Gastric fundus splenosis with hemangioma masquerading as a gastrointestinal stromal tumor in a patient with schistosomiasis and cirrhosis who underwent splenectomy: A case report and literature review

Abstract

Rationale: Splenosis is the heterotopic auto-transplantation of the splenic tissues. Gastric splenosis in a rare location mimics a gastrointestinal stromal tumor (GIST). Gastric splenosis with hemangioma has not been reported throughout the literature.

Patient concerns: We report a case of a 74-year-old schistosomiasis cirrhosis splenectomy woman diagnosed with gastric fundus mass. Preoperative computed tomography and endoscopic ultrasonography revealed findings suggestive of a GIST.

Diagnoses: The mass located in the gastric fundus muscularis propria, measuring 3.9 × 2.8 × 2.4 cm with a dark red color, was removed by surgery. In the mass, a 1 × 1-cm red-purple nodule was also found. On microscopic examination, a well-formed splenic tissue divided into two compartments-white pulp and red pulp-separated by an ill-defined interphase known as the marginal zone. However, a nodule in the heterotopic spleen was mainly composed of larger thin-walled muscular vessels. The final diagnosis was gastric splenosis with hemangioma.

Interventions: After discussion in a multidisciplinary conference, the patient was considered for a GIST resection under gastroscopy. In the process of peeling, the surface of the mucosal, submucosal, muscle layers and the tumor surface were diffusely oozing. The effect of electrocoagulation and hemostasis was extremely poor. Therefore, endoscopic surgery was arrested. After dealing with the patient's family, a combination of laparoscopic-gastroscope double-mirror surgery was decided in accordance with the principle of minimally invasive surgery to preserve the stomach. Owing to several adhesions and concealed the location of tumor, we stopped the double-mirror combination surgery plan. Considering the great possibility of a malignant GIST, we still decided to continue the traditional surgical resection. The tumor was then removed via surgery OUTCOMES:: The patient was favorable with healing and discharged on postoperative day 10.

Lessons: Gastric splenosis with an associated hemangioma is the first well-documented case. Its pathogenesis may be direct implantation. Appropriate medical history taking and Tc-99 m heat-denatured RBC spleen scintigraphy (Tc-99MHDRS) are valuable for its diagnosis; however, pathology is the gold standard. Surgery is a reasonable treatment for gastric splenosis with hemangioma.

Figure 1

(A) CT scan shows pipe stem cirrhosis. (B) CT scan reveals an approximately 4-cm mass in the gastric fundus wall with a homogeneous contrast enhancement, which is typical in GISTs, and a 1-cm low-density solid lesion with a clear outline within the mass (red arrow). (C) Gastroscopy shows a mass in the gastric fundus. (D) Endoscopic ultrasonography reveals a 3.95 × 2.82-cm slightly low echoic mass with a homogeneous appearance in the muscularis propria of the stomach fundus wall and a low echoic area with a clear boundary in the mass (red arrow). (E) The mucosa and submucosa were cut open, and the mass was exposed in the muscularis propria of the stomach fundus wall. The surface of the mass was covered by larger blood vessels. CT = computed tomography, GIST = gastrointestinal stromal tumor.

Figure 2

(A) Micrograph shows the same findings as in the normal splenic tissues and the white and red pulps with well-formed splenic corpuscles in the muscularis propria of the stomach fundus wall (H&E, ×40). (B) Micrograph shows a hemangioma in the heterotopic spleen of the stomach fundus wall (H&E, ×40). Endothelial cells of vascular are strongly positive for CD31 (C), CD34 (D), and Factor VIII (E) (×100). H&E = hematoxylin and eosin, CD = cluster of differentiation.