Huge splenic cyst with high level of CA 19-9: the rule or the exception?

for investigation of a large abdominal cystic lesion. The patient was 4 months postpartum and suffered from long-standing abdominal pain and discomfort that started 2 years prior to the current hospital admission. She complained of early satiety and had lost 10 kg in the previous year. Prenatal follow-up had not revealed any pathological findings and the delivery was normal. However, abdominal pain increased after the delivery. The patient's medical history was unremarkable for any abdominal trauma or close animal contact, B symptoms (intermittent fever, drenching night sweats) or recent infections. On physical examination, a huge abdominal mass occupying her left abdomen was palpated. The mass was smooth and non-tender. The liver was not enlarged and lymphadenopathy was not detected. Routine laboratory tests were within normal limits, as were serological tests for parasitic infection by Echinococcus granulosus. Tumor marker levels were CA 19-9 1300 u/ml (normal levels < 40 u/ml) and carcinoembryonic antigen 20 ng/ml (normal levels < 2.5 ng/ml). Ultrasound of the abdomen revealed a huge cystic lesion in the left upper abdominal quadrant. Within the cyst an echogenic non-vascular mass measuring 3.8 cm in diameter was observed. This mass was free of any attachments and was moving freely within the cystic fluid with gravitation. A computed tomog-raphy scan of the abdomen showed the same findings. There were no clear margins between the lesion and the spleen or the tail of the pancreas, and no vascular involvement was noted. Aspirated fluid from the cyst showed amylase levels similar to those in the serum, and the cytology analysis did not reveal malignant cells. Unfortunately, the cyst fluid was not examined for marker level. At laparotomy a huge cyst was found emerging from the upper pole of the spleen. The cyst was extensively adherent to the left diaphragm [Figure]. These findings resulted in total splenectomy, which was followed by an uneventful postoperative recovery. During the 4 weeks after the operation , CA 19-9 dropped to 60 u/ml and CEA to normal. Pathological examination revealed a benign epithelial splenic cyst. The oval mass that was present within the empty cyst was a thick tissue composed of dense fibrin deposits. cOmment We describe a large splenic cyst in a young woman. The clinical and pathological findings suggested a non-parasitic true cyst of the spleen. Splenic cysts can be either true cysts or pseudocysts depending on the presence or absence of an epi-thelial lining, respectively. …