Role of early splenectomy in malignant lymphomas with prominent splenic involvement (primary lymphomas of the spleen). A study of 59 cases

Splenic marginal zone lymphoma: a case report and literature review

BACKGROUND

Splenic marginal zone lymphoma (SMZL) is a rare non-Hodgkin lymphoma, and much little is known about its clinical characteristics and management strategies. Here we present a case of SMZL and review relevant literature to provide a better recognition of this disease entity.

CASE PRESENTATION

A 49-year-old Chinese female was admitted to our hospital with complaints of abdominal distension and acid reflux. Physical examinations and imaging investigations suggested the presence of splenomegaly. Laboratory workups revealed mildly reduced white blood cell count otherwise was not remarkable. The patient underwent splenectomy. Histological examination combined with immunohistochemical analysis of the resected spleen confirmed the diagnosis of SMZL. The patient recovered uneventfully during follow-ups.

CONCLUSIONS

Due to the rarity and unspecific clinical features, SMZL is extremely challenging to be diagnosed preoperatively. Patients with SMZL are generally associated with favorable prognosis. Combining the staging characteristics of non-Hodgkin's lymphoma and splenic primary lymphoma may assist in clinical staging management of SMZL.

Rare Causes of Isolated and Progressive Splenic Lesions: Challenges in Differential Diagnosis, Evaluation, and Treatment of Primary Splenic Lymphomas

The spleen is among the most common extranodal sites for Hodgkin and non-Hodgkin lymphomas (NHLs); however, among lymphomas arising from the spleen, primary splenic lymphomas (PSLs) are rare. The group of PSLs includes primary splenic diffuse large B-cell lymphoma (PS-DLBCL), splenic red pulp small B-cell lymphoma, splenic marginal zone lymphoma (SMZL), and a splenic hairy cell leukemia variant. Delineating between the PSL variants can be challenging, especially as fine-needle aspirate and core needle biopsy of the spleen are not routinely offered at most medical centers. Herein, we describe the clinical course of 2 representative patients who presented with non-specific gastrointestinal symptoms, the first who was diagnosed with PS-DLBCL and the second who was diagnosed with SMZL. We review and contrast the clinical presentations, imaging techniques, and laboratory findings of these discrete lymphoma variants and offer strategies on how to delineate between these varied splenic processes. We also examine the use of splenectomy and splenic needle biopsy as diagnostics and, in the case of splenectomy, a therapeutic tool. Finally, we also briefly review treatment options for these varied lymphoma sub-types while acknowledging that randomized trials to guide best practices for PSLs are lacking.

Fever of unknown origin revealed to be primary splenic lymphoma: A rare case report with review of the literature

Fever is a common clinical presentation of a number of diseases. A sustained unexplained fever >38.3°C lasting for >3 weeks without an established diagnosis despite intensive diagnostic evaluation is referred to as fever of unknown origin (FUO). FUO remains a clinical challenge for physicians, as it may be attributed to a wide range of disorders, mainly infections, malignancies, non-infectious inflammatory diseases and miscellaneous diseases. We herein report the case of a 59-year-old male patient who presented with prolonged unexplained fever and was found to have a diffusely enlarged hypermetabolic spleen, as shown on ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography examination. Following splenectomy, histopathological examination revealed primary splenic lymphoma (PSL) of B-cell origin. The patient received 6 courses of systemic chemotherapy with rituximab, etoposide, cyclophosphamide, doxorubicin, vincristine and prednisone (R-ECHOP regimen) and responded well to treatment. Thus, in patients with FUO and splenomegaly, the possibility of PSL should be taken into consideration.

Imaging findings of primary splenic lymphoma: a review of 17 cases in which diagnosis was made at splenectomy

Purpose

This study sought to characterize the imaging features of primary splenic lymphoma (PSL).

Materials and Methods

Pathological and imaging data from 17 patients with primary splenic lymphoma initially diagnosed at splenectomy were retrospectively analyzed. Pretreatment computed tomography (CT) imaging was available for 16 patients, and magnetic resonance imaging (MRI) data were available for 4 patients. Splenic lymphoma imaging data were categorized based on the gross pathological presentation in the following manner: type 1, homogeneous enlargement; type 2, miliary nodules; type 3, multifocal masses of varying size; and type 4, solitary large mass.

Results

Of the 17 patients with PSL, 16 cases were non-Hodgkin lymphoma, and of these, 9 cases were diffuse large B cell lymphomas (DLBCL) and 4 cases were splenic marginal zone B-cell lymphoma (SMZL). Imaging showed the following types of PSL presentation: 1 case of type 1, 0 cases of type 2, 4 cases of type 3, and 12 cases of type 4. There was evidence of necrosis in 12 cases (70.6%), and there was evidence of mild enhancement in enhanced CT in 14 cases and in enhanced MRI in 3 cases. Prior to surgery, PSL was considered possible in 8 patients.

Conclusion

The most frequent histological subtype was DLBCL, followed by SMZL. In both CT and MRI, PSL generally presents as a solitary mass or masses rather than as splenomegaly. In addition, necrosis and mild enhancement are commonly observed, and splenectomy may be required to confirm the diagnosis.

Primary splenic lymphoma presenting with ascites

An 84 year-old gentleman presented with abdominal distension, anorexia and occasional epigastric pain over a four-week period. Blood parameters revealed a hypochromic microcytic anaemia. Both CT and US scan identified ascites and a mass in the left upper quadrant. An ascitic tap was performed identifying bloody ascites and the presence of reactive mesothelial cells on cytology. A subsequent laparotomy and splenectomy was performed. Histology of the resected spleen revealed a Grade 2 follicular lymphoma (Figure 2). The patient had an uneventful postoperative recovery and was well at 6 months follow up. The spleen is an organ with an important immunological function. Primary splenic involvement occurs in less than 1% of non-hodgkin's lymphoma. Symptoms of primary splenic lymphoma (PSL) include pyrexia, weight-loss, night sweats, generalised weakness and left upper quadrant pain secondary to spleno - megaly. Ascites is a rare presenting feature of PSL. This report illustrates a case of primary splenic lymphoma which poses diagnostic challenges for the pathologist and clinician and ultimately requires definitive splenectomy to confirm a diagnosis.Figure 2Photograph of histology slide displaying the lymphoma at 10× magnification.

Surgical approach of primary splenic lymphoma: report of a case and review of the literature

A 80-year-old woman was hospitalized due to anemia and fever. Computed tomography depicted a solitary concentric, sharply marginated lesion of the spleen. Laparotomy identified a creamy-white soft tumor. Histopathological examination confirmed the diagnosis of non-Hodgkin B-cells anaplastic lymphoma. Extended range of pathological manifestations explains the variety of radiological appearances and difficulty in accurate diagnostic process of primary splenic lymphoma.

Excellent prognosis and prevalence of HCV infection of primary hepatic and splenic non-Hodgkin's lymphoma

BACKGROUND

Primary Hepatic (PHL) and Primary Splenic (PSL) non-Hodgkin's Lymphoma are rare entities. Small series of PHL and PSL have been reported, suggesting a non-fortuitous association with Hepatitis C Virus (HCV) infection. The prognosis is believed to be dismal, with early recurrence and short survival.

PATIENTS

We retrospectively reviewed all PHL and PSL patients diagnosed at our institution between 1990 and 2005.

RESULTS

Twenty-five adult patients were identified, six with PHL and 19 with PSL. Twenty-four patients had a B-cell lymphoma, defined as Diffuse Large B-cell lymphoma in 18. The prevalence of HCV infection was 68% among PSL and 66% among PHL. Combination chemotherapy was the mainstay of treatment for PHL and PSL; all but one patient with PSL underwent splenectomy before chemotherapy. Complete remission was achieved in all the cases after frontline therapy; only four patients relapsed but responded to additional chemotherapy courses. Most patients presented with aggressive histological subtypes; 92% were alive at a median follow up of 79 months. HCV infection did not appear to influence the results of therapy.

CONCLUSION

Our study confirms the rarity of PHL and PSL, shows a high prevalence of HCV infection, and demonstrates that the outcome of patients with PHL and PSL may be favourable.

Primary splenic lymphoma associated with hemophagocytic lymphohistiocytosis complicated with splenic rupture

Primary splenic lymphoma (PSL) is a rare disease with ambiguous definition, comprising less than 1% of non-Hodgkin's lymphoma. Even rarer is PSL combined with hemophagocytic lymphohistiocytosis (HLH), which has presentations of fever, cytopenia, hepatosplenomegaly, hyperferritinemia, and phagocytosis of hematopoietic cells in the reticuloendothelial system. We report the case of a 77-year-old man who presented with HLH initially. Refusing diagnostic splenectomy, he received chemotherapy. Spontaneous splenic rupture occurred after chemotherapy. In the following emergency operation, PSL was diagnosed. He received another 5 courses of chemotherapy with the R-CNOP regimen (rituximab, cyclophosphamide, mitoxantrone, vincristine, prednisolone). Now he has no residual or relapsed disease. Diagnostic splenectomy for adult HLH patients without definite etiologies may play an important role.

Lymphoma of the spleen

Splenic involvement in lymphoma is common, although it is detected with limited accuracy using most conventionally employed imaging techniques. This article reviews the spectrum of appearances of splenic lymphoma using both routine and more recently developed techniques, including functional imaging. The importance of accurate splenic imaging in lymphoma assessment is also discussed, which has changed in recent years due to advances in therapy resulting in improvements in overall prognosis for both advanced and relapsed disease.

Indications for Splenectomy

In the new millennium, indications for splenectomy have expanded. Proper patient selection based on an understanding of the biology of each individual's disease is essential for a favorable outcome. We review the most common diseases for which surgeons may be called on to perform splenectomy and while highlighting potential pitfalls and caveats.

Primary non-Hodgkin's lymphoma of the spleen presenting as space occupying lesion: a case report and review of literature

Primary splenic lymphoma (PSL) is rare with a reported incidence of less than 1%. Diffuse large cell pathology has been reported in 22-23% of the cases and is felt to have poor outcome. This study reports a 50 year old male who presented with fever and weakness. He was found to have a mass lesion in the spleen documented by CT scan. A splenectomy was performed which showed non-Hodgkin's lymphoma. Immunohistological studies showed a positivity for CD20 and CD30.

Three cases of diffuse large B-cell lymphoma presenting as primary splenic lymphoma

Primary splenic lymphoma (PSL) is often defined as generalized lymphoma with splenic involvement as the dominant feature. It is a rare disease that comprises approximately 1% of all malignant lymphomas. We investigated three cases of non-Hodgkin's splenic lymphoma that had different clinical features on presentation. The patients' survival times from diagnosis ranged from 59 to 143 months, without evidence of relapse after splenectomy and chemotherapy, with or without radiotherapy. This data suggest that PSL is potentially curable. Further studies are needed to evaluate the impact that different treatment modalities without splenectomy have on patient survival.

Treatment options for primary splenic low-grade non-Hodgkin's lymphomas

The purpose of this comparative study was to evaluate the response of primary splenic low-grade non-Hodgkin's lymphomas (NHL) to chemotherapy, splenectomy, and chemotherapy combined with splenectomy in order to elaborate the optimum treatment modality. A total of 104 patients (age range: 15-82 years) with primary low-grade B-cell NHL of the spleen were comprised by our study. Stage IV disease was determined in 102 (98.1%) cases. Regarding the treatment modality, splenectomy was performed in 14 patients, early splenectomy and single-agent chemotherapy in 15, early splenectomy and combined chemotherapy in 19, single-agent chemotherapy in 23, and combined chemotherapy in 33. In the above-mentioned order, complete remission rate was following: none, 40.0, 31.6, 21.8, and 18.2%. Partial remissions were achieved in 85.7, 46.7, 57.9, 30.4, and 69.7% of cases, respectively. The median remission duration turned out to be longer (74.5 months) in the group of patients with complete remissions attained by means of splenectomy and combined chemotherapy. Local relapses in the spleen developed in 19 (72.7%) patients treated with combined chemotherapy and in 9 (90.0%), who had undergone single-agent chemotherapy. The 5-year overall survival was 54.4% after splenectomy, 39.4% after single-agent chemotherapy, and 37.1% after combined chemotherapy, being significantly higher (P <0.05) after splenectomy and single-agent chemotherapy (67.2%), and splenectomy followed by combined chemotherapy (64.7%). Early splenectomy combined with chemotherapy is the optimum treatment option for primary low-grade NHL of the spleen because of the superiority in complete remission rate, remission duration, and in overall survival rate. Splenectomy leads to somatic compensation of patients, makes impossible local relapsing in the spleen, prevents continuous dissemination from the primary tumor site, and mostly corrects cytopenias, creating better conditions for chemotherapy.

Large B-cell lymphoma presenting in the spleen: identification of different clinicopathologic conditions

Only a few series of splenic large B-cell lymphoma have been previously reported, including limited immunophenotypic studies and clinical data. Here we review the clinical data, morphology, and immunophenotype of series of 33 cases of large B-cell lymphoma presenting in the spleen. Three main groups of tumors are identified. Group A was characterized by macronodular tumors (20 cases), with predominantly stage I disease and a favorable clinical outcome. All cases were bcl6 positive. Group B was characterized by a micronodular pattern (nine cases), including a subset with T-cell-rich B-cell lymphoma features. Most of the patients in this group were diagnosed at advanced clinical stages and died of the disease. All cases were bcl6 positive. Group C was characterized by diffuse red pulp infiltration (four cases) and advanced clinical stages and showed an aggressive behavior. All but one case were bcl6 positive. The results of this series define a characteristic type of large B-cell lymphoma presenting in the spleen as a tumoral mass, associated with a relatively favorable clinical course. Additionally, they provide evidence that clinical presentation as a tumor confined to the spleen and the hilar lymph nodes is associated with lower aggressivity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Splenectomy influences bone marrow infiltration in patients with splenic marginal zone cell lymphoma with or without villous lymphocytes

BACKGROUND

Splenic marginal zone cell lymphoma (SMZL) is a low grade B-cell lymphoma in which patients can have circulating villous lymphocytes and can show a peculiar intrasinusoidal bone marrow (BM) infiltration. Splenectomy is the reported treatment of choice for these patients. The objective of this study was to evaluate the effects of splenectomy on patients with BM lymphomatous infiltration.

METHODS

BM biopsies of 16 patients with SMZL were studied morphologically and immunohistochemically. In 12 patients, BM biopsies were taken before and after splenectomy. Four patients did not undergo splenectomy, and their BM biopsies were performed with an approximately 1 year interval.

RESULTS

BM infiltration ranged from 10% to 40% of overall cellularity and was mostly of the intrasinusoidal type. After splenectomy, BM infiltration tended to become frankly nodular and showed an increase in tumor burden. Nonsplenectomized patients showed an unmodified picture.

CONCLUSIONS

Splenectomy seems to induce important changes in patients with BM infiltration, probably through the lack of microenvironmental factors on circulating cells. These effects suggest reconsidering the role of splenectomy in the treatment of patients with SMZL.

Splenic marginal zone lymphoma with increased number of blasts: an aggressive variant?

Splenic marginal zone lymphoma (SMZL) is a recently described and distinctive type of splenic lymphoma and is characterized by an indolent clinical course. By analyzing a large series of SMZL cases, we recognized the existence of a subset of 6 cases characterized by an aggressive clinical course that led to death caused by the tumor in 5 of 6 cases, whereas the remaining patient showed signs of tumor progression. The morphological, immunohistological, and molecular study of these cases has allowed us to detect precise distinctive features of this SMZL variant. The cases included here were characterized by massive splenomegaly and a morphological picture showing a micronodular pattern of splenic involvement with follicle replacement, biphasic cytology, and marginal zone differentiation. Unlike classical SMZL cases, a conspicuous component of larger lymphocytes was distributed in the marginal zone ring, occasionally overrunning it, with isolated presence of the same cells within the central small cell component and also in the red pulp. The bone marrow and peripheral lymph nodes showed similar histological findings to those described for SMZL in these locations. The genetic and molecular study of these cases showed no alterations specific to other lymphoma types, such as t14;18 and t11;14. Instead of this, it showed 7q loss in 3 of 5 cases, p53 inactivation in 2 of 6 cases, cyclinD1 overexpression in 2 of 6 cases, and the presence of translocations involving the 1q32 region in 2 of 4 cases. The recognition of this aggressive variant, besides offering a prognostic indication, could lead to a more suitable form of clinical management of these patients. Further molecular studies would clarify the role of the different genetic alterations found.

Role of laparoscopy for Hodgkin's and non-Hodgkin's lymphoma

An efficacious approach to the diagnosis and treatment of lymphoma requires the expertise of both physicians and surgeons. The surgeon frequently is required to provide an adequate tissue diagnosis, stage the disease, and treat complications of the disease such as splenomegaly. Often, abdominal and retroperitoneal operations are required which may be unnecessarily morbid. Minimally invasive surgical techniques may favorably impact on the work-up and treatment of lymphoma. Laparoscopy can expeditiously access retroperitoneal lymphadenopathy, sample abdominal lymph node groups, and perform splenectomy with low morbidity and rapid recovery. In Hodgkin's disease, laparoscopic staging with splenectomy may be the best modality for infradiaphragmatic staging to tailor initial treatment. Laparoscopic splenectomy is also effective in the treatment of the symptoms and hematologic derangements of splenomegaly or primary splenic lymphoma. The technique of laparoscopic splenectomy is emphasized.

Early postoperative complications of splenectomy for hematologic disease

Splenectomy may be indicated in a variety of hematologic diseases for diagnostic reasons, therapeutic reasons, or both. Most reviews reveal a high proportion of procedures performed as part of the staging process for Hodgkin disease. Splenectomy for myelofibrosis has been associated with an increased postoperative complication rate. Other determinants of morbidity have been splenic weight and operative blood loss. The authors reviewed a series of 83 adult patients from a prospective database established in 1991 to determine the incidence of early postoperative complications associated with splenectomy for hematologic disease and to analyze patient characteristics that may predict their occurrence. Morbidity that occurred within 30 days of splenectomy was considered to be an early postoperative complication. Operative estimated blood loss and incidence of postoperative complications were correlated with patient age, preoperative platelet count, splenic weight, and diagnosis of myelofibrosis as regression covariates. Indications for splenectomy were therapeutic in 76 patients (92%). Median splenic weight was 760 g, and 22 patients had massive splenomegaly. Patients with splenic weight more than 1,500 g had a significantly higher median estimated blood loss (300 ml; p = 0.02). Splenic weight was the main determinant of estimated blood loss in a multiple linear regression analysis (p = 0.02). Twenty-two patients (27%) experienced postoperative complications and five of those patients died (6%). Patients with myelofibrosis had the highest incidence of complications (50%) and the highest postoperative mortality (21%; p = 0.04). In a logistic regression model, estimated blood loss was the only variable significantly correlated with postoperative complications (p = 0.02). Splenectomy for hematologic disease is associated with an acceptable early postoperative complication rate, even when the indication is predominantly therapeutic. Patients at particularly high risk include those with elevated operative blood loss, massive splenomegaly, and myelofibrosis.

Laparoscopic splenectomy for non-Hodgkin lymphoma

BACKGROUND AND OBJECTIVES

The spleen is frequently involved in patients with non-Hodgkin lymphoma (NHL). The indications for splenectomy in this disease include amelioration of symptoms from splenomegaly, correction of cytopenias, and the need to establish the diagnosis. The aim of this study was to determine the feasibility of laparoscopic splenectomy for patients with splenomegaly and NHL.

METHODS

Retrospective review was made of patients who underwent laparoscopic splenectomy for suspected NHL.

RESULTS

A total of 57 laparoscopic splenectomies have been performed in the lateral position; 9 of these patients had NHL. All patients had splenomegaly with a mean craniocaudal length of 17.8 cm and mean morcellated splenic weight of 765 gm. The mean operating-room time was 185 min, with a mean blood loss of 108 cc. None were converted to open splenectomy, and there was no mortality. The mean postoperative stay was 2-4 days. At a mean follow-up of 6.7 months, there have been no major complications or sepsis.

CONCLUSIONS

Laparoscopic splenectomy is indicated in the setting of splenomegaly and suspected lymphoma. The operation is best performed in the lateral position, which is successful in patients with massive splenomegaly.

Primary non-Hodgkin's splenic lymphoma

OBJECTIVES

To describe the imaging, clinical and pathological features of primary splenic lymphoma using a strict definition.

METHODS

Of 21 cases, plain films were available in nine, sonograms in 10 and CT in 16. We categorized the spleen as either normal, enlarged with no focal defects (type 1), studded with miliary masses (type 2), containing multifocal masses of varying size (1-10 cm) (type 3) or containing a solitary large mass >5 cm without (type 4A) or with (type 4B) central hypodensity/anechoic areas.

RESULTS

Clinical presentations were left upper quadrant pain, weight loss and/or fever. One case was found incidentally on CT. Fourteen were type 4A, three type 4B, four type 3 and none were type 1 or 2. Nine of 10 cases were hypoechoic. In 11/12 cases with enhanced scans, the lesions are hypodense relative to the splenic parenchyma, and in one case, the lesion was necrotic. Rim enhancement was seen in one case.

CONCLUSION

Primary splenic lymphoma usually presents as a mass or masses rather than with splenomegaly alone. Splenectomy may be required for diagnosis.

The relationship between primary splenic malignant lymphoma and chronic liver disease associated with hepatitis C virus infection

BACKGROUND

An etiologically important role has been suggested for hepatitis C virus (HCV) infection in the development of B-cell non-Hodgkin's lymphoma (NHL). HCV has been recognized as the major cause of non-A, non-B chronic hepatitis throughout the world. Moreover, the occurrence of primary splenic malignant lymphoma (PSML) has been demonstrated in patients with chronic liver disease.

METHODS

In this study, the authors describe three patients with PSML. The clinical, histologic, and immunohistochemical features of the lymphomas were studied. Clonal immunoglobulin heavy chain gene rearrangement was investigated by polymerase chain reaction.

RESULTS

All three cases of PSML were detected by imaging studies performed in routine follow-up of cases of chronic liver disease associated with HCV infection. Macronodular lesions were found in the three spleens; two of them were of normal weight and another was moderately enlarged. The former two were the smallest PSMLs reported to date. The histology was B-cell NHL in all cases. All 3 patients were alive after splenectomy with an average follow-up of 51.7 months (range, 35-74 months).

CONCLUSIONS

HCV infection may play an etiologic role in the development of splenic B-cell lymphoma. The long survival of the patients in this study may have been due to early splenectomy.

Splenectomy for non-Hodgkin's lymphoma

Splenomegaly is a common occurrence in the course of non-Hodgkin's lymphoma (NHL), sometimes leading to development of bulk symptoms or cytopenias. Splenomegaly may also be the primary manifestation of NHL. We reviewed our experience with diagnostic and therapeutic splenectomy for NHL over the past 3 years. In July of 1991, a prospective database had been established to evaluate elective splenectomy for hematologic disease; of 58 patients, 12 had NHL. Splenectomy was performed for diagnostic purposes, correction of cytopenias, and relief of bulk symptoms. Most patients had more than one indication for splenectomy. Operative hemorrhage requiring transfusion was seen only in patients with massive splenomegaly (> 1,500 g). Median postoperative hospital stay was 4 days. There was no operative mortality or major morbidity. Minor morbidity was seen in 17% of patients. A favorable hematologic response was seen in 80% of cytopenias at the 3-month postoperative interval. Splenectomy is safe and effective in appropriately selected patients with NHL.

Durable complete remission of macroglobulinemia after splenectomy: a report of two cases and review of the literature

Two patients with macroglobulinemia (monoclonal IgM in the serum) and massive splenomegaly were incapacitated by progressive disease refractory to standard chemotherapy. In each case, palliative splenectomy was followed by a prompt, complete, and unexpected clinical remission with disappearance from the serum of the monoclonal IgM component. One patient remains free of disease 12 years after splenectomy. The other patient remained free of detectable macroglobulinemia for 13 years after splenectomy. A review of the literature revealed other cases of remission of macroglobulinemia attributable to splenectomy alone. Data in humans and animals suggest that the spleen may facilitate IgM secretion by normal and malignant B lymphocytes. Splenectomy should be considered a possible treatment option for patients with massive splenomegaly and macroglobulinemia who progress on chemotherapy.

Multiple autoantibody production in a patient with splenic lymphoma

We report on a patient with splenic lymphoma of B-cell origin who developed autoimmune hemolytic anemia (AIHA). IgM lambda M-protein, IgM anticardiolipin antibody (ACA), and lupus anticoagulant (LA) were detected in the serum, and direct Coombs' test showed autoantibodies of the IgG1 and IgG2 subclasses on red blood cells (RBC). In in vitro culture, tumor cells isolated from the spleen produced only IgM ACA, which was enhanced by IL-6 but not by IL-4 or IL-5. The levels of ACA and LA decreased after splenectomy and chemotherapy; the strength of the direct Coombs' test, however, did not change. These findings indicated that in this patient the lymphoma cells produced IgM lambda ACA, but not autoantibodies of the IgG1 and IgG2 subclasses against RBC. It was also suggested that IL-6 might at least partially stimulate the production of ACA.

Splenectomy in patients with undiagnosed splenomegaly

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