Splenunculus

Splenunculi (also known as supernumerary spleens,accessory spleens, or splenules) are small nodules of spleen that are separate from the rest of the organ. 

Epidemiology

They are common, seen in up to 16% of CTs of the abdomen and up to 30% of autopsies ². 

Pathology

Accessory spleens are congenital nodules of normal splenic tissue. The spleen forms from multiple smaller components during embryogenesis, and failure of this fusion can lead to one or more nodules remaining separate ². Each component is extraperitoneal. They should not be confused with splenosis (see below) which is acquired and intraperitoneal.

Clinical presentation

They are benign and asymptomatic, so their importance is mainly related to the need to distinguish them from more sinister pathology.

In patients who undergo splenectomy for autoimmune disorders (most commonly idiopathic thrombocytopenic purpura and autoimmune hemolytic anemia), the growth of unrecognized accessory spleens is a classic cause of late relapse. Thus, accessory spleens should be identified preoperatively to ensure their removal.

Radiographic features

Splenunculi are typically a few centimetres in diameter when identified, well-circumscribed rounded or ovoid nodules. Although most are located near the spleen, they have been identified elsewhere in the abdominal cavity including ^2,3:

• gastrosplenic ligament
• splenorenal ligament
• pancreatic tail
• greater omentum
• small bowel mesentery
• stomach or bowel wall
• scrotum

CT

They have density and enhancing characteristics similar to the rest of the spleen. Small (<1 cm) and may appear hypodense compared with the spleen, most likely as an artefact of partial voluming ².

The converse of this is that if a mass is seen at the splenic hilum, which does not enhance in the same fashion as the adjacent spleen, then alternative diagnoses should be entertained.

Nuclear medicine

Tc99m sulfur colloid scan

In rare instances the diagnosis can be confirmed with a Tc99m sulfur colloid scan which will demonstrate increased uptake as long as the splenunculus is at least 2 cm in diameter.

Tc99m heat-denatured red blood cell scan

Splenic tissue (spleen and accessory spleens) will demonstrate intense physiological uptake ⁵.

Differential diagnosis

General imaging differential considerations include:

• peritoneal metastases
• lymph node enlargement
• tail of pancreas tumour or metastases
• renal tumour recurrence post-nephrectomy
• adrenal mass
• pancreatic neuroendocrine tumours ⁵

Other conditions with abnormal location or morphology of splenic tissue include:

• lobulations or clefts: represent incomplete but partial fusion and are very common ²
• polysplenia: rarely multiple splenules are seen without a 'parent' spleen; this is referred to as polysplenia and is seen associated with situs abnormalities.
• splenosis: splenic tissue deposits following abdominal trauma or surgery (e.g. splenectomy), and do not have splenic arterial supply
• wandering spleen: spleen located in an unusual position within the abdominal cavity

Treatment

Accessory spleens generally do not require any form of treatment ⁶. If accessory spleens are involved by haematological cancers or systemic disorders (eg leukaemia, lymphoma, thrombocytopenia), surgical treatment (excision) is requirement ⁷. Surgical treatment is also indicated if there is infarction, torsion or rupturing of the accessory spleen due to vascular pedicle complications ⁸.