Ann Thorac Surg 2005;80:1934-1936
© 2005 The Society of Thoracic Surgeons
Case report
Intrathoracic Splenosis
Vinod H. Thourani, MD,
Jyotirmay Sharma, MD,
Ignacio G. Duarte, MD,
Joseph I. Miller, Jr, MD
*
Joseph B. Whitehead Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
Accepted for publication June 7, 2004.
* Address correspondence to Dr Miller, Crawford Long Hospital, Section of Thoracic Surgery, 550 Peachtree St, NE, Medical Office Tower, 6th Floor, Atlanta, GA30308 (Email: jmille6331{at}aol.com).
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Abstract
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Intrathoracic splenosis is a rare condition involving autotransplantation of the splenic tissue into the pleural cavity. It is typically a result of diaphragmatic and splenic rupture after blunt or penetrating abdominal trauma. The diagnosis is usually determined by surgical biopsy of an incidental asymptomatic mass on a radiograph or computed tomography. The process is benign and can be generally followed with serial chest radiographs. We herein discuss a 34-year-old male who presented with sharp chest pains.
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Introduction
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Intrathoracic splenosis is referred to as the autotransplantation of splenic tissue to abnormal anatomic locations after splenic injury. Although abdominal splenosis is the most common form, intrathoracic splenosis can occur as a result of trauma to the left upper abdominal area with concomitant splenic damage and left diaphragmatic tear. The newly implanted splenic tissue derives its blood supply from adjacent tissue and matures generally in a benign fashion. Work-up is initiated after an incidental discovery of an asymptomatic peripheral pulmonary nodule on a routine chest radiograph. Although noninvasive imaging techniques may assist in the preoperative diagnosis of intrathoracic splenosis, definitive diagnosis is often a result of surgery.
A 34-year-old male presented to the emergency department with sharp left-sided chest pain for that spanned 1–3 days. The patient's past medical history included hypertension and sleep apnea and he had previously undergone a laparoscopic cholecystectomy. At the age of 14 he was involved in a motor vehicle collision in which he ruptured his left hemidiaphragm, spleen, and left kidney and underwent a left tube thoracostomy and explorative celiotomy with splenectomy, left hemidiaphragm repair, and nephrectomy. The patient exhibited no history of malignancy and was a nonsmoker. A chest radiograph demonstrated a left apical pleural-based mass. A computed tomogram (CT) of the chest demonstrated a 3 cm left pleural mass at the level of the third intercostal space (Fig 1). A CT-guided needle biopsy was indeterminate for definitive diagnostic pathology.
With the known history of spleen and diaphragm rupture and a pleural-based mass, a preoperative suspicion of intrathoracic splenosis was indicated. A limited left thoracotomy in the fifth intercostal space was performed. Examination of the thoracic cavity revealed numerous purplish implants suggestive of intrathoracic splenosis (Figs 2, 3).
These implants covered the left pleura, pericardium, and left hemidiaphragm. There was a similar large mass in the inferior pulmonary ligament. Multiple biopsies of the implants were obtained. Intraoperative frozen section and permanent sections revealed intrathoracic splenosis. A postoperative blood smear revealed the presence of Howell–Jolly bodies. The patient experienced an uneventful postoperative course and has performed favorably on follow-up at 12 months.
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Comment
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Intrathoracic splenosis is an uncommon condition involving autotransplantation of the ruptured splenic tissue. This occurs after blunt or penetrating trauma involving rupture of the diaphragm and spleen. In 1937 Shaw and Shafi [1] reported on this topic and since then fewer than 30 instances of intrathoracic splenosis have been described. Unlike abdominal splenosis, which can cause abdominal pain and bowel obstruction, intrathoracic splenosis is usually a benign condition. If symptomatic abdominal splenosis should be treated with surgical resection.
Our patient experienced a typical course of splenosis with presentation on a chest radiograph followed by CT evaluation, an indeterminate needle biopsy, and eventually an operative diagnosis. The CT findings of a pleural-based mass are nonspecific and several other etiologies are possible including mesothelioma, schwannoma, lymphoma, and metastatic disease [2–4]. With such other pathologies in the differential diagnosis, a tissue sample seems warranted using either a needle or thoracoscopic incisional biopsy. Intrathoracic splenosis may be diagnosed on the basis of a technetium 99m Tc-labeled heat-damaged erythrocyte scan, 99mTc sulfur colloid scintigraphy, or indium 111 In-labeled platelet scan [2, 5]. The postoperative examination of the peripheral blood smear revealed the presence of Howell–Jolly bodies—evidence that the ectopic splenic tissue is nonfunctional. Howell–Jolly bodies represent nuclear material within the erythrocyte and are normally retained by a functional spleen.
Preoperative diagnosis of intrathoracic splenosis should be considered in any patient who presents with left-sided pulmonary nodules and a history of thoracoabdominal trauma, particularly if the patient underwent a splenectomy. Most authors agree that intrathoracic splenosis is a benign process and may even provide a protective role.
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References
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- Shaw AFB, 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.
- Bizekis CS, Pua B, Glassman LR. Thoracic splenosismimicry of a neurogenic tumor. J Thorac Cardiovasc Surg 2003;125:1155-1156.[Free Full Text]
- Kwan AJ, Drum DE, Ahn CS, Tow DE. Intrathoracic splenosis mimicking metastatic lung cancer Clin Nucl Med 1994;19:93-95.[Medline]
- O'Connor JV, Brown CC, Thomas JK, Williams J, Wallsh E. Thoracic splenosis Ann Thorac Surg 1998;66:552-553.[Abstract/Free Full Text]
- Hagman TF, Winer-Muran HT, Meyer C, Jennings SG. Intrathoracic splenosissuperiority of technetium Tc99m heat-damaged RBC imaging. Chest 2001;120:2097-2098.[Abstract/Free Full Text]
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Abstract
Introduction
