Spleen Endoscopy: A sui generis Diagnosis of Colon Cancer.

Clinical Case

A 55-year-old man was hospitalized with fever of unknown origin associated with nonspecific complaints of anorexia, tremors, myalgia and lower back pain. He had no gastrointestinal or genitourinary symptoms. Physical examination was normal. He had a history of microcytic anemia with 3 months of evolution medicated with oral iron supplementation. He also had arterial hypertension medicated with an antihypertensive, and radical prostatectomy had been performed 7 months earlier for cancer. No known epidemiological context was observed and the patient had a good socioeconomic status.

The initial analytical profile revealed anemia with a hemoglobin level of 8.7 g/dL and elevation of inflammatory parameters (white cell count of 18.6 × 109/L and C-reactive protein of 20.0 mg/dL). Blood and urine cultures, infectious disease serology, serum protein electrophoresis and prostate-specific antigen were negative. Abdominal ultrasound performed in the urgency setting was normal. Given the persistence of complaints and the inconclusive laboratory study, an abdominal computed tomography (CT) scan was performed. In the spleen, there was a hypodense, 6.3-cm lesion with a central liquid component and peripheral contrast enhancement suggesting an abscess. This lesion was continuous with the colon splenic angle whose wall was thickened suggesting an expansive neoplasm (Fig. 1). It also revealed multiple infracentimetric pulmonary nodules that could be related to metastases.

Fig. 1

Contrast-enhanced abdominal CT showing a splenic abscess (red arrow) in continuity with a neoplasm of the splenic flexure of the colon (blue arrow). Colors refer to the online version only.

Colonoscopy was performed and at the splenic flexure, it revealed an exophytic, irregular and stenotic lesion followed by a dark-colored cavity corresponding to the interior of a splenic abscess allowing the direct visualization of the spleen (Fig. 2, 3). The biopsies taken on the colonic border of the lesion corresponded to an adenocarcinoma. The multidisciplinary team (encompassing oncologists and surgeons) opted for surgery; thus, the patient was admitted for left hemicolectomy with splenectomy.

Fig. 2

Communication between the colon and the spleen.

Fig. 3

Interior of the splenic abscess seen from colonoscopy.

The histopathological analysis of the surgical specimen revealed a low-grade adenocarcinoma of the splenic flexure of the colon (G2), with infiltration of all the wall layers and in continuity with the spleen (pTMN T4b N1b). Patient recovery was ordinary and he started adjuvant chemotherapy.

Discussion

The various presentations of colon carcinoma are well known, but splenic abscess is a rare presentation, with only a few case reports in the literature [1,2]. Splenic abscess can occur due to trauma, hematogenous spread or direct invasion. Diagnosis is often delayed since the clinical manifestations are nonspecific and include fever, abdominal pain, and leukocytosis [3]. Although CT scan of the abdomen is the most common tool for the diagnosis of splenic abscess, in our case the endoscopic examination was imperative for the histological diagnosis of splenic flexure neoplasm. It also allowed the exceptional visualization of the spleen pulp. Treatment of pTMN T4 colon cancer involves en bloc resection of the tumor and the involved tissue or organ. The overall survival is similar to that of tumors not requiring resection of additional organs, if complete resection is accomplished [4]. Additional adjuvant chemotherapy might be indicated depending on the nodal status [5].

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The authors declare that no experiments were performed on humans or animals for this study.

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