Splenic cysts can be classified as primary or secondary. Primary splenic cysts are divided into congenital (characterized by a mesothelial, transitional and/or stratified squamous cystic lining with trabeculated white-colored gross appearance) and neoplastic (characterized by endothelial cystic lining with blood content). The neoplastic category also includes dermoid cysts, which present ectopic, mature ectodermal tissues. On the other hand, secondary splenic cysts can be traumatic or necrotic based on positive trauma or infectious history (characterized by hemorrhagic gross appearance with a normal splenic architecture) [2, 5]. In our case, a mesothelial cystic lining confirmed at histopathological analysis was associated with blood content in a patient with a mute past illness history.
Furthermore, high levels of CA 19.9 or carcinoembryonic antigen (CEA) have been widely reported in the current literature. However, values of CA125 above the average levels are less common and not typically reported as an isolated finding [6, 7]. Interestingly, ours is an isolated case presenting with a mixed (mesothelial cystic lining with blood content) non-parasitic splenic cyst and high levels of CA125.
To date, no consensus exists about the best management. Non-operative treatment is the first choice in asymptomatic cysts and/or less than 5 cm in diameter [4, 8]. In the past, the treatment for huge splenic cysts was total splenectomy. With the discovery of the importance of the splenic immune system, spleen-preserving surgery is now preferred. Moreover, despite a longer operating time and increased technical difficulty, a laparoscopic approach is usually suggested due to a shorter hospitalization and less post-operative pain [4, 9]. Considering the size and position of the cyst, we opted for a laparoscopic approach with unroofing and partial cystectomy in order to preserve as much splenic parenchyma as possible. Arguably, while use of this technique may result in a higher rate of recurrence, this could be avoided with an extended resection of the cyst and by covering the parenchyma defect with the omentum [9, 10].
In conclusion, although CA 19.9 and CEA are considered the main markers for non-parasitic splenic cyst, it is our opinion that CA125 could be included in the diagnostic panel for this kind of disease, especially in the event of negativity of the other markers. Moreover, while the treatment of non-parasitic splenic cyst remains controversial, laparoscopic unroofing with partial cystectomy appears to be a valid and safe option to preserve the maximum amount of splenic parenchyma in complex cysts. Further studies are needed to confirm our findings.