum level opposed to high serum levels of carbohydrate antigen 19-9 and cancer antigens 125 and 50 in a case of true splenic cyst

True cysts of the spleen are rare. In a few cases, high serum levels of carbohydrate antigen (CA) 19-9 and carcinoembryonic antigen (CEA) have been reported. It has been suggested that they are produced by inner epithelium of the cyst. In such instances, cyst resection or splenectomy is indicated to rule out malignant lesions and to remove cancer antigen-producing epithelium. Furthermore, a high serum level of interleukin (IL)-10, an immunosuppressive cytokine, has been described in many neoplastic diseases, suggesting it as a potential new diagnostic method. Giant cystic lesion of the left upper abdomen associated with ovarian tumor was diagnosed in a young patient. Laboratory data revealed elevated serum levels of several tumor markers [CA 19-9, CEA, cancer antigens (CA) 125 and 50, and tissue polypeptide antigen]. In contrast, IL-10 serum level was normal. After splenectomy and ovariectomy, tumor marker serum levels normalized. Histology and immunohistochemical analysis revealed true splenic cyst with inner epithelium strongly positive for CA 19-9, CEA, and high levels of cancer antigens in fluid. Ovarian lesion was a serous cystoadenoma; its inner epithelium showed no immunoreactivity for tumor markers that were not measurable in fluid. The reported case showed that epithelium lining true splenic cysts may produce, in addition to CA 19-9, CEA, and other tumor markers, in particular CA 125 and CA 50. When malignant disease is suspected, IL-10 serum level could be useful to correctly predict the nature of the lesion.

Giant benign true cyst of the spleen with high serum level of CA 19-9

We report the case of a 21-year-old woman with a giant (20 cm) benign mesothelial splenic cyst and a high CA 19-9 serum level (1240 U/ml). The patient underwent resection of the cyst and splenectomy. True non-parasitic splenic cysts are very rare. Only 10 cases of benign true splenic cysts, with a high CA 19-9 serum level, have ever been published in the medical literature written in English. These are reviewed in this paper. We believe that the inner cellular lining of the cyst wall produces CA 19-9, which causes the high CA 19-9 serum level. This is supported by the facts that (1) the inner cellular lining is strongly positive for immunohistochemistry with CA 19-9, and (2) the CA 19-9 serum level returned to normal after resection of the cyst.

Ruptured epidermoid cyst and haematoma of spleen: a diagnostic clue of high levels of serum carcinoembryonic antigen, carbohydrate antigen 19-9 and Sialyl Lewis x

Splenic epidermoid cyst is a rare disease and that with haematoma is even more rare. The case of epidermoid cyst of the spleen is described, in a 36-year-old Japanese female, manifesting as left hypochondralgia and rupture of the cyst. Clinical features were splenic lesion 14 cm in diameter and consisting of round-hypovascular and crescent-hypervascular sublesions. Extravasation of cystic fluid was detected in abdominal cavity Preoperative diagnosis was difficult due to such uncommon features, however high levels of serum tumour markers (carcinoembryonic antigen, carbohydrate antigen 19-9, Sialyl Lewis x) strongly suggested epidermoid cyst. Laparotomic splenectomy and cholecystectomy were performed for splenic lesion and gallstones, and serum tumour markers decreased following surgery. Pathological diagnosis of the round-hypovascular lesion was epidermoid cyst and crescent-hypervascular lesion was haemorrhage (haematoma).

[Treatment of non-parasitic splenic cyst with percutaneous injection of alcohol]

We report a case of a 12-years-old girl treated by percuta-neous injection of a splenic epithelial cyst. Indication was due to the gradual cyst's growth and pain in left hypocondrium. A percutaneous drainage under ultrasonographic view was performed with direct puncture technique, inserting a pigtail catheter into the cyst. After the total aspiration of the contrast, we injected sterile absolute alcohol for 20 minutes. Subsecuently, it was aspirated and the catheter was pulled-out. After a follow up period of more than 4 years, the cyst remains collapsed. There were no complications.

A splenic cyst and a high serum CA 19-9: a case report

A 22-year-old man was admitted to our hospital with a palpable mass in the left upper quadrant. He had a history of blunt abdominal trauma. Computer tomography showed a large splenic cyst. Another finding was a markedly elevated concentration of the tumor marker CA 19-9 in his serum and cystic fluid. After surgical removal of the cyst this concentration decreased to a nearly normal level. Because no cellular lining of the cyst was found at histological examination, the cyst could have been regarded as 'false' or a 'pseudocyst'. However, since several cases of epithelial splenic cysts in combination with a high serum CA 19-9 have been described recently, our diagnosis was of an epithelial 'true' cyst. We assume that, for some reason, in primary splenic cysts, the thin cellular lining can be released before histological examination is performed.

Laparoscopic splenectomy for a giant splenic epidermoid cyst: report of a case

The use of laparoscopic splenectomy has increased in recent years, primarily for patients with idiopathic thrombocytopenic purpura (ITP). We describe herein the first known case of a laparoscopic splenectomy to be performed in Japan for a patient with a giant splenic epidermoid cyst. A 26-year-old woman presented to our hospital with the major complaint of a feeling of abdominal fullness. Prior to surgery, an ultrasound-guided splenic cyst puncture was conducted for diagnostic purposes as well as to reduce the size of the cyst. The carbohydrate antigen 19-9 (CA 19-9) level was found to be elevated in the cystic contents and in the serum. Under laparoscopic guidance, the splenic vessels were ligated using a device for extracorporeal ligation, then divided. After the resected spleen had been placed in a retrieval bag, it was delivered out of the abdominal cavity without fragmentation. Following surgery, the patient's serum CA 19-9 level returned to normal. Splenic epidermoid cysts are most often encountered in young women, and laparoscopic surgery to remove cysts of this type is both minimally invasive and excellent from a cosmetic standpoint. Thus, laparoscopic surgery should be considered as the method of choice for the majority of patients diagnosed with a splenic epidermoid cyst.