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      Intra-hepatic splenosis as an unexpected cause of a focal liver lesion in a patient with hepatitis C and liver cirrhosis: a case report

      case-report

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          Abstract

          Introduction

          Splenosis is the heterotopic autotransplantation of splenic tissue, mostly found after splenic trauma or surgery in the abdominal, pelvic or thoracic cavity. Here we report a patient with a history of splenectomy after polytrauma with chronic hepatitis C and liver cirrhosis presenting with an hepatic mass of unknown origin.

          Case presentation

          The lesion could not be exactly classified by ultrasound, computed tomography, angiography and biopsy, classical features of malignancy were not fulfilled, and on the other hand a neoplastic process could neither be excluded. After revision of a MRI performed in our centre it appeared that the liver mass contrasted in the same way as the remaining accessory spleens in the left upper quadrant. A selective Tc-99m-labelled heat-denatured autologous red blood cells scintigraphy of the spleen was performed and showed both the accessory spleens in the left upper quadrant and spleen-typical tissue in projection to the left liver lobe and confirmed the diagnosis of splenosis.

          Conclusion

          Although intrahepatic splenosis represents an extremely rare condition, this diagnosis should always be taken into consideration in patients with history of abdominal trauma with splenic involvement presenting with an indeterminate focal liver lesion. The diagnosis of splenosis may then be reliably confirmed by Tc-99m-DRBC scintigraphy.

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          Most cited references10

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          Incidence of hepatocellular carcinoma and associated risk factors in hepatitis C-related advanced liver disease.

          Anna S Lok, Leonard B Seeff, Timothy R Morgan … (2009)
          Although the incidence of hepatocellular carcinoma (HCC) is increasing in the United States, data from large prospective studies are limited. We evaluated the Hepatitis C Antiviral Long-Term Treatment Against Cirrhosis (HALT-C) cohort for the incidence of HCC and associated risk factors. Hepatitis C virus-positive patients with bridging fibrosis or cirrhosis who did not respond to peginterferon and ribavirin were randomized to groups that were given maintenance peginterferon for 3.5 years or no treatment. HCC incidence was determined by Kaplan-Meier analysis, and baseline factors associated with HCC were analyzed by Cox regression. 1,005 patients (mean age, 50.2 years; 71% male; 72% white race) were studied; 59% had bridging fibrosis, and 41% had cirrhosis. During a median follow-up of 4.6 years (maximum, 6.7 years), HCC developed in 48 patients (4.8%). The cumulative 5-year HCC incidence was similar for peginterferon-treated patients and controls, 5.4% vs 5.0%, respectively (P= .78), and was higher among patients with cirrhosis than those with bridging fibrosis, 7.0% vs 4.1%, respectively (P= .08). HCC developed in 8 (17%) patients whose serial biopsy specimens showed only fibrosis. A multivariate analysis model comprising older age, black race, lower platelet count, higher alkaline phosphatase, esophageal varices, and smoking was developed to predict the risk of HCC. We found that maintenance peginterferon did not reduce the incidence of HCC in the HALT-C cohort. Baseline clinical and laboratory features predicted risk for HCC. Additional studies are required to confirm our finding of HCC in patients with chronic hepatitis C and bridging fibrosis.
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            Characterization of small nodules in cirrhosis by assessment of vascularity: the problem of hypovascular hepatocellular carcinoma.

            W Grigioni, Luigi Bolondi, Simona Leoni … (2005)
            In a prospective study, we examined the impact of arterial hypervascularity, as established by the European Association for the Study of the Liver (EASL) recommendations, as a criterion for characterizing small (1-3 cm) nodules in cirrhosis. A total of 72 nodules (1-2 cm, n = 41; 2.1-3 cm, n = 31) detected by ultrasonography in 59 patients with cirrhosis were included in the study. When coincidental arterial hypervascularity was detected at contrast perfusional ultrasonography and helical computed tomography, the lesion was considered to be hepatocellular carcinoma (HCC) according to EASL criteria. When one or both techniques showed negative results, ultrasound-guided biopsy was performed. In cases with negative results for malignancy or high-grade dysplasia, biopsy was repeated when an increase in size was detected at the 3-month follow-up examination. Coincidental hypervascularity was found in 44 of 72 nodules (61%; 44% of 1-2-cm nodules and 84% of 2-3-cm nodules). Fourteen nodules (19.4%) had negative results with both techniques (hypovascular nodules). Biopsy showed HCC in 5 hypovascular nodules and in 11 of 14 nodules with hypervascularity using only one technique. All nodules larger than 2 cm finally resulted to be HCC. Not satisfying the EASL imaging criteria for diagnosis were 38% of HCCs 1 to 2 cm (17% hypovascular) and 16% of those 2 to 3 cm (none hypovascular). In conclusion, the noninvasive EASL criteria for diagnosis of HCC are satisfied in only 61% of small nodules in cirrhosis; thus, biopsy frequently is required in this setting. Relying on imaging techniques in nodules of 1 to 2 cm would miss the diagnosis of HCC in up to 38% of cases. Any nodule larger than 2 cm should be regarded as highly suspicious for HCC.
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              Splenosis: autotransplantation of splenic tissue.

              Price Dickson, Kevin C. Fleming, Wendy E Harrison (1976)
              Splenosis is the autotransplantation of splenic tissue that usually follows traumatic rupture of the spleen. Generally, the splenic implants are numerous and are located within the peritoneal cavity; however, extra-abdominal splenosis does occur. The implants are rarely clinically significant and are incidental findings at autopsy or at abdominal operation, unrelated to and distant from the splenic trauma and splenectomy. Splenic implants retain their ability to function, and recurrence of a hematologic disease for which the spleen was previously removed should alter the clinician to the possibility of splenosis. The differential diagnosis includes accessory spleens, endometriosis, hemangiomas and metastatic cancer. We report three cases, two of which represent unusual complications of splenosis: a twisted pedicle of a splenic implant, which apparently caused abdominal pain, and recurrent Felty's syndrome associated with splenosis and an accessory spleen.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cases J
                Title: Cases Journal
                Publisher: Cases Network Ltd
                ISSN (Electronic): 1757-1626
                Publication date (Electronic): 19 August 2009
                Publication date Collection: 2009
                Volume: 2
                Electronic Location Identifier: 8335
                Affiliations
                [1 ]simpleMedical Department 2, University of Munich - Grosshadern Marchioninistrasse 15, D-81377 MunichGermany
                [2 ]simpleInstitute of Clinical Radiology, University of Munich - Grosshadern Marchioninistrasse 15, D-81377 MunichGermany
                [3 ]simpleDepartment of Nuclear Medicine, University of Munich - Grosshadern Marchioninistrasse 15, D-81377 MunichGermany
                Article
                Publisher ID: 8335
                DOI: 10.4076/1757-1626-2-8335
                PMC ID: 2740154
                PubMed ID: 19830070
                SO-VID: c44c71c5-f0d5-4527-adf6-76db07e4fbc6
                Copyright © © 2009 Menth et al.; licensee Cases Network Ltd.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 24 February 2009
                Date accepted : 17 June 2009
                Categories
                Subject: Case report

                ScienceOpen disciplines: Medicine
                Data availability:
                ScienceOpen disciplines: Medicine

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