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Year : 2006  |  Volume : 16  |  Issue : 2  |  Page : 197-198
Case report: Huge splenic epidermoid cyst


S.S.G. Hospital, Medical College Baroda Vadodara Gujarat - 390001, India

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Keywords: Spleen, CT Cystic Lesions, Epidermoid Cyst

How to cite this article:
Sarvaiya A, Raniga S, Vohra P, Sharma A, Bhrtyan. Case report: Huge splenic epidermoid cyst. Indian J Radiol Imaging 2006;16:197-8

How to cite this URL:
Sarvaiya A, Raniga S, Vohra P, Sharma A, Bhrtyan. Case report: Huge splenic epidermoid cyst. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Nov 22];16:197-8. Available from: http://www.ijri.org/text.asp?2006/16/2/197/29089

   Introduction Top


Splenic cysts are rare. They may be parasitic, most frequently caused by Echinococcus granulosus, or nonparasitic [1]. Nonparasitic cysts are divided into true cysts, which exhibit an epithelial lining and secondary, so-called false cysts or pseudocysts which do not show an epithelial lining and are thought to result from trauma or hemorrhage. Pseudocysts are more frequent than epithelium-lined cysts [1].

We report a case of large splenic epidermoid cyst- a rare type of true non-parasitic splenic cyst.


   Case Report Top


A 26-year-old male presented with history of intermittent, dull, wandering pain in the left costal margin for last 2 years. There was no history of trauma. Physical examination revealed a smooth, firm, nontender mass in the left hypochondriac region.

Ultrasonography revealed splenomegaly with a large intrasplenic anechoic lesion with after enhancement suggestive cystic lesion within the spleen. The wall of the lesion was imperceptible.

CT scan was performed after oral and intravenous contrast administration. Axial non-contrast scans show a large well defined 14x13cm sized water attenuation lesion within spleen. The lesion doesn't show any enhancement on contrast study [Figure - 1]a & b. The lesion was displacing the stomach anteromedially and kidney inferiorly.

Exploratory laprotomy with splenectomy was performed and a large splenic cyst was identified. About 1500 ml of turbid-yellow fluid was drained from the cyst. Microscopically, the sections showed a picture of epidermoid cyst composed of a loosely fibrous wall and an interior lining of single layer of flattened or low-cuboidal epithelium, without skin appendage. The post-operation course was uneventful.


   Discussion Top


True cysts of the spleen are uncommon. Splenic cysts can be divided into two categories: primary or true and secondary or false cysts. Differential diagnoses of splenic cystic lesion include intrasplenic abscesses, true cystic neoplasms, hydatid cysts, and cystic metastases. True cystic tumors include hemangiomas, lymphangiomas, epidermoid and dermoid cysts [2]. Of these, hemangiomas are the most common and dermoid cysts, the least [2]. True cysts make up approximately 20% of splenic cysts [3]. The epidermoid cyst is the rarest, representing 10% of the benign, nonparasitic cysts [2]. Robbins reported a series of 42,327 autopsies over a 25-year period, which revealed only 32 patients with diagnosis of splenic cyst [4], [5]. Subsequent isolated case reports have appeared in the literature [5]. Splenic epidermoid cysts are "true" cysts as they possess an inner epithelial lining, in contrast to "false" cysts which have no cellular lining, and are usually related to prior trauma. The pseudocyst is thought to result from trauma, hemorrhage or infarction. The relationship of trauma in the pathogenesis of splenic cysts is still unclear [5].

The true origin of epidermoid cysts is not very clear. They may originate from infolding or entrapment of peritoneal mesothelial cells in the splenic cystic lesion include intrasplenic abscesses, true cystic neoplasms, hydatid cysts, and cystic metastases. True cystic tumors include hemangiomas, lymphangiomas, epidermoid and dermoid cysts [2]. Of these, hemangiomas are the most common and dermoid cysts, the least [2]. True cysts make up approximately 20% of splenic cysts [3]. The epidermoid cyst is the rarest, representing 10% of the benign, nonparasitic cysts [2]. Robbins reported a series of 42,327 autopsies over a 25-year period, which revealed only 32 patients with diagnosis of splenic cyst [4, 5]. Subsequent isolated case reports have appeared in the literature [5]. Splenic epidermoid cysts are "true" cysts as they possess an inner epithelial lining, in contrast to "false" cysts which have no cellular lining, and are usually related to prior trauma. The pseudocyst is thought to result from trauma, hemorrhage or infarction. The relationship of trauma in the pathogenesis of splenic cysts is still unclear [5].

The true origin of epidermoid cysts is not very clear. They may originate from infolding or entrapment of peritoneal mesothelial cells in the splenic parenchyma during embryogenesis. Another explanation can be that they originate from normal lymphatic spaces [6].

They usually are discovered incidentally in childhood or adolescence. Occasionally, they present as a palpable left upper quadrant mass which may cause epigastric fullness or dull pain. Patients with acute abdomen due to cyst rupture and/or infection have been described.

In 80% of cases, lesions are solitary and unilocular. Occasionally internal septations are seen. The wall of those primary cysts may show curvilinear or plaque-like calcifications, although these peripheral calcifications occur more frequently in post-traumatic - false cysts [6], [7].

On Ultrasonography, epidermoid cysts manifest as well-defined, thin-walled anechoic lesions. Wall calcification has been reported in 10% of cases [8]. Septations and cyst wall trabeculation may also be present. Intracystic fluid may have increased echogenicity due to cholesterol crystals, inflammatory debris, or hemorrhage [9].

At CT, epidermoid cysts manifest as rounded, well-demarcated nonenhancing water attenuation lesions. Trabeculations and calcifications may be more clearly depicted at CT [10], [11].

T1-and T2-weighted MRI images show well defined, rounded masses with signal intensity equal to that of water in non-complicated cysts. The signal intensity of those cysts, however, may be altered by high protein content or superimposed hemorrhage. Both of these result in hyperintense signal on T1-weighted images.

According to the stage of hemorrhage and the different blood degradation product content, signal intensity on T1-and T2-weighted images may vary [10], [11].

Splenectomy is the treatment of choice for large asymptomatic cysts. Other possible procedures include aspiration alone, incision and drainage. However, splenectomy remains a relatively safe procedure, associated with few complications and avoiding any future problems. [4]

Potential complications of huge splenic cyst include rupture with peritonitis, rupture with massive hemorrhage, infection, abscess formation and transdiaphragmatic perforation with pleural effusion or empyema. [2]

Although true and false cysts are usually indistinguishable on imaging studies, false cysts tend to have a thicker fibrous wall, more often eggshell - like wall calcifications and internal debris [5], [6].


   Conclusion Top


Radiological examinations, particularly US and CT, can diagnose splenic cysts unquestionably, correctly defining the relationships with adjacent organs. Splenomegaly or a splenic mass of a predominantly cystic nature with no clinical evidence of echinococcus suggests the diagnosis of splenic cyst. Reliable radiological distinction between true or false splenic cyst does not seem possible. CT and US helps in detecting septa or calcifications, which are definitely useful findings to distinguish true from false cysts, since internal septa are more frequent in true cysts while parietal calcifications are typical of pseudocysts. The final diagnosis, however, is made at histology. However, surgery is primarily recommended in both true and false large cysts for the prevention of complications as infection, hemorrhage, and rupture.

 
   References Top

1.Rywlin AM. Hemopoietic system: reticuloendothelial system, spleen, Iymph nodes, bone marrow, and blood. In: Klssane JM, ed. Anderson's Pathology. St. Louis: C.V.Mosby, 1985:1283.  Back to cited text no. 1    
2.Ross ME, Ellwood R, Yang SS, Lucas RJ. Epidermoid splenic cysts. Arch Surg 1977; 112:596-9.  Back to cited text no. 2    
3.Dachman A.H., Ros P.R., Murari P.J., et al.: Nonparasitic splenic cysts: a report of 52 cases with radiologic-pathologic correlation. AJR, 1986, 147: 537-542.  Back to cited text no. 3    
4.Davidson ED, Campbell WG, Hersh T. Epidermoid splenic cyst occurring in an intrapancreatic accessory spleen. Dig Dis Sci 1980; 25:964-7.  Back to cited text no. 4    
5.Robbins FG, Yellin AE, Lingua RW, Crsig JR, Turrill FL, Mikkelsen WP. Splenic epidermoid cysts. Ann Surg 1978; 187:231-5.  Back to cited text no. 5    
6.Dawes L.G., Malangoni M.A.: Cystic masses of the spleen. Am Surg, 1986, 52: 333-336.  Back to cited text no. 6    
7.De Schepper A.M., Vanhoenacker F.: Medical imaging of the spleen. Berlin: Springer-Verlag, 2000, 101-122.  Back to cited text no. 7    
8.Spencer NJB, Arthur RJ, Stringer MD. Ruptured splenic epidermoid cyst: case report and imaging appearances. Pediatr Radiol 1996; 26:871-873.  Back to cited text no. 8    
9.Dachman AH, Ros PR, Murari PJ, Olmsted WW, Lichtenstein JE. Nonparasitic splenic cysts: a report of 52 cases with radiologic-pathologic correlation. AJR 1986; 147:537-542.  Back to cited text no. 9    
10.Ito K, Mitchell DG, Honjo K, et al. MR imaging of acquired abnormalities of the spleen. AJR 1997; 168:697-702.  Back to cited text no. 10    
11.A Pattern-oriented Approach to Splenic Imaging in Infants and Children. Anne Paterson, Donald P. Frush, Lane F. Donnelly, Joseph N. Foss, Sara M. O'Hara, and George S. Bisset. Radiographics. 1999; 19:1465-1485.  Back to cited text no. 11    

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Correspondence Address:
S Raniga
81, Shantinagar, Tarsali Road, Vadodara-390009
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.29089

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[Figure - 1]

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    Introduction
    Case Report
    Discussion
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