Single Case Reports Solitary Splenic Metastasis of an Adenocarcinoma of the Lung ANDREW S. EDELMAN, M.D., PH.D. AND HEIDRUN ROTTERDAM, M.D.
Splenic metastasis of solid tumors is a rare event, most often diagnosed at the time of autopsy. Whereas in cases of widely disseminated cancer, splenic involvement may be fairly common, solitary splenic metastasis in the absence of other metastases is exceedingly rare. The authors report a case of a 63-year-old woman in whom the sole detectable distant metastasis of a lung carcinoma was a splenic mass. The splenic lesion was detected before the resection of the primary lung lesion during a complete metastatic work-up. At that time, however, it was considered unlikely that the mass in the spleen represented a metastasis because of the lack of metastatic disease elsewhere. (Key words: Spleen; Metastases; Adenocarcinoma) Am J Clin Pathol 1990;94:326-328
Department of Pathology, New York University Medical Center, New York, New York
METASTASIS TO THE spleen from solid tumors is considered rare and usually is detected only at autopsy.''2'4""68,10,11.13 Autopsy rates of splenic metastases range from a few percent to 36%, depending on the type of tumor— carcinomas of the breast 1 6 8 1 0 and lung 1 ' 2 ' 610 and melanoma 6 " being the most common primary tumors. The highest percentage was reported for malignant melanoma." In virtually all of these instances, splenic involvement was accompanied by widespread metastasis. Recent reports of solitary splenic metastases have shown a disproportionate number of gynecologic malignancies, three cases of endometrial cancer,3'7'9 two cases of cervical cancer,12 and one case of ovarian cancer.12 One patient with lung cancer9 and one with malignant melanoma 9 also have been reported as having solitary splenic metastasis. We describe a patient with lung cancer who presented at the time of initial diagnosis with a splenic mass. Because of the lack of evidence of widespread metastatic disease, a splenic metastasis was considered unlikely. Only close follow-up of the patient after resection of the lung mass revealed the true nature of the splenic lesion.
Received September 20, 1989; received revised manuscript and accepted for publication February 26, 1990. Address reprint requests to Dr. Rotterdam: New York University Medical Center, Department of Pathology, 560 First Avenue, New York, New York 10016.
A 63-year-old woman with a 50+ pack-year history of cigarette smoking was found to have a carcinoma in the left lung. A complete metastatic work-up was essentially negative except for the discovery of a 3-cm splenic mass by computed tomography (CT) scan. Abdominal ultrasound confirmed the presence of a 2.5-3-cm solid mass in the spleen. At the time of surgery, an incisional lung biopsy measuring 1.5 X 1.2 X .5 cm was sent for a frozen section and diagnosed as carcinoma. Gross examination of the surgical specimen (left lower lobe) showed residual subpleural tumor measuring 1.2 X 1.4 X 1.2 cm. Microscopically the tumor was a poorly differentiated adenocarcinoma (Fig. 1). One of seven peribronchial lymph nodes showed metastatic tumor. The patient was followed-up with repeat CT scans of the abdomen, bone scans, and chest x-rays. By 11 months the splenic mass had significantly increased in size, and a CT-guidedfine-needleaspirate was attempted. Because of low cellularity, a definitive diagnosis could not be made, but cells suspicious for malignancy were noted and the patient was admitted for splenectomy. The spleen weighed 233 g and contained a circumscribed, largely necrotic mass of 5 cm diameter (Fig. 2). Microscopically metastatic adenocarcinoma was diagnosed (Fig. 3), and the similarity to the primary lung tumor (Fig. 1) was noted.
Discussion The spleen, as part of the reticuloendothelial system, is a rather common site of secondary involvement with hematopoietic malignancies. The massive splenomegaly associated with chronic myelogenous leukemia is well recognized. In contrast, splenic metastasis of solid tumors, particularly in the absence of disseminated disease, is exceedingly rare. The incidence of splenic metastasis from solid tumor in autopsy studies varies from a few percent to 36%, depending upon the type of malignancy.'• 2 ' 4 " 6 ' 8 ' 0 " 13 Some malignancies show a disproportionately high or low incidence of splenic involvement. Adams and colleagues' in studying 1,000 autopsies of patients with carcinomas (melanoma excluded) reported an overall rate of 9% for splenic involvement. When broken down by primary tu-
326
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Report of a Case
Vol. 94 • No. 3
SINGLE CASE REPORTS
327
Splenic metastasis of solid tumors is a rare event, most often diagnosed at the time of autopsy. Whereas in cases of widely disseminated cancer, splenic involvement may be fairly common, solitary splenic metastasis in the absence of other metastases is exceedingly rare. The authors report a case of a 63-year-old woman in whom the sole detectable distant metastasis of a lung carcinoma was a splenic mass. The splenic lesion was detected before the resection of the primary lung lesion during a complete metastatic work-up. At that time, however, it was considered unlikely that the mass in the spleen represented a metastasis because of the lack of metastatic disease elsewhere. (Key words: Spleen; Metastases; Adenocarcinoma) Am J Clin Pathol 1990;94:326-328
Department of Pathology, New York University Medical Center, New York, New York
METASTASIS TO THE spleen from solid tumors is considered rare and usually is detected only at autopsy.''2'4""68,10,11.13 Autopsy rates of splenic metastases range from a few percent to 36%, depending on the type of tumor— carcinomas of the breast 1 6 8 1 0 and lung 1 ' 2 ' 610 and melanoma 6 " being the most common primary tumors. The highest percentage was reported for malignant melanoma." In virtually all of these instances, splenic involvement was accompanied by widespread metastasis. Recent reports of solitary splenic metastases have shown a disproportionate number of gynecologic malignancies, three cases of endometrial cancer,3'7'9 two cases of cervical cancer,12 and one case of ovarian cancer.12 One patient with lung cancer9 and one with malignant melanoma 9 also have been reported as having solitary splenic metastasis. We describe a patient with lung cancer who presented at the time of initial diagnosis with a splenic mass. Because of the lack of evidence of widespread metastatic disease, a splenic metastasis was considered unlikely. Only close follow-up of the patient after resection of the lung mass revealed the true nature of the splenic lesion.
Received September 20, 1989; received revised manuscript and accepted for publication February 26, 1990. Address reprint requests to Dr. Rotterdam: New York University Medical Center, Department of Pathology, 560 First Avenue, New York, New York 10016.
A 63-year-old woman with a 50+ pack-year history of cigarette smoking was found to have a carcinoma in the left lung. A complete metastatic work-up was essentially negative except for the discovery of a 3-cm splenic mass by computed tomography (CT) scan. Abdominal ultrasound confirmed the presence of a 2.5-3-cm solid mass in the spleen. At the time of surgery, an incisional lung biopsy measuring 1.5 X 1.2 X .5 cm was sent for a frozen section and diagnosed as carcinoma. Gross examination of the surgical specimen (left lower lobe) showed residual subpleural tumor measuring 1.2 X 1.4 X 1.2 cm. Microscopically the tumor was a poorly differentiated adenocarcinoma (Fig. 1). One of seven peribronchial lymph nodes showed metastatic tumor. The patient was followed-up with repeat CT scans of the abdomen, bone scans, and chest x-rays. By 11 months the splenic mass had significantly increased in size, and a CT-guidedfine-needleaspirate was attempted. Because of low cellularity, a definitive diagnosis could not be made, but cells suspicious for malignancy were noted and the patient was admitted for splenectomy. The spleen weighed 233 g and contained a circumscribed, largely necrotic mass of 5 cm diameter (Fig. 2). Microscopically metastatic adenocarcinoma was diagnosed (Fig. 3), and the similarity to the primary lung tumor (Fig. 1) was noted.
Discussion The spleen, as part of the reticuloendothelial system, is a rather common site of secondary involvement with hematopoietic malignancies. The massive splenomegaly associated with chronic myelogenous leukemia is well recognized. In contrast, splenic metastasis of solid tumors, particularly in the absence of disseminated disease, is exceedingly rare. The incidence of splenic metastasis from solid tumor in autopsy studies varies from a few percent to 36%, depending upon the type of malignancy.'• 2 ' 4 " 6 ' 8 ' 0 " 13 Some malignancies show a disproportionately high or low incidence of splenic involvement. Adams and colleagues' in studying 1,000 autopsies of patients with carcinomas (melanoma excluded) reported an overall rate of 9% for splenic involvement. When broken down by primary tu-
326
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Report of a Case
Vol. 94 • No. 3
SINGLE CASE REPORTS
327
