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Splenic Cysts

Cysts of the spleen are an uncommon cause of a left upper quadrant abdominal mass or vague abdominal symptoms. More than 600 cases of nonparasitic cysts have been reported in the medical literature in the past 160 years. Worldwide, parasitic splenic cysts, usually echinococcal, are more common.

Nonparasitic cysts are divided into true cysts and pseudocysts. In our experience, the latter are more common and are secondary to prior recognized or unrecognized trauma or splenic infarction. True cysts are categorized as epidermoid, dermoid, or originating in a lymphangioma or hemangioma. Not all lymphangiomas or hemangiomas have a major cystic component, and these may be better classified as benign tumors of the spleen. True cysts cannot always be differentiated from pseudocysts because the cellular lining of a true cyst may disappear in response to intracystic inflammation or increasing pressure from secretion of fluid; blood products may be present in either type.

Most splenic cysts are asymptomatic and are discovered incidentally after radiologic procedures or at autopsy. Some patients present with idiopathic splenomegaly. A few patients have left upper quadrant abdominal pain or left shoulder pain. If a splenic abnormality is suspected, ultrasonography, CT, or both will define the cystic nature of the lesion. Calcifications are common in hydatid cysts, and they may also be seen in pseudocysts, but they are rare in true cysts. CT can define better the multiloculations seen in patients with splenic hemangioma or lymphangioma. Because splenic hemangiomas are the most common of true cystic lesions of the spleen and offer the greatest risk of spontaneous or post-traumatic rupture, radiographic determination of this likely diagnosis may influence the decision regarding operation.

When a patient is in good health, most surgeons consider operative removal of any cystic lesion of the spleen. In some instances, partial splenectomy may be sufficient in patients with a unilocular cyst.

Primary Benign and Malignant Tumors of the Spleen

Tumors ofthe spleen are rare. Benign lesions include hamartoma, lipoma, hemangioma, lymphangioma, and hemangioendothelioma. Although hemangiomas and lymphangiomas have been mentioned under the discussion of splenic cysts, they are often more solid than cystic. Most of these lesions, including hamartomas, are small and of no clinical significance, but on rare occasions they can produce splenomegaly and occasionally hypersplenism. Operative removal of the spleen is required occasionally for definitive diagnosis of ill-defined splenomegaly or hypersplenic manifestations.

The most common, but still rare, primary malignant tumor of the spleen is angiosarcoma; the prognosis is dismal, and usually the lesion has metastasized by the time of discovery. Almost one third of patients will present with spontaneous rupture of the spleen. Others have abdominal pain and a palpable left upper quadrant abdominal mass. Anemia, which is common, may be microangiopathic. Rarer malignant lesions include malignant fibrous histiocytoma, fibrosarcoma, and leiomyosarcoma. Reports of "primary" lymphomas of the spleen, both Hodgkin's disease and non-Hodgkin's lymphoma, have appeared, but often the absence of extrasplenic disease has not been well documented. Current opinion indicates that, if a diagnosis of "primary splenic lymphoma" is made after splenectomy, adjuvant chemotherapy should be seriously considered.

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