CASE REPORT Annals of Nuclear Medicine Vol, 13, No. 5, 347-349, 1999 A case of diaphragm hernia containing accessory spleen and great omentum detected by Tc-99m phytate scintigraphy Hitoya OHTA,* Keijiro KOHNO,** Noriyuki KOJIMA,*** Noboru IHARA,*** Takashi ISHIGAKI,*** Giro TODO*** and Tomoo KOMIBUCHI* Departments of *Laboratories, **Surgery of Respiratory Diseases,*** Radiology, Osaka Red Cross Hospital A rare case of diaphragm hernia containing an accessory spleen and great omentum is reported. Tc-99m phytate SPECT showed tracer accumulation in the accessory spleen and was useful in the evaluation of the disease. Key words: Tc-99m phytate, SPECT, accessory spleen, diaphragm hernia INTRODUCTION SCINTIGRAPHY is one of the most useful examinations in the evaluation of accessory spleen.1-3 We present a rare case of diaphragm hernia containing an accessory spleen and great omentum in which Tc-99m phytate SPECT was very useful in the evaluation of the disease. CASE REPORT A 77-year-old woman consulted her family physician because of a cold. Chest roentogenogram showed an abnormal shadow in the left costophrenic angle (Fig. 1). She has no history of trauma. She was referred to our hospital for further evaluation. Blood analysis and blood chemistry findings were not remarkable. Chest CT revealed a fat density mass containing a soft-tissue dense nodule abutting on the left chest wall (Fig. 2A). The intrathoracic fat density mass seemed to be connected with intraabdominal fat tissue (Fig. 2B, C). The spleen was also recognized (Fig. 2C), and the soft-tissue dense nodule was apart from the left lobe of the liver. These findings suggested diaphragm hernia containing omentum and a soft-tissue dense nodule. Scintigraphy was performed 15 minutes after 185 MBq Tc-99m phytate injection to evaluate the soft-tissue nodule. SPECT was performed in 60 steps, through 360deg., 25 Received April 26, 1999, revision accepted June 18, 1999. For reprint contact: Hitoya Ohta, M.D., Department of Laboratories, Osaka Red Cross Hospital, Osaka 543-8555, JAPAN. seconds per step with a 128 x 128 matrix (TOSHIBA GCA-7200A). The prefilter was Butterworth (order 8, cut off 0.13) and the filter was Ramp. To produce a 3-D image, the upper threshold was 100% and the lower threshold was 35%. Transaxial and coronal images showed tracer accumulation concordant with a left costophrenic angle mass (Fig. 3A, B). The spleen was also normally visualized (Fig. 3A, C). A 3-D display also showed the accessory spleen more clearly (Fig. 4 LAO view). These findings showed that the soft-tissue nodule was an accessory spleen. The patient underwent no further invasive procedures. DISCUSSION This report describes Tc-99m phytate imaging in a rare case of diaphragm hernia containing an accessory spleen and great omentum, and is presented for two reasons. First, diaphragm hernia containing an accessory spleen and great omentum is rare. Second, Tc-99m phytate scintigraphy was diagnostic. To our knowledge, there is only one description of diaphragm hernia containing the accessory spleen. Tomioka and Nakajima have reported a case of Bochdalek hernia combined intrathoracic accessory spleen in a 65-year-old man. They have reported the usefulness of coronal and sagittal MR images. They also recommended splenic scintigraphy, but unfortunately it was not able to be performed.4 Wadham et al. have also reported the incidence and location of accessory spleen. According to the report, in 250 consecutive autopsies, accessory spleens were found in 47 cases (19%), and found in the hilum of the main spleen (41 %), the tail of the pancreas (11 %), lienorenal ligament (23 %), gastrosplenic ligament (13 %), the great omentum (7%), and in the connective tissue under the left diaphragm (4%).5 In the present case. CT suggested diaphragm hernia containing great omentum and a soft-tissue dense nodule. Tc-99m phytate scintigraphy showed that the nodule was an accessory spleen and prevented invasive procedures. ACKNOWLEDGMENTS The authors thank Mrs. Chie Ohta, Mr. Norimasa Takayanagi and Mr. Junsuke Uejima for their valuable assistance. REFERENCES 1. Gruze BH, Hawkins R. The utility of SPECT liver-spleen imaging in the evaluation of a possible accessory spleen. Clin Nucl Med 13: 496-497, 1988. 2. Koyanagi N. Kanematu T, Sugimati K. Preoperative computed tomography and scintigraphy to facilitate the detection of accessory spleen in patients with hematologic disorders. Jpn J Surg 18: 101-l04, 1988. 3. Kawase T, Fujii H, Hasegawa I, Kubo A. Enlarged accessory spleen after splenectomy in two cases with malignant lymphoma diagnosed by 99mTc hepatosplenic scintigraphy. Jpn J Clin Radiol 43: 395-398, 1998. 4. Tomioka H. Nakajima H. A case of Bochdalek hernia combined with intrathoracic accessory spleen in an adult. Jpn J Med Imaging 12: 408-413, 1993. 5. Wadham BM, Adams PB, Johnson MA. Incidence and location of accessory spleens. N Engl J Med 304: 1111, 1981.