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Spleen-preserving surgery in treatment of large mesothelial splenic cyst in children. - A case report and review of the literature

Z. Zvizdic, S. Dizdarevic, K. Karavdic, A. Jakić
Department of Pediatric Surgery, University Clinical Centre Sarajevo, Sarajevo, Bosnia and Herzegovina

 

Correspondence

Zlatan Zvizdic MD
Department of Pediatric Surgery, University Clinical Center Sarajevo,
Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina;
Tel: 387 33 297 142; 387 61 194 924
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Splenic cysts are rarely found in clinical practice, occurring in only 0.5%-2.0% of the population. We hereby present a case of incidental finding of a large splenic mesothelial cyst and its surgical treatment with preservation of the remaining splenic parenchyma. Key words: mesothelial splenic cysts, surgery, spleen preservation Introduction In 1829, Andral first described the splenic cyst found at the autopsy and Pean performed the first recorded splenectomy for cyst in 1867 [1,2]. Splenic cysts are rarely found in clinical practice, occurring in only 0.5%-2.0% of the population [3]. Splenic cysts are classified into primary and secondary cysts, according to the presence or absence of an epithelial lining of the lumen [4, 5]. The primary cysts are further subdivided into parasitic and nonparasitic [6, 7]. The nonparasitic cysts can occur as a congenital and neoplastic, whereas congenital cysts are originally classified into epidermoid, dermoid and endodermoid cysts [8]. Primary splenic cysts (parasitic and nonparasitic) account for 25% of the total percentage of the splenic cysts [9]. The epithelial cysts account for approximately 25% of all primary (true) splenic cysts [10, 11]. Primary splenic cysts occur more frequently in children and young adults [10, 12]. We hereby present a case of a large splenic mesothelial cyst and its treatment with preservation of the remaining splenic parenchyma.

Case Report

A 10-year-old girl was examined at the Department of Pediatric Gastroenterology of the University Clinical Center Sarajevo, Bosnia and Herzegovina, for celiac disease. During clinical evaluation, abdominal ultrasonography revealed a solitary splenic cyst located in the central part of the spleen with a maximum diameter of 4,4 cm with smooth wall and anechoic central areas. The patient had no history of trauma or infection. Physical examination revealed nothing abnormal, but mild tenderness was found in the left hypochondriac region. Follow-up abdominal ultrasonography, performed 3 and 6 months after the initial ultrasonography, and MRI, performed 6 months after the detection of splenic cyst, showed a moderate growth of the cyst (the cyst measured 6,24 x 6,07 x 5,96 cm in size) (fig. 1, 2).

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Figure 1: MRI- reconstruction of spleen and of the splenic cyst (T1 FS COR)

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Figure 2: MRI- reconstruction of a spleen and splenic cyst (6,4x6 cm in diameter) (T2 TSE TRA)

The patient was transferred to the Department of Pediatric Surgery. Since the diameter of the cyst was larger than 5 centimeters and the cyst showed progressive growth, we decided there was an indication for open surgical treatment. A left subcostal incision was performed. A large splenic cyst was revealed at the central part of the spleen (fig. 3).

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Figure 3: Large splenic mesothelial cyst

The two thirds of the spleen tissue were occupied by the cyst. The cyst roof was punctured and about 150 ml of serous fluid was aspirated and sent for culture and cytological examination (bacteriological cultures and cytological examination of the fluid were negative). Visible portion of the collapsed cyst wall was excised and then the entire cyst wall was “peeled” from the splenic parenchyma to exclude the risk of recurrence (fig. 4), with careful preservation of the remaining spleen tissue.

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Figure 4: Wall of the cyst and the cyst cavity

Successful hemostasis was achieved by lining of the cyst cavity with Surgicel and by splenorrhaphy. The diagnosis of a primary mesothelial cyst was based on the histology report. Microscopically, the lining is composed of cuboidal to low columnar non-ciliated (mesothelial-like) epithelium (fig. 5).

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Figure 5: Histopathological view cross-section of the mesothelial splenic cyst. Lining is composed of cuboidal to low columnar non-ciliated (mesothelial-like) epithelium (H and E X400)

There were no postoperative complications. The patient was postoperatively hemodynamically stable and postoperative ultrasonography scan and platelet counts showed preservation of splenic function. The patient was discharged on the ninth postoperative day.

Discussion

Although the etiology, pathogenesis and development of the congenital splenic cysts are not completely clear, proposed mechanisms include: involution of pluripotent cells in the splenic parenchyma during development with subsequent squamous metaplasia; entrapment of peritoneal endothelial cells or coelomic mesothelium within the developing spleen, and invagination of the surface mesothelium or dilatation of normal lymph spaces [10]. During the diagnostic evaluation of the spleen cysts, ultrasonography was able to show that the cysts are either anechoic or hypoechoic and that they have a smooth thin wall, whereas solid tumors are either isoechoic or hypoechoic [13].

Computerized tomography and magnetic resonance imaging can provide additional relevant information related to the morphology of the cyst, composition of the cystic fluid, the precise localization of the cyst within the spleen and its anatomical relationship with the surrounding abdominal organs [14]. Open splenectomy was acceptable therapeutic modality in the treatment of splenic cysts until 1970s. Being aware of the important role of the spleen in hematopoiesis, immune function and protection against infections, especially in children as well as recognizing the possibility of overwhelming life-threatening septicemia [12, 15], spleen preservation has been established as essential in the treatment of splenic cysts, when feasible. Recently, recommended treatment options are partial splenectomy, total splenic cystectomy, partial splenic cystectomy (cyst decapsulation, unroofing) or marsupialization, performed by laparotomy or laparoscopy [12, 16, 17, 18]. Nevertheless, when splenic tissue is completely replaced by the cyst or giant cysts are severely inflamed or infected, total splenectomy should be performed [19].

Conclusions

True splenic cysts are very rare clinical entity. They are surgically treated in case of life threatening complications like rupture, intracystic hemorrhage, abscess formation, compression of the adjacent abdominal organs or if their diameter exceeds 5 cm [20, 21]. Because of the exceptional importance of the spleen in hematological and immunological functions of the organism, the recommended treatment goals include elimination of the cyst, prevention of recurrence with preservation of as much spleen tissue as possible. Preservation of more than 25% of splenic parenchyma is sufficient for physiological function of the spleen, primarily in providing immunological protection [12]. Our case shows that spleen-preserving surgery in treatment of the large splenic cysts is possible and safe procedure with maintenance of the splenic function.

 

 

 

References

1. Andral G. Précis d’Anatomie Pathologique. Paris: Gabon 1829:432.

2. Schwartz SI. The spleen. In: Schwartz SI, Harold E, editors. Maingot’s Abdominal Operations. Vol II. 9th ed. Connecticut, USA: Appleton & Lange, 1990:1679-80.

3. Higaki K, Jimi A, Watanabe J, Kusaba A, Kojiro M. Epidermoid cyst of the spleen with CA19-9 or carcinoembryonic antigen productions : report of three cases. Am J Surg Pathol 1998; 22:704-8.

4. Martin JW. Congenital Splenic Cyst. Am J Surg 1958; 96:302-8.

5. Williams RJ, Glazer G. Splenic Cysts: Changes in Diagnosis, Treatment and Aetiological Concepts. Ann R Coll Surg Engl. 1993; 75(2):87-9.

6. Avital S, Kashtan H. A Large Epithelial Splenic Cyst. N Engl J Med 2003; 349: 2173-74.

7. Robertson F, Leander P, EkbergO. Radilogy of the Spleen. Eur Radiol. 2001; 11:80-95.

8. Reddi VR, Reddi MK, Srinivas B, Sekhar CC, Ramesh O. Mesothelial Splenic Cyst-a Case Report. Ann Acad Med Sinapore 1998; 27: 880-2.

9. Nakae Y, Hayakawa T, Kondo T, Shibata T, Kitagawa M, Sakai Y, et al. Epidermoid cyst occurring in a pancreatic accessory spleen. J Clin Gastroenterol 1991; 13:362-4.

10. Giovagnoni A, Giorgi C, Goteri G. Tumours of the Spleen. Cancer Imaging 2005; 5:73-7.

11. Robbins FG. Yellin AE, Lingua RW. Splenic epidermoid cysts . Ann Surg 1987; 187:231-5.

12. Hansen MB, Moller AC. Splenic cysts. Surg Laparosc Endosc percutan Tech 2004; 14: 316-22.

13. Siniluoto TM, Paivansalo MJ, Lahde ST, Alavaikko MJ, Lohela PK, Typpo AB, Suramo IJ. Nonparasitic splenic cysts. Ultrasonographic features and follow-up. Acta Radiol 1994; 35:447-51.

14. Robertson F, Leander P, Ekberg O. Radiology of the spleen. Eur Radiol 2001; 11:80-95.

15. Shaw JHF, Print CG. Postsplenectomy sepsis. Br J Surg 1989; 76:1074-81.

16. Till H, Schaarschmidt K. Partial laparoscopic decapsulation of congenital splenic cysts. Surg Endosc 2004; 18:626-8.

17. Touloukian RJ, Maharaj A, Ghoussoub R, Reyes M. Partial decapsulation of splenic epithelial cysts: studies on etiology and outcome. J Pediatr Surg 1997; 32: 272-4.

18. McColl RJ, Hochman DJ, Sample C. Laparoscopic management of splenic cysts: marsupialization, cavity lining with surgicel and omentopexy to prevent recurrence. Surg Laparosc Endosc Percutan Tech 2007; 17(5): 455-8.

19. Madia C, Lumchi F, Veroux M, Fiamingo P, Gringeri E, Brolese A, Zanus G, Cillo U, D’Amico CF. Giant Splenic Epithelial Cyst with Elevated Serum Markers CEA and CA, 19-9 Levels : An Incidental Association ? Anticancer Res 2003; 23 : 773-6.

20. Gianom D, Wildisen A, Hotz T, Goti F, Decurtins M. Open and laparoscopic treatment of nonparasitic splenic cysts. Dig Surg 2003; 20 : 74-8.

21. Matsubayashi H, Kuraoka K, Kobayashi Y, Yokota T, Iiri T, Tada T, Satoh K, Kijima H. Ruptured epidermoid cyst and haematoma of spleen : a diagnostic clue of high levels of serum carcinoembryonic antigen, carbohydrate antigen, 19-9 and Sialyl Lewis x. Dig Liver Dis 2001; 33 : 595-9.