Presentation
Abdominal pain, fever, elevated WBC and weight loss. No change in bowel habits.
Patient Data
The spleen is normal in size with a few different sizes of hypoechoic lesions.
Echogenic linear band with shadowing artifact at its lower pole suggestive of intra-parenchymal gas.
Perisplenic free fluid is noted.
Thick-walled splenic flexure with a posterior fluid collection.
Appearances are suspicious for splenic abscess.
The spleen is normal in size with a few different sizes of hypodense lesions.
Constant wall thickening is seen involving a medium length segment of splenic flexure with evidence of invasion of the adjacent lower pole of spleen anteriorly and loss of normal intervening fat between them, associated with multiple pockets of fluid within the involved area of spleen suggestive of abscess formation.
There is associated peri-colonic necrotic lymph node measures about 10x9 mm, facial plan thickening, dirty mesenteric fat, reactive lymph nodes, and free fluid.
Two well-formed peripherally enhancing wall pockets of fluid with small internal gas seen behind the splenic flexure, the largest measures about 3.7x2.2 cm suggestive of peri-colonic abscess formation. Minimal dilatation of the proximal colon.
The liver enhances homogeneously with a small cyst seen in the segment IV-A.
The pancreas and adrenal glands appear unremarkable. No significant para-aortic lymph node enlargement.
Mild bilateral pleural effusions more on the left side.
Conclusion:
Features are representing inflammatory process associated with complicated splenic flexure pathology, most likely perforated/rupture splenic flexure tumor which invading the spleen with secondary splenic and peri-colonic abscesses.
The image is illustrating the same area of the intra-splenic gas on ultrasound and corresponding CT.
Lt hemicolectomy & splenectomy
Left hemicolectomy and splenectomy in one block.
Note the invading tumor to the spleen.
Histopathology report
Microscopic Description:
- Specimen: Left colon and spleen.
- Procedure: Left hemicolectomy and splenectomy.
- Specimen Length: 36 cm.
- Tumor Site: Splenic flexure.
- Tumor Configuration: Exophytic /ulcerated.
- Tumor Size: 4x4x1 cm.
- Macroscopic tumor perforation: Not identified.
- Histologic type: Adenocarcinoma.
- Histologic grade: Moderately differentiated.
- Intra-tumoral lymphocytic response (tumor infiltrating lymphocytes): Mild
- Peritumoral lymphocytic response (Crohn-like response): Mild
- Tumor subtype and differentiation: And sternal-type (conventional).
- Microscopic tumor Extension: Direct invasion of other organ (spleen).
- Margins: Not involved.
- Treatment Effect: No prior treatment.
- Lymph—vascular Invasion: Present.
- Perineural Invasion: Present
- Tumor Deposits: Not identified.
Additional pathologic findings:
- Splenic hilum lymph node is involved by tumor (direct invasion).
- Splenic abscess.
- Foreign body type multinucleated giant cell cells and food particles.
- Ancillary Studies: Not performed.
- Regional lymph Nodes: 2/25 lymph nodes are involved by tumor.
- Tumor Border Configuration: Infiltrative.
- Distant Metastasis: Unknown, clinical classification.
- AJCC Classification: pT4bN1b, stage III C.
Final diagnosis:
LEFT COLON AND SPLEEN
- Moderately differentiated colonic adenocarcinoma with direct splenic invasion.
- Two lymph nodes out of twenty five are involved by tumor.
- Margins are not involved.
- Splenic abscess.
- AJCC (8th edition) pT4bN1b , stage III c.
Case Discussion
The patient undergoes left hemicolectomy and splenectomy in one block confirming the radiologic findings.
Abscess formation is a rare complication of colon cancer resulting from perforation or invasion to the adjacent organ such as the spleen. Splenic abscesses are uncommon and are an unusual presentation of colon cancer. Causes include immune deficiency, infection, infarction, and trauma. The presentation is non-specific.