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Ann Thorac Surg 1998;66:552-553
© 1998 The Society of Thoracic Surgeons

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Case Reports

Thoracic splenosis

^a Division of Cardiovascular Surgery, Texas Tech Medical Center, Lubbock, Texas, USA
^b Department of Surgery, Texas Tech Medical Center, Lubbock, Texas, USA
^c Department of Radiology, Texas Tech Medical Center, Lubbock, Texas, USA
^d Department of Pathology, Texas Tech Medical Center, Lubbock, Texas, USA

Accepted for publication February 17, 1998.

Address reprint requests to Dr O’Connor, Division of Cardiovascular Surgery, Texas Tech Medical Center, 3601 4th St/Rm 3A124, Lubbock, TX 79430

	Abstract

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Thoracic splenosis is a rare pathologic entity resulting from seeding of splenic tissue in the pleural cavity after thoracoabdominal trauma. A 45-year-old man with a history of splenectomy secondary to abdominal trauma presented with a left lung mass and an inconclusive tissue diagnosis after needle biopsy. Thoracic splenosis was not suspected preoperatively, considered on an intraoperative frozen section, and established on permanent pathologic biopsy specimens obtained during thoracotomy. A history of thoracoabdominal trauma, combined with radiologic and radionuclide imaging studies, may establish the diagnosis without thoracotomy.

	Introduction

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A 45-year-old man presented with a new, asymptomatic lung mass. The patient underwent exploratory laparatomy and splenectomy for a gunshot wound to the abdomen at age 18 years, after which he had an abnormal chest radiograph with a density at the base of the left lung. A new subpleural mass was found on a routine chest radiograph and confirmed by computed tomographic (CT) scan. A CT-guided needle biopsy revealed hematoma, and the patient was referred to the Thoracic Surgery Service. He denied any pulmonary symptoms and had a 35 pack-year history of smoking. Physical examination was unremarkable. Chest radiographs demonstrated two left subpleural masses, and a CT scan revealed both masses to be of soft tissue density, one measuring 7 x 4 cm with poorly defined borders laterally and a 4 x 4 cm mass inferiorly (Fig 1). No mediastinal adenopathy was identified. Unfortunately, no prior chest radiographs were available for comparison. An apparently new pulmonary lesion, history of smoking, lack of prior chest radiographs for comparison, and an inconclusive tissue diagnosis dictated the need to exclude a malignancy.

View larger version (56K): [in this window] [in a new window]   Fig 1. Preoperative computed tomographic scans demonstrate (A) the superior mass and (B) the inferior mass.

Because of these unusual findings, the operative record from the prior exploratory laparatomy was obtained. Injuries included a through-and-through gunshot wound to both the liver and the stomach, as well as extensive splenic injury. The liver lacerations and through-and-through gastric wounds were repaired and splenectomy was performed. A 2.5-cm tear in the diaphragm was repaired with interrupted sutures, and a left tube thoracostomy drained 700 mL of blood. A febrile postoperative course complicated the exploratory laparotomy and splenectomy. Results of fluoroscopy of the diaphragm and a liver spleen scan were normal. A left subphrenic abscess was subsequently drained with an uneventful recovery.

Thoracic splenosis was not considered in the differential diagnosis of this patient because there was no history of thoracoabdominal trauma. The history, radiologic findings, and results of the CT-guided needle biopsy were inconclusive, and a malignant pulmonary lesion could not be excluded. Suspicion of the true diagnosis was aroused only when multiple dense thoracic adhesions were encountered and the frozen section diagnosis was consistent with lymphoid tissue.

	Comment

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Splenosis describes ectopic implantation of splenic tissue to the peritoneal cavity. It is postulated to provide a protective effect, with respect to sepsis, prompting some authors to suggest it may, in fact, be a beneficial condition [1]. Pearson and associates [2] found splenosis and return of splenic function occurred more frequently than anticipated and postulated it led to lower rates of bacterial sepsis. Other authors have disputed this finding and have reported fatal sepsis in a patient with splenosis [3].

In comparison, thoracic splenosis is rare; to our knowledge, only 22 previously reported cases have been described in the English-language literature [4]. This condition was first reported in 1937 by Shaw and Shafi as an autopsy finding [5]. The patients have a history of thoracoabdominal trauma with splenic injury or splenectomy, with the interval between the initial trauma and discovery of the thoracic splenosis averaging 16 years [6].

Thoracic splenosis typically presents on chest radiographs as an asymptomatic pulmonary mass, either solitary or multiple. Computed tomographic scan usually demonstrates a subpleural mass; however, the CT characteristics are not diagnostic. Our patient had a typical presentation of an asymptomatic pulmonary mass confirmed on CT scan with an inconclusive needle biopsy. Diagnosis of thoracic splenosis can be established with the use of radionuclide scans [7].

The diagnosis of thoracic splenosis frequently is made at the time of operation. Thoracotomy can be avoided if the diagnosis is entertained preoperatively in a patient with a new pulmonary mass and a history of thoracoabdominal trauma, no matter how remote. Appropriate radionuclide studies will confirm the diagnosis, and because the natural history of this entity is thought to be benign, observation with serial chest radiographs is warranted [6]. This approach may avoid the need for thoracotomy and removing splenic tissue, which may provide protection against sepsis.

	References

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1. Widmann W.D., Laubscher F.A. Splenosis: a disease of beneficial condition?. Arch Surg 1971;102:152-158.[Abstract/Free Full Text]
2. Pearson H.A., Johnston D., Smith K.A., Touloukian R.J. The born-again spleen: return of splenic function after splenectomy for trauma. N Engl J Med 1978;298:1389-1392.[Abstract]
3. Sass W., Bergholz M., Kehl A., Seifert J., Hamelmann H. Overwhelming infection after splenectomy in spite of some spleen remaining and splenosis. Klin Wochenschr 1983;61:1075-1079.[Medline]
4. Madjar S., Weissberg D. Thoracic splenosis. Thorax 1994;49:1020-1022.[Abstract/Free Full Text]
5. Shaw A.F.B., Shafi A. Traumatic autoplastic transplantation of splenic tissue in man with observations on the late results of splenectomy in six cases. J Pathol 1937;45:215-235.
6. Roucos S., Tabet G., Jebara V.A., Ghossain M.A., Biagini J., Saade B. Thoracic splenosis: case report and literature review. J Thorac Cardiovasc Surg 1990;99:361-363.[Abstract]
7. Moncada R., Williams V., Fareed J., Messmore H. Thoracic splenosis. AJR 1985;144:705-706.[Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James V. O’Connor James Williams Eugene Wallsh Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by O’Connor, J. V. Articles by Wallsh, E. Search for Related Content PubMed PubMed Citation Articles by O’Connor, J. V. Articles by Wallsh, E.