Hepatic splenosis: Rare yet important - A case report and literature review

A Rare Red Herring: Intrahepatic Splenosis Masquerading as Hepatocellular Carcinoma

Splenosis is defined as viable splenic tissue that is autotransplanted into other compartments in the body. Intrahepatic splenosis is a rare diagnosis that can be difficult for clinicians to identify. The most common causes of splenosis include abdominal trauma and splenectomy. While most patients with intrahepatic splenosis are asymptomatic, in the presence of risk factors of hepatocellular carcinoma, it is paramount to rule out malignancy. In this report, we present a patient with imaging findings concerning for hepatocellular carcinoma, ultimately diagnosed with percutaneous biopsy and technetium-99m-tagged heat-damaged red blood cell scintigraphy-proven intrahepatic splenosis.

Intrahepatic splenosis: Contrast enhanced ultrasound and magnetic resonance imaging findings

OBJECTIVE

To evaluate the contrast enhanced ultrasound (CEUS) and contrast enhanced magnetic resonance imaging (CEMRI) features of intrahepatic splenosis (IHS).

METHODS & MATERIALS

Five patients (three males and two females, median age, 44 years; range,32-73 years) with seven IHSs were retrieved from the database of our hospital from March 2012 to October 2021. All IHSs were confirmed histologically by surgery. The CEUS and CEMRI characteristics of individual lesion were fully analyzed.

RESULTS

All IHS patients were asymptomatic and four out of five patients had history of splenectomy. On CEUS, all IHSs were hyperenhancement in arterial phase. 71.4% (5/7) of IHSs manifested overall filling within few seconds, the other two lesions showed centripetal filling. Subcapsular vascular hyperenhancement and feeding artery was seen in 28.6% (2/7) and 42.9% (3/7) of IHSs, respectively. During portal venous phase, IHSs presented hyperenhancement (2/7) or isoenhancement (5/7). Moreover, rim-like hypoenhanced area was uniquely observed surrounding 85.7% (6/7) of IHSs. In late phase, seven IHSs remained continuous hyper- or isoenhancement. On CEMRI, five IHSs showed mosaic hyperintense in early arterial phase, the other two lesions showed homogeneous hyperintense. In portal venous phase, all IHSs revealed continuous hyper- (71.4%, 5/7) or iso-intense (28.6%, 2/7). During late phase, one IHS (14.3%, 1/7) became hypointense, the other lesions remained hyper- or isointense.

CONCLUSION

Diagnosis of IHS can be based on typical CEUS and CEMRI features in patients with history of splenectomy.

The use of fluorescence laparoscopy in the resection of splenic tissue replantation in the right lobe of the liver: A case report and literature review

BACKGROUND

Ectopic replantation and regeneration of splenic tissue fragments following splenic trauma or splenectomy is known as replantation of splenic tissue. It typically takes place in the abdominal cavity, however, splenic tissue replantation in the liver is extremely rare and difficult to diagnose. It is often misdiagnosed as a liver tumor and removed.

CASE PRESENTATION

We present the case of a patient with a history of traumatic splenectomy 15 years prior to the replantation of splenic tissue in the liver. A 4 cm mass in the liver was found during the most recent physical examination, and a computed tomography scan indicated the possibility of a malignant tumor. The tumor was then removed using fluorescence laparoscopy.

CONCLUSION

There is a possibility of intrahepatic replantation of splenic tissue in patients who have had a splenectomy in the past, have recently discovered an intrahepatic space-occupying lesion, and do not have any high-risk factors for liver cancer. Unnecessary surgery can be avoided if 99mTc-labeled red blood cells imaging using mass puncture or radionuclide examination provides a clear preoperative diagnosis. Globally, there are no reports of the use of fluorescence laparoscopy in resecting replanted splenic tissue in the liver. Specifically, in the current case, there was no indocyanine green uptake in the mass, and only a small amount was found in the normally functioning liver tissue surrounding the tumor.

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.

Pelvic mass causing hematospermia: splenosis

Background

Most patients with splenosis have no clinical symptoms and do not need intervention. Hematospermia and testicular pain occurred in this patient, which was considered to be related to the huge pelvic implantation of the spleen, which was relatively rare in clinical practice, so we hereby report this case.

Case presentation

A 28-year-old male patient with a history of splenectomy was admitted to the Urology Department of the Second Affiliated Hospital of Anhui Medical University with the chief complaint of "Hematospermia for 1 month and testicular pain for 2 days". Preoperative imaging examination indicated pelvic mass. Combined with the patient's history of splenectomy for splenic rupture in childhood, the possibility of pelvic spleen implantation was considered. Laparoscopic pelvic exploration was performed. During the operation, multiple grayish-brown nodular tissues were observed in the space between the posterior bladder and rectum, and a lobulated grayish-brown mass with a diameter of about 9 cm was observed in the posterior upper part of the prostate gland and seminal vesicle at the pelvic floor. Two nodular tissues were removed intraoperatively and sent for quick frozen pathology, which was reported as spleen tissue. Further resection of the huge mass was performed, and the postoperative pathological results were consistent with the diagnosis of splenosis.

Conclusion

We report a rare case of splenosis presenting with hemospermia and testicular pain.

Transplantation of splenic tissue after splenectomy: A case report

Transplantation of splenic tissue is a rare condition that usually occurs after splenic trauma and splenectomy. It usually requires surgery for diagnosis and treatment. A 38-year-old Asian male with familial hemolytic disease underwent laparoscopic splenectomy for a traumatic rupture of the spleen one year prior. The patient developed middle-upper abdominal pain without any obvious cause, radiating to the back and chest seven months prior to presentation. The condition improved with conservative treatment but the patient experienced recurrent episodes. Abdominal CT suggested multiple gallstones in the gallbladder that changed after splenectomy and multiple nodules in the original splenic area; thus, transplantation of splenic tissue was considered. MRI suggested thick gall bladder bile, multiple stones and cholecystitis, and the spleen was not observed (the patient underwent laparoscopic splenectomy at our hospital one year previously due to traumatic splenic rupture); furthermore, there were multiple abnormal signal foci in the splenic area, so the possibility of spleen implantation was considered. Considering the patient's family history of a hereditary hemolytic disease, laparoscopic cholecystectomy was performed simultaneously with laparoscopic accessory splenectomy. The final pathological report revealed chronic cholecystitis, mixed calculi, red pulp dilation, hyperemia and bleeding in round tissue with blood clot formation and acute and chronic inflammatory cell infiltration. Clinicians must bear in mind the possibility of splenosis after splenic trauma and its image variations.

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.

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 supposed hepatocellular adenoma turns out to be intrahepatic splenosis - a case report]

We report the case of a 62-year-old Caucasian male patient who presented with epigastric pain to our outpatient clinic. On abdominal ultrasound we detected a 26 mm oval hypoechoic lesion in segment 2 of the left liver lobe. Performing contrast-enhanced ultrasound this lesion showed an arterial hypervascularization with centripetal filling and a spoke wheel pattern. Due to a hyperenhancement during the portal and late phase this lesion led to the diagnosis of a benign liver tumor, probably a hepatocellular adenoma (HCA). As focal nodular hyperplasia (FNH) was still another possible diagnosis, we decided to perform an MRI, which could not differentiate between HCA and hepatocellular carcinoma (HCC). Therefore, we performed liver biopsy of this lesion. Histology and immunohistochemistry led to the final diagnosis of intrahepatic splenosis. Reassessment of patient history revealed an abdominal trauma with splenic rupture 5 years ago. Intrahepatic splenosis should be considered as an important differential diagnosis in patients with unknown liver tumor and a history of splenic trauma.

Gastric splenosis mimicking a gastrointestinal stromal tumor: A case report

BACKGROUND

Mass lesions located in the wall of the stomach (and also of the bowel) are referred to as “intramural.” The differential diagnosis of such lesions can be challenging in some cases. As such, it may occur that an inconclusive fine needle aspiration (FNA) result give way to an unexpected diagnosis upon final surgical pathology. Herein, we present a case of an intramural gastric nodule mimicking a gastric gastrointestinal stromal tumor (GIST).

CASE SUMMARY

A 47-year-old Caucasian woman, who had undergone splenectomy for trauma at the age of 16, underwent gastroscopy for long-lasting epigastric pain and dyspepsia. It revealed a 15 mm submucosal nodule bulging into the gastric lumen with smooth margins and normal overlying mucosa. A thoraco-abdominal computed tomography scan showed in the gastric fundus a rounded mass (30 mm in diameter) with an exophytic growth and intense enhancement after administration of intravenous contrast. Endoscopic ultrasound scan showed a hypoechoic nodule, and fine needle FNA was inconclusive. Gastric GIST was considered the most probable diagnosis, and surgical resection was proposed due to symptoms. A laparoscopic gastric wedge resection was performed. The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day. The final pathology report described a rounded encapsulated accumulation of lymphoid tissue of about 4 cm in diameter consistent with spleen parenchyma implanted during the previous splenectomy.

CONCLUSION

Splenosis is a rare condition that should always be considered as a possible diagnosis in splenectomized patients who present with an intramural gastric nodule.

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.