Spleen: Cysts, Tumours, Abscesses
DEFINITION

Various splenic conditions discussed
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EPIDEMIOLOGY

Uncommon
See conditions
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AETIOLOGY

Cysts
Primary (true cysts)
- parasitic (almost always Hydatids)
- non-parasitic: congenital, epidermoid, dermoid, mesothelial (serous)
- neoplastic
Secondary (pseudocysts)
- traumatic
- degenerative
- inflammatory
- haemorrhagic

Tumours
Benign
- hemangioma, hamartoma, lymphangioma
- sclerosing angiomatoid nodular transformation
Malignant
- Primary, e.g. angiosarcoma
- lymphoma; Non-Hodgkin, Hodgkin, CLL
- Myeloproliferative
- Metastatic tumours

Abscesses
Bacterial
Fungal

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BIOLOGICAL BEHAVIOUR

Cysts

Parasitic vs not parasitic
- practically parasitic = hydatids, so careful history, imaging and serology can help to focus management.
- if non-parasitic then most are post-traumatic secondary cysts or pseudocysts
- commonest non-parsitic primary cyst (true capsule) is epidermoid cysts
Can rupture (25% risk if >5cm)

Echniococcal Cysts
See hydatids
6% of hydatid showers via portal vein may come to rest in spleen.
Risk of rupture --> treat surgically. 

Non-parasitic Cysts
Uncommon; 10-20%, true / primary or false / secondary, as above.
- but true may be only partly lined by epithelium.
Primary = congenital
- arise from invagination of the mesothelium during development; may be dermoid or epidermoid (much more common)
- other types as above
Secondary = pseduocysts
- 70-80% of non-parasitic
- would want to elicit a history of previous trauma, organized / degenerative haematoma suggested by haemorrhagic thick walled cyst (most common type)
- less commonly splenic infarcts

Tumours

Primary splenic tumours
Rare, include lymphomas.
Benign tend to arise from red pulp.
- hamartomas can be solid or cystic
Haemangiomas / vascular tumours can cause hypersplenism.
Lymphangiomas are rare, cystic, can lead to hypersplenism; splenectomy only for palliation.
Sclerosing angiomatoid nodular transformation = rare, benign perculiar vascular leions
- have a good stellate scar, nodules made up of vascular spaces liked with epithelial cells, shares features with IG4-related sclerosing disease

Malignant tumours
As per haematologic spleen notes

Abscesses
Rare, but lethal.
Haematogenous spread from septic foci usually staph, strep, salmonella, sometimes fungi (eg. immunocompromised)
IV drug users, HIV pts prone.


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MANIFESTATIONS

Cysts
Incidentally discovered often.
Considerable growth can cause a mass effect or bleeding into the cysts.
Vauge LUQ pains, referred shoulder pain, can kink the kidney or impair the kidney
Abdo pain from rupture.

Tumours
Variable according to type, size, effect, hypersplenism

Abscesses
Localizing pain with systemic upset
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INVESTIGATIONS

Imaging
CT for planning.
- helps selection, defines anatomy, identifies accessory spleens

?Tumour
Diagnostic splenectomy is reasonable.
Observation with serial imaging if uncertain.

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MANAGEMENT

Principles

1. Spleen preservation?
Preservation of 25% allows sufficient splenic function.
Shift towards partial splenectomy in some centres, depending on size, location and pre-op assessment.
- depends also on anatomy; e.g. relationship of hilar vessels and parenchyma/

2. Unroofing and Marsupialization
This can help preserve splenic fx in select cases.

3. Lap or Open?
Depends on surgeon factors, disease factors and pt factors.
Spleen size and prior surgery is important.
Conversion rates low for small spleens, high for massive spleens (500-1000g)
- should be <25cm in craniocaudal access else very challenging; 30cm spleens leave little working room.


Specific Management

Echinococcal cysts
Standard = total splenectomy without rupturing the cyst.
Spleen-preserving surgery possible in expert hands, but only location allows it.
Usual hydatid treatment pre-op and post op (see notes)

Other cysts
Indication to operate depends on symptoms and site.
- also, risk of rupture increases if cyst >5cm.
Consider carefully the anatomy, and role of spleen-preserving unroofing, etc.

Operative Approaches
1. Splenectomy
Multiple cysts, large /hilar lesions.
Ideally laparoscopically

2. Unroofing, fenestration and marsupialization
For superficial peripheral simple cysts
May be approached laparoscopically

3. Partial Splenectomy
Polar lesions more amenable.
Control sgmental blood supply then devide parenchyma, e.g. as per liver or using staplers, harmonic scalpel, argon-beam coag.

Tumours
Splenectomy

Abscess
Splenectomy is definitive.
IV ABs etc.
Image guided draining continues to evolve and increasingly popular sae and effective including under USS or CT.
- Failure in up to 50% though, with prolongation of stay as cost of conservative management.
- May need repeat imaging if ongoing fevers.

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REFERENCES
Cameron 10th