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Neoplasms of the Spleen
Mark G. Coleman and Michael R. Thompson
Aims
● To identify the origin of splenic neo- plasms.
● To discuss the most efficient modes of investigation and diagnosis.
● To give the indications for splenectomy.
● To explain how to manage the complica- tions and sequelae of splenectomy.
The spleen is an organ full of mystery (Galen, Greek physician AD129–200)
Introduction
The spleen is the largest lymphoid organ in the body, and is situated in the left hypochondrium.
The size and shape of a spleen varies, but is described as being solid, measuring around 3× 8 × 13 cms in dimension, weighing 75–100 g and lying between the ninth and eleventh ribs [1]. There are two anatomical components: the red pulp, consisting of sinuses lined by endothe- lial macrophages and cords (spaces), and the white pulp, which has a structure similar to lym- phoid follicles. The marginal zone separates them. Its arterial blood supply, the splenic
artery, is a branch of the coeliac axis, and its venous drainage, via the splenic vein, is through the portal venous system. Between 14 and 30%
of individuals have accessory splenic tissue, usually found within the gastrocolic or greater omenta. Splenic enlargement, splenomegaly, is first clinically detectable by an increase in percussion dullness before it is palpable in the abdomen below the left costal margin on inspi- ration.
The spleen is part of the reticuloendothelial system and has many roles as part of immune and haematological processing. These include filtering bloodborne bacteria and debris, removing fragmented, damaged or senescent red cells, red cell remodelling, and in certain cir- cumstances, haemopoiesis. There is also a red cell, platelet and lymphocyte storage capacity, which is limited in humans. Like lymph nodes, the spleen also has immune functions including antibody production, cell-mediated responses and phagocytosis.
Not surprisingly, therefore, most neoplastic processes that involve the spleen are a mani- festation of a wider haematological disorder, most often lymphoma. Primary neoplasms of the spleen are rare. The majority of non- haematogenous malignancies are a result of direct spread from adjacent organs, e.g. carci- nomas of the stomach, pancreas, kidney or colon. The diagnosis is usually made by cross- sectional imaging such as ultrasound (US), computed tomography (CT) or magnetic reso- nance scan (MR).
Differential Diagnosis
Space-occupying lesions in the spleen may be classified as cystic, cystic/solid or solid (Table 16.1). Solid lesions may be diffuse or discrete lesions, and discrete lesions may be solitary or multiple. In each case there will be a differential diagnosis.
Causes of Splenic Enlargement
Primary
• Primary non-haematopoietic neoplasms of the spleen are rare. There are two types depending on the cell of origin.
The commonest are of vascular origin, the sinus endothelium giving rise to angiosarcomas and endotheliomas. The connective tissue elements give rise to spindle cell tumours and fibrosarcomas.
• Primary splenic neoplasms may be classified into benign lesions, which include haemangiomas, lymphangiomas or hamartomas, intermediate lesions such as haemangioendotheiomas, and malignant lesions such as angiosarco- mas.
Non-neoplastic splenic enlargement is covered in Chapter 10.
Angiosarcoma
Angiosarcomas are the most common primary malignancy found in the spleen [2]. Most often, a solitary well-defined haemorrhagic nodule is found, though the spleen may be diffusely
involved. Presentation clinically in 75% of patients is with abdominal pain, the remainder through spontaneous rupture, or through symptoms of hypersplenism such as anaemia, thrombocytopenia or a consumption coagu- lopathy. There are characteristic contrast enhancement features on CT and MR that can aid the diagnosis. The spleen is palpable in 85%
of patients. The prognosis is poor, with a rapidly fatal course. Pathogenesis is unknown although arsenicals, vinyl chloride (used in the manufac- ture of plastics) and thorium oxide (Thorotrast, a contrast medium used in radiology in the first half of the twentieth century) have been impli- cated. Treatment is by prompt splenectomy and chemotherapy, although response is poor.
Haemangioma
Haemangiomas are the most frequently occur- ring benign neoplasm found in the spleen. In autopsy series they are found in 0.03 to 14%
of patients [3,4]. They are believed to be con- genital in origin and arise from sinusoidal epithelium. They may be single or multiple and occur as part of a widespread angiomatosis.
Infarction, thrombosis, haemorrhage or fibrosis may occur (Figure 16.1). They are slow growing and tend to be asymptomatic, though they may present with pain, rupture and features of hypersplenism such as anaemia or consumption coagulopathy. Rarely, they undergo malignant transformation.
Littoral Cell Angiomas
Littoral cell angiomas are a form of angioma that occur exclusively in the spleen and display distinct immunohistochemical properties [5].
They contain vascular and histiocytic elements and most often form multiple nodules within the spleen although a focal form is described.
1111 2 3 4 5 6 7 8 9 1011 1 2 3 4 5 6 7 8 9 2011 1 2 3 4 5 6 7 8 9 3011 1 2 3 4 5 6 7 8 9 4011 1 2 3 4 5 6 7 8 9 5011 1 2 311 Table 16.1. The differential diagnosis and category of space occupying lesions of the spleen
Cystic Cystic/Solid Solid – diffuse Solid – discrete
Epidermoid cysts Abscess Lymphoma Hamartoma
Haemangiomas Metastasis Leukaemia Metastasis
Lymphangiomas Epidermoid cysts Infarct
Haemangiomas Angiosarcoma
Lymphangiomas Lymphoma
Haematoma Lymphoma
There is also a malignant variant described.
Littoral cell angiomas usually present with fea- tures of hypersplenism such as splenomegaly, thrombocythaemia and anaemia. On contrast- enhanced CT there are multiple small low atten- uation areas in the portal venous phase.
Lymphangioma
Lymphangiomas are rare benign congenital neoplasms that are most commonly found in the neck or axillae [6]. They rarely occur in the spleen and are usually asymptomatic. They may be visualised on US as single or multiple hypoe- choic lesions, or on CT, which will demonstrate splenomegaly with multiple discrete low atten- uation lesions, which are non-enhancing on injection of intravenous contrast.
Haemangioendotheliomas
Haemangioendotheliomas of the spleen are rare, and are considered to be of intermedi- ate/borderline malignancy. Microscopically, they are composed of vascular and stromal ele- ments [7]. Both types of elements show moder- ate atypia and rare mitoses.
Haematological Malignancy
Leukaemia
Most leukaemias are associated with infiltration of the spleen, which may result in functional hypersplenism. Although the overall risk of spontaneous rupture in leukaemic patients is 1%, this is the single commonest cause of spontaneous splenic rupture, especially in acute leukaemias. Rupture is particularly associated with acute myeloid, acute lymphoblastic and hairy cell leukaemias. The pattern of splenic involvement follows the migratory pathway of the normal benign cellular counterparts.
Chronic lymphocytic leukaemia (CLL)
Fifty per cent of patients with CLL have splenomegaly, though it is usually a late feature.
In 5% of CLL patients, splenomegaly is pro- gressive. Splenic infiltration may be diffuse or miliary and affects both the red and white pulp.
The density of the infiltrate reflects the periph- eral lymphocyte count.
Chronic Myeloid Leukaemia (CML)
Splenomegaly is a characteristic feature of CML and is found in 90% of cases [8]. The red pulp is preferentially affected and the spleen becomes large, red and diffusely involved.
Marked splenomegaly is an adverse prognostic factor due to impairment of the response to platelet transfusion and other effects of hyper- splenism.
Hairy Cell Leukaemia
This is a low grade B-cell malignancy that mainly affects middle-aged men and results in splenomegaly in about two-thirds of cases [9].
Most commonly the spleen is diffusely enlarged and massive splenomegaly may occur. Micro- scopically, only the red pulp is infiltrated in con- trast to other B-cell malignancies, and there is an absence of nodules. The splenic hilar nodes are often involved.
Lymphomas
Lymphomas are malignant tumours of the lymphoreticular system that are classified in Hodgkin’s and various subtypes of non- Hodgkin’s according to the histological appear- 111
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Figure 16.1. A computer tomogram (oral and intravenous contrast) of the abdomen in a 42-year-old man with an acute abdomen. There is a large central splenic haemangioma, which has ruptured into the peritoneal cavity. Spontaneous rupture is an uncommon mode of presentation of splenic neoplasm, which requires prompt recognition and treatment by emergency splenectomy.
ance. Most lymphomas present with fever, malaise and weight loss, often associated with painless lymphadenopathy.
Various patterns of involvement of the spleen are noted in lymphoma from reactive enlarge- ment to lymphomatous replacement of its substance (Figure 16.2). Prior to the advent of CT, abdominal lymphoma staging was carried out by laparotomy. At laparotomy, the para- aortic and coeliac lymph nodes were biopsied, wedge and needle liver biopsy was carried out, a splenectomy performed, and an iliac crest bone marrow biopsy done. Staging laparotomy, against CT has not been shown to improve sur- vival and has important negative effects such as delay in commencement of chemotherapy, infection risk following splenectomy and the potential for serious complications. Splenome- galy in all lymphoma cases has a 36% sensitiv- ity and 61% specificity for splenic involvement [10].
Hodgkin’s Disease
In Hodgkin’s disease, the earliest involvement is by recognisable Reed–Sternberg cells at the periphery of the Malphigian body. Typically later involvement is with scattered foci and architectural destruction. A spleen over 400 g in weight is always histologically infiltrated and
many below this weight. Splenic infiltration is a manifestation of bloodborne dissemination of the disease, and occurs in one-third of patients with Hodgkin’s disease. Splenomegaly may also be observed as a secondary effect without malignant infiltration. Malignant infiltration occurs initially in the white pulp, in the T-cell- dependent peri-arteriolar lymphoid sheath, and the red pulp becomes enlarged secondarily by extension. As the process of splenic infiltration continues, single or multiple discrete tumour nodules form which become confluent with pro- gression. There is adverse prognosis associated with nodular splenic involvement.
Non-Hodgkin’s Lymphoma (NHL)
NHL is the most common malignant process to affect the spleen, with 40–50% of NHL patients having splenic involvement, but the spleen is usually only mildly or moderately enlarged. In about 1% the spleen is the only detectably involved organ. NHL is characterised by diffuse homogeneous, or miliary infiltration, or by masses that are either solitary or multiple with varying histological patterns according to the type and grade of the disease. The commonest form is the low grade type, in which miliary infiltration usually occurs, and the second com- monest, the large cell type, in which solitary or multiple masses are usually found. Expansion by infiltration occurs in the white pulp, partic- ularly with low grade lymphoma. Discrete tumour-like masses are characteristic of the more aggressive intermediate or high grade lymphoma. Microscopically, B-cell lymphomas initially involve the B-cell-dependent germinal centres and mantle zones. T-cell lymphoma infiltration occurs in the peri-arteriolar sheaths and less frequently in the marginal zones.
Secondary Malignancy
Isolated metastasis to the spleen is relatively rare compared with metastases to other organs such as liver, lungs and bone [11]. Theoretically, this is thought to be because the microenviron- ment of the spleen is not favourable to the growth of tumour cells, or because of the lack of afferent lymphatics to the spleen, or the sharp origin of the splenic artery from the coeliac trunk. Most often it occurs in the presence of widespread disseminated malignant disease.
The incidence of splenic metastases ranges from 1111 2 3 4 5 6 7 8 9 1011 1 2 3 4 5 6 7 8 9 2011 1 2 3 4 5 6 7 8 9 3011 1 2 3 4 5 6 7 8 9 4011 1 2 3 4 5 6 7 8 9 5011 1 2 311 Figure 16.2. A computer tomogram (oral and intravenous con-
trast) of the abdomen in a patient with diffuse lymphomatous infiltration of the spleen and para-aortic lyphadenopathy. CT has superseded laparotomy in the staging of lymphoma.
0.3 to 7% of patients with disseminated malig- nancy at post-mortem [12]. The majority are asymptomatic and discovered either during staging investigations, at surgery or at autopsy.
The common causes in large autopsy series are breast, lung, colorectal and ovarian carcinomas, and melanomas, which probably reflects the incidence of the primary disease.
Direct Spread
The location of the spleen results in direct spread of tumours of the pancreas, colon and stomach.
Gastric Cancer
Direct spread to the spleen may occur from a cancer of the greater curve or fundus of the stomach. The practice in general from gastric cancer is to avoid splenectomy unless specifi- cally indicated because of direct invasion and the need for total macroscopic clearance.
Splenectomy is only indicated if a curative result can be achieved by en-bloc splenectomy or pan- creaticosplenectomy. In such cases a node dis- section of the splenic artery or hilum may be required, but this is now often accomplished without splenectomy in most cases (station 10 node dissection) [13]. The addition of splenec- tomy to resection of the stomach, pancreas or colon may result in increased rate of septic and thromboembolic complications. Theoretically there may be a long-standing adverse effect on the immune system in these cancer patients.
Colon Cancer
In colon carcinoma, as with other organs directly invaded by a colonic primary, the spleen is often ressected in continuity with the bowel to achieve a curative margin. There is no evidence that this is to the detriment of long-term survival in such patients [14]. Several cases of isolated splenic metastasis have been described, also treated by splenectomy [15].
Diagnosis
Plain Radiology
On a plain abdominal radiograph, the spleen may leave an impression on the gastric air
bubble or an indentation on the splenic flexure.
It is invisible on straight X-ray if it is of normal size.
Isotope Scanning
Technetium-99m radio-isotope labelled colloid injected intravenously is preferentially taken up by reticuloendothelial cells in the spleen [16].
When scanned using a gamma camera, splenic size may be assessed and perfusion defects noted. This technique has fallen from general use since the advent of CT but would differen- tiate between avascular and vascular neoplasms.
Ultrasound Scanning
Ultrasonography is often used as a preliminary diagnostic tool and can help to differentiate between benign and malignant lesions in the spleen [17]. Solitary lesions, anechoic mass or lesions with hyperechoic foci suggesting cal- cification are predictive for benign lesions, whereas multifocal or diffuse lesions, mixed echoic lesions and the presence of extrasplenic abdominal masses are predictive of a malignant process.
Lymphomatous infiltration may be nodular or diffuse; in Hodgkin’s lymphoma, the lesions are uniformly hypodense. Due to its superior- ity in the detection and evaluation of intra- abdominal lymphadenopathy, CT has largely superseded US in the staging of lymphoma.
Computed Tomography
CT has superseded operative staging for abdom- inal lymphoma [18]. Its advantages are that it is non-invasive. However, it cannot detect disease in normal size nodes (micronodular involve- ment) or differentiate reactive from infiltrated nodes.
Hamartomas have equal attenuation to nor- mal splenic tissue and can be difficult to detect.
Magnetic Resonance Imaging
Since the magnetic tissue characteristics of the normal spleen are indistinguishable from the average tissue characteristics of metastatic cancer, there is a limit to the use of MR in the detection and evaluation of solid splenic neo- plasms [19].
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Hamartomas may be hyper- or hypointense relative to normal spleen on a T2-weighted image, and all demonstrate heterogeneous enhancement on administration of contrast (gadolinium) [20].
Indications for
Splenectomy (Table 16.2)
Before the advent of accurate cross-sectional imaging, splenectomy was used in neoplasms of the spleen for accurate diagnosis and staging, often in conjunction with node sampling.
However, this is uncommon since the advent of CT [21]. Occasionally, for lymphoma or leukaemia, where the spleen involvement is predominant, splenectomy may be indicated to downstage disease prior to conventional chemotherapy. Contiguous spread or local node involvement from a gastric, pancreatic, colonic, renal or adrenal primary may necessitate splenectomy en-bloc to achieve a curative resec- tion (see above). Symptomatic enlargement producing abdominal pain and fullness, and hypersplenism (anaemia, thrombocytopenia or consumptive coagulopathy) may also be indi- cations for splenectomy [22]. Occasionally, spontaneous rupture may require emergency splenectomy.
Preoperative Preparation
The patient should be immunised against pneu- mococcal, Haemophilus and meningococcal infections as soon as the decision to operate is made [23]. Splenectomy results in reduced antibody responsiveness, especially in young or immunosuppressed patients. Vaccination results in a twofold increase in the antibody
titres within 2 weeks. The resulting protection lasts at least 5 years though the exact duration is unknown. Immunisation should be carried out as soon as the decision to operate is made.
In the presence of coagulopathy due to thrombocytopenia, perioperative platelet trans- fusion may be required. In cases where the platelet count is very low (<20× 109/l), such transfusion may only be effective once the vas- cular pedicle is secured and divided due to rapid platelet consumption by the spleen [24].
Technique
The operative approach depends upon the indi- cation and the degree of splenomegaly and asso- ciated conditions such as portal hypertension.
Open Splenectomy
The spleen is usually approached through an upper midline or left paramedian incision. The paramedian incision may give better access to the spleen, but it is less useful if the spleen is massive or other procedures such as cholecys- tectomy are contemplated. Initial ligation of the splenic artery through the lesser sac may reduce bleeding during removal of the spleen.
This is best approached through the gastrocolic omentum. Thereafter the spleen can be safely immobilised by division of the splenorenal lig- ament. Alternatively the hilar structures may be approached, dissected and divided directly without resort to the lesser sac. The chosen approach is the preference of the operating surgeon.
Laparoscopic Splenectomy
The safety and efficacy of laparoscopic splenec- tomy is well established for benign conditions such as idiopathic thrombocytopenia purpura or hereditary spherocytosis [25]. The potential risks of this approach for malignant neoplasms are dissemination of malignant cells in the peritoneum or the trocar sites, and architectural disruption during the process of maceration required to remove the specimen through a small incision. Thorough preoperative staging investigations, careful operative technique and the use of wound protectors during maceration and removal should mitigate these problems.
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Diagnosis – lymphomas, now largely superseded by CT Staging – lymphomas, now largely superseded by CT Downstaging – isolated splenic lymphomas Metastasis – isolated or direct spread Symptoms – pain, fullness or early satiety Hypersplenism – anaemia, thrombocytopenia, consumptive coagulopathy
Conditions that increase the vascularity and fri- ability of the spleen such as lymphoma, as well as massive splenomegaly (>1.5 kg), may be rel- ative contraindications to laparoscopic splenec- tomy. The operating time for laparoscopic splenectomy is greater than for open splenec- tomy, although the newer technique is in its rel- ative infancy. There is a comparable incidence of the numbers of accessory spleens found during the procedure. The morbidity of the open and laparoscopic procedures is similar.
Postoperative hospital stay is reduced for the laparoscopic approach [26].
Postoperative Complications
General
After splenectomy, pulmonary atelectasis com- monly affects the left lower lobe, which is reduced by preoperative physiotherapy. Gastric ileus is also common and a nasogastric tube is usually required for 2–3 days postoperatively.
Significant per- and postoperative haemor- rhage may occur with splenectomy (Table 16.3), especially after removal of a large spleen (> 1500 g) [27]. Reoperation may be required, or a sub- phrenic haematoma may develop. A tube drain is often placed at the time of splenectomy, though there is no evidence that this reduces the possibility of reoperation. Patients with myelofi- brosis are particularly at high risk.
Specific Complications
Thrombocytosis
In up to 75% of patients there is an increase in the platelet count immediately after splenec- tomy, which peaks at 7–12 days and lasts for 2–3
weeks (usually 600–1000× 109/l) [28]. If the platelet count is over 750× 109, oral aspirin should be administered (150 mg/dl). This does not seem to be associated with an elevated risk of deep vein thrombosis and specific anti- thromboembolic prophylaxis is not indicated in patients undergoing splenectomy [29].
Portal vein thrombosis may occur, particu- larly after splenectomy for massive spleno- megaly and where the platelet count is high. The consequences may be serious with intractable ascites, hepatic failure and, often, death.
Overwhelming Post-splenectomy Infection (OPSI)
This is a fulminant bacteraemia that may occur after splenectomy. Clinically it presents with shock, coma, coagulopathy and adrenal haem- orrhage. The common organisms isolated are Streptococcus pneumoniae, Escherichia coli, Neisseria meningitides and Haemophilus influenzae [30].
It occurs for two reasons: first, due to the lack of red pulp, which results in a deficiency of phagocytosis to clear exogenous organisms, and second, due to the lack of white pulp, which leads to a failure of bacterial opsonisation with antibodies. The incidence of OPSI is 1–5% in large series, and it is more common in children and adolescents [31]. It usually occurs within 3 years after splenectomy, but has been described up to 30 years later. There is a very high mor- tality, up to 75% [31]. There is also an increased susceptibility to parasitic infections such as malaria [31].
Long-term Management
All splenectomised patients should receive post- operative prophylactic penicillin for at least 2 years; thereafter they should also be covered 111
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Table 16.3. The specific complications of splenectomy
Peroperative Early postoperative Late postoperative
Bleeding Bleeding Overwhelming post-splenectomy infection (OPSI)
Gastrotomy Gastroparesis or perforation
Pancreatic damage Pancreatic abscess, fistula or pancreatitis Missed splenunculus Thrombocytosis
Portal vein thrombosis
Pulmonary; lobar collapse or effusion
with penicillin during any infectious illness [32].
Guidelines may vary in different centres. The hazard of overwhelming infection is greatest in:
• children under the age of 16
• the first 2 years after splenectomy
• patients with underlying impairment of immune function.
Pneumococci are susceptible to a range of antibiotics. An increasing proportion of pneu- mococci, however, have become resistant to antibiotics, although the proportion in the UK is much lower than in many other European countries. Data collected by the Public Health Laboratory Service (PHLS) have shown that the proportion of pneumococci resistant to penicillin has risen from 0.3% in 1989 to 7.5%
in 1997, and the proportion resistant to ery- thromycin has risen from 3.3% in 1989 to 11.8%
in 1997 [33].
Antibiotics
A typical regimen for antibiotics is 250–500 mg phenoxymethylpenicillin or amoxicillin once a day (adults), or in the case of allergy to peni- cillin, erythromycin (250 mg once a day in adults). Amoxicillin is better absorbed than phe- noxymethylpenicillin and has a longer shelf life.
A therapeutic dose should be taken in the event of any illness with shivering, fever or malaise.
Doctors attending any asplenic patients with severe infection should give parenteral ben- zylpenicillin and arrange hospital admission.
Patient Identification (Figure 16.3)
It is recommended that patients after splenec- tomy carry a card or wear a medical alert bracelet to identify their asplenic status in case of subsequent illness or injury. Cards are avail- able from the Department of Health (PO Box 410, Wetherby, LS23 7LL, UK). This is of par- ticular importance after laparoscopic splenec- tomy where no major incision will be visible.
Immunisation
A single dose of polyvalent polysaccharide pneumococcal vaccine is recommended for all patients aged 2 years or above for whom it is not contraindicated. This should be done as soon as possible after splenectomy or ideally 4–6 weeks
before surgery. There is a conjugated vaccine available for children between 2 months and 2 years. Reimmunisation is recommended every 5–10 years.
Immunisation against Haemophilus B should be given in a single dose at the same time as pneumococcal vaccination. The recommenda- tions for reimmunisation are under review.
Annual immunisation for influenza may be beneficial.
All patients should be offered meningococcal C conjugate vaccine. There is no information on the need for further doses.
Conclusions
Surgery for the spleen is currently changing since the development of advanced laparoscopic surgery over the last decade. In most instances surgeons well trained in complex minimal access techniques carry out such procedures.
Whilst laparoscopic surgery has much to offer in terms of the reduction of postoperative pain and hospital stay, it is vital that this is not at the expense of increased morbidity when compared to open surgery.
There remains no general consensus as to the long-term prevention of infective illness in asplenic patients. It is therefore the responsibil- ity of the individual clinician to take appropri- ate advice in this regard.
Areas of Controversy
• Laparoscopic splenectomy
• Long-term antibiotics
• Immunisation
Questions
1. Give the differential diagnosis of space- occupying lesions of the spleen.
2. What is the most common malignant process to affect the spleen?
3. What immunisations are recommended prior to surgery and how long is this effective for?
4. Detail postoperative risks of splenec- tomy.
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Figure 16.3. A card issued by the Department of Health for patients to carry after splenectomy. These are available with an information leaflet for patients from the Department of Health, PO Box 777, London SE1 6XH.
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