Images in Clinical Urology Hepatic Splenosis Diagnosed After Inappropriate Metastatic Evaluation in Patient With Low-risk Prostate Cancer Hanhan Li, Devon Snow-Lisy, and Eric A. Klein A man interested in active surveillance of low-risk prostate cancer sought a second opinion after having undergone an inappropriate metastatic evaluation that demonstrated multiple enhancing liver masses. Because of his history of splenectomy for trauma, hepatic splenosis was suspected. Despite reassurance, the patient desired biopsy of the masses to confirm splenosis. The imaging features and pathophysiology of hepatic splenosis are presented. Owing to the low rates of metastatic disease, the current guidelines do not recommend diagnostic imaging for low-risk prostate cancer. The present case illustrates the dangers of the current widespread practice of inappropriate diagnostic imaging of patients with low-risk prostate cancer. UROLOGY 79: e73– e74, 2012. © 2012 Elsevier Inc. A 61-year-old man with Stage cT1c prostate cancer meeting the Epstein criteria and history of trau- matic splenectomy presented for a second opin- ion. 1 The evaluation before presentation consisted of bone scan and computed tomography, which demonstrated mul- tiple hepatic nodules (Fig. 1). Magnetic resonance imaging revealed peritoneal and liver nodules consistent with the suspicion of splenosis (Fig. 2). Owing to patient concern, the findings were confirmed by needle biopsy. At the last follow-up, the patient was receiving active surveillance. Splenosis occurs when the splenic tissue is autotrans- planted to the peritoneum, thoracic cavity, liver, or subcu- taneous tissue after splenic rupture and is often mistaken for malignancy. 2 Diagnosis can be confirmed with biopsy or technetium-99m heat-damaged red blood cells. 3 Imaging of low-risk prostate cancer (ie, prostate-spe- cific antigen 10 ng/mL, Stage cT1c or cT2a, and Glea- son score 6) is not recommended because of the very low rates of metastasis. 4-6 However, although the guide- lines are clear, inappropriate imaging is widespread, with 48% of low-risk patients undergoing metastatic evalu- ation. 7,8 This case illustrates the many disadvantages of inappropriate imaging. These include the risks and costs associated with increased patient concern, increased ra- diation and contrast exposure from initial and confirma- tory imaging, and confirmatory biopsy. References 1. Epstein JI, Walsh PC, Carmichael M, et al. Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA. 1994;271:368-374. From the Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio; and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio Reprint requests: Devon Snow-Lisy, M.D., Glickman Urological and Kidney Insti- tute, Desk Q10-1, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail: snowlid@ccf.org Submitted: July 12, 2011, accepted (with revisions): September 28, 2011 Figure 1. (A) Computed tomography of isointense hepatic masses (asterisk) mirroring residual spleen (number sign) on noncontrast-enhanced imaging. (B) Contrast enhancement seen on computed tomography of both hepatic masses (aster- isk) and residual spleen (number sign). © 2012 Elsevier Inc. 0090-4295/12/$36.00 e73 All Rights Reserved doi:10.1016/j.urology.2011.09.041