Heterotopic peripancreatic spleens presenting as possible tumors of the body and tail of the pancreas

Abstract

Accessory spleens are found in about 10% of routine postmortem autopsies, usually near the hilum of the spleen and the tail of the pancreas. In 16% of cases, the accessory spleen may be found within the pancreatic tail) Its importance arises when computed tomography (CT) scan reveals a tumor in or about the tail of the pancreas. The diagnosis of intrapancreatic accessory spleen may be suggested when the CT scan, following intravenous contrast injection, shows the mass to be enhanced in a manner characteristic of that of a spleen. Accessory spleen can be identified using technetium 99m(99mTc)-labelled heated red cells or 99mTc sulfur colloid. 2 We report a patient with heterotopic spleens, questioned by CT scan for pancreatic tumors, but accurately diagnosed by 99mTc sulfur colloid scan.Key words: accessory spleens, pancreas, sulphur colloid Case reportAn 87-year-old white man presented to the emergency department with abdominal pain in May 1993. He had a history of splenectomy in 1950 (following rupture of the spleen by blunt trauma). The abdomen was slightly firm and distended. He was nauseated and he vomited. His vital signs were normal. Hospital admission for observation was elected. He was malnourished and unable to eat, and intravenous fluids were initiated. Laboratory profile included white cell count 10.9 • 103/ mm, hemoglobin 13.5, hematocrit 40. With hydration, the hemoglobin and hematocrit fell to 11.5 and 35.8, respectively. His biochemical profile, including serum amylase level, was normal, except that his serum calcium was 7.7mg%. An upper gastrointestinal series revealed a Zenker's diverticulum and a slight narrowing Offprint requests to: J.M. HowardReceived for publication on Aug. 28, 1995; accepted on Oct. 25, 1995 of the gastro-esophageal junction. Results of ultrasonography of the gallbladder were negative. After 48h, he was eating and was free of pain. Computed tomography (CT) scan of the abdomen, utilizing intravenous and oral contrasts, revealed normal liver and kidneys. The spleen was surgically absent. Two tumor masses were noted behind the stomach in the area of the body of the pancreas. One, 4.3 • 3cm, was in continuity with the superior border of the pancreas and was tucked under the posterior surface of the gastric body. A second nodular mass, 1.5 cm in diameter, appeared to arise at a more posterior level not separated from the tail of the pancreas (Fig. 1). The pancreas otherwise appeared to be normal. Surgical referral was initiated, with a tentative diagnosis of tumors of the pancreas. Results of clinical examination were negative and he had become asymptomatic. His serum amylase and CA 19-9 levels were normal. Review of the CT films raised the suspicion of a diagnosis of heterotopic spleens.For confirmation of the diagnosis, sulfur colloid examination of the liver and spleen with axial singlephoton emission computed tomography (SPECT) demonstrated two focal areas of increased activity consistent with the two soft tissue masses identified on the CT scan (Fig. 2). These two...