Difficulties in Diagnosing Volumetric Formations of the Spleen: an Example of a Clinical Case

Full Text

Focal formations of the spleen relative to neoplasms of other organs are rare, as a rule, they are characterized by slow growth, prolonged asymptomatic course and, in most cases, are detected by chance [1, 2]. Benign neoplasms of this organ cause difficulties for clinicians not only in differential diagnosis, despite modern imaging tools, but also in therapeutic tactics [3, 4]. Often, splenectomy is the final stage of diagnosis, and in the case of benign formations - the main link, after which no additional treatment is required.
Patient S., 34 years old, upon admission to the Voronezh Regional Clinical Hospital, complained of heaviness in the left hypochondrium, discomfort in the upper abdomen, unrelated to eating, but increasing with physical exertion. The above symptoms appeared about six months ago. In the polyclinic at the place where the patient applied, an ultrasound examination and computed tomography of the abdominal organs were performed, which revealed cystic formations in the spleen. Due to the high probability of the parasitic nature of the neoplasms, the patient was referred for consultation to an infectious diseases hospital, where she was diagnosed with "parasitic cysts of the spleen". The patient was sent to Voronezh Regional Clinical Hospital No. 1 for planned surgical treatment.
Upon admission, the general condition is satisfactory. Temperature 36.6. Peripheral lymph nodes: not enlarged. Hemodynamics is stable; blood pressure 120/70 mm Hg; pulse 76 beats per 1min. Heart tones: rhythmic; sonorous. From the side of the chest organs during physical examination without features. The tongue is moist, overlaid with a white coating. The abdomen is symmetrical, not swollen, participates in the act of breathing, with palpation soft, sensitive in the right hypochondrium. Liver along the edge of the costal arch. The spleen is not palpable. The symptoms of Ortner, Georgievsky-Mussy are negative. Palpation infiltrates, formations in the abdominal cavity are not determined. Peristalsis is not auscultatively changed. There are no peritoneal symptoms. The symptom of pounding on the lumbar region is negative on both sides. Stool, urination without peculiarities.
General and biochemical blood tests, general urine analysis, hemostasis indicators = within the range of reference values.
ELISA (general): the studied component of echinococcus Ig G is negative.
ECG, conclusion: sinus rhythm, normal EOS position, heart rate 83 in one minute.
Ultrasound of abdominal organs: liver size 128*110*55 , the contour is smooth, the echogenicity is normal, the echostructure is homogeneous, the intrahepatic bile ducts are not dilated, the portal vein is 8 mm in diameter; the gallbladder is reduced, located typically, the contour is smooth, the common bile duct is up to 5 mm (not dilated); the pancreas is not enlarged, the head is 24 mm, the body is 12 mm, the tail is 14 mm, the contour is indistinct, the echogenicity is increased, the echostructure is diffusely heterogeneous, the virsung duct is not expanded, the retropancreatic fiber is not infiltrated; the spleen is slightly enlarged (140*65*50 mm), the contour is smooth, multiple thin-walled inclusions from 16 to 25 mm in diameter are determined in the thickness of the organ, free fluid in the abdominal cavity is not determined. Conclusion – multiple cystic formations of the spleen.
Multisection computed tomography of abdominal organs: liver enlarged to 174 mm, with smooth contours, parenchymal density is normal, focal formations are not determined, intrahepatic bile ducts without features, gallbladder is not enlarged, choledoch 8 mm; pancreas of normal size, has wavy outlines, parenchymal structure without features, virsung duct is not determined, the adjacent peripancreatic fiber is unchanged; the spleen is enlarged, the size 130*112*70 mm, SI = 1019, the contours are even and clear, in the parenchyma there are multiple rounded hypodens formations merging with each other, up to 26 mm in diameter, with clear even contours, density +15-+25el.X; adrenal glands are not changed; kidneys of normal size, usually located, bean-shaped, smooth contours, parenchyma of sufficient thickness, kidney CHLS, ureters are not expanded, the bladder is filled, without features; free fluid in the abdominal cavity is not determined, enlarged lymph nodes, bone-destructive changes are not determined. Conclusion: with native CT scanning, there are signs of hepatosplenomegaly, multiple spleen cysts (Fig.1).
Magnetic resonance imaging of abdominal organs in three projections spleen, liver, pancreas and large vessels are usually located, free fluid in the abdominal cavity and pleural sinuses is not determined; spleen size 12,6*11,2*7,0 cm, contains multiple cystic, mainly multicameral (multifocal with membranes) formations (with bumpy contours). from 0.5 cm to 3.5*3 cm without perifocal edema (fig. 1); liver with smooth, clear contours, enlarged, right lobe along the midclavicular line up to 17.3 cm (norm up to 15 cm), small cyst of the VIII segment of the liver up to 3-4 mm, otherwise the structure of the liver is without features; intra and extrahepatic bile ducts are not expanded, filled with bile; gallbladder size 8.0 * 3.0 cm, filled diffusely heterogeneous bile with sediment; choledochus is not expanded, 0.5 cm in diameter; portal vein 1.0 cm; pancreas with clear smoothed contours, homogeneous structure, not enlarged, dimensions: head 2.8 cm, body 1.9 cm, tail 1.5 cm, virsung duct differentiates in the area of the head and body, up to 0.2 cm in diameter; large vessels of the abdominal region and lymph nodes without pathological features; kidney cups are moderately dilated. Conclusion: multiple cystic formations of the spleen. MR-signs of hepatomegaly.
As a result of the examination, the diagnosis was made – multiple cysts of the spleen. Most likely of an infectious nature. It was decided to carry out surgical treatment – removal of the spleen.
The patient underwent splenectomy from an oblique laparotomy access along the Cherniker in the left hypochondrium. The removed organ was transferred for morphological examination (Fig. 2). Macroscopic description of the drug: the spleen is presented for examination 13*6*4 cm, on the sections of the cellular type, the diameter of the cells is from 0.5 to 1.5 cm (Fig. 3).
Lifetime pathoanatomic examination of biopsy (surgical) material. Microscopic description: spleen tissue, in the thickness of which cavities of various sizes are visible, lined with epithelium, the cavities
are partly filled with blood, partly with pinkish liquid with an admixture of a small number of lymphocytes. (Fig. 4). Conclusion: the morphological picture is characteristic of lymphangioma. The latter is a benign tumor, the intraabdominal location of which occurs in one in 25-250 thousand hospitalized [5].

In the postoperative period, intensive complex treatment was carried out (antibacterial, anti-inflammatory, symptomatic therapy.). On the 10th day after the operation, the patient was discharged from the hospital in a satisfactory condition for outpatient follow-up treatment.
A year after the operation, the woman feels well, a control examination and examination of the pathology did not reveal.
discussion
Analysis of the literature data has demonstrated that we are not the only ones who faced errors in diagnosis before surgery [6]. Diagnostic and therapeutic difficulties of spleen neoplasms are associated not only with the low awareness of practitioners about this pathology and its rare occurrence, but also with the lack of a generally accepted classification of focal spleen formations, a clear diagnostic protocol and morphological verification [2-4]. The most complete classification of spleen neoplasms was proposed by Yu.A. Stepanova and co-authors [7]. It is based on the Pathological and genetic classification of soft tissue and bone tumors edited by C.D.M. Fletcher et al., adopted in Lyon in 2002 [8].
Non–tumor formations of the spleen include:
I. Cysts - primary and secondary.
II. Pseudotumor formations – hamartoma, peliosis.
III. Traumatic formations – hematoma.
IV. Circulatory disorders – infarction.
V. Inflammatory formations - abscess.
At the same time, the most diverse group is cysts. Among the primary cysts, there are true (congenital), dermoid, epidermoid and
parasitic. The latter are echinococcal, alveococcal, cysticercoccal. Secondary cysts include traumatic, pancreatogenic, cysts as the outcome of a heart attack (degenerative), hemorrhages, abscess.
Classification of tumor diseases of the spleen consists of the following morphological groups:
I. Vascular tumors
A. Hemangioma – capillary, cavernous, mixed.
B. “Coastal cell” angioma.
B. Hemangioendothelioma – benign, malignant.
G. Muscular angioendothelioma.
D. Hemangiopericytoma – benign, malignant.
E. Angiosarcoma.
II. Tumors of hematopoietic and lymphoid tissues.
A. Various forms of lymphocytic leukemia (lymphocytic leukemia).
B. Lymphomas.
V. Plasmocytic dyscrasias (plasmocytomas).
G. Lymphangioma.
D. Plasmocytoma.
E. Reticulosarcoma.
III. Tumors from adipose tissue – lipoma, liposarcoma.
IV. Tumors from connective tissue.
Solitary fibrous tumor.
Inflammatory myofibroblastic tumor.
Fibroblastic sarcoma.
Fibrous histiocytoma – benign and malignant.
V. Smooth muscle tumors – leiomyoma, leiomyosarcoma.
VI. Tumors from embryonic remains are mature, immature and malignant teratoma.
VII. Metastases of malignant tumors of various localization

Obtaining material for morphological examination by percutaneous biopsy of spleen formations under ultrasound control is limited due to the high probability of intra-abdominal bleeding, tumor spread, infectious-toxic shock or contamination of the abdominal cavity. As a rule, the correct diagnosis can be made only after performing an organ-bearing operation and examining the removed material.
conclusion
This clinical example and the literature studied show that modern diagnostic methods do not allow us to confidently establish the nature of the volumetric formations of the spleen, which dictates the need for surgical removal of it as the only correct method of final diagnosis, which will be the final stage of treatment for benign formations or will not allow a malignant tumor to be missed.
Additional information. Conflict of interest. The authors declare the absence of obvious and potential conflicts of interest related to the publication of this article.

About the authors

Mariia Valerievna Aralova

N.N. Burdenko Voronezh State Medical University; Voronezh Regional Clinical Hospital №1

Email: Mashaaralova@mail.ru
ORCID iD: 0000-0003-4257-5120
SPIN-code: 8115-2155

MD, Professor of the Department of General and Outpatient Surgery; Head of the Department of Outpatient Surgery with a day hospital

Russian Federation, 394036, Russia, Voronezh, 10 Studentskaya str; 394066, Russia, Voronezh, Moskovsky prospect, 151

Yulia Nikolaevna Alimkina

N.N. Burdenko Voronezh State Medical University

Email: amica3@mail.ru
ORCID iD: 0000-0003-4971-201X
SPIN-code: 8308-9750

Assistant of the Department of Specialized Surgical Disciplines

Russian Federation, 394036, Russia, Voronezh, 10 Studentskaya str

Alexander Vasilyevich Chernyh

N.N. Burdenko Voronezh State Medical University

Email: chernyh@vsmaburdenko.ru
ORCID iD: 0000-0002-1762-3920

M.D., Professor, Head of the Department of Operative Surgery with Topographic Anatomy

Russian Federation, 394036, Russia, Voronezh, 10 Studentskaya str

Anton Petrovich Ostroushko

N.N. Burdenko Voronezh State Medical University

Email: antonostroushko@yandex.ru
ORCID iD: 0000-0003-3656-5954
SPIN-code: 9811-2385

Ph.D., Associate Professor of the Department of General and Outpatient Surgery

Russian Federation, 394036, Russia, Voronezh, 10 Studentskaya str

Vladislava Sergeevna Brezhneva

N.N. Burdenko Voronezh State Medical University

Author for correspondence.
Email: vladislava51094@mail.ru
ORCID iD: 0009-0007-5491-1888
SPIN-code: 1557-9010

Assistant of the Department of General and Outpatient Surgery

Russian Federation, 394036, Russia, Voronezh, 10 Studentskaya str

References

Supplementary files