Littoral Cell Angioma of the Spleen: An Additional Report of Four Cases with Emphasis on the Association with Visceral Organ Cancers

Incidental littoral cell angioma of the spleen: cross-sectional imaging findings and review of the literature

Littoral cell angioma (LCA) is a primary splenic hemangioma found mostly in normal red sinus shore cells of the reticuloendothelial cell system of the spleen. In most cases is benign, but sometimes malignancies have been reported. This tumor displayed epithelial and histiocytic properties based on its cell of origin, splenic littoral cells. In this case report, we will describe a case of a 21-year-male presenting with an incidentally discovered LCA illustrated by cross-sectional imaging techniques, highlighting how the diffusional sequence and the positron emission tomography study, thanks to their greater specificity, have contributed to reaching a correct diagnostic orientation more than dynamic studies with contrast agent in both computed tomography and magnetic resonance.

Clinical Landscape of Littoral Cell Angioma in the Spleen Based on a Comprehensive Analysis

Objective

Littoral cell angioma (LCA) is currently considered to be a rare splenic tumor with malignant potential. As the epidemiology, pathogenesis, clinical manifestation, treatment, and prognosis remain unclear, the clinical diagnosis and treatment of LCA have not been standardized. Hence, we performed a comprehensive analysis of 189 observational studies comprising 435 patients to improve the current status of diagnosis and treatment.

Methods

PubMed, Embase, WanFang and CNKI were searched from inception to May 2021 to identify LCA studies that were published in English and Chinese. The clinical information of LCA patients were extracted and analyzed.

Results

The LCA has a male-to-female ratio of 0.90 and a solitary-to-multiple ratio of 0.31. In terms of clinical features, 69.7% of the patients showed splenomegaly, 49.7% were asymptomatic, and 39.2% experienced epigastric discomfort. As the imaging findings of patients with LCA were nonspecific, an image-guided biopsy (10/12) was a safe and effective method for diagnosing in this condition. Notably, results of the prognostic analysis indicated that LCA has a lower risk of recurrence and metastasis. The patient may develop a stable disease or the tumor will grow but will not metastasize. Besides, the novel immunohistochemical pattern of LCA was described as CD31⁺/ERG⁺/FVIII Antigen⁺/CD68⁺/CD163⁺/lysozyme⁺/CD8⁻/WT1⁻.

Conclusion

LCA should be reconsidered as a benign primary splenic vascular neoplasm, which is more like an intra-splenic manifestation of abnormal body function. Image-guided biopsy with follow-up might be a beneficial choice for LCA patients. For LCA patients with abdominal discomfort, pathological uncertainty or continuous tumor enlargement, splenectomy remains the preferred treatment.

Rare case of littoral cell angioma recognised on CT simulation for adjuvant radiation treatment for early stage breast cancer

A 63-year-old woman with pathological anatomic/prognostic stage IA ER+/PR+/HER2- multifocal invasive mammary carcinoma with mixed ductal and lobular features of the left breast underwent lumpectomy with sentinel lymph node biopsy. During evaluation of the CT simulation for adjuvant radiation (RT) treatment planning, a liver lesion and splenomegaly were noted. A subsequent MRI abdomen revealed a large, indeterminate splenic lesion with a wide differential and a benign liver cyst. The patient ultimately underwent splenectomy, with pathology consistent with littoral cell angioma, a rare entity associated with several malignancies. At last follow-up, 7 months after completion of RT, she remained cancer free while on anastrazole and was doing well clinically.

Incidental Splenic Findings on Cross-Sectional Imaging

Incidental splenic focal findings are commonly encountered in clinical practice and frequently represent a diagnostic dilemma due to nonspecific imaging features. Most are benign, particularly in patients without a history of malignancy and without symptoms of fever, weight loss, or left upper quadrant or epigastric pain. Incidental malignant splenic processes are exceedingly rare. This article reviews imaging characteristics of incidental focal splenic findings, and proposes a practical approach for management of such findings, which can prevent unnecessary workup and its related drawbacks in clinical practice.

Vascular neoplasms and non-neoplastic vascular lesions of the spleen

Vascular neoplasms are among the most common conditions affecting the spleen. The majority of these are idiopathic, benign in nature and asymptomatic and therefore treated with a conservative management. Only rare cases cause splenomegaly and/or chronic consumption coagulopathies, thus requiring splenectomy. Among these, the most common is splenic hemangioma, followed by littoral cell angioma and lymphangioma. Peliosis is a peculiar tumor-like non-neoplastic vascular lesion that diffusely affects the spleen and frequently presents with concomitant hepatic involvement. As a distinctive feature, peliosis can occur as a secondary manifestation of infections, malignancies and in individuals using certain drugs. On the opposite spectrum of clinical behavior lies splenic angiosarcoma, a vascular endothelial malignancy with aggressive presentation and poor prognosis. In some cases the endothelial nature of this neoplasm may not be evident on routine histologic examination and immunohistochemistry is used to disclose such phenotype. The term hemangioendothelioma is rarely used to describe borderline vascular neoplasms which appear more aggressive than conventional hemangiomas, but that do not entirely fulfill the diagnostic criteria for angiosarcoma. Some of these neoplasms coexpress endothelial and histiocytic markers and therefore have been proposed as the borderline counterpart of littoral cell angioma. The existence of hemangioendothelioma as a diagnostic entity per se is debated and this diagnosis should be rendered with caution. The current review aims at highlighting the main histologic features of vascular neoplasms and non-neoplastic vascular lesions of the spleen.

The Sequence of the Evil: A Case Report of Idiopathic Noncirrhotic Portal Hypertension Associated With Littoral Cell Angioma of the Spleen, 4 Years After the Successful Treatment of a Colon Cancer

Idiopathic noncirrhotic portal hypertension is a rare clinical entity. Even rarer is the littoral cell angioma of the spleen. The almost simultaneous appearance of the two disorders in a 64-year-old Greek woman was a tempting stimulus for us to attempt to identify a common denominator between these two, apparently distinct, entities.

Littoral cell angioma of the spleen: a study of 25 cases with confirmation of frequent association with visceral malignancies

AIMS

Littoral cell angioma (LCA) is a rare primary splenic tumour that is frequently associated with internal malignancies. Immunohistochemistry can demonstrate a distinct hybrid endothelial-histiocytic phenotype of littoral cells, and is a helpful adjunct for making the correct diagnosis. The aims of this study were to present a series of 25 LCAs, with an emphasis on the frequent association of the neoplasm with visceral malignancies, and to provide a detailed immunohistochemical analysis by employing new markers.

METHODS AND RESULTS

All 25 cases with available tissue blocks were immunohistochemically stained for endothelial and histiocytic markers. Clinical and follow-up data were retrieved from the respective institutions. The tumours were obtained from 16 males and nine females, whose age ranged from 32 to 86 years (mean 56.2 years). Clinical information was available for 24 of 25 patients, and follow-up for 11 of 25 patients (range 2-19 years; mean 11.6 years). Immunohistochemically, all cases were positive for LYVE-1, factor VIII, FLI-1, vascular endothelial growth factor receptor (VEGFR)-2, VEGFR-3, claudin-5, ERG, LMO2, CD31, CD163, lysozyme, and CD4, but negative for D2-40, CD8, and factor XIIIa. Fifteen of 25 cases were associated with various malignancies, including epithelial, mesenchymal and haematological tumours.

CONCLUSIONS

The cohort of 25 patients is the largest series of LCAs published to date. By using antibodies against recently introduced endothelial markers, we have expanded the immunoprofile of LCA. We have further highlighted the clinical significance of LCA, as more than half of the patients in this study also harboured a coexisting visceral malignancy. Therefore, we conclude that the finding of splenic LCA mandates a thorough clinical evaluation for a concomitant malignancy.

Littoral cell angioma in a patient with Crohn's disease

Littoral cell angioma is a rare vascular tumor of the spleen. The pathogenesis is unknown but the lesion is associated with several malignancies and immunological disorders. The diagnosis requires histopathological examination. The malignant potential of this lesion is unknown, which is why splenectomy is recommend for all cases. Symptomatic cases generally suffer from hypersplenism and pyrexia. A previously healthy 20-year-old female was diagnosed with colonic Crohn's disease; as part of the work-up a magnetic resonance enterography was performed which showed multiple signal changes of the spleen. The patient reported chronic abdominal pain in the left upper quadrant, malaise, and fever. The unknown splenic lesions prompted a laparoscopic splenectomy; pathology revealed a littoral cell angioma. The abdominal pain and malaise remitted but the fever persisted one year despite adequate treatment of the patient's Crohn's disease. Littoral cell angioma is associated with immune-dysregulation including Crohn's disease with several reported cases. Signs and symptoms of hypersplenism and splenic lesions on imaging should raise suspicion of littoral cell angioma in patients with Crohn's disease. Magnetic resonance enterography to assess disease severity in Crohn's disease may provide an opportunity to study the prevalence and natural history of this rare splenic 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.

SIRPα/CD172a and FHOD1 are unique markers of littoral cells, a recently evolved major cell population of red pulp of human spleen

Asplenic individuals are compromised not only in their ability to destroy infectious agents, but are at increased risk for death from autoimmune disease, certain tumors, and ischemic heart disease. Enhanced mortality is attributed to lack of phagocytes sequestered in spleen that efficiently engulf and destroy appropriate targets, although related cells are found elsewhere. To determine whether a unique population regulates RBC-pathogen clearance and filtration of altered self, we reviewed the anatomic literature and analyzed in situ by immunohistochemistry and immunofluorescence the expression patterns of a little-characterized cell that dominates the splenic red pulp of humans and closely related primates: the venous sinus-lining or littoral cell (LC). High expression of the formin homology domain protein 1 outlines the LC population. Although LCs are endothelial-like in distribution, they express several macrophage-directed proteins, the RBC Duffy Ag receptor for chemokines and T cell coreceptor CD8α/α, yet they lack lineage-associated markers CD34 and CD45. Strikingly, SIRPα (CD172a) expression in human spleen concentrates on LCs, consistent with recent demonstration of a key role in RBC turnover and elimination versus release of infected or altered self. Our results indicate human LCs (SIRPα(+), formin homology domain protein 1(+), CD8α/α(+), CD34(-), CD45(-)) comprise a highly plastic barrier cell population that emerged late in primate evolution coordinate with CD8 expression. Unique to Hominidae, LCs may be the ultimate determinant of which cells recirculate after passage through human spleen.

Littoral cell angioma mimicking hepatic tumor

Littoral cell angioma is a rare vascular tumor of the spleen that was described by Falk et al. in 1991. Because of the limited number, untypical imaging manifestations, and lack of knowledge on this tumor type, these tumors are often misdiagnosed. In most cases, the tumor presents with multiple small hypoattenuating nodules in the spleen with delayed enhancement. However, solitary littoral cell angiomas have not been well described. We present the CT features of an unusual littoral cell angioma mimicking hepatic tumor.

The splenic Littoral cell angioma in China: a case report and review

Littoral cell angioma (LCA) is a rare splenic vascular neoplasm that arises from the cells lining the red pulp sinuses. It is deemed to be a benign and incidental lesion. The earliest literature report of littoral cell angioma has been described by Falk. The examination of samples after splenectomy reveals similar pathological change and its change rule is summarized. However, many recent reports have described it to be a malignant tumor with congenital and immunological associations. Generally speaking, the definitive diagnosis can only be made after histological and immunohistochemical profiles. In this case report, we presented the case of a 48-year-old woman with multiple splenic LCAs. Initially, the patient was characteristics of abdominal distension, weakness and fatigue. Multiple hemangiomas were observed in the spleen through abdominal ultrasonic diagnosis. Computed tomography (CT) scans revealed the splenomegaly with multiple round and hyperdense lesions. The patient subsequently underwent splenectomy. Postoperative histological and immunohistochemical studies confirmed the diagnosis of LCA. Based on the presentation of this case, clinical, radiographic and pathological results of LCA as well as recent advances in our understanding of this uncommon splenic lesion were reviewed. LCA is an uncommon splenic tumor diagnosed in patients with or without abdominal discomfort. Only a few case reports regarding this kind of tumor have been published as inconsistent results. In the present paper, we have reported a case of LCA and reviewed the literature.

Littoral cell angioma of the spleen in a patient with previous pulmonary sarcoidosis: a TNF-α related pathogenesis?

BACKGROUND

Littoral cell angioma (LCA) is a rare vascular tumor of the spleen. Generally thought to be benign, additional cases of LCA with malignant features have been described. Thus, its malignant potential seems to vary and must be considered uncertain. The etiology remains unclear, but an immune dysregulation for the apparent association with malignancies of visceral organs or immune-mediated diseases has been proposed.

CASE PRESENTATION

We report a case of LCA in a 43-year old male patient who presented with a loss of appetite and intermittent upper abdominal pain. Computed tomography showed multiple hypoattenuating splenic lesions which were hyperechogenic on abdominal ultrasound. Lymphoma was presumed and splenectomy was performed. Pathological evaluation revealed LCA.

CONCLUSIONS

LCA is a rare, primary vascular neoplasm of the spleen that might etiologically be associated with immune dysregulation. In addition, it shows a striking association with synchronous or prior malignancies. With about one-third of the reported cases to date being co-existent with malignancies of visceral organs or immune-mediated diseases, this advocates for close follow-ups in all patients diagnosed with LCA. To our knowledge, this report is the first one of LCA associated with previous pulmonary sarcoidosis and hypothesizes a TNF-α related pathogenesis of this splenic tumor.

Littoral cell angioma of the spleen diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy

Littoral cell angiomas are uncommon primary vascular neoplasms that arise from the sinusoidal lining or littoral cells of the splenic red pulp, and hence are unique to the spleen. We report a case of littoral cell angioma in 34-year-old woman, which was diagnosed by endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB). The cytologic features of littoral cell angiomas have been described only in three previous case reports, one of which was a bench-top aspirate. In our case, we have utilized the fine-needle aspiration samples obtained by a linear endoscopic ultrasound examination for establishing the diagnosis. The characteristic cytologic features identified on the smears along with immunohistochemical analysis performed on the compact cellblock prepared from the aspirate aided in the confirmation of the diagnosis. We suggest that EUS-FNAB is a safe and reliable method in the diagnosis of vascular lesions of the spleen.

Littoral cell angiomas of the spleen associated with solid pseudopapillary tumor of the pancreas

Littoral cell angiomas (LCA) of the spleen are vascular tumors of unknown etiology arising from the littoral cells of the splenic red pulp sinuses. Usually a benign and incidental finding, LCA have been repeatedly reported in association with a variety of visceral malignancies and hold the potential for dissemination per se. We encountered a case of a 30 year old female who was diagnosed with solid pseudopapillary tumor of the head and distal pancreas by fine needle aspiration cytology. A distal pancreatectomy with splenectomy was performed in addition to a pylorus-preserving Whipple’s procedure and cholecystectomy. Histopathological examination confirmed solid pseudopapillary tumor of the pancreas and showed multiple well-circumscribed anastomosing vascular channels in the spleen. The diagnosis of LCA of the spleen was confirmed by immunohistochemistry that revealed co-expression of endothelial cell marker, CD31 and CD34, along with histiocytic marker, CD68 by the vascular lining cells. LCA has been previously reported in association with colorectal and pancreatic adenocarcinoma, malignant lymphoma, myelodysplasia and autoimmune disorders. We report the first case of LCA associated with solid pseudopapillary tumor of the pancreas.

[Littoral cell angioma of the spleen. Association with colon and hepatocellular carcinoma]

Littoral cell angioma is a rare vascular tumor of the spleen. An increased association with concomitant malignancies has been described. We report the case of a 67-year-old man suffering from colon carcinoma and presenting with a tumor of the spleen which could be seen using radiography. Splenectomy was performed and histology revealed a 2.1 cm vascular tumor with a characteristic immunophenotype (CD31/68+). In addition a hepatocellular carcinoma was found. Due to the relationship with malignant tumors littoral cell angioma should be considered in every case of a splenic tumoral space-occupying mass, particularly in carcinoma patients.

Littoral cell angioma in main and accessory intrapancreatic spleen presenting as splenic rupture

We report the incidental finding of a nodular mass in the pancreatic tail on a contrast-enhanced computed tomography scan preinterventional to emergency laparotomy for splenic rupture. Because of the past surgical history and radiologic appearance, differential diagnosis included atypical lymphoma in the spleen and regional lymph node, pancreatic adenocarcinoma with splenic metastasis, and intrapancreatic metastase of malignant melanoma; the patient underwent both splenectomy and pancreatic tail resection. A diagnosis of littoral cell angioma in main and accessory intrapancreatic spleen was made. To our knowledge, this is the first description of littoral cell angioma of the spleen involving both main and accessory organ presenting as splenic rupture.

Rapid progression of littoral cell angioma of the spleen in a man with multiple infections

Littoral cell angioma is an uncommon primary vascular neoplasm of the spleen. It frequently follows a benign course, but cases with aggressive behavior have been described. We present a case of this rare disease highlighting radiological examinations showing a rapid increase in the size of the spleen as well as an increase in the number and size of existing nodules. We also discuss the relationship of this disorder to chronic infections and its possible association with Epstein Barr virus.

[Vascular proliferations of the spleen]

Vascular proliferations of the spleen reflect the variability of vascular structures occurring in the normal spleen. Besides haemangiomas, there is a spleen-specific vascular neoplasm, littoral cell angioma, that often occurs as a paraneoplastic lesion and thus may require the differential diagnostic delineation of metastases to the spleen in patients with known neoplasms. The most common malignant vascular tumours of the spleen are angiosarcomas. A recently described vascular lesion of unknown pathogenesis, sclerosing angiomatoid nodular transformation (SANT) of the spleen, usually is an incidental finding detected in the course of imaging studies.

Partial splenectomy for littoral cell angioma

Littoral cell angioma is a rare primary splenic tumor that is difficult to differentiate preoperatively from other benign and malignant splenic lesions and may have immunogenic origins. Preoperative ultrasound and computed tomographic scan showed that our patient's lesion was solitary and localized. Total splenectomy is usually required because littoral cell angioma is generally large and/or diffuse. However, a partial splenectomy was able to be performed, making this the first reported partial splenectomy for littoral cell angioma.

Incidental littoral cell angioma of the spleen

BACKGROUND

Littoral cell angioma (LCA) is a recently described primary vascular neoplasm of the spleen that may be associated with other malignancies and may itself also have malignant potential.

CASE PRESENTATION

We present a case of LCA that was discovered incidentally in a 52-year-old woman who presented with biliary colic at the time of consultation for cholecystectomy. This vascular neoplasm was evaluated by ultrasound, CT, MRI, Tc-99m labelled red blood cell scintigraphy, and core biopsy. A splenectomy revealed LCA by pathological evaluation. Post-operative outcome was favourable with no evidence of complication or recurrent disease. Following this case presentation, clinical, radiographic, and pathological features of LCA will be reviewed as well as recent advances in our understanding of this uncommon splenic lesion.

CONCLUSION

LCA is a rare, generally benign, primary vascular tumour of the spleen that typically is discovered incidentally. Individuals diagnosed with this tumour must be carefully evaluated to exclude primary, secondary, and synchronous malignancies.

Laparoscopic Treatment of Simultaneous Splenic Lymphangioma and Non-Hodgkin's Lymphoma: Report of a Case

We report, to the best of our knowledge, the first case of simultaneous splenic lymphangioma and non-Hodgkin's B-cell lymphoma with liver and bone marrow involvement arising in a 69-year-old woman suffering from chronic hepatitis C infection treated with laparoscopic splenectomy followed by polychemotherapy. After 22 months from surgical treatment, the patient is alive without signs of residual disease. According to our experience, laparoscopic splenectomy followed by polychemotherapy seems to be an effective treatment for simultaneous splenic lymphangioma and non-Hodgkin's B-cell lymphoma.

Littoral cell angioma of the spleen

Littoral cell angiomas (LCAs) are rare splenic vascular neoplasms that arise from the cells lining the red pulp sinuses. The clinical course is benign and in most cases asymptomatic. However, as has been described in the literature, we have seen an association with malignant neoplasms and haematological disorders. The definitive diagnosis is made on histology and confirmed with immunohistochemistry. The use of percutaneous fine-needle aspiration biopsy (FNA) in preoperative diagnosis is controversial.

Splenic metastases: clinicopathologic presentation, differential diagnosis, and pathogenesis

CONTEXT

Splenic metastases from solid tumors, defined as parenchymal lesion, are considered exceptional. Nevertheless, the number of case reports has been increasing due to the improvement of imaging techniques and the long-term follow-up of patients with cancer. Splenic metastases occur in a context of multivisceral disseminated cancer or as a solitary lesion.

OBJECTIVE

To provide a general overview of the clinicopathologic features, differential diagnosis, and pathogenesis of splenic metastases.

DATA SOURCES

Relevant articles indexed in PubMed (National Library of Medicine) database. The search was based on the following terms: (metastasis or metastases) and spleen.

CONCLUSIONS

The most common primary sources of splenic metastasis are breast, lung, colorectal, and ovarian carcinomas and melanoma in cases of multivisceral cancer and colorectal and ovarian carcinomas in cases of solitary splenic lesion. Splenectomy can be replaced by less aggressive methods such as fine-needle aspiration or percutaneous biopsy for establishing the diagnosis of solitary splenic metastasis. The main differential diagnoses are primary lymphoma, vascular tumors, and infectious lesions of the spleen. The relative rarity of splenic metastases could be explained by anatomic factors and the inhibitory effect of the splenic microenvironment on the growth of metastatic cells. The analysis of clinical case reports suggests that solitary splenic metastases may result from the growth of an early blood-borne micrometastasis following a period of clinical latency, often several years after the diagnosis of the primary tumor.

Primary vascular neoplasms unique to the spleen: littoral cell angioma and splenic hamartoma diagnosis by fine-needle aspiration biopsy

We report the fine-needle aspiration (FNA) biopsy diagnosis of two rare cases of primary vascular neoplasms unique to the spleen: a littoral cell angioma from a 31-yr-old Caucasian woman and a splenic hamartoma from a 46-yr-old black man. The cytologic features of splenic hamartoma and of littoral cell angioma of the spleen were described three times in cytologic literature: two were bench-top aspirates and one was FNA biopsy thought to be metastatic carcinoma. To the best of our knowledge, the current two cases were the first diagnosed by FNA biopsy. Our approach to the FNA biopsy diagnosis of these rare vascular neoplasms via compact cell block and immunohistochemistry is described. The differential diagnosis with other primary vascular splenic neoplasms is also discussed.

Littoral-cell angioma as a rare cause of splenomegaly

We report the case of a littoral-cell angioma of the spleen, a recently described benign vascular tumour, whose imaging and pathological characteristics have been discussed only by a few authors. The diagnosis was made after elective splenectomy. The CT images, scintigraphy and histological specimens are presented, and differential diagnoses discussed.

Multiple littoral cell angioma of the spleen in a case of myelodysplastic syndrome

Littoral cell angioma (LCA) of the spleen is a relatively recently described rare entity, which is associated with haemophagocytosis. In this case report, we will present a case of myelodysplastic syndrome with multiple LCA of the spleen. The patient presented with pancytopenia and multiple haemangiomas were observed in spleen during diagnostic abdominal ultrasound. She required a transfusion of one to two units of packed blood every 4-6 weeks and she eventually underwent a splenectomy in order to decrease the transfusion requirement. Although the patient's pancytopenia improved after surgery, the patient did not achieve a normal haemoglobin level in the two years following the splenectomy. Following further studies, bone marrow aspiration was undertaken and demonstrated minimal dysplasia in erythroid series including nuclear abnormalities, irregular cytoplasmic borders and irregular staining of the cytoplasm. The patient was diagnosed as myelodysplastic syndrome. As LCA of the spleen and myelodysplastic syndrome may both cause cytopenia their co-existence may complicate the clinical presentation leading to an incomplete or inappropriate diagnosis. In cases of haematological disorders with an atypical course, the radiological examination of the spleen should be considered and the possibility of angiomas must be included to the differential diagnosis.

Littoral cell angioma (LCA) associated with liver cirrhosis

A littoral cell angioma (LCA) is a rare benign vascular tumor of the spleen. A 60-year-old man, with multiple nodules in imaging study and liver cirrhosis graded as Child-Pugh classification class A, was transferred for splenomegaly. A thrombocytopenia was found on hematological evaluation. Because there was no evidence of hematological and visceral malignancy, a splenectomy was performed for a definitive diagnosis. The histological and immunohistochemical features of the splenic specimens were consistent with a LCA. After the splenectomy, the thrombocytopenia recovered to the normal platelet count. There has been no previous report of a LCA combined with liver cirrhosis. Herein, the first case of a LCA in Korea, diagnosed and treated by a splenectomy, is reported.

Littoral cell angioma presenting as metastatic thyroid carcinoma to the spleen

Papillary thyroid carcinoma (PTC) commonly metastasizes to cervical lymph nodes. Distant metastases are unusual with the lungs most frequently involved. Well-differentiated thyroid carcinoma very rarely presents with metastases to the spleen. This is the case of a 25-year-old man with a history of PTC (1.4 cm primary; no capsular invasion and negative lymph node metastases). One year after initial surgery, recurrent disease was found in multiple neck nodes by central neck dissection. Whole body scan (WBS) following a therapeutic ablation dose of 150 mCi I(131) revealed mediastinal metastases. Computerized axial tomography (CT) of the chest one year later showed no gross mediastinal or pulmonary disease. However, multiple large splenic lesions were incidentally noted. Evaluation by ultrasound (US) showed lesions to be solid echogenic masses without remarkable Doppler characteristics to suggest vascular tumors. US-guided percutaneous fine-needle aspiration biopsy (FNAB) of one lesion was nondiagnostic. After withdrawal from Levothyroxine, serum TSH was >100 mU/L with a thyroglobulin of 9.4 ng/mL and negative anti-thyroglobulin antibodies. Diagnostic WBS revealed faint splenic uptake but was otherwise unremarkable. Following treatment with 192 mCi I(131), WBS demonstrated increased activity in the mediastinum as well as in the spleen suggesting mediastinal and splenic metastases. Contrast CT of the abdomen showed multiple low-attenuated heterogeneously enhancing splenic masses, normal liver and no intra-abdominal lymphadenopathy. The largest mass (4.5 x 3.5 cm) was exophytic and in close proximity to the splenic capsule. Despite the serum thyroglobulin of only 9.4 ng/mL, the finding of I(131) accumulation within solid splenic masses led to a preoperative diagnosis of thyroid carcinoma metastases. To establish the diagnosis and to remove the risk for splenic rupture, a laparoscopic splenectomy was performed. Histopathologic analysis showed large littoral cell angiomas (LCA). False-positive radioiodine scintigraphy in the setting of PTC involving a vertebral hemangioma has been reported. To our knowledge, this is the first case that describes multiple angiomas mimicking metastatic thyroid carcinoma to the spleen. In one-third of all cases reported, LCA co-exists with various visceral organ cancers or malignant lymphoma. This is the first report of an association between LCA and thyroid carcinoma.

From the Archives of the AFIP

Primary vascular neoplasms of the spleen constitute the majority of nonhematolymphoid splenic tumors. The benign primary vascular tumors include hemangioma, hamartoma, and lymphangioma, whereas those of variable or uncertain biologic behavior include littoral cell angioma, hemangioendothelioma, and hemangiopericytoma. The primary malignant vascular neoplasm of the spleen is angiosarcoma. Peliosis is a rare lesion of unknown cause that is usually found incidentally in asymptomatic patients but may be associated with hematologic or metastatic disease. Although these vascular neoplasms of the spleen are uncommon, their importance lies in that they must be differentiated from the more common neoplastic disorders of the spleen, such as lymphoma and metastasis. The most common echogenic solid or complex cystic mass in an asymptomatic patient is splenic hemangioma. However, the imaging appearance of splenic hemangiomas may be complex, and differentiation of these lesions from malignant disease may not be possible. The diagnosis of splenic hamartoma may be suggested when findings of increased blood flow on color Doppler images are seen in association with a homogeneous solid echogenic mass. A large subcapsular solitary cystic abnormality discovered incidentally in a child in association with internal septations and tiny mural nodules favors the diagnosis of lymphangioma. Any invasion of the surrounding splenic parenchyma by a splenic lesion should indicate a more aggressive or malignant process. Evaluation of a focal splenic abnormality identified on sonograms should be followed up with computed tomography or magnetic resonance imaging with and without contrast material enhancement. Splenectomy may be required for definitive evaluation of a splenic mass with atypical features.

Splenic vascular tumors

Splenic vascular tumors are uncommon and are more typically encountered as benign incidental findings. By contrast, splenic angiosarcoma may present acutely and dramatically and typically pursues a very aggressive clinical course. Vascular tumors in the spleen may show conventional endothelial, specialized endothelial (sinusoidal/littoral cell) or lymphatic differentiation and there is morphologic overlap between some of the currently defined diagnostic categories, within which benign, intermediate, and malignant subsets are recognized. The greatest problem in trying to better define and analyze these tumors is the availability of only relatively small case numbers. This overview describes the diagnosis and differential diagnosis of splenic vascular tumors as presently understood.

Littoral cell angiomatosis with poorly differentiated adenocarcinoma of the lung

We report on a 64-year-old male United States Navy Veteran of World War II, one of two identical twins, diagnosed with littoral cell angiomatosis of the spleen, liver, and lymph nodes, later found to have a massive poorly differentiated adenocarcinoma involving the mediastinum, adjoining lung, and sternum with widespread metastases. Herein we include our findings at autopsy, pertinent immunohistochemical studies, and a review of the literature pertaining to littoral cell angiomatosis with comment on its association with visceral malignancies.

Littoral cell angioma of the spleen: appearance on sonography and CT

Littoral cell angioma (LCA) is a rare benign vascular tumor of the spleen with characteristic histomorphologic features. Only a few descriptions of the radiologic appearance of this tumor have been published, and those descriptions are variable. We report a case of LCA in a 37-year-old man with psoriasis and nonspecific symptoms of weakness, pain and fatigue, normocytic anemia, and thrombocytopenia. The results of abdominal sonography and contrast-enhanced CT correlated: the 2 modalities revealed hepatosplenomegaly and multiple round splenic lesions of similar appearance and size (on sonograms, ill-defined echogenic lesions up to 3.2 cm without acoustic enhancement; on CT scans, hypodense, nonenhancing lesions up to 3.5 cm). Because making a differential diagnosis was difficult and our presumptive diagnosis was hemangioma or lymphoma, splenectomy was performed. Postoperative pathologic examinations confirmed a final diagnosis of LCA. The patient's recovery was uneventful. LCA should be considered when making a differential diagnosis of splenic lesions, and sonography may be more helpful than CT in reaching a diagnosis of LCA.