Are splenic cysts problematic?

Splenic Cysts: Clinical Significance and Management

Splenic cysts are generally benign and asymptomatic, with a prevalence of approximately 7% in the general population, similar to the rate in people with autosomal dominant polycystic kidney disease. 1

Types of Splenic Cysts

• Splenic cysts are classified as primary (true) or secondary (pseudocysts) based on the presence of an epithelial lining 2, 3
• Primary cysts include:
  • Congenital (epidermoid, dermoid, or endodermoid) 4
  • Parasitic (hydatid cysts) 2, 3
• Secondary cysts are typically post-traumatic or post-infarction 2, 3

Clinical Presentation

• Most splenic cysts are asymptomatic and discovered incidentally on imaging 5, 2
• Symptoms, when present, typically correlate with cyst size and may include:
  • Left upper quadrant abdominal pain 2
  • Sensation of fullness 4
• Clinical splenomegaly may be present in up to 30% of cases but is not a reliable sign of underlying splenic pathology 6

Diagnosis

• Ultrasound, CT with contrast, and MRI are all effective for diagnosing splenic cysts 6
• On imaging, splenic cysts typically appear as well-defined, non-enhancing fluid collections 6
• Cysts should be differentiated from other splenic lesions such as:
  • Splenic infarcts (typically wedge-shaped, peripheral) 6
  • Abscesses (contrast-enhancing with possible septations) 6
  • Pseudocysts of the pancreas 2

Management Approach

• Observation is appropriate for asymptomatic splenic cysts regardless of size 5
  • Data shows a negative overall growth rate for asymptomatic cysts under observation 5
• Intervention is indicated for:
  • Symptomatic cysts causing pain or discomfort 2, 4
  • Cysts with complications (rupture, hemorrhage, infection) 7
  • Cysts where malignancy cannot be excluded 2

Treatment Options

• Spleen-preserving approaches are preferred when intervention is necessary 2, 3:
  • Laparoscopic partial decapsulation/fenestration for accessible cysts 4
  • Marsupialization or partial cystectomy for appropriate candidates 3
• Splenectomy may be required for:
  • Cysts deep within splenic parenchyma 2
  • Hydatid cysts 2
  • Complicated cysts with hemorrhage or infection 7
  • Cases where malignancy is suspected 2

Follow-up and Monitoring

• Asymptomatic cysts can be safely monitored with periodic imaging 5
• Percutaneous drainage has a high recurrence rate and should be reserved for:
  • Patients who are not surgical candidates 5
  • Cases of diagnostic uncertainty 5

Complications

• Rare complications of splenic cysts include:
  • Rupture with hemorrhage 7
  • Infection 7
  • Very rarely, malignant transformation 7

Special Considerations

• In the context of autosomal dominant polycystic kidney disease (ADPKD), splenic cysts are considered an extrarenal manifestation with similar prevalence (approximately 7%) to the general population 1
• When splenic cysts are found incidentally on imaging, they can be classified as ONCO-RADS category 2 (benign finding highly likely) 1

In summary, most splenic cysts are benign, asymptomatic findings that can be safely observed without intervention. Treatment should be reserved for symptomatic cysts or those with complications.