Splenic Hilum Research Articles

How to divide the pancreatic parenchyma in patients with a portal annular pancreas: laparoscopic spleen-preserving distal pancreatectomy for serous cystic neoplasms

BackgroundPortal annular pancreas (PAP) is a rare pancreatic anomaly in which the uncinate process wraps annularly around the portal vein and fuses to the body of the pancreas. PAP is highly relevant to the development of postoperative pancreatic fistula (POPF) in pancreatic surgery. Here, we describe our experience and surgical technique of laparoscopic spleen-preserving distal pancreatectomy using Warshaw’s procedure for patients with the PAP.Case presentationA 49-year-old woman with PAP was referred to our hospital for a suspicious mucinous cystic neoplasms 1.5 cm in diameter in the pancreatic tail. Laparoscopic spleen-preserving distal pancreatectomy using Warshaw’s procedure was performed. Mobilization of the pancreatic tail was first performed, and then, the splenic artery was cut. After dividing the pancreatic tail from the splenic hilum, the ventral pancreatic parenchyma was divided using a stapler. After cutting the splenic vein, complete mobilization of the pancreatic body and tail enabled easy division of the PAP. Finally, the PAP was also divided using the stapler. Although grade B POPF occurred, she was discharged on the 9th postoperative day.ConclusionsSurgeons should understand the anatomical characteristics of PAP and be aware of the possibility of POPF.

ARE DRAIN FLUID AMYLASE LEVELS HELPFUL ON SECREENING PANCREATIC FISTULA SECONDARY TO PANCREATIC INJURY DURING EMERGENCY SPLENECTOMY?

Objective: Splenectomy is a major surgical intervention that brings several complications as well as saving life in the surgical treatment of blunt/penetrating spleen trauma. Although it is a highly standardized procedure in terms of the surgical technique used, pancreatic tail injuries can also be observed, especially during dissection and ligation of the splenic hilum. In this study, we investigated the possible helpful effects of the amylase levels of serum and drainage fluid when there was suspicion for pancreatic injury during splenic hilum dissection.Material and Methods: Forty-two patients who underwent splenectomy under emergency conditions for splenic injury secondary to acute trauma were included in the study. Nine of the patients developed pancreatic leakage/fistula (Group-1), while 33 did not in the control group (Group-2). Amylase levels measured in both the drain in the site of the surgery and in the serum at postoperative 8, 24, 48 and 72nd hours period were compared. Patients with severe systemic diseases and former hepatobiliary disease excluded.Results: There was no statistically significant difference in mean blood amylase levels between Group-1 and Group-2 (p>0.05), however, when it was examined with regard to the measured mean amylase levels, the measurement values of Group-1 were significantly higher than those of Group-2 (p<0.05).Conclusion: Considering tissue ischemia-necrosis, intraabdominal infection-abscesses, possible intraabdominal adhesions, and other serious complications occurred secondary to chemical trauma as a result of the dissemination of pancreatic secretions into the peritoneal cavity, it is very important to protect the peritoneal cavity from contact with these enzymes. For this purpose, we suggest that the use of early stage drainage fluid amylase measurement is very important.

İntraoperatif splenik hilus kanaması ve splenomegali robotik ve laparoskopik splenektomiden açık cerrahiye geçişe etki eden risk faktörleridir

Minimal invasive surgery is one of the most popular treatment approaches which is safe and effective in experienced hands in different clinical practices. In the present study, we aimed to evaluate the risks factors for conversion to open splenectomy and the performance of indirect hilum dissection technique. A total of 56 patients who underwent laparoscopic or robotic splenectomy for isolated spleen diseases were included into the study. Patients were divided into two groups as robotic or laparoscopic splenectomy (Group 1; n= 48) and conversion to open surgery (Group 2; n= 8). Patients were retrospectively evaluated according to clinical, biochemical, hematological and microbiological parameters and morbidity. No statistically significant difference was found between the groups in terms of age, gender, body mass index (BMI), ASA score, co-morbid disease, operation time, hospital stay, follow-up period, accessory spleen, diagnosis, international normalized ratio (INR), red cell distribution width (RDW), platelet distribution width (PDW), platelet to lymphocyte ratio (PLR), neutrophil to lymphocyte ratio (NLR), reapplication, splenosis, surgical site infection, vascular thrombus and incisional hernia (p> 0.05). On the other hand, intraoperative splenic hilum hemorrhage and increased spleen size (p <0.05) were higher in the conversion to open surgery group. In logistic regression analysis, intraoperative splenic hilum hemorrhage (B= 4.127) (OR= 61.974) (95% CI= 3.913-981.454) (p= 0.003) and increased spleen volume (B= 3.114) (OR= 22.509) (95% CI= 1.818-278.714) (p= 0.015) were found as risk factors for conversion to open surgery. Intraoperative hemorrhage from the splenic hilum and increased spleen volume (> 400 cm3) are risk factors for conversion to open splenectomy in patients undergoing elective robotic or laparoscopic splenectomy. Indirect splenic hilum dissection can decrease intraoperative hemorrhage and conversion to open surgery.

Short-term efficacy evaluation of laparoscopic spleen-preserving splenic hilus lymphadenectomy and left epigastrium mesogastric excision for advanced proximal gastric cancer based on mesangial anatomy

Objective: To investigate short-term efficacy of laparoscopic spleen-preserving splenic hilus lymphadenectomy and left epigastrium mesogastric excision for advanced proximal gastric cancer based on mesangial anatomy. Methods: A case series study was carried out. Case inclusion criteria: (1) patient was confirmed as gastric adenocarcinoma by gastroscopic biopsy before operation; (2) locally advanced gastric cancer was confirmed by abdominal CT before operation; (3) no distant metastases such as liver, lung, and posterior peritoneal lymph nodes, and no tumor directly invading the pancreas, spleen, liver, and colon were verified by superficial lymph node ultrasound, chest and abdominal CT before operation;(4) total gastrectomy or proximal gastrectomy plus D2 lymphadenectomy were performed, and R0 resection was confirmed by postoperative pathology. Exclusion criteria: (1) intraperitoneal dissemination or distant metastasis was found during laparoscopic exploration; (2) No.10 lymph nodes were significantly enlarged or fused into clusters; (3) pathological diagnostic data were incomplete. According to above criteria, the clinicopathological data of 36 patients who underwent laparoscopic spleen-preserving No.10 lymphadenectomy and left epigastrium mesogastric excision based on interspace anatomy for advanced proximal gastric cancer in The First Affiliated Hospital of Zhengzhou University from June 2017 to March 2018 were retrospectively collected and analyzed. The intraoperative conditions, postoperative recovery and complications of patients were analyzed. Results: In 36 patients, the mean age was (59.8±8.0) years, the mean BMI was (23.9±3.5) kg/m(2), and 8 cases (22.2%) received preoperative chemotherapy. All the patients underwent successfully the laparoscopic spleen-preserving splenic hilus lymphadenectomy and left epigastrium mesogastric excision. In the examination of postoperative resected specimens, it was found that the mesangial boundary of the upper and posterior part of the stomach was smooth, indicating the efficiency of complete mesangial resection. No case was converted to open operation. The mean time of lymph node dissection and mesangial resection was (34.2±11.4) minutes. The mean blood loss during operation was (44.8±21.3) ml. The mean number of lymph node dissection per patient was 45.6±17.6. The mean number of No. 11p+11d lymph node dissection was 3.1± 2.8 per patient, and 7 patients were pathologically positive with metastasis rate of 19.4% (7/36). The mean number of No.10 lymph node dissection was 2.9±2.5 per patient, and 2 patients were pathologically positive with metastasis rate of 5.6% (2/36). The time to postoperative flatus was (3.8±0.6) days, time to removal of nasogastric was (1.9±0.7) days, time to the first intake of fluid was (3.0±0.4) days, time to removal of drainage tube was (6.0±1.2) days. Postoperative mean hospital stay was (12.8±4.0) days. One case (2.7%) developed pulmonary embolism and 1 case (2.7%) developed gastroplegia after operation. The morbidity of postoperative complication was 5.6% (2/36). No operative site infection, postoperative bleeding and death within postoperative 30-day were observed. All the 36 patients were followed up and the median follow-up was 18 months (12-28 months). Seven patients died of tumor relapse and metastasis (3 cases died within postoperative 1 year) and another 1 case developed colonic cancer 17 months after operation. Conclusion: Laparoscopic spleen-preserving splenic hilus lymphadenectomy and left epigastrium mesogastric excision for advanced proximal gastric cancer based on mesangial anatomy is safe and feasible.

Necessity of prophylactic splenic hilum lymph node clearance for middle and upper third gastric cancer: a network meta-analysis

BackgroundIt remains controversial whether prophylactic No.10 lymph node clearance is necessary for gastric cancer. Thus, the present study aims to investigate the impact of prophylactic No.10 lymph node clearance on the perioperative complications and prognosis of upper and middle third gastric cancer.MethodsA network meta-analysis to identify both direct and indirect evidence with respect to the comparison of gastrectomy alone (G-A), gastrectomy combination with splenectomy (G + S) and gastrectomy combination with spleen-preserving splenic hilar dissection (G + SPSHD) was conducted. We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for studies published before September 2018. Perioperative complications and overall survival were analyzed. Hazard ratios (HR) were extracted from the publications on the basis of reported values or were extracted from survival curves by established methods.ResultsTen retrospective studies involving 2565 patients were included. In the direct comparison analyses, G-A showed comparable 5-year overall survival rate (HR: 1.1, 95%CI: 0.97–1.3) but lower total complication rate (OR: 0.37, 95%CI: 0.17–0.77) compared with G + S. Similarly, the 5-year overall survival rate between G + SPSHD and G + S was comparable (HR: 1.1, 95%CI: 0.92–1.4), while the total complication rate of G + SPSHD was lower than that of G + S (OR: 0.50, 95%CI: 0.28–0.88). In the indirect comparison analyses, both the 5-year overall survival rate (HR: 1.0, 95%CI: 0.78–1.3) and total complication rate (OR: 0.75, 95%CI: 0.29–1.9) were comparable between G-A and G + SPSHD.ConclusionsProphylactic No.10 lymph node clearance was not recommended for treatment of upper and middle third gastric cancer.

Distal pancreatectomy for pancreatic neoplasia: is splenectomy really necessary? A bicentric retrospective analysis of surgical specimens

BackgroundWhile distal pancreatectomy with splenectomy (DPS) is the reference treatment for pancreatic body and tail neoplasia, oncological benefits of splenectomy have never been demonstrated. Involvement of spleen, splenic hilum and lymph nodes (LN) was therefore assessed on DPS specimens. MethodsAll DPS pancreatic neoplasia specimens obtained in 2 Brussels University Hospitals over 15 years (2004–2018) were reviewed retrospectively, using both preoperative radiological imaging and postoperative pathological analyses of splenic parenchyma, hilar tissue and LN. ResultsThe total of 130 DPS specimens included 85 adenocarcinomas, 37 neuroendocrine neoplasms and 8 other carcinomas. Tumours involved the pancreatic body without tail invasion for 59 specimens (B, Body group), and the pancreatic tail with/without body for 71 (T, Tail group). At pathology, direct splenic and/or hilar involvement was observed in 13 T specimens (13/71, 18.3%), but in none belonging to the Body group. The observed numbers of splenic hilar LN (only reported in 49/130 patients) were low, only one T adenocarcinoma had positive splenic LN in addition to direct splenic involvement. ConclusionSplenectomy remains justified during pancreatectomy for neoplasia involving the pancreatic tail, but in case of pancreatic body tumours, its benefits should be questioned in the light of absent splenic LN/parenchymal involvement.

Is splenectomy really necessary in left pancreatectomy for pancreatic neoplasia? A bicentric retrospective analysis of surgical specimens

Background: Although left pancreatectomy with splenectomy (LPS) is considered as the gold standard for the treatment of neoplasia from the pancreatic body and tail, the oncological benefit of spleen removal has never been demonstrated. This study aimed to assess the involvement of the spleen, the splenic hilum and lymph nodes (LN) on pathological specimens of LPS for neoplasia. Methods: All patients undergoing LPS for pancreatic carcinoma or neuroendocrine neoplasia in 2 tertiary centers were retrospectively reviewed. Pathological analysis of the splenic parenchyma, the hilar tissue and the peripancreatic and splenic hilar lymph nodes (LN) was reviewed, such as the pancreatic tumor location on preoperative imaging. Results: Between 2004 and 2018, 161 patients had a LPS for pancreatic neoplasia, including 114 adenocarcinoma, 38 neuroendocrine neoplasia and 9 other rare carcinoma. Tumor was located into the pancreatic body without infiltrating the tail in 81 patients (group Body), and involved the tail with or without the body in 80 patients (group Tail). The median number of LN found on specimens was 15 (± 16). Positive LN were present in 48% (39/81) and 45% (36/81) of patients from groups Body and Tail, respectively. Splenic hilar LN were not frequent, and were positive in only 1 patient from group Tail (1%) and no patient from group Body. Direct involvement of the splenic parenchyma and/or hilum was observed in 9 patients from group Tail (11%) and absent in group Body. Conclusions: According to the Results of the present study, the value of performing a splenectomy in patients with a neoplasia located into the pancreatic body should be questioned. Resection of the splenic vessels remains essential for regional lymphadenectomy, so the splenic preservation using the Warshaw technique could be a good option.

A Splendid Pelvic Tumor, Indeed

Accessory spleen is not a common finding, usually located nearby the normal anatomic location of the spleen, oftentimes in the splenic hilum, the great omentum and the pancreas. Pelvic accessory spleen is a very rare finding, mostly asymptomatic and incidentally radiologically detected. Herein, we present an 18 years old male who underwent an investigation for daytime urinary frequency and suspicious small right pelvic mass was demonstrated by both ultrasound and MRI scans. In view of being a potentially malignant tumor, a robotic-assisted removal was uneventfully performed and the final pathology was surprisingly compatible with an accessory spleen.

Atraumatic splenic rupture was attributed to intra-cystic haemorrhage and hypersplenism in a patient with cirrhosis and portal hypertension: A case report

Liver cirrhosis with splenomegaly and portal hypertension has been described in the medical literature as increasing the risk of splenic rupture. We report a case of atraumatic splenic rupture in a male with liver cirrhosis associated with splenomegaly, which was further complicated by hypersplenism and intra-cystic haemorrhage in the spleen. The 56-year-old man was hospitalized because of sudden onset of intermittent pain in the left quadrant abdomen with no history of trauma. Upon admission, the patient presented no fever, palpable abdominal tenderness, splenomegaly, and hypersplenism. Enhanced computed tomography revealed a splenic subcapsular haematoma connected to a cystic mass located at the splenic hilum and free fluid in the abdomen, which is indicative of splenic rupture. The patient underwent immediate laparotomy and splenectomy followed by proper management. Post-surgery diagnostic microscopy indicated liver steatosis, perivenular fibrosis, and regenerative nodules, which are suggestive of cirrhosis. The patient was discharged from the hospital with an uneventful recovery.

SUBCAPSULAR HAEMATOMA OF THE SPLEEN - A COMPLICATION OF ACUTE PANCREATITIS

The intimate relationship of the tail of the pancreas and the splenic hilum makes the spleen vulnerable to the inflammation of the body and the tail of the pancreas. The involvement of the spleen in pancreatitis is increasing and it includes lesions like perisplenic or intrasplenic pseudocysts, subcapsular hematomas, intrasplenic haemorrhage, splenic infarction and splenic rupture. We present the case of a nontraumatic subcapsular haematoma of the spleen in a patient with alcohol related pancreatitis

Laparoscopic Multivisceral Resection of Gastrointestinal Stromal Tumor Post Neoadjuvant Imatinib Therapy: A Series Of Two Cases.

Title: Laparoscopic Multivisceral Resection of Gastrointestinal Stromal Tumor Post Neoadjuvant Imatinib Therapy: A Series Of Two Cases. Introduction: Gastrointestinal stromal tumor is the most common mesenchymal tumor of gastrointestinal tract. Surgery is the cornerstone of management. Targeted chemotherapy viz. Imatinib, sunitinib, regorafenib had reported to be useful in locally advanced cases for downstaging. Here we are presenting two cases, one was arising from the stomach another from tail of the pancreas. Both were successfully managed by laparoscopic multivisceral resection of gastrointestinal stromal tumor after downstaging of tumors. Case report 1: A 47 years old male presented with postprandial fullness and early satiety for 8 months associated with on an off episode of melena. His general, physical and abdominal examination was unremarkable. Endoscopy revealed, normal gastric mucosa with an extrinsic bulge. USG abdomen and CECT revealed a heterogeneously enhancing lesion probably arising from the greater curvature of the stomach and abutting spleen and pancreas. Neoadjuvant therapy started in view of locally advanced disease. He underwent laparoscopic sleeve resection of gastric GIST with distal pancreatico-splenectomy. After a year follow up, no signs of recurrence seen. Case report 2: A 64 years old male presented with dyspepsia and postprandial fullness for 2 years with no history of melena. He also had a loss of appetite and weight. UGI endoscopy revealed extrinsic compression with normal mucosa. USG abdomen and CECT revealed a 17.2 x 11 x 10.5 cm solid cystic lesion abutting greater curvature of the stomach and extending up to splenic hilum and effacing pancreas. In view of locally advanced disease he received imatinib for 1 year followed by laparoscopic distal pancreaticosplenectomy. On six months follow up he is doing well. Conclusion: Gastrointestinal stromal tumor is a rare mesenchymal tumor that has metastatic potential. Open surgery is the preferred view to avoid spill and positive resection margins. Here both patients were managed by multivisceral resection, laparoscopically. Though there is a dearth of literature regarding laparoscopic surgery. However, it is feasible in experienced hands.

Analysis of the Factors Affecting Survival in the Patients Who Underwent Curative-Intent Gastrectomy due to Gastric Adenocarcinoma

Objectives:Gastric cancer is the fifth most common cancer and the third most common cause of cancer-related deaths in the world. In this study, we aimed to evaluate the impact of clinicopathological factors on overall survival in the patients who underwent curative-intent gastrectomy due to gastric adenocarcinoma.Methods:The medical records of 644 patients who underwent gastrectomy between January 2007 and January 2017 in our clinic were retrospectively reviewed. Among these patients, 359 patients were included in this study. The impact of several prognostic factors on survival was investigated.Results:The mean age was 59.2±11.6 (29-83). Male/female ratio was 2.12. The median follow-up time was 19 months (CI=10.1-31.1). Median overall survival was 23±2.3 months (CI=18.3-27.6). Splenectomy, R1 (microscopically incomplete) resection, and advanced stage were independent risk factors for poor prognosis.Conclusion:R1 resection, splenectomy, and advanced TNM stage were associated with poor prognosis in gastric cancer. Splenectomy should be avoided in the absence of direct invasion of the tumour or metastasis of lymph nodes on splenic hilum to prevent postoperative infectious complication-related mortality.

Systemic Review and Meta-analysis of Impact of Splenectomy for Advanced Gastric Cancer.

Prophylactic splenectomy has shown no inferiority for tumors not invading the greater curvature side. Despite this, the clinical impact of prophylactic splenectomy for proximal advanced gastric cancer is not clear. This review aimed to clarify the impact of splenectomy for advanced gastric cancer in the upper third of the stomach. A systematic review and meta-analysis were conducted based on PubMed and EMBASE databases. The following search terms were used: "gastric cancer" OR "splenectomy" OR upper third of the stomach" OR preservation of the spleen. Out of 765 articles, 18 studies (combined n=6,341) were included in the analysis. Four randomized controlled trials (RCT) and eight retrospective studies suggested the benefits of spleen-preserving gastrectomy. Six retrospective studies showed no significant benefit of spleen-preserving gastrectomy. Prophylactic splenectomy showed a close association with a higher incidence of postoperative morbidity (pancreatic fistula and anastomotic leakage) with no concomitant improvement in overall survival. Prophylactic splenectomy should not be routinely performed and RCTs are necessary to confirm the impact of splenectomy for cN(+) at the splenic hilum tumors and tumors invading the greater curvature.

Exploration and development of indocyanine green fluorescence applied in laparoscopic splenic hilum lymph node dissection for gastric cancer

With the continuous development of laparoscopic techniques and the concept of individualized treatment, laparoscopic surgery is also moving from "minimally invasive" to "minimally invasive plus precision" . Lymph node metastasis is one of the most important risk factors affecting the prognosis of gastric cancer (GC). Reasonable lymph node dissection has always been an important exploration direction in the field of GC surgery. In recent years, domestic and foreign studies have found that the new tracer, indocyanine green (ICG), can detect the lymphatic vasculature non-invasively, and more accurately display the perigastric lymph nodes, providing a new perspective in laparoscopic lymph node dissection for GC. Alternatively, since the application of ICG in laparoscopic gastrointestinal tumor surgery, especially in gastric cancer surgery is still in the early stage of exploration and experience accumulation, more high-level medical evidences are needed to evaluate its clinical value.

Laparoscopic splenectomy: clip ligation or en-bloc stapling?

Various techniques are used in the management of splenic hilum during laparoscopic splenectomy. Among them, the most used ones are polymer clips, en-bloc stapling and ultrasonic devices. To the best of our knowledge, there is no study in the literature comparing the results of clip and stapler techniques. This study was aimed to compare our results of clip ligation and en-bloc stapling of the splenic hilum. The records of 67 patients undergoing laparoscopic splenectomy between December 2012 and October 2017 were reviewed. Patients were divided into two groups according to surgical method (stapler group: 26 patients and clip group: 41 patients). Patient age, sex, diagnosis, surgical technique, operation time, spleen dimensions, perioperative complications, postoperative hospital stay, blood transfusions, postoperative thrombocyte and hemoglobin levels were recorded. Operating time was median 115 min (75-230) in the stapler group and 120 min (60-210) in the clip group, and there was no significant difference between the groups (p= 0.2593). There were no significant difference between the groups in terms of the postoperative complications (p= 0.59). Postop- erative hospital stay was median 3.5 (2-8) days in the stapler group and 3 (2-6) days in the clip group with no significant difference (p= 0.0733). Clip ligation and en-bloc stapling techniques have no superiority over each other. Our results also showed that both techniques are safe and feasible. We suggest opting for the method according to the surgeon's experience and hospital facilities.

A case report of carcinoma of uterine cervix throwing heterochronous metastasis to the skin, spleen, and pancreas: the role of multimodality treatment approach

BackgroundCancer of cervix often fails locally and/or within the pelvis. One to two percent of cervical squamous cell carcinoma patients have lung metastases at presentation, and 5–35% develop pulmonary metastases later on. Common sites of metastases are the liver, bone, and bowel. We report a rare case presentation of cervical squamous cell cancer where heterochronous metastasis occurred in the skin, spleen, and pancreas without loco-regional recurrence and skipping of visceral organs such as the lung, liver, and brain.Case presentationA 55-year-old, postmenopausal lady presented with a complaint of bleeding of the vagina for 2 months duration. Cervical biopsy revealed squamous cell carcinoma of the cervix, and she was staged as a case of FIGO stage IIIB. She received external beam-beam radiotherapy of 50 Gy in 25 fractions along with concurrent weekly cisplatin at 35 mg/m2 followed by 3 fractions of intracavitary brachytherapy of 6 Gy each. After 30 months of follow-up, she presented with a skin lesion of 6 × 5 cm2 in the infrascapular region for 2 months duration. Biopsy revealed metastatic squamous cell carcinoma. Her metastatic work-up revealed no other lesions. Palliative radiotherapy to local site of 8 Gy in single fraction was delivered. The lesion disappeared within 4 weeks. She was given 6 cycles of cisplatin and paclitaxel salvage chemotherapy. After 30 months of follow-up, she presented with a skin lesion of 6 × 5 cm2 in the infrascapular region. Biopsy revealed metastatic squamous cell carcinoma. Her metastatic work-up revealed no other lesions. Palliative radiotherapy to the local site was planned, and a dose of 8 Gy in a single fraction was delivered. The lesion disappeared within 4 weeks. She was given 6 cycles of cisplatin and paclitaxel salvage chemotherapy. Six months after the completion of salvage therapy, she reported with the complaints of recurrent bouts of hematemesis and melena. Her CECT scan revealed 2 × 1.5 cm2 growth in the body of the pancreas and a subcentric splenic hilum node. She underwent open splenectomy with distal pancreatectomy. Histopathology report showed metastatic infiltration in pancreatic tissue by squamous cell carcinoma and one metastatic node in the splenic hilum. Post-treatment, 6 months, the patient was asymptomatic with no recurrence.ConclusionsThis is a rare heterochronous metastatic presentation of cervical cancer without loco-regional recurrence and visceral organs such as the lung, liver, and brain. The optimal treatment remains undefined for these patients. Multimodality treatment is necessary to manage the patients.

Accessory Spleen in Human Fetuses: A Cadaveric Study

Abstract Background The aim of the study was to assess the morphological and histological features of accessory spleen in formalin-preserved human fetuses. Methods The study was conducted on spleen of 40 human fetuses of varied gestational ages without any congenital anomalies with due clearance from the ethical committee. The existence of accessory spleen was investigated during dissection. These were then dissected, weighed, and stained by hematoxylin and eosin as well as Masson’s trichrome method and observed under compound light microscope. Results In 5 (12.5%) cases, the accessory spleen was revealed in fetuses aged between 29th and 40th gestational weeks. These were located near the splenic hilum. On histological examination, the tissue of accessory spleen revealed a well-defined capsule. White pulp was less differentiated as compared with red pulp area. Conclusion The accessory spleen is often misdiagnosed by the clinicians for neoplastic growth or lymph node enlargement; therefore, its awareness is important.

1355 Accessory Spleen: An Unusual Pancreatic Mass Posing a Diagnostic Dilemma

INTRODUCTION: There are two main causes of accessory spleen; failure of fusion of the splenic anlage during the fifth week of fetal life and following autotransplantation after a splenectomy. They are structurally identical to the spleen and are most commonly found in the splenic hilum or pancreatic tail. Although rarely noted on radiograph due to low spatial resolution, their detection is increasing with more advanced modalities. This can result in the finding of a pancreatic mass that poses a diagnostic dilemma. CASE DESCRIPTION/METHODS: The patient is a 62-year-old man with a history of hepatitis B infection. On routine surveillance he had ultrasound findings of a liver calcification with inability to determine the presence of cirrhosis and a mildly elevated alpha-fetoprotein level. He was sent for an MRI, which revealed a 2.3 × 1.9 cm mass in the pancreatic tail showing mild hyperintense T2 signal and hypointense T1 signal. A CT from 2011 showed a slight contour bulge to the pancreatic tail in the same region, without appreciation of a discrete lesion. He underwent EGD with endoscopic ultrasound (EUS). A 21.4 × 13.7 mm well-circumscribed, homogeneous lesion was found in the pancreatic tail and biopsied. The pathology shows an immunohistochemical-staining pattern consistent with splenic tissue, confirming the diagnosis of an intrapancreatic accessory spleen (IPAS). No further intervention was needed and the patient was sent home. DISCUSSION: Pancreatic cancer has a 5-year survival rate of 9%, therefore it is imperative that all pancreatic masses are investigated thoroughly and promptly. In cases of an IPAS, its differentiation from a pancreatic mass is difficult as splenic tissue can mimic pancreatic tumors, especially on MRI. It is essential to differentiate between the two as IPAS are only clinical relevant when there is torsion, rupture, hemorrhage, or the patient carries a diagnosis of idiopathic thrombocytopenic purpura requiring the removal of all splenic tissue. Imaging modalities such as ultrasound, CT, MRI, and scintigraphy can aid in the diagnosis of IPAS. However, these have limitations and have not shown to provide a definitive diagnosis. EUS with fine needle aspiration is being increasingly used to characterize pancreatic lesions. In this case, it enabled adequate tissue sampling while avoiding unnecessary procedures. This case illustrates another use for EUS in an otherwise difficult diagnostic scenario.

2202 Liver Mass in Cirrhotic Patients: Is It Always Hepatocellular Carcinoma (HCC)?

INTRODUCTION: Pancreatic acinar cell carcinomas (PACCs) comprise only 1-2% of all pancreatic cancers. Patients with PACC have a prognosis better than pancreatic ductal adenocarcinomas but worse than pancreatic neuroendocrine tumors. They are easier to differentiate from the prior, but may have many similar morphological features to the latter. The majority of pancreatic tumors are adenocarcinomas of the ductal type; and carcinomas with multiple lineage differentiation are extremely rare. We present a rare case of PACC with neuroendocrine differentiation. CASE DESCRIPTION/METHODS: 51-year-old male with history of chronic Hepatitis B infection, liver cirrhosis (CPT class B, MELD 15) was admitted for abdominal pain, leg swelling and worsening renal function. Pertinent physical exam revealed a tense abdomen and diffuse tenderness. An abdominal non-contrast computed tomography (CT) scan revealed a large cm ill-defined mass in the central liver involving both right and left liver lobes. A large mass medial to the splenic hilum measuring approximately 8.7 × 6.8 cm, abutting the stomach, pancreas and spleen was also seen. An Endoscopic Ultrasound (EUS) confirmed an anechoic splenic hilum mass measuring 8 cm in greatest dimension. A 2.4 cm × 2.2 cm anechoic left liver lobe mass was also appreciated. Fine needle aspiration (FNA) was performed for each of these masses. Histopathology revealed acinar-cell carcinoma with neuroendocrine differentiation. Positive Periodic acid-Schiff (PAS), Trypsin and Chromotrypsin stains on immunohistochemistry (IHC) supported the acinar differentiation. Positive synaptophysin and chromogranin stains supported neuroendocrine differentiation. Diagnosis of pancreatic neoplasm with metastasis to the liver was made and patient was referred to an oncologist. DISCUSSION: Forming the diagnosis of a mixed carcinoma requires thorough assessment of individual components in the tumor. Current theories suggest their origin from a stem cell with propensity for multi-directional differentiation. Close morphological examination and immunohistochemical staining are fundamental in making an accurate diagnosis. Better understanding of prognosis and treatment of pancreatic tumor with multi-lineage origin requires evaluation of additional cases due to their paucity.

Metastasis patterns of the spleen and association with survival outcomes in advanced ovarian-tubal-peritoneal epithelial cancer.

To evaluate the significance of parenchymal, hilar and capsular involvement of the spleen with regard to survival. All patients who underwent primary cytoreductive surgery for advanced ovarian-tubal-peritoneal (OTP) epithelial cancer were reviewed retrospectively. Stage 3C patients who had an upper abdomen involvement and who were optimally debulked were included. Patients who had abdomen-confined disease, but were upstaged to stage 4B due to splenic parenchymal metastases were also included. Seventy four patients eligible with the inclusion criteria who underwent splenectomy and 69 patients who did not undergo splenectomy were included. The median follow-up time was 39.1months. The median overall survival of the study group was 61.4months. Patients who underwent splenectomy were grouped according to the involved site of the spleen: parenchyma subgroup, hilus subgroup, capsule subgroup and benign subgroup. The median overall survival of patients in the hilus subgroup was 41.1months. The median overall survival of patients who were not in the hilus subgroup was 65.5months. Patients in the hilus subgroup showed significantly shorter survival (p = 0.035). Hilus subgroup was associated with a statistically significant increase in mortality risk (hazard ratio 1.971; 95% confidence interval 1.1-3.531). Splenic hilus involvement predicts poorer survival outcomes among stage 3C epithelial OTP cancer patients with disease expansion to upper abdomen. According to current study and many published studies, hilar involvement had a higher incidence rate compared to parenchymal involvement. Thus, hilar involvement would be a beneficial clinical predictor of survival for larger number of patients.