Solitary Perihepatic Splenosis Mimicking Liver Lesion

Hepatic splenosis, one type of manifestation of ectopic spleen tissue, is rarely reported. It cannot be distinguished from hepatic malignancies because of lack of significant radiological features. By means of this case report and 31 literature reviews, potential treatment modalities concerning clinical diagnostics, patient’s management could be discussed. The report presents the case of a 33-year-old man with a liver lesion. Finally, after a mini-incision laparotomy, the lesion was resected and the diagnosis confirmed it as hepatic splenosis. A literature search for case reports published between January 1, 1900, and August 1, 2014, was performed on PubMed. Approximately 80% (27/34) of patients diagnosed with hepatic splenosis had a history of splenectomy. The mean time interval between splenectomy and hepatic splenosis detection was 25 (1.5–47) years. The median size of reported hepatic splenosis is 30 mm in diameter. Technetium-99m-labeled heat denatured red-blood-cells scintigraphy or superparamagnetic iron oxide-enhanced magnetic resonance imaging is now considered to be the optimal method of diagnosing splenosis. Hepatic splenosis requires no treatment in most cases. Operation should be performed if it is accompanied by hypersplenism in hematological diseases. When the diagnosis remains unclear, further biopsy or laparoscopy is recommended. If hepatic splenosis is confirmed, careful follow-up is beneficial. (Medicine 94(9):e586) Abbreviations: CT = computed tomography, DWI = diffusionweighted imaging, HAV = hepatitis A virus, HBV = hepatitis B virus, HCC = hepatocellular carcinoma, SPIO-MRI = superparamagnetic iron oxide-enhanced magnetic resonance , Bixiang Zhang, MD, and Xiaoping Chen, MD INTRODUCTION S plenosis is one manifestation of ectopic spleen tissue, which usually occurs after splenic trauma or splenectomy. The pathogenesis is possibly the autotransplantation of spleen fragment. It is mostly found in the peritoneal, pelvic, or thoracic cavity. However, hepatic splenosis, especially solitary perihepatic splenosis mimicking liver lesion, was rarely reported in the literature. With the deficiency of significant features, normal radiological examination cannot distinguish this from hepatic malignancies. Here, we report a patient with hepatic splenosis mimicking liver lesion. Literatures were reviewed and analyzed to provide information for clinicians to distinguish and treat this disease. Ethical approval was neither obliged nor sought because all management strategies and treatment procedures were part of routine health care. However, we have obtained the approval from the patient to report the case. CASE PRESENTATION A 33-year-old man presented to our hospital after detection of a hepatic lesion from a routine examination. He claimed no discomfort. His medical history included an urgent splenectomy due to traumatic rupture of spleen from a traffic accident 12 years ago and hepatitis A virus (HAV) infection in childhood. No family or genetic history was found. There was no positive sign on physical examination except a previous operation scar. Blood routine and liver–renal function laboratory tests remained normal except mild elevated platelet count 372 10/L (normal range: 100–300 10/L) and total bilirubin 21.5mmol/L (normal range: 3.4–20.5mmol/L). The Child–Pugh grade was A (score 5). Besides tumor markers including a-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 19-9, HAV immunoglobulin M and hepatitis B virus (HBV) deoxyribonucleic acid were unremarkable. Abdominal ultrasonography revealed a 3.5 2.2 cm diameter hypoechoic lesion in the left hepatic lobe near diaphragm (Figure 1A). Electrocardiogram and chest radiography were normal. Plain computed tomography (CT) scan demonstrated a homogeneous hypodensity mass relative to the surrounding liver parenchyma, measuring 2.1 3.4 cm in diameter (Figure 1B). MRI with perfusion-weighted and diffusionweighted imaging confirmed the presence of a solitary 3.5 2.0 cm lesion, which suggests hepatocellular carcinoma (HCC), lying in segment II in a subcapsular position according to radiological features (Figure 2). Biopsy was recommended to the patient for clear diagnosis. However, being afraid of liver malignancy, the patient wanted to confirm the status of the lesion and chose surgery. With sufficient preoperative preparation, the patient underwent an exploratory surgery. Consulting with the previous operational adhesion, we performed the mini-incision laparotomy. Exploration showed that an cm splenosis between liver segment II nt on the surface of liver could be seen. nd was performed and excluded any www.md-journal.com | 1 FIGURE 1. (A) Ultrasonography indicates a 3.5 2.2 cm diameter hypoechoic lesion, which envelope is integrated (white arrow). (B) Plain CT scan demonstrated a homogeneous hypodensity mass relative to the surrounding liver parenchyma, measuring 2.1 3.4 cm in diameter (white arrow). CT 1⁄4 computed tomography. FIGURE 2. (A) T1-weighted MR image: the lesion is of low signal intensity (white arrow). (B) T2-weighted MR image: the lesion is of high signal intensity (white arrow). (C) Liver acceleration volume acquisition contrast: the lesion is of slight hypointensity (black arrow). (D) DWI: the lesion is of slight hyperintensity (white arrow). DWI 1⁄4 diffusion-weighted imaging, MR 1⁄4 magnetic resonance. FIGURE 3. (A) Pathological result (hematoxylin–eosin staining, original magnification: 10 ). (B) Pathological result (hematoxylin–eosin staining, original magnification: 40 ). Wu et al Medicine Volume 94, Number 9, March 2015 2 | www.md-journal.com Copyright # 2015 Wolters Kluwer Health, Inc. All rights reserved. T A B L E 1 . Li te ra tu re R e vi e w o f H e p a ti c S p le n o si s C as e A ge , y/ S ex R ea so n of S p le n ec to m y T im e In te rv al , y R is k of L iv er T u m or N u m b er L oc at io n S iz e, m m P ri m ar y D ia gn os is C on fi rm ed