Ann Thorac Surg 1999;68:243-244
© 1999 The Society of Thoracic Surgeons
Case Reports
Noninvasive methods of diagnosing thoracic splenosis
Margaret F. Naylor, MDa,
Nolan Karstaedt, MB, BCha,
Sanford J. Finck, MDa,
Omer L. Burnett, MDa
a Department of Diagnostic Radiology and the Section of Cardiovascular and Thoracic Surgery, Mayo Clinic Jacksonville, Jacksonville, Florida, USA
Address reprint requests to Dr Finck, Department of Diagnostic Radiology and the Section of Cardiovascular and Thoracic Surgery, Mayo Clinic Jacksonville, 4500 San Pablo Rd, Jacksonville, FL 32224
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Abstract
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Thoracic splenosis is a rare condition resulting from concomitant rupture of the spleen and left hemidiaphragm, with autotransplantation of splenic tissue into the left hemithorax. It is usually an incidental finding on chest plain film or computed tomogram and is rarely diagnosed without biopsy or operation. A history of old splenic trauma and findings of left-sided, pleural-based nodules should indicate the diagnosis, which can be confirmed with nuclear medicine studies.
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Introduction
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Thoracic splenosis is a rare condition resulting from simultaneous rupture of the spleen and left hemidiaphragm, with autotransplantation of splenic tissue into the left hemithorax. It is usually an incidental finding on chest plain film or chest computed tomogram (CT) and is rarely diagnosed without biopsy or operation. However, the appropriate clinical history and the findings of left-sided, pleural-based nodules on chest plain film or CT should lead one to suspect the diagnosis, which can then be confirmed with nuclear medicine studies, thus avoiding the potential complications of percutaneous biopsy or thoracotomy and preserving functional splenic tissue. Only 6 cases of nonoperative diagnosis of intrathoracic splenosis have been reported in the literature [1–4]. We report 2 additional cases.
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Case reports
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Patient 1
A 48-year-old woman presented with an 8-month history of substernal chest pain. A contrast-enhanced CT of the chest demonstrated multiple, well-circumscribed pleural-based nodules along the lateral aspect of the left hemithorax and on the superior aspect of the left hemidiaphragm (Fig 1). A normal spleen was not present. The patient had no history of malignancy, but she admitted to a splenectomy 20 years ago after a motor vehicle accident. Given the constellation of trauma history and CT findings, we suspected thoracic and abdominal splenosis and performed a 99mTc sulfur colloid liver-spleen scan, which demonstrated multiple small foci of uptake in the left hemithorax and left upper abdomen (Fig 2), consistent with thoracic and abdominal splenosis.
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Fig 2. Technetium 99m sulfur colloid scan demonstrates uptake in the liver (large arrow) and a few small foci of uptake in the inferior left hemithorax (small arrows).
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Patient 2
A 74-year-old man presented with a several-month history of progressive difficulty in walking. As part of a work-up for an occult malignancy, a CT scan of the chest was performed and revealed a pleural-based nodule (Fig 3). His medical history was significant for a gunshot wound to the left upper quadrant of the abdomen 30 years previously, requiring removal of spleen and repair of diaphragmatic rupture. Thoracic splenosis was suspected and a 99mTc sulfur colloid liver-spleen scan was performed and confirmed the diagnosis (Fig 4).
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Fig 4. Posterior view of 99mTc sulfur colloid scan demonstrates uptake in liver (large arrow), abdomen, and chest (small arrow).
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Comment
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First described by Shaw and Shafi [5] in 1937, thoracic splenosis is a rare condition resulting from concomitant rupture of the spleen and left hemidiaphragm. Small pieces of splenic tissue are displaced into the left hemithorax, and they implant and grow on the pleura. Fewer than 25 cases have been reported in the literature, and most of these were diagnosed surgically or by biopsy. The nodules of ectopic splenic tissue are usually smaller than 3 cm, but masses as large as 8.5 cm have been reported [1]. Surgically confirmed intrathoracic splenic implants have been attached to the visceral or parietal pleura, but in a surgically unconfirmed case, several implants appeared to be in the lung parenchyma, possibly reaching this destination through a lung laceration [2]. These splenic implants are usually an incidental, asymptomatic finding on chest plain film or CT, although there is one report of a patient who had ectopic thoracic splenic tissue presenting with recurrent hemoptysis [6]. The average interval between the originating trauma and the diagnosis is 18.8 years [7]. Thoracic splenosis is commonly accompanied by abdominal splenosis [3].
The finding of pleural-based nodules and masses is nonspecific, and the principle differential diagnostic considerations include pleural metastases when there are multiple nodules or masses and fibrous tumor of the pleura when the nodule or mass is solitary. However, the presence of multiple, left-sided, pleural-based nodules or masses, in conjunction with historical evidence of prior splenic trauma, should raise the suspicion of thoracic splenosis. The radiologic diagnosis can be confirmed by 99mTc sulfur colloid scintigraphy, 111In-labeled platelet scan, or 99mTc-labeled heat-damaged erythrocyte study. (A literature review back to 1966 failed to reveal any false-positive studies [Karstaedt N, unpublished data].) Radiologic diagnosis of thoracic splenosis avoids subjecting the patient to biopsy or operation and preserves what may be the only remaining splenic tissue in a splenectomized patient.
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References
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Hardin V.M., Morgan M.E. Thoracic splenosis. Clin Nucl Med 1994;19:438-440.[Medline]
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Scales F.E., Lee M.E. Nonoperative diagnosis of intrathoracic splenosis. AJR Am J Roentgenol 1983;141:1273-1274.[Free Full Text]
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Normand J.P., Rioux M., Dumont M., Bouchard G., Letourneau L. Thoracic splenosis after blunt trauma. AJR Am J Roentgenol 1993;161:739-741.[Abstract/Free Full Text]
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Moncada R., Williams V., Fareed J., Messmore H. Thoracic splenosis. AJR Am J Roentgenol 1985;144:705-706.[Free Full Text]
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Shaw A.F.B., Shafi A. Traumatic autoplastic transplantation of splenic tissue in man with observations on late results of splenectomy in 6 cases. J Pathol Bacteriol 1937;45:215-235.
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Cordier J.F., Gamondes J.P., Marx P., Heinen I., Loire R. Thoracic splenosis presenting with hemoptysis. Chest 1992;102:626-627.[Abstract/Free Full Text]
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Gaines J.J., Crosby J.H., Vinayak Kamath M. Diagnosis of thoracic splenosis by Tru-cut needle biopsy. Am Rev Respir Dis 1986;133:1199-1201.[Medline]
Accepted for publication December 17, 1998.
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Abstract
Introduction
