Wandering spleen

Clinical History

A 74-year-old female patient with a 2.2 cm enhancing left renal mass, suspected to be renal cell carcinoma, underwent a robotic partial nephrectomy. Postoperatively the patient developed fever, hence repeat CT abdomen was performed.

Imaging Findings

Preoperative CT revealed a 2.2 cm heterogenously enhancing left lower pole renal mass suspected to be a neoplasm. The spleen was in the expected location and appeared unremarkable. Following a partial nephrectomy, the renal mass was proven to be an oncocytoma on histopathology. Postoperatively the patient developed fever, hence a repeat CT was performed 3 days after the surgery. Contrast enhanced CT of the abdomen revealed absence of spleen in the left upper quadrant and a soft-tissue mass resembling spleen anterior to the pancreas. The ectopically located spleen was situated anteriorly and rotated, which was new since the previous CT examination. The splenic artery and vein were patent without evidence of splenic infarction. There was no evidence of ascites. The pancreatic tail was homogenously perfused.

Discussion

A wandering spleen is a rare entity with an incidence of less than 0.2% [1]. It is characterized by the absence or weakness of one or more of the ligaments responsible for holding the spleen in its normal position in the upper left abdomen [2]. This condition is more common in women, usually occurring at 20 to 40 years of age [3]. Clinical symptoms include nausea, vomiting, fever, leukocytosis, peritoneal signs, and a palpable mass in the abdomen/pelvis [4]. Patients with limited symptomatology may be managed medically. However, if they have worsening symptoms indicating progressive splenic torsion or gastrointestinal compression, detorsion and splenopexy may be considered. Splenic preservation is recommended in extremely young patients who are at risk for postsplenectomy sepsis [5]. Splenic torsion, being rare, can be confused with appendicitis or ovarian torsion [4]. Ultrasound can confirm location of the spleen in the upper left quadrant. If the spleen cannot be identified in the expected location, Doppler should be performed for evaluation of the splenic pedicle. Decreased or absent blood flow findings may indicate torsion. Technetium 99Tc- sulphur colloid has lower spatial resolution, however, can aid in identifying the location. More importantly, it helps determine the spleen function. The most specific sign of splenic torsion is a "whirl-like" appearance of splenic vessels and surrounding fat at the splenic hilum, noted on CT. Absence of splenic perfusion is consistent with torsion. CT is more sensitive in the evaluation of the pancreatic tail for necrosis and anatomic relations with surrounding structures. Arteriography allows definitive evaluation of the splenic vasculature and signs of left-sided portal hypertension, if present [6].
Wandering spleen is associated with diaphragmatic hernias and subtotal splenectomies. In this case we suggest that the ectopic location of the spleen is most likely secondary to disruption of the splenorenal ligament following robotic partial nephrectomy for excision of the left renal mass.

Differential Diagnosis List

Final Diagnosis

Wandering spleen

URL:	https://www.eurorad.org/case/12476
DOI:	10.1594/EURORAD/CASE.12476
ISSN:	1563-4086