Splenic surprise in a case of renal cell carcinoma: Unusual case or association?

Littoral cell angioma (LCA) is a rare benign tumor originating exclusively from the venous sinus lining cells of the splenic red pulp. These cells are unique in having a distinctive hybrid endothelial/histiocytic phenotype. Also, there are reports of the association of LCA with internal malignancies. We present a case report highlighting an unusual association of LCA with conventional renal cell carcinoma (RCC), masquerading as a metastatic lesion. Knowledge of such an association is necessary to avoid misdiagnosis and prevent potential overtreatment.

Littoral cell angiomas: Benign lesion with a penchant for visceral malignancies

Littoral cell angiomas are rare vascular tumors of the spleen. Because of their rarity, unclear etiopathogenesis, and association with other malignancies, these tumors can pose diagnostic and therapeutic challenges. Due to paucity of published literature on this entity often limited to case reports, relevant data on this topic were procured and synthesized with the aid of a comprehensive Medline search in addition to oncologic, pathologic, radiologic, and surgical literature review on littoral cell angiomas. This article provides an in-depth review into postulated etiopathogenesis, pathology, clinical manifestations, associated malignancies, and prognostic features of littoral cell angiomas.

Early postsurgical lethal outcome due to splenic littoral cell angioma: A case report

BACKGROUND

Littoral cell angioma (LCA) is a rare benign vascular tumor of the spleen. Given its rarity, standard diagnostic and therapeutic recommendations have yet to be developed for reported cases. Splenectomy is the only method of obtaining a pathological diagnosis and providing treatment to obtain a favorable prognosis.

CASE SUMMARY

A 33-year-old female presented with abdominal pain for one month. Computed tomography and ultrasound revealed splenomegaly with multiple lesions and two accessory spleens. The patient underwent laparoscopic total splenectomy and accessory splenectomy, and splenic LCA was confirmed by pathology. Four months after surgery, the patient presented with acute liver failure, was readmitted, rapidly progressed to multiple organ dysfunction syndrome and died.

CONCLUSION

Preoperative diagnosis of LCA is challenging. We systematically reviewed online databases to identify the relevant literature and found a close relationship between malignancy and immunodysregulation. When a patient suffers from both splenic tumors and malignancy or immune-related disease, LCA is possible. Due to potential malignancy, total splenectomy (including accessory spleen) and regular follow-up after surgery are recommended. If LCA is diagnosed after surgery, a comprehensive postoperative examination is needed.

Case report: Infrequent littoral cell angioma of the spleen

Introduction and importance

Littoral cell angioma is a rare solid spleen tumor with uncertain malignant potential. It is usually asymptomatic; therefore, its diagnosis is usually incidental. There are approximately 150 cases reported in the medical literature, but none of them in the Hispanic population.

Case presentation

We present a case of a 54-year-old woman who presented to our clinic with nonspecific abdominal pain. Imaging studies show a splenic mass with littoral cell angioma characteristics. The patient underwent an open splenectomy with subsequent histopathologic and immunohistochemical studies that confirmed the presence of a littoral cell angioma of a diameter of 8 × 4.5 × 3.5 cm. The patient was discharged after an uneventful postoperative recovery and was referred to the outpatient clinic for follow up.

Clinical discussion

This case report highlights the close relationship between the littoral cell angioma, neoplasias, and autoimmune diseases. Even though LCA has a good prognosis, there is still the possibility of malignant transformation, especially when the spleen weighs 1500 g; our patient's sample pointed towards a benign pathology. LCA has a positive IHC for endothelial and histiocyte tissues. The IHC results of our patient were positive for CD34⁺ and CD68⁺, confirming the LCA diagnosis.

Conclusion

Within red pulp spleen tumors, LCA should be highly considered as a differential diagnosis in all types of populations. In the case of a confirmed LCA, routine screening for neoplasias and autoimmune diseases should be performed.

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LCA is a benign tumor with endothelial and histiocytic differentiation.

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LCA has a close relationship with neoplasias and autoimmune diseases.

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LCA is more prevalent in Asia, but it can also be seen in South America.

Laparoscopic Central Splenectomy for Littoral Cell Angioma

BACKGROUND

Splenic littoral cell angioma (LCA) is a rare vascular tumor with malignant potential originating from the red pulp of the spleen.1,2 Although laparoscopic splenectomy is the treatment choice for LCA,³ patients suffer from long-term complications of sepsis, thrombosis, and tumor.4,5 Laparoscopic central splenectomy (LCS) for LCA is a technically challenging operation mainly due to the risk of intraoperative hemorrhage. However, it can be a valuable alternative particularly for adolescent patients in whom maximum preservation of splenic function outweighs the risks associated with organ preservation.

METHODS

A 15-year-old young man was admitted with left upper abdominal dull pain for 1 month. Laboratory tests and enhanced abdominal CT scans were performed. Laboratory test results were all normal, as follows: complete blood count showed normal WBC: 5.74 × 10⁹/l, platelets: 173 × 10⁹/l, Hb: 151 g/l, tumor markers (CEA: 1.62 ng/ml, CA19-9: 10.30 U/ml, AFP: 1.13 ng/ml) which were within normal limits. CT scan showed that a 5 × 5.9-cm solid tumor was discovered in the middle part of the spleen during diagnosis, and the density of this tumor was high in the early artery phase and low in the late portal venous phase of contrast-enhanced CT. LCS was performed where the trunk of the splenic artery was intermittently occluded and several branches of the vessels were freed from the tumor which was then resected. The splenic parenchyma was dissected by following a line 0.5 cm from demarcation line. The tumor was completely removed with the activity of the splenic parenchyma being preserved to the maximum extent. Total operation time was 175 min, with an estimated blood loss of 200 ml; thus, no blood transfusion was required. Intraoperative frozen section suggested vascular tumor-like lesions, and then the tumor was completely removed with the resection margin being free of tumor involvement.

RESULTS

The patient was fully recovered after a 7-day hospital stay. The reason for the 7-day hospital stay is that the patient maintains normal ambulating independent assistance on POD-3 and can eat without intravenous fluids on POD-4. Meanwhile, the patient needs to remove the drainage tube after the abdominal CT scan on POD-6, rather than postoperative complications. Diagnosis of LCA was confirmed using histology, and the symptoms disappearing after the operation was done. A total of 86·laparoscopic partial splenectomy (LPS) procedures were performed at the Department of Pancreatic Surgery, West China Hospital and Department of Hepatopancreatobiliary Minimal Invasive Surgery, Chengdu ShangJin NanFu Hospital from May 2011 to May 2020. Five patients among the total number of patients were diagnosed with LCA of which LPS was performed in four patients and LCS performed for one patient. The mean duration of surgery for LPS was 100 min (range of 80-120 min) while the mean estimated blood loss was 125 ml (range of 100-200 ml). On the other hand, the mean length of hospital stay was 7.5 days (range of 5-11 days) and the mean tumor diameter was 5.1 cm (range of 3.2-7 cm). All patients recovered without complications. In addition, there were no signs of immune insufficiency, thrombosis, and tumor recurrence during the follow-up which had a mean of 31.2 months (range from 10 to 53 months).

CONCLUSION

LCS is a technically feasible technique for a select group of patients with centrally located LCA. The technique helps to maximize preservation of splenic function and maintains the advantages of minimally invasive surgery.

Littoral cell angioma of the spleen: A case report

Spleen tumors are an uncommon disease. Littoral cell angioma belongs to the group of vascular tumors. It is believed that this tumor originates from the tissue of the red pulp sinuses, specifically from the cells that are lining the sinuses. If this rare tumor is diagnosed, it is necessary to search for synchronous or metachronous visceral neoplasia. Littoral cell angioma can also mimic metastatic lesion of the spleen. This case report wants to draw attention on this rare tumor of the spleen which is very often associated with other visceral malignancy.

Langerin staining identifies most littoral cell angiomas but not most other splenic angiomatous lesions

Although littoral cell angiomas (LCAs) are phenotypically well characterized, the antibodies used to support the diagnosis identify many other cells in the normal spleen, and some may be found in other angiomatous lesions. Based on a langerin/CD207+ LCA index case, langerin and other selected immunohistochemical staining was performed on 10 LCAs, 20 other splenic angiomatous lesions, and 7 reactive lymph nodes to further investigate the role of langerin as a diagnostic tool. Ninety percent (9/10) of LCAs were langerin positive, whereas only 1 (5%) of 20 other splenic vascular lesions was partially positive (P < .00001). All LCAs were CD1a-, CD68+, CD34-, and CD8-; 20% were S100+, 70% CD21+, and 90% cyclin D1+. Ultrastructural studies of one LCA did not show Birbeck-type granules in definite lining cells. Sinus lining cells in 7 of 7 reactive lymph nodes showed partial langerin positivity, and 4 of 4 showed partial cyclin D1 positivity. In conclusion, langerin staining is an easily interpreted and highly sensitive and specific (sensitivity [0.90], specificity [0.95]) ancillary study to help distinguish LCA from other vascular tumors of the spleen. Whether this represents cross-reactivity or true CD207 expression is uncertain, as other immunohistochemical and ultrastructural studies do not support a Langerhans cell origin. The cyclin D1 staining seen in most LCA would be consistent with their expression of other selected vascular and histiocytic markers. The similar staining pattern in some lymph node sinus lining cells suggests a possible similar cell of origin, although LCA of lymph nodes is not described.

Littoral Cell Angioma: A Rare Cause of Pediatric Thrombocytopenia

Littoral cell angioma is a rare primary splenic vascular tumor, originating from the littoral cells lining the red pulp sinuses of the spleen, with variable presentation. Here, we present the case of a 2-year-old male child presenting with chronic thrombocytopenia which resolved after splenectomy.

Case report of a littoral cell angioma of the spleen and accessory spleens: A benign vascular tumour

Introduction

Littoral- cell angioma (LCA) is a rare benign vascular tumour of the spleen. There have been less then 80 cases reported in the literature.

Recent reports have described it to be a malignant lesion with congenital and immunologic associations. We report a case of LCA of the spleen.

Presentation of case

A 52 -year-old male patient was admitted to hospital with a three month duration of intermittent upper abdominal pain and nausea. Imaging studies, including computer tomography (CT) and magnetic resonance imaging (MRI), showed multiple lesions in the spleen as well as in the accessory spleens.

An open splenectomy was performed and his post-operative recovery was uneventful.

Discussion

Littoral cell angioma of the spleen is a benign vascular tumour that has been infrequently reported in the English literature. While it does have malignant potential, the vast majority are benign. Diagnosis depends on the expression of endothelial markers like CD31 and histiocytic markers like CD68.Malignant potential is enhanced by the presence of splenomegaly as well.

Conclusion

This rare condition is made even more rare by the presence of the tumour in the two accessory spleens as well.

Littoral cell angioma: A case report

Primary splenic lesions are rare entities among which littoral cell angioma (LCA) is a recently described, uncommon vascular lesion that is unique to the spleen. It has heretofore been described primarily in pathologic series and has been found mostly to behave as a benign entity. A few reports of malignant variants have been reported. We present a case report of a solitary LCA discovered after splenectomy for an incidentally discovered splenic lesion, along with a literature review.

Littoral cell angioma of the spleen: report of three cases and literature review

Littoral cell angioma (LCA) is an extremely rare benign splenic tumor with typical histomorphologic features, which is difficult to be distinguished preoperatively from other benign or malignant splenic tumors. It is a unique vascular tumor of the spleen, with abdominal pain or as an incidental finding when undergoing physical examination. In this paper, we reported three cases of LCA treated in our hospital. Their clinical symptoms, pathological features, clinical treatment as well as the prognosis are discussed.

Laparoscopic splenectomy for splenic littoral cell angioma

AIM: To establish the safety and feasibility of laparoscopic splenectomy (LS) for littoral cell angioma (LCA).

METHODS: From September 2003 to November 2013, 27 patients were diagnosed with LCA in our institution. These patients were divided into two groups based on operative procedure: LS (13 cases, Group 1) and open splenectomy (14 cases, Group 2). Data were collected retrospectively by chart review. Comparisons were performed between the two groups in terms of demographic characteristics (sex and age); operative outcomes (operative time, estimated blood loss, transfusion, and conversion); postoperative details (length of postoperative stay and complications); and follow-up outcome.

RESULTS: LS was successfully carried out in all patients except one in Group 1, who required conversion to hand-assisted LS because of perisplenic adhesions. The average operative time for patients in Group 1 was significantly shorter than that in Group 2 (127 ± 34 min vs 177 ± 25 min, P = 0.001). The average estimated blood loss in Group 1 was significantly lower than in Group 2 (62 ± 48 mL vs 138 ± 64 mL, P < 0.01). No patient in Group 1 required a blood transfusion, whereas one in Group 2 required a transfusion. Two patients in Group 1 and four in Group 2 suffered from postoperative complications. All the complications were cured by conservative therapy. There were no deaths in our series. All patients were followed up and no recurrence or abdominal metastasis were found.

CONCLUSION: LS for patients with LCA is safe and feasible, with preferable operative outcomes and long-term tumor-free survival.

Distinctive immunohistochemical staining in littoral cell angioma using ERG and WT-1

Littoral cell angioma (LCA) is a rare vascular tumor of the spleen. It has an immunohistochemical staining pattern that is somewhat distinctive but can still be occasionally confused with other vascular and stromal proliferations in the spleen. In this study, LCA was evaluated using Ets-related gene (ERG) and Wilms tumor-1 (WT-1), relatively recently described vascular markers. In addition, other vascular lesions including normal spleen, hemangiomas, hamartoma, peliosis, and sclerosing angiomatoid nodular transformation were evaluated using these stains. In LCA, ERG stains the endothelial cells of the tumor as expected. ERG also was uniformly positive in vascular elements of other lesions except peliosis. However, in contrast to most other vascular elements, LCA was negative for WT-1 staining. This staining pattern may prove useful in diagnosing LCA and may provide insight into the derivation of the distinctive tumor.

Littoral cell angioma of spleen: an uncommon presentation of a rare neoplasm

Littoral cell angioma (LCA) is a rare primary splenic tumor that is difficult to differentiate preoperatively from other benign and malignant splenic lesions. Most of the cases present as multiple nodules in the spleen. We report a case of large solitary LCA of the spleen, an uncommon presentation. LCA should be considered in the differential diagnosis of multiple and solitary splenic lesions.