Isolated splenic metastasis from primary lung adenocarcinoma.
Abstract: Metastatic Metastatic
The term used to describe a secondary cancer, or one that has spread from one area of the body to another.
Mentioned in: Coagulation Disorders
pertaining to or of the nature of a metastasis. disease involving the spleen is uncommon, and isolated metastasis metastasis /me·tas·ta·sis/ (me-tas´tah-sis) pl. metas´tases
1. transfer of disease from one organ or part of the body to another not directly connected with it, due either to transfer of pathogenic microorganisms or to to the spleen is extremely rare. Most patients with splenic splenic /splen·ic/ (splen´ik) pertaining to the spleen.
Of, in, near, or relating to the spleen.
pertaining to the spleen. metastases Metastasis (plural, metastases)
A tumor growth or deposit that has spread via lymph or blood to an area of the body remote from the primary tumor.
Mentioned in: Malignant Melanoma have widely disseminated metastatic disease. A current literature review shows the incidence of isolated splenic metastasis ranges from 0 to 26% of all patients with splenic metastases. The reported primary malignancies of patients with splenic metastases include lung, colorectal, endometrial endometrial /en·do·me·tri·al/ (en?do-me´tre-il) pertaining to the endometrium.
n relating to the end-ometrium or cavity of the uterus. , ovarian, thyroid, pancreatic, gastric cancers, and, most commonly, melanoma. Although most patients with splenic metastases are clinically asymptomatic for splenic lesions, there have been reports of painful splenomegaly splenomegaly /sple·no·meg·a·ly/ (-meg´ah-le) enlargement of the spleen.
congestive splenomegaly Banti's disease; splenomegaly secondary to portal hypertension. , splenic vein splenic vein
A vein that arises by the union of several small veins at the hilum on the anterior surface of the spleen, passes to the left kidney, and runs to the neck of the pancreas where it joins the superior mesenteric vein to form the portal vein. thrombosis, and splenic rupture, making diagnosis and consideration of prompt therapeutic intervention important. The time from diagnosis of a primary lung tumor to the discovery of splenic metastases ranges from 0 to 8 years in the literature. We report a rare case of an asymptomatic, isolated splenic metastasis in a 72-year-old man diagnosed 25 months after resection of an adenocarcinoma adenocarcinoma: see neoplasm. of the lung.
Key Words: lung cancer lung cancer, cancer that originates in the tissues of the lungs. Lung cancer is the leading cause of cancer death in the United States in both men and women. Like other cancers, lung cancer occurs after repeated insults to the genetic material of the cell. , splenic metastasis
The incidence of solitary splenic metastasis in patients with lung cancer is very rare. There have been eight cases of isolated splenic metastasis due to lung carcinoma in the English literature to date. (1-7,9) The majority of splenic metastases from lung cancer have been reported as part of a diffuse metastatic process involving an average of 3.1 organs. (2,13)
A 72-year-old man who was being followed for a treated lung carcinoma presented to the Mayo Clinic Jacksonville in April 2000 after a routine computed tomographic (CT) scan demonstrated a solitary splenic nodule nodule: see concretion.
In geology, a rounded mineral concretion that is distinct from, and may be separated from, the formation in which it occurs. . His pertinent history dated back to March 1996 when he developed a persistent cough, for which he sought workup work·up
n. Abbr. w/u
A thorough medical examination for diagnostic purposes. at an outside institution. The patient had a 70 pack-year history of tobacco use as well as a history of coronary artery disease coronary artery disease, condition that results when the coronary arteries are narrowed or occluded, most commonly by atherosclerotic deposits of fibrous and fatty tissue. . He had no other chest or abdominal symptoms. Subsequent workup included a chest x-ray chest x-ray,
n an examination of the chest using x-rays. Routinely performed in patients complaining of chest pain to rule out respiratory or heart disease.
chest X-ray Chest film, see there , which showed a nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik)
1. not due to any single known cause.
2. not directed against a particular agent, but rather having a general effect.
1. lesion in the left lung. A CT scan CT scan: see CAT scan.
See CAT scan. of the chest showed a 1.0 X 1.5 cm nodule in the left mid-lung posteriorly. He elected to have the nodule followed with subsequent CT scans rather than undergo biopsy and possible surgery. The nodule size was unchanged until December 1997 when a chest CT scan was repeated and showed the nodule had enlarged to 1.5 cm X 2.0 cm. In early January 1998, the patient underwent transthoracic transthoracic /trans·tho·rac·ic/ (-thah-ras´ik) through the thoracic cavity or across the chest wall.
Across or through the thoracic cavity or chest wall. needle biopsy needle biopsy
Removal of a specimen for biopsy by aspirating it through a needle or trocar that pierces the skin or the external surface of an organ and continues into the underlying tissue to be examined. Also called aspiration biopsy. of the lesion, which was negative for malignancy. He was advised by his primary physician to undergo a thoracoscopic biopsy of the lesion and decided to seek a second opinion and treatment at Mayo Clinic Jacksonville. Thoracoscopic lung biopsy Lung Biopsy Definition
Lung biopsy is a medical procedure performed to obtain a small piece of lung tissue for examination under a microscope. Biopsy examinations are usually performed by pathologists, who are doctors with special training in tissue demonstrated malignancy, and in early March 1998 he underwent a left lower lobectomy lobectomy /lo·bec·to·my/ (lo-bek´tah-me) excision of a lobe, as of the lung, brain, or liver.
Excision of a lobe of an organ or a gland. . Pathologic examination demonstrated a moderately differentiated adenocarcinoma 2.5 X 1.5 X 2.0 cm, with negative surgical margins and negative lymph nodes Lymph nodes
Small, bean-shaped masses of tissue scattered along the lymphatic system that act as filters and immune monitors, removing fluids, bacteria, or cancer cells that travel through the lymph system. . In October 1998 a follow-up chest CT scan revealed mediastinal mediastinal /me·di·as·ti·nal/ (-as-ti´n'l) of or pertaining to the mediastinum.
of or pertaining to the mediastinum. lymphadenopathy lymphadenopathy /lym·phad·e·nop·a·thy/ (-op´ah-the) disease of the lymph nodes.
angioimmunoblastic lymphadenopathy , angioimmunoblastic lymphadenopathy with dysproteinemia . A complete metastatic workup was performed, including abdominal CT scan, head CT scan, chest x-ray, and bone scan. The results of these tests revealed no other metastatic disease and he was referred for chemotherapy and chest radiotherapy. Serial chest and abdominal CT scan results were stable until April 2000, when a 1.6-cm splenic mass was discovered. A 3-month follow-up CT scan was recommended. By July 2000, the splenic lesion had enlarged to 2.2 cm. Results from a positron emission tomographic (PET) scan showed the splenic lesion to be hypermetabolic. Further metastatic workup, including chest x-ray and CT scan of the brain, revealed no other metastatic disease. Splenectomy Splenectomy Definition
Splenectomy is the surgical removal of the spleen, which is an organ that is part of the lymphatic system. The spleen is a dark-purple, bean-shaped organ located in the upper left side of the abdomen, just behind the bottom of the was advised. On August 30, 2000, the patient underwent exploratory laparotomy and splenectomy. There was no other intra-abdominal pathology evident. Pathology demonstrated a solitary 2.4-cm lesion of moderately differentiated metastatic carcinoma in the upper pole of the spleen compatible with a lung primary. Follow-up to date has not demonstrated any evidence of recurrent metastatic disease.
Splenic metastases have been reported as rare in most series. (1-9,11,12,14) The most common primary tumors which metastasize me·tas·ta·size
To be transmitted or transferred by or as if by metastasis.
Spread of cells from the original site of the cancer to other parts of the body where secondary tumors are formed. to the spleen are breast, lung, colorectal, gastric, prostate, ovarian, liver and pancreatic cancers, and melanoma. (2,4,10,13,14) Berge et al (13) published a large postmortem postmortem /post·mor·tem/ (post-mort´im) performed or occurring after death.
Relating to or occurring during the period after death.
See autopsy. series in 1974. They found that there were an average of 3.1 other organs and 2.5 lymph node groups involved in lung cancer patients with splenic metastases. Isolated splenic metastases, on the other hand, have been rarely reported. A recent review uncovered only 40 cases of isolated splenic metastases from all sources. (4) Lee et al (5) reviewed 417 splenectomy specimens over a 9.5-year period and found 31 splenic metastases, of which 26% had disease limited to the spleen. Reported cases of isolated splenic metastases due to lung cancer are extremely rare. Only eight cases have been reported to date in the literature. (1-7,9)
The duration from primary lung cancer primary lung cancer Oncology Lung cancer arising in lung tissue–eg, trachea, bronchial tree, parenchyma. See Bronchoalveolar carcinoma, Small cell carcinoma, Squamous cell carcinoma. Cf Metastatic lung cancer. detection to splenectomy for isolated metastasis ranges from 0 to 8 years (Table 1). (5) Kinoshita et al (2) found that splenic metastasis, with or without isolated disease, is most often associated with carcinoma of the left lung, perhaps due to preferentially higher blood flow compared with the right lung. Survival of four lung cancer patients with isolated splenic metastases ranged from 1 to 49 months postsplenectomy, with one patient still alive at 8 years postsplenectomy. (2,3,6,9)
Our case demonstrates that a new splenic mass in a patient with a history of malignancy should be considered metastatic disease until proven otherwise. If other metastatic disease can be ruled out, the appropriate management is splenectomy to avoid further metastatic disease, to provide the potential for cure or extended survival, and to avoid the complications of painful splenomegaly, splenic vein thrombosis, and splenic rupture. The interval from primary tumor diagnosis to solitary splenic metastasis may be delayed, in some incidences for many years, so that careful and extended follow-up of oncologic patients with the potential for splenic metastasis is warranted. (12)
Pessimists complain about the wind. Optimists hope it will change. Realists adjust the sails. --William Arthur Ward Table 1. Incidence of isolated splenic metastasis from lung carcinoma (a) Interval from primary Type of Primary tumor tumor to Study (ref. no.) study types metastasis Klein et al, 1987 (3) Case report Bronchioalveolar CA 20 mo Edelman and Case report Lung--poorly 0 Rotterdam, 1990 (1) differentiated adenocarcinoma Macheers and Case study/ Lung--large cell, 0 Mansour, 1992 (6) review of undifferentiated literature Gupta and Harvey, Case report RT hilar neoplasm 0 1993 (11) Kinoshita et al, Two case 1) Squamous cell 1) 14 mo 1995 (2) reports/ lung CA review 2) Poorly 2) None differentiated lung CA 3) Review of lung CA primaries Takada and Takami, Case report Bronchopulmonary 8 yr 1998 (8) carcinoid Lam and Tang, Autopsy review Lung: 19 cases Mean 1.2 mo 2004 (4) Massarweh and Case report Lung adenocarcinoma 0 Ohinga, 2001 (7) No. of isolated Symptoms/signs Study (ref. no.) metastases Follow-up of metastasis Klein et al, 1987 (3) 1 Died 49 mo after Painful splenectomy splenomegaly Edelman and 1 -- Asymptomatic Rotterdam, 1990 (1) Macheers and 1 Pt had splenectomy Asymptomatic Mansour, 1992 (6) not thoracotomy; Pt died 1 mo after diagnosis Gupta and Harvey, 0 Died 8 wk after Splenic rupture 1993 (11) splenectomy Kinoshita et al, 1/2 1) Died 27 mo after 1) Asymptomatic 1995 (2) splenectomy 2) Died 2 mo after 2) Shoulder pain diagnosis 0/15 in review Takada and Takami, 1 -- LUQ pain 1998 (8) Lam and Tang, 0 All pts died as 1 patient with 2004 (4) result of splenic metastatic rupture complications Massarweh and 1 -- Severe abdominal Ohinga, 2001 (7) pain/splenic rupture (a) Rt. right: pt. patient; --, no data; LUQ. left upper quadrant.
Accepted September 24, 2002.
Copyright [c] 2004 by The Southern Medical Association
1. Edelman A, Rotterdam H. Solitary splenic metastasis of an adenocarcinoma of the lung. Am J Clin Pathol 1990;94:326-328.
2. Kinoshita A, Nakano M, Fukuda M, et al. Splenic metastasis from lung cancer. Neth J Med 1995;47:219-223.
3. Klein B, Stein M, Kuten A, et al. Splenomegaly and solitary spleen metastasis in solid tumors. Cancer 1987;60:100-102.
4. Lam K, Tang V. Metastatic tumors to the spleen: A 25-year clinicopathologic study. Arch Pathol Lab Med 2000;124:526-530.
5. Lee S, Morgenstern L, Phillips E, et al. Splenectomy for splenic metastases: A changing clinical spectrum. Am Surg 2000;66:837-840.
6. Macheers S, Mansour K. Management of isolated splenic metastases from carcinoma of the lung: A case report and review of the literature. Am Surg 1992;58:683-685.
7. Massarweh S, Dhingra H. Solitary splenic metastasis in lung cancer with spontaneous rupture. J Clin Oncol 2001;19:1574-1575.
8. Takada T, Takami H. Solitary splenic metastasis of a carcinoid carcinoid /car·ci·noid/ (kahr´si-noid) a yellow circumscribed tumor arising from enterochromaffin cells, usually in the gastrointestinal tract; the term is sometimes used to refer specifically to the gastrointestinal tumor tumor of the lung 8 years postoperatively. J Surg Oncol 1998;67:47-48.
9. Berge T. Splenic metastases, frequencies, and patterns. Acta Pathol Microbiol Scand 1974;82:499-506.
10. Sabiston DC. Textbook of Surgery. Philadelphia, PA, W. B. Saunders Co., 1997, 15th ed, pp 1187-1214, 1865-1876.
11. Gupta P, Harvey L. Spontaneous rupture of the spleen secondary to metastatic carcinoma. Br J Surg 1993;80:613.
12. Nash D, Sampson C. Secondary carcinoma of the spleen, its incidence in 544 cases, and a review of the literature. J Natl Med Assoc 1966;58:442-446.
13. Rydell W, Ellis R. Spontaneous rupture of the spleen from metastatic carcinoma. JAMA JAMA
Journal of the American Medical Association 1978;240:53-54.
14. Morgenstern L, Rosenberg J, Geller S. Tumors of the spleen. World J Surg 1985;9:468-476.
RELATED ARTICLE: Key Points
* Isolated splenic metastasis from lung cancer is rare.
* Few cases of isolated splenic metastasis from primary lung cancer have been described in the English literature.
* Early diagnosis is crucial to prevent the potentially life-threatening complications of painful splenomegaly, splenic rupture, and splenic vein thrombosis.
Brian J. Schmidt, MD and Stephen L. Smith, MD
From the Department of General Surgery, Mayo Clinic Jacksonville, Jacksonville, FL.
Reprint requests to Stephen L. Smith, MD, 4500 San Pablo Road, Jacksonville, FL 32224. Email: firstname.lastname@example.org