Splenic metastases from caecal carcinoma: Diagnostic considerations and therapeutic strategy()

INTRODUCTION: The spleen is a highly vascular organ and is in close proximity to many potential primary sites such as the stomach, breast, pancreas and colon. It is however an unusual site for metastatic disease. The reasons for this are not fully understood at the present time. A number of hypotheses have been postulated. Definitive diagnosis and subsequent treatment of metastatic disease to the spleen presents a number of challenges for the surgeon and the wider multi disciplinary team. PRESENTATION OF CASE: A 60 year old male presented with a three week history of lower abdominal pain, distension, nausea and a palpable mass in the right iliac fossa. Imaging revealed a large circumferential caecal mass consistent with malignancy with secondary small bowel obstruction. The patient underwent an emergency right hemicolectomy and was subsequently treated with systemic chemotherapy for lymph node positive caecal adenocarcinoma. Two years following initial presentation, two suspicious lesions were noted within the spleen during routine surveillance imaging with computerised tomography of the thorax, abdomen and pelvis. Of note, one month prior to this the patient had a normal surveillance colonoscopy performed with multiple interval carcinoembryonic antigen (CEA) levels recorded within the normal range. Image guided splenic biopsy and subsequent histology confirmed metastatic caecal adenocarcinoma. DISCUSSION: Splenic metastases from any source including the colon are a rare phenomenon. CONCLUSION: This case questions the value of routine post operative CEA monitoring, underlines the importance of multimodal pathways of surveillance and highlights recent advances in image guided splenic biopsy techniques.