CASE 10172 Published on 20.06.2012

Hepatic splenosis mimicking HCC in a patient with hepatitis C liver cirrhosis

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Vincenzo Schininà*, Giovanni Vennarecci°, Massimo Cristofaro*, Roberto Santoro*, Domenico Chiappetta*, Giuseppe M. Ettorre°, Elisa Busi Rizzi*.

lazzaro spallanzani,
istituto nazionale delle malattie infettive,
diagnostica per immmagini;
via portunese 292 00149 roma;
Email:busirizzi@inmi.it
Patient

46 years, male

Categories
Area of Interest Liver ; Imaging Technique MR
Clinical History
A 46-year-old cirrhotic patient was referred to us with a hepatic mass depicted during chronic hepatitis follow up, not identified five months ago, while the patient was hospitalised for osteomyelitis. The patient had hepatitis C cirrhosis, after receiving blood transfusions at post-traumatic splenectomy.
Imaging Findings
The patient underwent Computed Tomography (CT), that confirmed cirrhotic liver. Contrast material produced arterial enhancement of a 3 cm × 2.5 cm x 2.5 cm nodule, located near the liver capsule at the segment 4 (Fig. 1). The lesion becomes isoattenuating during the venous phases, and depicted a single 2.5 cm sub diaphragmatic mass consistent with accessory spleen. Because magnetic resonance imaging (MRI) with hepatocyte-specific phase often helps with focal liver lesions differentiation, the patient underwent MRI using Gadolinium BOPTA. The contrast dynamic scan results were quite different than CT examination, since in the venous phases the lesion showed a central wash out and mild persistent rim of enhancement at the periphery (Fig. 2). In the hepatocyte-specific phase, performed after a delay of 1h, the mass become again hypointense to the surrounding liver (Fig. 3).
Discussion
A. Splenosis is the heterotopic implantation of splenic fragments following splenic injury or elective splenectomy, which can occur anywhere within the abdominal cavity.
The two mechanisms cited to explain the intrahepatic location are direct seeding of the liver capsule and the migration of spleen cells through blood [5, 6].The splenosis usually is localized on the peritoneal serosa with some areas of choice: small intestine, omentum, mesentery, parietal peritoneum [7].
B. The incidence of splenosis after traumatic rupture of the spleen is estimated at over 67%, however, it is certainly underestimated. Because of its asymptomatic nature it is most often incidentally discovered during surgery or during the regular monitoring by ultrasound for the detection of hepatocellular carcinoma in patients followed for chronic liver disease [8].
C. During the arterial phase of enhancement, the splenic parenchyma shows a heterogeneous enhancement pattern, attributed to a differential perfusion of the red and white pulp, while in the portal venous phases the normal splenic parenchyma has an homogeneous appearance, that produces the same density of the surrounding liver parenchyma in CT, and in MRI determines T1 hypointensity, features also consistent with HCC. The liver nodules can be surrounded by a capsule hypodense on CT or hyperechoic on ultrasound, a finding not usual in HCC. However, in our case, dynamic enhanced MRI identified a pseudo capsule in the venous phase, as can be seen in HCC. Subcapsular topography and location in the left liver are criteria to suggest the diagnosis of splenosis [9]. Scintigraphy with labeled red cells may be useful to search for other locations, which may strengthen the diagnosis [10].
D. Laparoscopy was sufficient in confirming diagnosis of splenosis, as well as excluding coexistent malignancy with a significant impact of clinical plans and patient management. It is already recognized that laparoscopic resection of symptomatic or suspicious splenosis is a minimally invasive and feasible procedure [11], because it provides just a little port entry, and allows access for potential subsequent biopsy or resection
E. There are no typical radiological features of intrahepatic splenosis and it is usually difficult to distinguish this condition from other liver tumors. In cirrhotic liver hypervascular tumors suggests HCC, however, establishing the correct diagnosis can to be difficult, in most cases, correct diagnosis was possible only on histological examination after a laparotomy and open liver resection [2-4].
Differential Diagnosis List
The lesion was resected laparoscopically.The histopathological diagnosis was hepatic splenosis.
benign focal liver lesions
malignant focal liver lesions
Final Diagnosis
The lesion was resected laparoscopically.The histopathological diagnosis was hepatic splenosis.
Case information
URL: https://www.eurorad.org/case/10172
DOI: 10.1594/EURORAD/CASE.10172
ISSN: 1563-4086