S p e c i a l A r t i c l e s P i c t o r i a l E s s ay

Lake et al.
CT of Splenosis

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Special Articles
Pictorial Essay

CT of Splenosis: Patterns and Pitfalls

Spencer T. Lake1
Pamela T. Johnson2
Satomi Kawamoto2
Ralph H. Hruban 3
Elliot K. Fishman2
Lake ST, Johnson PT, Kawamoto S,
Hruban RH, Fishman EK

Keywords: CT, spleen, splenectomy, splenosis,

99mTc-labeled sulfur colloid
DOI:10.2214/AJR.11.7896
Received September 13, 2011; accepted after revision
May 13, 2012.
1

Johns Hopkins School of Medicine, Baltimore, MD.

The Russell H. Morgan Department of Radiology and

Radiologic Science, Johns Hopkins School of Medicine,
601 N Caroline St, Rm 3140D, Baltimore, MD 21287. Address
correspondence to P. T. Johnson (pjohnso5@jhmi.edu).

3
Department of Pathology, Johns Hopkins Hospital,
Baltimore, MD.

WEB
This is a Web exclusive article.
AJR 2012; 199:W686W693
0361803X/12/1996W686
American Roentgen Ray Society

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OBJECTIVE. After traumatic splenic injury or splenectomy, small isolated spleens may
develop. These implants are not limited to the left upper quadrant, and splenosis in other locations can mimic other pathologic entities. This pictorial essay presents the range of appearances of intraabdominal and pelvic splenosis.
CONCLUSION. Radiologists can suggest or establish the correct diagnosis of splenosis in the
appropriate clinical setting, particularly in less typical cases, to avert unnecessary tissue sampling.

plenosis is the benign acquired

condition of heterotopic autotransplantation of splenic tissue in another anatomic compartment of the
body after splenic rupture, usually either traumatic or iatrogenic. It is often found incidentally, but rarely it can present symptomatically.
Splenosis most frequently occurs in the abdominal and pelvic cavities, but it has also been described in numerous other locations throughout
the body. Radiographically, splenosis can mimic various pathologic entities, including primary malignancy or metastatic disease [1].
Other entities with multiple splenic nodules
include polysplenia and the presence of accessory spleens. The specific diagnosis of polysplenia syndrome is established by the absence
of a history of splenectomy combined with the
presence of other findings of left-sided isomerism. Splenosis, which is relatively rare, is distinct from accessory spleens, which is more
common. Accessory spleens are congenital, are
supplied by the splenic artery, are usually few
in number, and are usually found near the splenopancreatic or gastrosplenic ligament. In splenosis, on the other hand, splenic nodules can
be found throughout the body, and they derive
their blood supply from neighboring tissues [2,
3]. Splenosis is presumed to occur by direct
seeding of splenic tissue in nearby body cavities after splenic rupture, although cases of splenosis in more distant locations suggest possible
hematogenous spread as well [4].
Imaging Features
Although splenosis is a benign condition, it
presents a diagnostic challenge when it mimics

malignancy. Splenic nodules are often first seen

incidentally on ultrasound or CT. Neither ultrasound nor CT reveals that the masses are definitively of splenic origin; however, imaging features on IV contrast-enhanced CT can lead to
the correct diagnosis.
On unenhanced and contrast-enhanced CT,
the masses are similar in attenuation to the expected appearance of otherwise normal splenic tissue [2, 3]. On MRI, the intensity and enhancement of the splenic nodules resemble that
of normal splenic tissue [1, 2], The advantages of MRI include the lack of ionizing radiation and routine use of dynamic multiphasic acquisitions, which can provide higher specificity
compared with single-phase CT. MRI with IV
superparamagnetic iron oxide has been used
for the diagnosis of splenosis because this
contrast agent is specific for the cells of the reticuloendothelial system of the liver and spleen
[3]; however, IV iron oxides are no longer
readily available in the United States for MRI.
The splenic tissue present in splenosis is active, as evidenced by the absence of HowellJolly bodies, Heinz bodies, and other erythrocyte abnormalities in the peripheral smears
of many asplenic patients with splenosis [5].
Therefore, nuclear scintigraphy using heatdamaged RBCs tagged with technetium-99
is currently the diagnostic tool of choice because of the high uptake of damaged erythrocytes by this ectopic splenic tissue. This technique has been shown to be more sensitive
and specific than 99mTc-labeled sulfur colloid
scintigraphy [6] and can noninvasively confirm the diagnosis of splenosis if suspected
on cross-sectional imaging.

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CT of Splenosis
Splenosis by Location
Thorax
Thoracic splenosis in a relatively rare condition that usually occurs as a result of simultaneous diaphragmatic rupture and splenic rupture.
Splenic tissue is then transported into the left
hemithorax (Fig. 1), most frequently to the parietal or visceral pleura. In a review of 38 cases
of thoracic splenosis, the average time between
the inciting event and reported thoracic splenosis was 21 years, with a range of from 3 to 45
years [7]. The discovery of splenosis in these
cases is usually incidental. Thoracic splenosis
can be found on various imaging modalities,
including chest radiography or CT, in addition
to during surgical investigations.
In 25% of thoracic splenosis cases, chest
CT shows a solitary pleura-based nodule, and
multiple nodules are seen in the remaining
75% of cases. Nodule attenuation reflects that
of normal splenic tissue [8]. The splenic implants can easily be confused with other processes including primary or metastatic tumor
or infection particularly if the abdomen is not
imaged to disclose the absence of the spleen.
Abdomen
Splenosis in the abdominal or pelvic cavity
is thought to occur in as many as 65% of cases
of splenic rupture [1]. The most frequent locations include the greater omentum (Figs. 2 and
3), small-bowel serosa, parietal peritoneum,
and undersurface of the diaphragm [9] (Fig. 3).
Once splenosis implants have been identified,
careful evaluation may disclose additional implants throughout the peritoneum; the implants
can be widespread (Fig. 2). The average time
between the inciting trauma and abdominal or
pelvic splenosis is 10 years, although splenosis
has been found to occur in as few as 5 months
after trauma [1]. Although abdominal splenosis is frequently asymptomatic, it can present
with hemorrhage, pain secondary to infarction or torsion, or obstruction of the intestinal or
urinary tract [1, 5]. As with thoracic splenosis,
these implants may be confused with primary
or metastatic malignancy, including lymphoma,
and may also be confused with endometriosis.
Pancreas
Splenic nodules in the pancreas can represent either intrapancreatic accessory spleen
or splenosis, the latter of which is rare [10].
These entities must be differentiated from
pancreatic malignancyspecifically, pancreatic neuroendocrine (islet) tumor or metastatic disease if the patient has a primary ma-

lignancy elsewhere. On CT, the diagnosis of

intrapancreatic splenic tissues should be considered when a well-defined nodule with enhancement paralleling that of the spleen is
identified in the pancreatic tail region, particularly along the dorsal surface [11] (Fig. 4).
Pelvis
Splenosis can present with pelvic nodules
(Figs. 2, 5, and 6), which may mimic metastases as well as other entities in women including endometriosis, ovarian masses, and
uterine and cervical masses. These nodules
may present with pelvic pain, but they are
most frequently asymptomatic [12]. Reports
of pelvic involvement have included retrovesical and pararectal masses [3].
Unusual and Rare Locations
LiverSeeding of splenic tissue into the liver is rare and thought to occur via invagination
of splenic implants or via splenic vein emboli
(Fig. 7) into the liver. These potential sources
explain their frequently subcapsular location
[13]. Splenosis in the liver typically presents as
a nodular lesion that can be confused with hepatic adenoma, hepatocellular carcinoma, hemangioma, lymphoma, or metastases [2, 13].
KidneysSplenosis has been reported
to mimic renal masses when found near or
adherent to the surface of the kidneys. In a
case report [9], investigators described a
large splenic nodule adherent to the left kidney that developed a cystic component, thus
complicating diagnosis. Cystic changes are
hypothesized to be the result of central necrosis secondary to inadequate blood supply
from surrounding tissues [9].
CerebrumInvestigators described a case
of cerebral splenosis mimicking meningioma in the right occipital lobe 15 years after
posttraumatic splenectomy. Because the patient had no penetrating head injuries at the
time of the trauma, splenosis was presumed
to be secondary to hematogenous spread [4].
Subcutaneous tissuesSubcutaneous splenosis is rare and is always associated with the
scar site of a surgical incision or a traumatic
wound, such as a gunshot wound. In a 2006
review [14] of 11 cases of subcutaneous splenosis, investigators described splenic implants
in old abdominal scars in eight cases and in
exit gunshot wounds in three cases. When encountered, this rare finding may be confused
with lymphoma, cutaneous lymphoid hyperplasia, Kaposi sarcoma, or subcutaneous vascular malformations [1].

Conclusion
In patients with a history of splenic trauma
or splenectomy, splenosis can arise throughout the abdominal or pelvic cavity in addition
to the chest, subcutaneous tissues, and other
less common locations. This pictorial essay
illustrates many of the possible locations and
CT appearances of splenosis to prompt consideration of this diagnosis in the appropriate
clinical setting.
References
1. Fremont RD, Rice TW. Splenosis: a review. South
Med J 2007; 100:589593
2. Tsitouridis I, Michaelides M, Sotiriadis C, Arvaniti M. CT and MRI of intraperitoneal splenosis. Diagn Interv Radiol 2010; 16:145149
3. Akay S, Ilica AT, Battal B, Karaman B, Guvenc I.
Pararectal mass: an atypical location of splenosis. J
Clin Ultrasound 2011 May 27 [Epub ahead of print]
4. Rickert CH, Maasjosthusmann U, Probst-Cousin
S, August C, Gullotta F. A unique case of cerebral
spleen. Am J Surg Pathol 1998; 22:894896
5. Sikov WM, Schiffman FJ, Weaver M, Dyckman
J, Shulman R, Torgan P. Splenosis presenting as
occult gastrointestinal bleeding. Am J Hematol
2000; 65:5661
6. Short NJ, Hayes TG, Bhargava P. Intra-abdominal
splenosis mimicking metastatic cancer. Am J Med
Sci 2011; 341:246249
7. Yammine JN, Yatim A, Barbari A. Radionuclide
imaging in thoracic splenosis and a review of the
literature. Clin Nucl Med 2003; 28:121123
8. Javadrashid R, Paak N, Salehi A. Combined subcutaneous, intrathoracic and abdominal splenosis.
Arch Iran Med 2010; 13:436439
9. Grses B, Kabaki N, Akit HZ, Yencilek F,
Kovanlikaya A, Kovanlikaya I. Cystic splenosis
mimicking a renal mass: a case report and review of
the literature. Australas Radiol 2007; 51(spec no):
B52B55
10. Fiamingo P, Veroux M, Da Rold A, et al. A rare diagnosis for a pancreatic mass: splenosis. J Gastrointest Surg 2004; 8:915916
11. Kawamoto S, Johnson PT, Hall H, Cameron JL,
Hruban RH, Fishman EK. Intrapancreatic accessory
spleen: CT apearance and different diagnosis. Abdominal Imaging 2001; Dec 13 [Epub ahead of print]
12. Talati H, Radhi J. Ovarian splenosis: a case report.
Case Report Med 2010 Jun 13 [Epub ahead of print]
13. Mescoli C, Castoro C, Sergio A, Ruol A, Farinati F,
Rugge M. Hepatic spleen nodules (HSN). Scand J
Gastroenterol 2010; 45:628632
14. Yeh CJ, Chuang WY, Kuo TT. Unusual subcutaneous splenosis occurring in a gunshot wound scar:
pathology and immunohistochemical identification.
Pathol Int 2006; 56:336339

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Lake et al.

C
Fig. 155-year-old man who presented for CT to evaluate renal mass. Patient had history of splenectomy after gunshot wound years earlier.
AC, Axial section (A) and coronal multiplanar reconstructions (B and C) from IV contrast-enhanced CT show lobulated implants (arrows) along left pleural surface.
Presumably splenosis, these implants are unchanged from study performed 3 years earlier (not shown).

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CT of Splenosis

Fig. 236-year-old man who presented for liver imaging. Patient had undergone
splenectomy after trauma during childhood. Liver is enlarged with diffuse
steatosis.
AE, Splenic implants (arrows) are identified throughout peritoneal cavity,
including along serosal surface of bowel and within pelvis, on axial images (A and
CE) and on coronal multiplanar reconstruction (B) from IV contrast-enhanced CT.

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Lake et al.

Fig. 375-year-old man who had undergone splenectomy for ruptured spleen after trauma more than 2 decades earlier, with healed posterior left rib fracture (not shown).
A, Axial unenhanced CT image shows lobulated mass (arrow) in left greater omentum and smaller nodules (arrowhead) along undersurface of left hemidiaphragm.
B, Axial 99mTc-labeled sulfur colloid scan confirms mass (arrows) to be splenic tissue.
C, Coronal multiplanar reconstruction better shows splenic tissue (arrow) implanted along undersurface of left hemidiaphragm than A.
D, Coronal 99mTc-labeled sulfur colloid scan confirms that omental mass (arrow) and diaphragmatic implant (arrowhead) are splenic tissue.

Fig. 460-year-old woman with enhancing mass in pancreatic tail that was later removed because of concern for islet cell tumor. Pathologic results proved mass was
intrapancreatic splenule.
A and B, Arterial phase (A) and venous phase (B) axial CT images show round mass (arrows) along dorsal surface of pancreatic tail. This location is typical for
intrapancreatic splenule. Note heterogeneous arterial phase enhancement that is characteristic of splenic tissue.

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CT of Splenosis

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Fig. 574-year-old man who presented for follow-up imaging after splenectomy.
AE, Axial images (AD) and coronal multiplanar reconstruction (E) from IV
contrast-enhanced CT show splenic tissue (arrows) is distributed throughout
peritoneal cavity and mesentery, including pelvis. H = hemangioma in B.

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Lake et al.

Fig. 662-year-old woman with breast cancer and colon cancer who presented for imaging decades after splenectomy.
A and B, Coronal multiplanar reconstruction (MPR) (A) and axial image (B) from IV contrast-enhanced CT of pelvis show small enhancing nodules in left omentum
(arrows, A) and solid enhancing mass in right pelvis (arrow, B); these findings are concerning for metastatic implants.
C and D, Axial image (C) and coronal MPR (D) from SPECT/CT 99mTc-labeled sulfur colloid scanning confirm that pelvic and left upper quadrant nodules (arrows) are
splenic tissue, thereby averting biopsy.

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CT of Splenosis

Fig. 749-year-old man with history of splenectomy after motor vehicle collision
who presented for hepatic imaging.
AD, Axial arterial phase (A), axial venous phase (B), and coronal (C) and sagittal
(D) multiplanar reconstructions (MPRs) show cirrhosis and 3-cm hepatic mass
(arrow). Mass was presumed to be hepatocellular carcinoma; however, pathologic
finding after liver transplant revealed that mass was splenic tissue.
E, Additional splenic implant (arrow) is visible in left upper quadrant on coronal
MPR.

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