Case 1
A contrast-enhanced computed tomography (CT) scan (Fig. 2a, b) showed innumerable splenic tumors, which were homogeneous, but poorly demarcated. The maximum diameter of the largest tumor was 3 cm. The tumors were not enhanced. The attending physician decided to perform a follow-up CT scan 6 months later.
The patient was referred to our surgical department to undergo a more detailed consultation at that time. A laboratory workup demonstrated a normal complete blood count, an elevated lactate dehydrogenase level (404 IU/L), and a slightly elevated cancer antigen 19-9 (CA19-9) level (58.1 U/mL), but a normal carcinoembryonic antigen (CEA) level (2.3 ng/mL). A follow-up contrast-enhanced CT scan showed slight enlargement of the tumors (maximum diameter: 3.5 cm) without any findings that were indicative of diseases affecting other organs, such as solid cancer (Fig. 2c, d). No specific findings were noted during upper or lower endoscopy. We could not rule out a malignant tumor because of the following: 1. The tumors exhibited poor demarcation. 2. The tumors were slightly enlarged. 3. The patient’s CA19-9 level was slightly elevated. Although Heller’s strategy recommends positron emission tomography/CT or a biopsy as a next step, since the tumors were innumerable and small, we performed laparoscopic splenectomy as a “diagnostic treatment” (Fig. 3).