N.G. VELITCHKOV*, K.T. KJOSSEV*, J.E. LOSANOFF*
and V.A. KAVARDJIKOVA#
Departments of *Emergency Surgery and #Pathology, Military Medical Academy, Sofia,
Bulgaria
We describe a unique case of combined thoracic and subcutaneous splenosis.
Keywords: subcutaneous splenosis, thoracic splenosis, diagnosis
J.R.Coll.Surg.Edinb., 44, February 2000, 66
Splenosis is defined as the autotransplantation of splenic tissues, usually after splenic rupture.1 It is often found intra-peritoneally, but only exceptionally in the thoracic cavity or in a laparotomy scar.
A 47-year-old man presented with a tumour of the abdominal wall, which had doubled in size during the past two years. The patient had undergone a laparotomy for blunt abdominal trauma four years previously. At that time, his spleen had been removed and a rupture of the left haemidiaphragm repaired. Physical examination showed a palpable 2x3cm, soft subcutaneous lump in the upper third of the laparotomy scar; the skin overlying the tumour was was reddish-blue. Laboratory data were within normal limits. A chest radiograph demonstrated a 4x5cm mass in the lower lobe of the left lung adjacent to the diaphragm. A diagnosis of carcinoma of the lung with metastasis to the soft tissue of the abdominal wall was made. The cutaneous lesion was excised in toto and sent for histology. This revealed “splenic tissue surrounded by fat”. Based on this, thoracic splenosis was suspected, and the patient was submitted for radionuclide scanning for a definitive diagnosis. A 99m technetium-labelled sulphur colloid scan showed uptake by the lesion, thus suggesting splenic tissue. No further treatment was indicated. Now, more than two years later, the patient is well and symptom-free.
Peritoneal splenosis is common after traumatic injury to the spleen, and occurs in up to 67% of cases.2 By contrast, subcutaneous splenosis is extremely rare, with only seven cases published in the English-language literature. It has been suggested that, once a subcutaneous lesion is found in or near the scar from a laparotomy carried out for traumatic rupture of the spleen, the diagnosis of splenosis should be considered.2 In our patient, metastatic disease was suspected instead of splenosis in the presence of a pulmonary mass, as it is known that 15% to 20% of patients with lung cancer first present with distant metastases, including metastases to superficial soft tissues.3
Intrathoracic autotransplantation of splenic tissue is also considered to be a rarity. Up to 1994, only 22 cases had been described in the English-language literature. In half of the reported cases, the diagnosis was made at operation, the indication for surgery being intrathoracic neoplasia, usually lung cancer.1 In the presence of a history of left thoracoabdominal trauma, thoracic splenosis should be included in the differential diagnosis of a left lower pulmonary mass, and is best demonstrated by percutaneous biopsy or radionuclide imaging, thereby avoiding needless thoracotomy.4 In the case of our patient, the diagnosis was suspected after we were aware of the result of the histology of the exised skin lesion, and it was further confirmed by radionuclide scanning, thus avoiding thoracotomy. The intrathoracic spleen implant has remained in situ and the risk of rendering the patient asplenic avoided, as described by others.1,4 We believe that implanted splenic tissue may be beneficial with regard to the patient’s immune status and host defences.
In reviewing the literature we were unable to identify any other cases of combined thoracic and subcutaneous splenosis. In this unique case, the presence of a subcutaneous spleen implant gave a clue to the diagnosis of thoracic splenosis.
Copyright date: 24th June 1999
Correspondence: Dr JE Losanoff, PO Box 159, Sofia 1606, Bulgaria. Email: freckles@public.digsys.bg
©2000 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.,45; 1: 66