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Epidermoid cyst of the spleen


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Splenic cysts are not frequently encountered in everyday surgical practice. They are either parasitic (usually hydatid cysts) or non parasitic (true cysts with epithelial lining or more commonly false cysts). We report the case of a patient with a palpable mass and abdominal pain in the left upper quadrant. USG and CECT abdomen revealed it to be a large splenic cyst. Histopathological examination confirmed it as an epidermoid cyst and splenectomy was done. splenic cyst, splenomegaly, splenectomy
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Verma M, Vashist M G, Dalal S, Chanchal, Singla A
Splenic cysts are not frequently encountered in everyday surgical practice. They are either parasitic (usually
hydatid cysts) or non parasitic (true cysts with epithelial lining or more commonly false cysts). We report the
case of a patient with a palpable mass and abdominal pain in the left upper quadrant. USG and CECT abdomen
revealed it to be a large splenic cyst. Histopathological examination confirmed it as an epidermoid cyst and
splenectomy was done.
splenic cyst, splenomegaly, splenectomy
Epidermoid cyst of the spleen
Splenic cyst can be parasitic (hydatid) or
nonparasitic. Primary nonparasitic splenic cysts
(PNSC) are rare and account for 10% of all
nonparasitic splenic cysts, but they are the most
frequent type of splenic cysts in children. They are
classified as primary (true epithelial), lined by an
epithelial cover (epidermoid, dermoid and
mesothelial) or endothelial cover (hemangioma,
lymphangioma) and secondary (pseudocysts, non-
epithelial), which are usually of post-traumatic
origin. Though the cysts are asymptomatic, except
for pain due to mass effect in the abdomen. It can
get infected or rupture causing acute abdomen.
A 31-year-old man presented with history of
abdominal discomfort and fullness in his left upper
abdomen since ten months. Physical examination
revealed a large, smooth, nontender mass
occupying the left hypochondrium. The routine
hematological and biochemical tests were normal.
Serologic tests were negative for parasitic
infection. USG and CT abdomen showed a well
defined splenic cyst of size 16 x 14 cm, displacing
the stomach to the right (Fig 1).
Fig.1: CT abdomen showing hypoechoic cyst of spleen
The diagnosis of a splenic cyst was confirmed and
the exploratory laparotomy was scheduled in two
weeks. On exploration, a very large cyst of the
spleen occupying the entire left upper abdomen
was found. The large size and little splenic
parenchyma made preservation of the spleen
impossible. The splenectomy was performed and
sent for histopathological examination. The excised
organ measured 26 X 18 X 16 cm and weighed
750gms with intact surface. The cyst was unilocular
and contained about 550ml of yellowish brown
granular fluid.
The inner surface was yellowish to whitish
glistening with marked trabeculations and normal
appearing adjacent splenic parenchyma of size 8 x 3
cm. Histology revealed picture of a true cyst
composed of a wall lined by both squamous and
mesothelial cubic epithelia, consistent with the
diagnosis of an epidermoid cyst of the spleen. (Fig
2) The postoperative course was uneventful and
the patient was discharged 5 days after the
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IJRRMS 2013;3(2)
Case Report
Fig.2: Microscopic examination of splenic epidermoid
Andral G was credited for first to report a splenic cyst
at autopsy. Majority of splenic cysts are parasitic
and are due to Echinococcus granulosus infestation
particularly in endemic areas. Martin offered a
sim plif i ed cl inica l cla ssifi cati on wh e re i n
hemangioma was the most common primary cyst
and dermoid was the rarest. Nonparasitic splenic
cysts may be completely asymptomatic or may
present with acute abdominal symptoms due to
displacement of surrounding structures by the
enlarging splenic mass. Gradual enlargement may
be due to the proliferation and the secretions of the
lining cells or to the bleeding from the cystic wall, as
well as to an osmotic imbalance of the cystic fluid.
USG, CT and MRI provide most of the necessary
information about the morphology of the cyst, the
composition of the cystic fluid and their location in
the spleen, the position of the cyst and its
relationship with the surrounding tissues. Earlier,
the classical approach to splenic cysts has been
open complete splenectomy but today the options
hav e c h a ng e d t o p ar t ia l s pl e ne c to m y,
marsup i a l i z a t i o n , o r cyst deca p s u l a t i o n
(unroofing), accessed either by open laparotomy
or lap a r o s copy. Pa r t i al splenecto m y is
recommended, if the cyst is located in the poles of
the spleen.
Present case serves to highlight that though splenic
epidermoid cyst is an infrequent entity, it should be
considered in the differential diagnosis of a splenic
cystic mass. An attempt should be made to
preserve the spleen provided there is adequate
parenchyma, otherwise splenectomy is the rule.
Assistant Professor,
E - m ail : m ani s h. v e rma 4 26 @g mai l .c om
(Corresponding Author)
Senior Professor
Junior Resident
Junior Resident
Department of General Surgery, Pt. B. D. Sharma
Postgraduate Institute of Medical Sciences,
Manish Verma,
M. G. Vashist,
Satish Dalal,
Amit Singla,
1. Reddi VR, Reddy MK, Srinivas B, Sekhar CC, Ramesh O. Mesothelial splenic cyst--a case report. Ann Acad
Med Singapore. 1998 Nov;27(6):880-2.
2. Andral G. Precis d'anatomie patliologique. Paris : Gabon, l829 ; 2: 432
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 Jun;22(6):704-8.
4. Morgenstern L. Nonparasitic splenic cysts: pathogenesis, classification, and treatment. J Am Coll Surg.
2002 Mar;194(3):306-14.
5. Robertson F, Leander P, Ekberg O. Radiology of the spleen. Eur Radiol.2001;11(1):80-95.
6. Labruzzo C, Haritopoulos KN, El Tayar AR, Hakim NS. Posttraumatic cyst of the spleen: a case report and
review of the literature. Int Surg. 2002Jul-Sep;87(3):152-6.
7. Till H, Schaarschmidt K. Partial laparoscopic decapsulation of congenital splenic cysts. A medium-term
evaluation proves the efficiency in children. Surg Endosc. 2004 Apr;18(4):626-8.
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Verma M et al. Epidermoid cyst of the spleen
Two cases of epidermoid cysts of the spleen are presented with a review of the current literature. This brings the total number of reported cases to thirty-one.
True splenic cyst is a relatively rare disease, and the majority of the cases are classified as epidermoid cysts. Three cases of epidermoid cysts in the spleen or accessory spleen were studied using an immunohistochemical technique and staining for mucin. In case 1, serum carcinoembryonic antigen (CEA) and CA19-9, and in cases 2 and 3, serum CA19-9, before surgery were markedly elevated, and these levels decreased postoperatively. This strongly indicates the relationship between the increase of tumor marker levels and the presence of the epidermoid cyst. In addition, stratified squamous epithelium in the resected tissues of cases 1 and 2 was positive for anti-CEA antibody and anti-CA19-9 antibody, and that of case 3 was positive for anti-CA19-9 antibody. This strongly supports CEA or CA19-9 production in the squamous epithelium.
A 26-year-old male presented with a left upper abdominal mass of one year's duration. Ultrasonography revealed a cystic lesion arising from the lower pole of the spleen. Total splenectomy was done and pathological examination of the cyst confirmed a true cyst with mesothelial lining without squamous metaplasia. The epithelial linings of these true cysts ranged from flattened low cuboidal, low columnar to squamous type and unilayered or stratified. The pathogenetic hypotheses as well as clinicopathological features of this rare lesion, which is usually found in children and young adults, were reviewed.
The spleen is generally not considered a challenge to the radiologist. Most often it poses a problem by anomalies or an irregular but normal contrast enhancement; however, a variety of inflammatory, infectious and neoplastic diseases may involve the spleen. CT and ultrasonography are screening modalities for the spleen. For problem solving, MR imaging can be helpful, especially due to its free choice of the imaging plane and because of the high resolution in contrast MR imaging. Splenic angiography as a diagnostic tool has generally been replaced by CT, ultrasound, or MR and is now used as an interventional method, e. g., in non-surgical management of patients with chronic idiopathic thrombocytopenia or in patients with splenic trauma. This article reviews the radiology of the spleen, including anatomy, embryology, splenomegaly, splenic injury, infarction, cysts, tumors, abscesses, sarcoidosis, and AIDS. Knowledge about the use of different imaging modalities and underlying gross and microscopic pathologic features leads to a better understanding of the radiologic findings.
Nonparasitic splenic cysts (NPSCs) are uncommon lesions of the spleen, many being reported in anecdotal fashion. Early classifications of this disorder have been based on the presence or absence of an epithelial lining, indicating either a congenital or traumatic etiology. This criterion has led to confusion and mistaken reporting because the lining alone is not a reliable criterion. Over a 28-year period, the author has observed and studied 23 patients with NPSC. Special attention has been given to the role of trauma in the history, the nature (or absence) of a cyst lining, the gross pathology, and the preferred method of treatment. NPSC present as lesions with a very characteristic gross appearance and lining. The trabeculated interior can be lined with epidermoid, transitional, or mesothelial epithelium. Desquamation of the lining can lead to a spurious diagnosis, but careful search usually discloses the lining remnant. Although most NPSC in this series were treated by open partial splenectomy, the more recent approach by laparoscopic techniques offers great promise. A new classification of NPSC is offered, based on characteristic gross findings. NPSC are of congenital origin, with a lining derived from mesothelium. Trauma does not play a primary role in pathogenesis. Cysts that are symptomatic or over 5 cm in diameter should be removed by partial splenectomy or near-total cystectomy "decapsulation," either by the open or laparoscopic approach.
Splenic cysts are rare lesions. They are mainly divided into primary or genuine cysts and secondary or false cysts according to their etiology and pathophysiology. Primary cysts have a cellular lining that can be caused by either congenital events or parasitic infestations (Echinococcus). Secondary cysts have no cellular lining and may be of hemorrhagic, serous, inflammatory, or degenerative origin. It is important for surgeons to assess each individual case and decide on the most suitable treatment, taking into account the features of the cyst, the time of onset, and the age of the patient, to avoid possible complications. We report a case of posttraumatic pseudocyst treated successfully by splenectomy and we review the literature.
In children, laparoscopic decapsulation of large congenital splenic cysts has occasionally been advocated, but substantial series focusing on its long-term success are still lacking. We report the follow-up experiences from two pediatric surgical centers. The decision to proceed to surgery was based on patient symptoms and cyst size (>4 cm and/or progression), after strictly exclusion of a parasitic cause (by serology and CT scan). With the use of three ports (5-10-mm) and a Harmonic Scalpel, the epithelial portion of the cyst was radically excised. The remaining hilar epithelium was coagulated carefully. After discharge, the children were examined regularly by ultrasound to detect recurrences. From 1998 until 2002, eight children (mean age, 11.1 years; range, 3.1-16.4) were treated for cysts ranging from 4 to 15 cm in diameter. All procedures were completed without significant intraoperative complications (no major bleeding, no conversions). The mean operating time was 75 min (range, 56-184). Postoperatively, one child developed a cystic remnant (2 cm), which remained unchanged during 30 months of observation. After a mean follow-up of 2.2 years (range, 13-38 months), none of the patients showed any evidence of recurrent growth, and all of them had healthy splenic remnants. Partial laparoscopic decapsulation is an advantageous approach to large splenic cysts in children, because it is effective, preserves splenic tissue, and provides good medium-term results.