PMC9713805_01
(A) Spleen mass found on the day of routine physical examination. Ultrasound examination revealed a mass in the spleen. The mass measured 4.5x7.5 cm. The mass displayed with hyperecho, clear boundary and irregular shape. CDFI indicated blood flow signals. Red arrow denotes the mass. (B) Ultrasound examination at 74 days after the spleen mass was found indicated a mass in the spleen. The mass measured 10.4x8.5 cm. The mass displayed with hyperecho, clear boundary and irregular shape. CDFI indicated blood flow signals. Red arrow denotes the mass. (C) Contrast-enhanced computed tomography at 74 days after the spleen mass was found revealed enlargement of the spleen, a low-density mass shadow was observed in the spleen parenchyma, and the mass measured 10x7.5 cm; the boundary of the mass was clear and multiple small patchy low-density areas were visible in the mass. Enhanced scanning indicated that most areas of the mass had gradual moderate enhancement and multiple patchy non-enhanced areas. Red arrow denotes the mass. (D) Computed tomography at 53 days after the splenectomy indicated that there were numerous masses of different sizes in the spleen operation area, the gap between the intestines and around the incision of the anterior abdominal wall, of which the largest mass measured 4.4x3.2 cm. The boundary between the mass and the small intestine was not clear. There was no peritoneal effusion. Red arrow denotes the mass. (E) Computed tomography at 114 days after the splenectomy indicated that numerous masses were located in the splenic surgical area, abdominal cavity, pelvic cavity, bowel space and around the incision of the anterior abdominal wall. The maximum measures of the mass were 10.6x10.2 cm and the boundary was not clear. Certain masses fused and their interior had low-density tissue necrosis areas. There was no clear boundary between the masses and bilateral rectus abdominis, peritoneum and bowel, and the surgical area had strip-shaped high-density images. Red arrow denotes the mass. (F) Computed tomography at 135 days after the splenectomy indicated that numerous masses were located in the splenic surgery area, abdominal cavity, pelvic cavity, bowel space and around the incision of the anterior abdominal wall. The maximum mass measured 13.6x11.6 cm and the boundary was not clear. Certain masses fused and the interior had a low-density tissue necrosis area. The boundary between the mass and rectus abdominis, peritoneum and bowel was not clear and the adjacent tissues were compressed and deformed by the mass. Red arrow denotes the mass. CDFI, colour Doppler flow imaging.
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Ultrasound and computed tomography images of the patient are provided in Fig. 1. At the first presentation, ultrasound examination with a Mindray M9 (Shenzhen Mindray Biomedical Electronics Co., Ltd; two-dimensional; Colo Flow; model of ultrasonic probe, C5-1S, 8 Hz) indicated that the dimensions of the tumor were 4.5x7.5 cm (Fig. 1A) and the patient did not undergo any immediate surgical treatment, as there was no discomfort. Ultrasound indicated a tumor mass in the spleen, which had grown, with a measured size of 10.4x8.5 cm (Fig. 1B). The measured dimensions of the mass were 10x7.5 cm (Fig. 1C). The patient's abdominal computed tomography indicated that more nodules and lumpy soft tissue density shadows were present in the spleen area, intestinal space and anterior abdominal wall incision area, and the measured dimensions of the larger mass were 4.4x2.3 cm (Fig. 1D) 53 days after the splenectomy. The computed tomography scan of the patient's abdomen suggested that the volume of the abdominal mass had increased, and the measured dimensions were 10.6x10.2 cm (Fig. 1E) 114 days after the splenectomy. The computed tomography scan of the patient's abdomen indicated that the size of abdominal mass had yet increased to 13.6x11.6 cm (Fig. 1F) 135 days after the splenectomy.
Histology images. (A) Tumor cells. A large number of tumor cells were spindle-shaped. Red arrow denotes tumor cells. (B) Perisplenic lymph node. Red arrow denotes lymphoid nodule. (C) Tumor cells. The spindle-shaped tumor cells are arranged in bundles with a large number of lymphocytes and plasma cells in the background. Red arrow denotes tumor cells (scale bars, 200 microm). (D) Boundary of the tumor. The tumor boundary is clear. Red arrow denotes boundary (scale bar, 500 microm). (E) The tumor cells had a spindle-like morphology, focal coagulative necrosis was present and tumor cells invaded the fat and vascular tissue on the concave surface of the spleen. Red arrow denotes tumor cells (scale bar, 100 microm). (F) Tumor cells. Red arrow denotes spindle-shaped tumor cell (scale bar, 50 microm).
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The pathological examination of frozen splenic masses during the operation indicated sarcoma (Fig. 2A). The pathological examination results of perisplenic lymph nodes were normal and no sarcoma cells were found (Fig. 2B). Microscopic observation indicated that the spindle-shaped tumor cells were arranged in bundles with a large number of lymphocytes and plasma cells in the background (Fig. 2C). The tumor boundary was clear (Fig. 2D). The tumor cells were spindle cells, focal coagulative necrosis was present and tumor cells invaded the fat and vascular tissue on the concave surface of the spleen (Fig. 2E and F).
Representative immunohistochemical staining images. (A) CD 21 (+) (magnification, x100; scale bar, 200 microm); (B) CD23 (+); (C) CD35 (+) (magnification, x200; scale bar, 100 microm); red arrow denotes tumor cells with positive staining. Positive expression of markers is indicated by pale brown staining. (D) CD34 (-), the vascular endothelium was brown (white arrow); (E) Desmin (-); (F) S100 (-) (magnification, x100; scale bar, 200 microm); (G) ALK1 (-) (magnification, x400; scale bar, 50 microm). In D-G, red arrow denotes tumor cells without special color and non-specific staining (white arrow) was brown.
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The inspection results indicated the following: CD21 (+) (Fig. 3A), CD23 (+) (Fig. 3B), CD35 (+) (Fig. 3C), CD34 (-) (Fig. 3D), Desmin (-) (Fig. 3E), S-100 (-) (Fig. 3F), ALK1 (-) (Fig. 3G), Vimentin (-), CD68 (-), CD16.3 (-), CD31 (-), CD4 (-), CD13 (-), CD10 (-), Lysozyme (-), CD1a (-), Langerin (-), CD15 (-), Myeloperoxidase (-), CD117 (-), CK7 (-), SMA (-), Myogenin (-), MyoD1 (-), MDM2 (-), CDK4 (-), CD30 (-), SOX-10 (-), Melan-A (-), STAT6 (-), DOG1 (-), Ki-67 (+, 5-10%) and EBV-encoded RNA (-).