Incidental splenomegaly: An approach to diagnosis

Craig B. Reeder

Research output: Chapter in Book/Report/Conference proceedingChapter


Case 1 A 65-year-old man was diagnosed with prostate cancer and underwent robotic prostatectomy. Preoperative complete blood count (CBC) showed hemogloblin (Hb) 13.0 g/dL, white blood cell count (WBC) 5.9 × 109/L, platelets 106 × 109/L with absolute neutrophil count (ANC) 5.0 × 109/L and absolute lymphocyte count (ALC) 0.48 × 109/L. Two years later he had a biochemical relapse of prostate cancer with rising prostate-specific antigen and was referred for oncology consultation. A CBC showed Hb 15.0 g/dL, WBC 7.6 × 109/L, platelets 92 × 109/L with ANC 6.45 × 109/L and ALC 0.52 × 109/L. Computed tomography (CT) scans of the abdomen and pelvis showed splenomegaly, 17 cm in length with multiple hypodense masses. A bone scan was negative. Bone marrow aspiration and core biopsy showed normocellularity and was negative for obvious malignancy. CT/positron emission tomography scan showed no fluorodeoxyglucose-avid lesion in the spleen or elsewhere. Observation was recommended. A follow-up abdominal ultrasound 3 years later showed persistent mild splenomegaly and a possible right renal mass. CT scanning confirmed a new 1.8-cm renal mass, no adenopathy, and persistent splenomegaly, very slightly enlarged from the earlier scan. A CBC showed Hb 14.3 g/dL, WBC 6.3 × 109/L, platelets 72 × 109/L, with ANC 5.32 × 109/L and ALC 0.52 × 109/L. Repeat marrow examination was normal morphologically but on flow cytometry a small B-cell clone was identified. He remained asymptomatic. He subsequently underwent hand-assisted laparoscopic splenectomy followed by robotic partial right nephrectomy. Pathology revealed a papillary clear cell carcinoma of the kidney and a low-grade B-cell lymphoma of the spleen, with the immunophenotype (+)lambda, CD19, CD20 (bright), CD22, FMC7, and negative for CD5, CD10, CD11c, CD23, CD25, and CD103. This is most consistent with splenic marginal zone lymphoma. Multiple hemangiomas were also present, accounting for the hypodensities seen on CT. Two months post-op his CBC showed Hb 12.2 g/dL, WBC 8.0 × 109/L, platelets 526 × 109/L with normal ANC and ALC counts. No further treatment was advised. He feels quite fortunate that follow-up scans were performed as recommended, leading to the discovery of the renal cancer.

Original languageEnglish (US)
Title of host publicationManaging Myeloproliferative Neoplasms
Subtitle of host publicationA Case-Based Approach
PublisherCambridge University Press
Number of pages5
ISBN (Electronic)9781316017852
ISBN (Print)9781107444430
StatePublished - Jan 1 2016

ASJC Scopus subject areas

  • General Medicine


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