Unmasking the malignancy beneath - re-evaluating splenic pseudocysts as potential precursors of lymphoma

Sep 29, 2026

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Letter to the editor discusses management of splenic cysts traditionally treated conservatively, such as cyst deroofing, because most are considered benign. A reported exception describes fibrin-associated large B-cell lymphoma (FA-LBCL) hidden within an apparently simple splenic pseudocyst, challenging routine practice. The text reviews rarity, diagnostic pitfalls of imaging, and limitations of standard histopathology without immunohistochemistry. It emphasizes risk stratification, thorough tissue analysis, and reconsideration of suspicion protocols for atypical lesions.

LanguageEnglish

CategoryHealthcare

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Letter to the Editor

Conservative management and the reported exception

Rarity and clinical presentation of splenic cysts

Diagnostic challenges and the role of immunohistochemistry

EBV–fibrin interaction and immune evasion

Need for risk stratification and updated suspicion protocols

Letter to the Editor Unmasking the malignancy beneath: re-evaluating splenic pseudocysts as potential precursors of lymphoma Asra Amjad, MBBSa , Armeen Shahzad, MBBSb , Ruben Simon Roy, MBBSc , Raghabendra Kumar Mahato, MBBSd ,*, Umair Ali, Pharm De Dear Editor, Management of splenic cysts has traditionally favored conservative, spleen-preserving methods like cyst deroofing, based on the belief that these cysts are usually benign. However, a recent case by Justo et al revealed a rare but important exception: a fibrin-associated large B-cell lymphoma (FA-LBCL) hidden within a seemingly simple pseudocyst treated with deroofing [1] . This finding challenges conventional practice, urging clinicians to look beyond appearances, consider hidden malignancy, and carefully evaluate before deciding on management, even when the situation seems straightforward. Splenic cysts are so uncommon that they account for less than 1% of all splenectomies. Pseudocyst form only a small fraction of these, and many develop post-traumatic [2] . Most remain asymptomatic and are incidentally discovered. Only large or symptomatic cysts usually push clinicians toward surgery, whether that involves removing the slim or trying to preserve it. The fact that only a handful of cases have been reported worldwide highlights how challenging these cysts are to evaluate. Although cancer developing in a splenic cyst is exceptionally rare, the rarity of the cysts themselves makes any malignant change all the more meaningful and clinical practice. FA-LBCL is a rare Epstein-Barr virus (EBV)-related lymphoma that arises in fibrin-rich areas like large splenic pseudocysts. Often discovered incidentally after procedures like cyst aDepartment of Medicine, Islamic International Medical College, Riphah International University, Rawalpindi, Pakistan, bDepartment of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan, cDepartment of Medicine, Jawaharlal Nehru Medical College, Belgaum, India, dDepartment of Medicine, Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal and eDepartment of pharmacy,University of Swabi, Swabi, Pakistan Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. *Corresponding author. Address: Department of Medicine, Gandaki Medical College Teaching Hospital and Research Center Pokhara 33700, Nepal. Tel.: +977-9745829807. E-mail: [102raghabendrakumarmahato@gmail.com](102raghabendrakumarmahato@gmail.com)[ ](102raghabendrakumarmahato@gmail.com)(R. K. Mahato). Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Annals of Medicine & Surgery (2026) 88:1132–1133 Received 22 November 2025; Accepted 25 November 2025 Published online 12 December 2025 [http://dx.doi.org/10.1097/MS9.0000000000004541](http://dx.doi.org/10.1097/MS9.0000000000004541) deroofing, it poses a diagnostic challenge due to its subtle presence – scattered malignant cells within necrotic cystic tissue. Traditional imaging and tumor markers usually fail to detect it, and routine histopathology may miss it without specialized immunohistochemistry. This highlights the need for careful suspicion and thorough tissue analysis in such cases[3] . FA-LBCL develops in fibrin-rich spaces, providing a sanctuary niche in which EBV escapes immunodetection. EBV infects B cells and establishes lifelong latent infection with periodic reactivation while modulating the immune response to prevent its elimination. This immunosuppressive environment within the fibrinous pseudocysts permits persistence of EBV-infected cells wi

FAQs

Why is conservative, spleen-preserving management often chosen for splenic cysts?

Because splenic cysts are generally believed to be benign, so methods like cyst deroofing are often favored to preserve the spleen.

What case challenges this conventional approach?

A report of fibrin-associated large B-cell lymphoma (FA-LBCL) hidden within a seemingly simple splenic pseudocyst treated with deroofing.

Why can FA-LBCL be difficult to diagnose before treatment?

Traditional imaging and tumor markers may fail, and routine histopathology can miss it without specialized immunohistochemistry due to subtle scattered malignant cells in necrotic tissue.

Sep 29, 2026

Uploaded by dhado