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Splenic Histology and Histopathology: An Update

Madeleine D. Kraus, MD

● The spleen can be a troublesome specimen for the surgical pathologist, not only because experience with the range of
“normal” splenic histology is limited by its rarity but also because there is an often a frustrating discordance between the
patient’s clinical condition and the perceived findings. Patients with a dramatic clinical presentation that points to splenic
pathology (“hypersplenism” or marked splenomegaly) not infrequently have no discernable or have barely perceptible
histologic abnormalities of the spleen. Similarly, patients whose spleens contain histologic findings that seem to deviate
significantly from the “norm” (histiocytic proliferations, vasoformative lesions, stromal hyperplasia) may have no clinically
detectable hematologic complaints. For most pathologists, the frame of reference for normal splenic histomorphology
derives largely from experience with autopsy spleens and spleens removed for trauma or immune thrombocytopenia.
These are all settings in which pre-existing disease, the immune status of the patient, and therapy influence the findings
and – in cases in which fixation has been delayed – even the ability to make the findings. This review presents practical
aspects of splenic development and immunoarchitecture and relates this to the pathologist’s approach in evaluating the
abnormal spleen and assists in resolving such discordances. Benign conditions that contrast with the subjects of
subsequent articles in this issue are emphasized.
© 2003 Elsevier Inc. All rights reserved.

INDEX WORDS: Spleen, splenectomy, hypersplenism, red pulp, white pulp, littoral, splenomegaly

M UCH OF WHAT we know about benign and

neoplastic disorders of the spleen derives from
our knowledge of the normal cellular components of
The embryonic spleen appears in the first trimester of
that organ. Primary lymphomas, for instance, arise gestation as a multiply lobated condensation of highly
from or home to the marginal, mantle, or follicular vascular mesenchyme that is interposed in the arterial
compartments of the white pulp, and classification of circulation in the dorsal mesogastrum.1 While the full
these diseases follows criteria founded on B-cell ontog- scope of the genetic underpinnings of organogenesis is
eny. The same can be said of pseudoneoplastic, hamar- incompletely known, Hox11, WT1, and other genes are
tomatous, and vasoformative lesions, which may have essential for the development of the splenic anlage.2,3
as their ontogenic substrate, the histiocytic, stromal, Defects in the expression of these and other homeobox
‘pericytic,’ lymphatic, vascular, and splenic endothelial genes lead to asplenia or polysplenia.1,4 Subsequent
(littoral) cells of the normal spleen. Because the spleen expression of capsulin is required for complete orga-
is uncommon as a diagnostic specimen in all but large nogenesis,5 apparently through control of branching
tertiary medical centers (and because it is seldom given morphogenesis of vessels; in capsulin knockout mice,
more than cursory treatment in textbooks), the general the spleen anlage develops but then disappears through
pathologist is often unfamiliar with the full range of apoptotic mechanisms.5,6
splenic pathology. This article presents practical as- In its mature state, the spleen maintains many of the
pects of splenic development and immunoarchitecture attributes of its vascular and mesenchymal origins.7,8
and relates this to the pathologist’s approach in evalu- Its principle structure is based on an arborizing array of
ating the abnormal spleen. Benign conditions that con- arterioles that bifurcate and narrow until they terminate
trast with the subjects of subsequent articles in this either 1) into the stroma of the cords, forming the open
circulation; or 2) directly into the sinusoids which,
issue are emphasized.
being in continuity with the venous system, form the
closed circulation of the spleen (Fig 1). The cordal
From the Division of Immunopathology, Department of Pathology, elements include histiocytes, antigen presenting reticu-
Weill Medical College of Cornell Medical Center, New York, NY. lum cells, pericytes, fibroblasts, and other cells neces-
Address reprint requests to Madeleine D. Kraus, MD, Division of sary to maintain the discontinuous basal lamina that
Immunopathology – Starr 709, Weill Medical College of Cornell separates the cords from the sinus lumena.9 Lymphatics
Medical Center, 525 East 68th St, New York, NY 10021; e-mail: are inconspicuous, but can be identified in the T-cell
© 2003 Elsevier Inc. All rights reserved. rich zones of the periarteriolar lymphoid sheaths if
0740-2570/03/2002-0002$30.00/0 special techniques are applied.10,11 A Periodic Acid
doi:10.1016/S0740-2570(03)00024-8 Schiff (PAS) stain is particularly helpful in evaluating

84 Seminars in Diagnostic Pathology, VOL 20, NO 2 (MAY), 2003: pp 84-93


the histomorphology of the spleen since the reagents established accounting for the bulk of the remainder.22
both clear the hemoglobin from red blood cells and Unexpected pathology is encountered in these speci-
accentuate the presence of the discontinuous basal lam- mens and is rare (⬃1% of cases), although it can be
ina that separates the cords from the sinuses (Fig 2). clinically significant.22. Significant splenomegaly
The arterial vascular tree, lined by conventional (spleen weight ⬎300 g) or focal lesions are the prosec-
CD31⫹ CD34⫹ endothelial cells, branches into arte- tor’s cue that the specimen requires more than a routine
rioles that terminate abruptly in caps of cordal macro- evaluation. Approximately 10% of the time the spleen
phages that formed blood elements must cross in order is removed with diagnostic intent because radiologic
to enter the sinusoids (Fig 1). The sinusoids, essentially studies disclose either splenomegaly or discrete splenic
the origin of the venous component of the splenic masses and evaluation of peripheral blood, bone mar-
vasculature, are lined by specialized “littoral” cells with row, and lymph nodes fails to disclose the cause. It is
combined phagocytic and endothelial qualities and a these latter cases that can consume a disproportionate
distinctive CD31⫹, CD34-negative, CD68⫹, CD8⫹ amount of the pathologist’s time: care in prosection and
(␣␣type) phenotypic profile (Fig 3).12-14 Similar to con- triaging of tissue is the key to rendering a timely
ventional vasculature, pericytic support cells, with an diagnosis in difficult cases.
SMA⫹, desmin ⫾ phenotype are also present (Fig Hilar fat is often present on the splenectomy speci-
4).15-17) Interdigitating reticulum cells, with their men, and it should be carefully sectioned, with repre-
CD45⫹, s100⫹ phenotype, are distributed throughout sentative tissue from hilar lymph nodes distributed for
the peri-arteriolar sheaths. Fibroblasts within the red all appropriate studies, including flow cytometry. Com-
pulp of the perifollicular zone play a role in lymphocyte pared to lymph nodes, the more abundant stroma of the
homing to specific white pulp compartments through a spleen can interfere with the efficiency of disaggregat-
regulated display of cell adhesion molecules not char- ing viable cells for flow cytometric analysis. Then, too,
acteristic of fibroblasts elsewhere.18 the patterns of morphologic changes associated with
The development lymphoid compartment of the specific reactive conditions are more readily recognized
spleen, the white pulp, begins early in the second tri- in lymph node specimens, which lack the distorting
mester as interdigitating reticulum cells mediate the effects of the stroma, red blood cells, and marginal zone
migration and coalescence of lymphocytes along the compartments of the spleen.
vascular tree. T lymphocytes, principally CD4⫹, form Primary fixation. Few factors contribute more to
a continuous layer along the length of the vessels ease of diagnosis in splenectomy specimens than proper
(“periarteriolar sheaths”), while CD8⫹ T cells home to fixation. Both the lymphoid constituents and the retic-
and reside in the splenic cords (Fig 5).8 A specialized ular structure of the splenic red pulp are delicate, and
subset of ␥/␦T-cell homes to the red pulp cords as well, delayed or incomplete fixation has a more profound
though in adults is generally inconspicuous except in effect on splenic histology than it does other organs.
altered immune states such as graft versus host dis- Ideally, the ratio of formalin to tissue in the jar used for
ease.19 IgD⫹ and IgG⫹ B lymphocytes form localized primary fixation should be ⬃10:1 so that the bloodiness
deposits, the primary follicles. In utero, this B-cell of the specimen does not dilute the efficacy of the
compartment is also rich in CD20⫹, CD5⫹ B cells, formalin. With adequate formalin fixed material, B5
although this diminishes in quantity after birth and fixation can be used selectively or omitted in therapeu-
re-emerges in adults in some systemic conditions asso- tic or incidental splenectomies, but the superior cyto-
ciated with autoimmunity. Secondary follicles arise logic detail that it offers makes it quite helpful in
postnatally, after first exposure to immunologic stimuli diagnostic cases.
and have a distinctive tripartite structure that includes a Ancillary studies. Because most cases of unex-
germinal center, distinct IgD⫹ mantle zone, and a plained splenomegaly are eventually diagnosed as
peripheral IgD-negative, IgM⫹, IgG⫾ marginal zone some form of low-grade lymphoma22 having material
(Fig 6).20,21 available for flow cytometric analysis is invaluable
in the work-up of enlarged spleens. Polymerase chain
Prosection Issues reaction-based studies can be applied to paraffin em-
Clinical intent. Trauma, staging, and surgical con- bedded material, but the quality of DNA is better in
venience together account for over half of all splenec- fresh tissue and a broader array of molecular tests
tomies at large medical centers, with therapeutic sple- can be performed, so an effort should be made to
nectomy in patients whose diagnosis is already snap freeze lesional tissue wherever possible. Fluo-

Fig 1. Formed blood elements must pass from the arte- Fig 4. Smooth muscle actin (SMA)-positive pericytic
rial vascular system into the red pulp of the spleen. In the cells are numerous in the cords of the red pulp, where they
open circulation, arterioles such as the one at the top of the coalesce around cordal venules. Pericytes also form cir-
figure, terminate abruptly in spaces lined by splenic littoral cumferential arrays around white pulp elements, as is ev-
cells. Smooth muscle actin (SMA) highlights the media of the ident in Figure 1. (smooth muscle actin stain, 200X).
large penicillary artery at the top of this image. Note the
germinal center at lower left, which is surrounded by SMAⴙ
pericytes (smooth muscle actin stain, 200X).

Fig 5. While CD4ⴙ T cells are more abundant around

Fig 2. A Periodic Acid Shiff stain is an especially helpful penicillary arterioles, CD8ⴙ T cells home preferentially to the
standard stain for the spleen: red blood cells are lysed, and cords of the red pulp. Shifts in the distribution of these T-cell
the boundary between red pulp and white pulp elements is subsets can be the first cue to an evolving lymphoprolifera-
delimited by the deeply acidophilic and discontinuous tive disorder. (A) CD4 stain, 200X; (B) CD8 stain, 400X.
basal lamina (Periodic Acid Shiff stain, 400X).

Fig 6. IgDⴙ mantle cells form a discrete boundary be-

tween the germinal center and the marginal zone of the
Fig 3. The lining cells of the splenic sinuses, the littoral Malpighian corpuscles. Disturbances of this tripartite
cells, have a distinctive CD8ⴙ phenotype. In contrast to structure may occur in benign as well as neoplastic dis-
true vascular endothelium, they also express CD68 and ease, although a complete loss of one or multiple layers
they are non-reactive for CD34 (CD8 stain, 200X). would favor the latter (IgD stain, 200X).

Table 1. Diseases Manifested in the Spleen Typically via distribute tissue for the full range of ancillary stud-
Mass-forming Lesions ies. Although marginal zone lymphoma was the most
Neoplastic common type of lymphoma to cause unexplained
Large cell lymphoma splenomegaly in one large study,22 other low-grade
Follicular lymphoma (grades II and III) lymphomas that can closely mimic marginal zone
Hodgkin lymphoma lymphoma accounted for over half of the cases in this
Metastatic carcinoma
category.27,28 In addition, rare cases of both large cell
Metastatic sarcoma
Primary vascular and littoral tumors (benign and malignant) lymphoma29 and metastatic carcinoma may involve
Reactive the spleen in a diffuse manner30 and have unexpect-
Cysts and pseudocysts edly aggressive clinical course. Leukemias of lym-
Hamartomas phoid and myeloid types both produce diffuse
splenomegaly25,31,32 but the diagnosis is seldom un-
known at the time of splenectomy.


rescence in situ hybridization probes for most of the HYPERPLASIA
disease-defining translocations are commercially The contents of the cords and sinuses together con-
available and can be applied either to formalin fixed stitute the red pulp of the spleen, whose principle
material or touch preparations made from the fresh function is filtration of serum components of the blood
spleen. Such touch preparations can also be stained and targeted culling of red blood cells that are poorly
with a Wright-Giemsa stain or used for myeloperox- deformable either because of intrinsic factors or be-
idase and naphthyl butyryl esterase stains when full cause of inclusions or parasites. In nonprimate mam-
characterization of a myeloid disorder is necessary.23 mals, the red pulp of the spleen serves as a site for
ongoing hematopoiesis and storage reservoir of red
Macroscopic Findings and Their Histopathologic
blood cells, but these are of vestigial significance in
adult humans.9 Expansion of the red pulp compartment
The gross appearance of splenectomy specimens is or red pulp hyperplasia may occur in any hyper-phago-
closely predictive of final diagnostic categories, with
splenic masses leading to one set of common diag-
noses, and splenomegaly leading to another.22,24 Table 2. Diseases Manifested in the Spleen Typically via
Macroscopic findings therefore are of great practical Splenomegaly
value not only in targeting which areas to sample, but Neoplastic
also in establishing an initial differential diagnosis Low-grade lymphomas, all types (including grade I
from which a rational plan for ancillary studies can follicular lymphoma)
be made. Prolymphocytic leukemia/lymphoma
T lineage lymphomas, all types
Unexplained splenic masses. With few exceptions, Hemophagocytic syndrome
clinically unexplained noncystic splenic masses are Myeloid malignancy (myelodysplasia, myeloproliferative
caused by a malignancy, and, in virtually all cases (Table disorders, mast cell disease)
1), the diagnosis seldom requires sophisticated ancillary Amyloid deposition in the setting of a plasma cell
studies or esoteric markers. In one study of 1280 sequen-
tial splenectomy specimens,22 the single most common Granulomatous splenitis (infectious, sarcoidal)
diagnosis was large cell lymphoma, with metastatic car- Extramedullary hematopoiesis
cinoma following close behind. Hamartomas, histiocytic Congestive splenomegaly (sinusoidal erythrocytosis,
neoplasms, and vascular tumors fall within this category stromal hyperplasia)
Storage disorders
too, and, where frozen section or touch preparation find-
Infection (infectious mononucleosis, mycobacterial,
ings dictate, setting tissue aside for electron microscopy leishmania, malaria)
may be of help in establishing a final diagnosis. Hemoglobinopathies (hereditary spherocytosis,
Unexplained splenomegaly. Diffuse splenomeg- thalassemia)
aly is commonly caused by lymphoma,22,24-26 but Immune mediated hemolytic anemia, thrombocytopenia
Felty’s syndrome
benign conditions are frequent enough in this setting
Nonspecific lymphoid hyperplasia
(Table 2) that it is essential for the prosector to

cytic condition, when the spleen assumes an extramed- recognized guidelines, histological sections are also of
ullary hematopoietic function, or as a result of diffuse limited use in defining patients in transition to acceler-
stromal hyperplasia.33,34 ated phase, nor in distinguishing between myeloprolif-
Minor amounts of erythrophagocytosis are invari- erative disorders and myelodysplastic syndromes (Fig
ably present in the spleen, reflecting the normal culling 9B). Submission of fresh tissue for cytogenetic analysis
of senescent red blood cells, but it may be pronounced is much more helpful in this regard.
in autoimmune conditions, immune-mediated hemo- Chronic obstruction to the vascular outflow of the
lytic anemia, viral infection, and in allo-immunized spleen typically produces mild or moderate amounts of
transfusion recipients (Fig 7A).35-37 Some acute my- splenomegaly through stromal hyperplasia, although it
eloid leukemias and some lymphomas, (particularly may lead to benign massive splenomegaly in some
peripheral T-cell lymphomas38 and those that elaborate cases. The histologic changes of stromal hyperplasia
autoreactive antibodies), are malignancies that may are subtle on H&E stained sections (Fig 10A), and, if
also lead to significant splenic erythrophagocytosis (Fig the clinical condition causing the obstruction is not
7B).39 Free macrophages within the sinusoids contain clear (or is not disclosed) the pathologist may find
red blood cell fragments and, when the process is himself/herself in the frustrating situation of having no
pronounced, the activated littoral cells become cuboidal explanation for a spleen that is up to 1000 g in size.
and stand out on the basement membrane in a ‘hobnail’ Paraffin section immunohistochemistry will disclose
like fashion. In contrast to autoimmune hemolytic ane- the presence of an increase in the number of red pulp
mia, hemoglobinopathies such as hereditary spherocy- histiocytes (CD68) a global increase in the number of
tosis and elliptocytosis lead to sequestration of the stromal myoid cells (SMA)16,17 and extra-cellular ma-
poorly deformable red blood cells in the cords, but trix (reticulin, collagen IV, and laminin stains)44 (Fig
relatively little intra-sinusoidal erythrocytosis or he- 10B). A nodular array of stromal elements is not a
mophagocytosis. There is no histopathologic means of typical congestive change, should prompt consideration
distinguishing secondary and incidental hemophagocy- of benign or borderline mesenchymal neoplasms,12,45,46
tosis from the potentially life-threatening primary or as well as reactive histiocytic or vasoformative pro-
idiopathic hemophagocytic syndromes: the clinical set- cesses such as mycobacterial spindle cell tumors and
ting and laboratory values such as serum ferritin are a bacillary angiomatosis (Fig 11).
better guide.40 In the benign spleen, the cords vary in thickness but
Extramedullary hematopoiesis is commonly encoun- tend to range from 4 to 6 cell widths thick. In benign
tered in the “normal” spleen, usually in the form of rare cordal lymphocytosis, there may be focal expansions
megakaryocytes and occasional clusters of intra-sinu- such that there are dilatations of the sinus-sinus in-
soidal pronormoblasts (Fig 8A).41 However, the pres- terspace to 10 to 12 cell width span, but most cords area
ence of appreciable numbers of myeloid precursors of normal (4-6 cell widths) dimension. Such changes
should prompt investigation for an underlying myelo- are easiest to recognize on a PAS or CD8 stain (Fig 12).
proliferative or myelodysplastic disorder.42,43 These are The lymphocytes are small and cytologically bland, and
most conspicuous immediately adjacent to the trabec- histiocytes, macrophages, and occasional activated
ulae and in the interface between red pulp and peri- lymphocytes are intermingled.
arteriolar sheaths, and they can be rendered more con- Diffuse red pulp lymphocytosis in the form of uni-
spicuous by Leder (chloracetate esterase) and Giemsa form expansions of the cords is an abnormal finding
stains (Fig 8B). Typical splenic findings in myelodys- that should prompt the pathologist to investigate the
plasia include erythroid colonies in the sinusoids, clinical circumstances that led to splenectomy. Uniform
cordal plasmacytosis, and active erythrophagocytosis expansions of the cords without concomitant germinal
by the littoral cells, all changes that correlate to some center hyperplasia in a child may relate to a congenital
degree with the patient’s ineffective hematopoiesis, immunodeficiency state, particularly hyper-IgM syn-
neutropenia, and degree of transfusion-related alloim- drome. In adults, uniform expansion of all cordal plates
munization.23 Touch preparations facilitate recognition is highly suspicious for lymphoma; findings of cyto-
of dyserythropoietic and dysmyelopoietic precursors, logic monotony, atypia, and breakdown of the cord-
and an enumeration of specific elements (such as blasts sinus boundaries are helpful additional clues (Fig
and monocytes) can be made (Fig 9A). CD34 and 13).47,48 Because the principle lymphocyte type in the
CD117 immunostaining may help identify early my- cords of the normal spleen is the CD8⫹ T cell, in-
eloid precursors and blasts, but, since there are no creased numbers of CD20⫹ B cells, CD4⫹ T cells or

Fig 7. (A) Erythrophagocytosis that distends the Fig 9. (A) Touch preparations made of cut sections of
splenic cords and fills the sinuses to this extent is sugges- the fresh spleen provide an excellent look at the morphol-
tive of an auto-immune condition or allo-immunized trans- ogy of all cellular elements, and permits accurate distinc-
fusion recipient, and may also be seen in patients with tion between mononuclear elements – lymphoid, mono-
lymphomas or leukemias (H&E stain, 200X). (B) In this pa- cytic, and blasts (Wright-Giemsa stain, 1000x). (B) While
tient with a primary myelodysplastic syndrome, the pa- the number of CD34ⴙ cells can be evaluated by immuno-
tient’s hemophagocytic syndrome had several possible histochemistry stain, the significance of small clusters of
etiologies: CMV infection, transfusion related allo-immuni- such phenotypic myeloblasts is not clear, and no means of
zation, or as a paraneoplastic (cytokine related) phenom- translating these results into prognosis can be made
enon (H&E stain, 100X). (CD34 stain, 200X).

CD56 or CD57⫹ natural killer suggests some form of spontaneous or trauma-related rupture. In infectious
lymphoma or leukemia.49 Large granular lymphocyte mononucleosis, the cue to the diagnosis is the charac-
leukemia, in particular, may present in cryptic fashion, teristic mixture of polyclonal lymphoplasmacytic and
with rheumatoid arthritis-like symptoms, selective cy- immunoblastic cells within the cords and peri-arteriolar
topenias, and splenomegaly, and spleens from such sheaths; in situ hybridization for Epstein Barr virus
patients may initially be removed for the clinical diag- encoded ribonucleotides (EBERs) and rising IgM anti-
nosis of Felty’s Syndrome.50-53 viral capsid antigen titers should be confirmatory (Fig
Viral infections may also cause a cordal lymphocy-
tosis, and splenectomy may be performed because of

Fig 10. (A) Stromal hyperplasia is a common conse-

quence of congestive splenomegaly, but it can be difficult
to perceive on routine stains. In the cords of normal
Fig 8. (A) Even in normal spleens, there are small ac- spleens, stroma is scant, and elongated cells with a fibro-
cumulations of extramedullary erythropoiesis Exceptional blast like morphology are rare. In this 800gm splenectomy
numbers of erythroid precursors such as the array of the specimen, taken from a patient with established cirrhosis,
numerous intra-sinusoidal pronormoblasts are abnormal, both reticulin fibrosis and increased stromal elements are
and point toward a stress on erythropoiesis, such as an readily apparent (H&E stain, 400X). (B) Smooth muscle ac-
hemoglobinopathy, B12 deficiency, and severe hemolytic tin and reticulin stains are a ready means of documenting
anemia (H&E stain, 100X). (B) When the spleen is signifi- stromal hyperplasia. Compare the large masses of actinⴙ
cantly involved by extramedulary myelopoiesis, the precur- cells in the cords of this case with the delicate reticular
sor cells tend to aggregate near the trabeculae (myeloper- array in the normal spleen illustrated in Figures 1 and 4
oxidase stain, 200X). (Smooth muscle actin stain, 200X).

Fig 11. In the stromal hyperplasia secondary to ob- Fig 14. The lymphoid hyperplasia seen in self limited in-
struction of venous outflow, the stromal hyperplasia forms fectious mononucleosis may cause minor distortions in the
stellate arrays of fusiform cells within intact cords, spleen’s histomorphology and a shift in cellular constituents.
whereas stromal neoplasms, such as the myoid angioen- In sustained EBV-driven lymphoproliferative disorders, the
dothelioma illustrated at right here, form rounded arrays changes are usually dramatic and parallel the near complete
with borders that compress and push aside normal struc- effacement of architecture seen in lymph nodes. A lympho-
tures (CD8 stain, 200X). plasmacytosis is generally present, with variable numbers of
large activated and transformed cells (H&E stain, 400X).

Fig 12. Cordal lymphocytosis may catch the patholo-

gist’s eye on routine sections. When the cords are of uni-
form thickness and less than 6 cell layers thick, a benign
diagnosis is likely (H&E stain, 100X). Fig 15. Grossly evident nodular lymphoid hyperplasia
is rare, but, when it occurs, it produces a pattern of coa-
lescing Malpighian corpusclces. Differential diagnostic
considerations include Hodgkin lymphoma and follicular
lymphoma. (H&E stain, 100X).

Fig 13. (A) Large cordal nodules of cytologically atypical

lymphocytes, or uniform expansions of the cords to >10 cell
layers are more characteristic of leukemias and lymphomas.
An additional helpful cue to the neoplastic nature of the
process is the breakdown of the cord-sinus structure, as is
evident in the upper left hand corner of this case of chronic Fig 16. The marginal zone is markedly expanded by a
lymphocytic leukemia (CD8 stain, 100X). (B) Large accumu- monotony of cells with monocytoid features. The usual
lations of CD4ⴙ T cells within the splenic cords are not tripartite structure is clearly lacking in this example of early
characteristic of reactive conditions and instead raises the splenic involvement by marginal zone lymphoma; an IgD
possibility of a T lineage small lymphoid neoplasm such as stain would accentuate the absence of the mantle zone in
large granular lymphocyte leukemia (CD4 stain, 100X). more subtle cases (H&E stain 100X).

14).54-56 There is a strong correlation between hepatitis mon pattern, and the key feature is a balanced and
C virus infection and cryoglobulinemia,57 and the proportionate expansion of all lymphoid compartments
spleen is almost invariably enlarged as much because of – the follicles, the mantle and marginal zones, and the
the evolving hepatitis and/or cirrhosis is because of PALS. A disproportionate expansion of the mantle or
cordal expansions by lymphocytes and plasma cells. marginal zones, particularly in the presence of cordal
The process is often polyclonal in nature, but Dutcher B-cell lymphocytosis, is highly suspicious for a low-
bodies, breakdown of the cord-sinus boundaries (PAS grade B-cell lymphoma (Fig 16).60 Because most lym-
stain, CD68 stain), amyloid deposition, or cordal lym- phomas composed of small B cells have the capacity to
phocytosis with concomitant expansion of the marginal expand the marginal zone compartment, classification
zone of the follicles all favor lymphoma.39,58 Immuno- should incorporate immunophenotypic as well as cyto-
phenotypic studies are essential to secure the diagnosis. logic and architectural features.64-66 If fresh tissue for
immunophenotypic analysis was not set aside from a
NORMAL WHITE PULP AND WHITE PULP splenectomy specimen that proves to contain a clonal
HYPERPLASIA population of cells by gene rearrangement studies, pe-
A singularly important function of the spleen is im- ripheral blood and bone marrow analysis by flow cy-
munosurveillance, and the spleen plays a central role in tometry may yield the necessary information for com-
removing opsonized pathogens, encapsulated bacteria, plete classification. Selective hyperplasia of the PALS
and antibody-coated erythrocytes and platelets from the without concomitant germinal center formation is ex-
circulation. The periarteriolar lymphoid sheaths ceptional, and instead is more characteristic of periph-
(PALS) and Malpighian corpuscles together constitute eral T-cell lymphomas, particularly if it is associated
the white pulp of the spleen where maturation of the with cordal lymphocytosis.
immune response occurs.11 The PALS are the primary
location for most of the spleen’s CD4⫹ T cells, and the SUMMARY
Malpighian corpuscles, with their characteristic tripar- For the pathologist in training and attending alike,
tite follicular-mantle-marginal zone structure, represent the spleen can be deceptively simple. It is rare as a
periodic expansions of the PALS at branch points along surgical specimen and, when it is encountered, it sel-
the penicilliary arterioles. In addition, the spleen is dom contains an abnormality. However, occasionally
home to a substantial number of cordal plasma cells the spleen’s troublingly complex nature is unmasked
that secrete immunoglobulin as part of the humoral when findings do not correspond to a well-defined
immune response.59 category of disease or the splenic parenchyma obscures
White pulp hyperplasia is usually a diffuse process, diagnostic features. Inevitably, it is these cases in which
but it may occasionally be localized and therefore be there is often great clinical pressure, and the temptation
macroscopically evident as a 1cm (or larger) white may be great to force the findings into an existing
nodule in a background of uniformly punctate Mal- category of node-based or soft tissue-based nosology.
pighian corpuscles. This focal nodular lymphoid hy- The key to timely and accurate diagnosis in such situ-
perplasia60 retains many of the morphologic features ations lays in preparation: obtaining complete clinical
of follicular hyperplasia, but there may be some overlap information about the patient, taking a systematic ap-
with the morphology of lymphoma (Fig 15). Demon- proach to prosection, preparing thin sections from well-
strable polarization of bcl2-negative germinal centers, fixed tissue, and becoming familiar with the stains and
retained IgD⫹ mantle and marginal zones, polytypia by studies that define the intactness of splenic immunoar-
flow cytometry and polyclonality on molecular studies chitecture.
all support a benign interpretation and assist in exclud-
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