Diagnostic and Interventional Imaging (2014) 95, 1103—1104
LETTER / Thoracic imaging A rare cause of pleural nodules: Thoracic splenosis Keywords: Thoracic splenosis; Pleural nodules; Labeled red blood cell scintigraphy Splenosis is the rare and benign diagnosis of ectopic implantation of splenic tissue, occurring mainly after rupture of the spleen. The majority of cases described involve the abdomen. Location in the thorax is very much less frequent. We report here a case of thoracic splenosis in a man whose spleen was removed 30 years previously due to a penetrating trauma. The diagnosis was confirmed by labeled red blood cell scintigraphy. Case observation A 47-year-old man was referred for management of respiratory insufficiency. He had no particular history apart from a splenectomy 30 years previously. The clinical examination found dyspnea with no serious signs or any other abnormality. Blood tests only showed polycythemia (hemoglobin = 171 g/L). A thoracic CT scan was performed and revealed numerous well-delineated nodules with regular margins, enhanced after contrast injection, which had developed in the mediastinal and visceral pleura of the left cardiophrenic angle (Fig. 1).
Owing to the presence of this large number of pleural nodules in the left hemithorax in a splenectomized patient, the diagnosis suggested was thoracic splenosis. The Tc99m-labeled red blood cell scintigraphy merged with the CT data showed increased fixation by the left pleural nodules (Fig. 1). We were thus able to confirm the diagnosis of thoracic splenosis non-invasively. Discussion Splenosis was described for the first time in 1937; it is the ectopic auto-transplantation of splenic tissue following rupture of the spleen or splenectomy. Even though this condition is rare, it concerns 67% of splenectomized patients. The nodules of splenosis can implant themselves anywhere in the abdominal cavity but are more likely to be found on the serosa of the small intestine, the large omentum, the peritoneum, the colon, the mesentery and the inferior surface of the diaphragm. Thoracic splenosis arises where there is an associated wound to the diaphragm, in about 18% of patients presenting a ruptured spleen [1]. This percentage is almost certainly an under-estimate because it is generally asymptomatic. The mean period of time before it is discovered is therefore long (∼ 21 years) [1]. The male/female sex ratio is 30/8 [1], probably related to the very high frequency of splenic trauma in young men. Clinically, forms have been described that cause the following symptoms: pleural pain [2], hemoptysis [3], dyspnea.
Figure 1. Pleural nodules in thoracic splenosis (white arrows): a: CT with contrast injection, axial slice; b: labeled red blood cell scintigraphy; c: CT scan/scintigram merged. http://dx.doi.org/10.1016/j.diii.2014.02.024 2211-5684/© 2014 Éditions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved.
1104 The splenic implants colonize above all the pleura of the left hemithorax [2], the mediastinum [2], and more rarely the lung parenchyma, and may measure up to 13 cm [2]. With imaging, they present as numerous, wellcircumscribed, non-calcified nodules, with enhancement kinetics similar to the spleen. Diagnosis is confirmed by a positive result from technetium 99m-labeled red blood cell scintigraphy, which is more sensitive than sulfur colloid scintigraphy [4]; this also avoids having to perform percutaneous or thoracoscopic biopsy [5]. Surgery is only for complicated forms. Not removing splenosis nodules in splenectomized patients would preserve a certain degree of immunity and reduce the risk of infection [6]. In conclusion, splenectomy in the history associated with the presence of numerous left unilateral pleural nodules should suggest the diagnosis of thoracic splenosis. Labeled red blood cell scintigraphy confirms the diagnosis in a noninvasive manner. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Yammine JN, Yatim A, Barbari A. Radionuclide imaging in thoracic splenosis and a review of the literature. Clin Nucl Med 2003;28(2):121—3.
Letter [2] Fukuhara S, Tyagi S, Yun J, Karpeh M, Reyes A. Intrathoracic splenosis presenting as persistent chest pain. J Cardiothorac Surg 2012;7:84. [3] Cordier JF, Gamondes JP, Marx P, Heinen I, Loire R. Thoracic splenosis presenting with hemoptysis. Chest 1992;102(2): 626—7. [4] Brancatelli G, Vilgrain V, Zappa M, Lagalla R. Case 80: splenosis. Radiology 2005;234(3):728—32. [5] Khan AM, Manzoor K, Malik Z, Avsar Y, Yasim A, Shim C. Thoracic splenosis: know it-avoid unnecessary investigations, interventions, and thoracotomy. Gen Thorac Cardiovasc Surg 2011;59(4):245—53. [6] Chagnaud C, Champsaur P, Costanzo VD, Petit P, Chamati S, Charifi AB, et al. Splénose péritonéale simulant une masse retropéritonéale droite. J Radiol 1998;79: 1407—9.
D. Chemouni a,∗ , O. Laas b , J.-M. Caporossi c , S. Coze a , M. Panuel a , K. Chaumoitre a a AP—HM, Radiology Department, hôpital Nord, 265, chemin des Bourrely, 13015 Marseille, France b AP—HM, Nuclear Medicine Department, hôpital Nord, 2, chemin des Bourrely, 13015 Marseille, France c AP—HM, Radiology Department, hôpital de la Timone, 264, rue Saint-Pierre, 13005 Marseille, France ∗ Corresponding
author. E-mail address: [email protected] (D. Chemouni)
LETTER / Thoracic imaging A rare cause of pleural nodules: Thoracic splenosis Keywords: Thoracic splenosis; Pleural nodules; Labeled red blood cell scintigraphy Splenosis is the rare and benign diagnosis of ectopic implantation of splenic tissue, occurring mainly after rupture of the spleen. The majority of cases described involve the abdomen. Location in the thorax is very much less frequent. We report here a case of thoracic splenosis in a man whose spleen was removed 30 years previously due to a penetrating trauma. The diagnosis was confirmed by labeled red blood cell scintigraphy. Case observation A 47-year-old man was referred for management of respiratory insufficiency. He had no particular history apart from a splenectomy 30 years previously. The clinical examination found dyspnea with no serious signs or any other abnormality. Blood tests only showed polycythemia (hemoglobin = 171 g/L). A thoracic CT scan was performed and revealed numerous well-delineated nodules with regular margins, enhanced after contrast injection, which had developed in the mediastinal and visceral pleura of the left cardiophrenic angle (Fig. 1).
Owing to the presence of this large number of pleural nodules in the left hemithorax in a splenectomized patient, the diagnosis suggested was thoracic splenosis. The Tc99m-labeled red blood cell scintigraphy merged with the CT data showed increased fixation by the left pleural nodules (Fig. 1). We were thus able to confirm the diagnosis of thoracic splenosis non-invasively. Discussion Splenosis was described for the first time in 1937; it is the ectopic auto-transplantation of splenic tissue following rupture of the spleen or splenectomy. Even though this condition is rare, it concerns 67% of splenectomized patients. The nodules of splenosis can implant themselves anywhere in the abdominal cavity but are more likely to be found on the serosa of the small intestine, the large omentum, the peritoneum, the colon, the mesentery and the inferior surface of the diaphragm. Thoracic splenosis arises where there is an associated wound to the diaphragm, in about 18% of patients presenting a ruptured spleen [1]. This percentage is almost certainly an under-estimate because it is generally asymptomatic. The mean period of time before it is discovered is therefore long (∼ 21 years) [1]. The male/female sex ratio is 30/8 [1], probably related to the very high frequency of splenic trauma in young men. Clinically, forms have been described that cause the following symptoms: pleural pain [2], hemoptysis [3], dyspnea.
Figure 1. Pleural nodules in thoracic splenosis (white arrows): a: CT with contrast injection, axial slice; b: labeled red blood cell scintigraphy; c: CT scan/scintigram merged. http://dx.doi.org/10.1016/j.diii.2014.02.024 2211-5684/© 2014 Éditions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved.
1104 The splenic implants colonize above all the pleura of the left hemithorax [2], the mediastinum [2], and more rarely the lung parenchyma, and may measure up to 13 cm [2]. With imaging, they present as numerous, wellcircumscribed, non-calcified nodules, with enhancement kinetics similar to the spleen. Diagnosis is confirmed by a positive result from technetium 99m-labeled red blood cell scintigraphy, which is more sensitive than sulfur colloid scintigraphy [4]; this also avoids having to perform percutaneous or thoracoscopic biopsy [5]. Surgery is only for complicated forms. Not removing splenosis nodules in splenectomized patients would preserve a certain degree of immunity and reduce the risk of infection [6]. In conclusion, splenectomy in the history associated with the presence of numerous left unilateral pleural nodules should suggest the diagnosis of thoracic splenosis. Labeled red blood cell scintigraphy confirms the diagnosis in a noninvasive manner. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Yammine JN, Yatim A, Barbari A. Radionuclide imaging in thoracic splenosis and a review of the literature. Clin Nucl Med 2003;28(2):121—3.
Letter [2] Fukuhara S, Tyagi S, Yun J, Karpeh M, Reyes A. Intrathoracic splenosis presenting as persistent chest pain. J Cardiothorac Surg 2012;7:84. [3] Cordier JF, Gamondes JP, Marx P, Heinen I, Loire R. Thoracic splenosis presenting with hemoptysis. Chest 1992;102(2): 626—7. [4] Brancatelli G, Vilgrain V, Zappa M, Lagalla R. Case 80: splenosis. Radiology 2005;234(3):728—32. [5] Khan AM, Manzoor K, Malik Z, Avsar Y, Yasim A, Shim C. Thoracic splenosis: know it-avoid unnecessary investigations, interventions, and thoracotomy. Gen Thorac Cardiovasc Surg 2011;59(4):245—53. [6] Chagnaud C, Champsaur P, Costanzo VD, Petit P, Chamati S, Charifi AB, et al. Splénose péritonéale simulant une masse retropéritonéale droite. J Radiol 1998;79: 1407—9.
D. Chemouni a,∗ , O. Laas b , J.-M. Caporossi c , S. Coze a , M. Panuel a , K. Chaumoitre a a AP—HM, Radiology Department, hôpital Nord, 265, chemin des Bourrely, 13015 Marseille, France b AP—HM, Nuclear Medicine Department, hôpital Nord, 2, chemin des Bourrely, 13015 Marseille, France c AP—HM, Radiology Department, hôpital de la Timone, 264, rue Saint-Pierre, 13005 Marseille, France ∗ Corresponding
author. E-mail address: [email protected] (D. Chemouni)
