Pearls And Pitfalls In The Evaluation Of Large Splenic Lesions: How We Do It
Pearls And Pitfalls In The Evaluation Of Large Splenic Lesions: How We Do It Elliot K. Fishman MD Linda Chu MD Satomi Kawamoto MD Johns Hopkins Hospital |
While most incidentally discovered splenic lesions are benign and require no further work up, in clinical practice the management of splenic masses is often challenging. The question of how to manage this successfully in practice is the subject of this educational exhibit. Purpose: To evaluate whether an incidentally noted splenic mass at abdominal computed tomography (CT) requires further imaging work-up. Conclusion: In an incidental splenic mass, the likelihood of malignancy is very low (1.0%). Therefore, follow-up of incidental splenic masses may not be indicated. The Incidental Splenic Mass at CT: Does It Need Further Work-up? An Observational Study Siewert B et al. Radiology 2018; 287:156–166 |
The Challenge of the Large Splenic Mass to the Radiologist
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The Challenge of the Large Splenic Mass to the Radiologist
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Key Findings that are visualized on a CT scan and can help with a specific diagnosis.
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Splenic Mass: Beyond a Differential Diagnosis
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Cystic Splenic Lesions: Differential Diagnosis
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”Cysts typically measure up to 8–16 cm in diameter. On CT, these hydatid cysts are typically well-marginated with internal fluid attenuation and occasional air-fluid levels. At all stages, hydatid cysts may have curvilinear, ringlike peripheral calcifications of the pericyst in up to 20–30% of cases.” Calcified Splenic Lesions: Pattern Recognition Approach on CT With Pathologic Correlation Consul N et al. AJR 2020; 214:1083–1091 |
“Some cysts may have internal septations that enhance with contrast administration. Up to 14% of true epithelial cysts can have thin curvilinear wall calcifications, but calcifications can also be seen within septations. When compared with pseudocysts, which are the primary differential diagnostic consideration for these lesions, true epithelial cysts are more likely to have internal enhancing septations but are less likely to have wall calcifications.” Calcified Splenic Lesions: Pattern Recognition Approach on CT With Pathologic Correlation Consul N et al. AJR 2020; 214:1083–1091 |
Simple Splenic Cyst on Path  |
Epithelial Cyst Spleen Compresses Tail of Pancreas and is exophytic. The lesion looks extra-splenic on the axial images.  |
Calcified Cyst Spleen  Rim like calcification point to a learn term issue and is usually due to old trauma |
LUQ Pain: Vascular Mass with EMH and Areas of Hemorrhage/Necrosis  Not our first diagnosis and a challenging case |
Incidental Splenic Lesion with Solid Component was an old hematoma with faint calcifications  |
Splenic Mass Which is Solid and Well Defined
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Incidental Finding is a Splenic Hemangioma  Factoid: Key CT findings include a hypodense lesion which had sharp margins but no evidence of neovascularity. The lesions cystic components are well seen on the images with Cinematic Rendering. |
Splenic Hemangioma  |
Splenic Hamartoma  A key to the diagnosis of hamartoma is the bulging of the splenic border and the prominent vascularity of the lesions as shown in these 2 cases |
Splenic Hamartoma  |
Littoral Cell Angioma  |
Littoral Cell Splenic Angioma: Facts
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Inflammatory Pseudotumor of the Spleen  |
”The definitive diagnosis is established with the histological findings, characterized by the presence of inflammatory cells with areas of necrosis and fibrosis. There are multiple differentials diagnoses: metastasis, lymphoma, splenic infarction, hemangiomas, vascular malformations, lymphangioma, plasmacytoma, reactive lymphoid hyperplasia, abscess and infectious granulomatous processes; therefore suspicion of malignant neoplasm must be considered, being indicated splenectomy to confirm the diagnosis.” ”Radiological tests could orientate but there are not pathognomonic images. Ultrasound can show a hypoechoic splenic mass with or without calcifications. CT can show a low density injury that usually has an attenuated central zone corresponding with fibrosis in the histological findings. Calcifications may be present.” “Inflammatory pseudotumor of the spleen is a rare benign process with nonspecific CT features. The mass was generally hypodense with delayed enhancement on CT.” Inflammatory pseudotumor of spleen: a case report. Ugalde P et al. Int J Surg Case Rep. 2015;7C:145‐148. |
The large mass is best described as an infiltrating tumor and is in part exophytic to the splenic margins. No extra-splenic findings were seen but the lesion is best described as infiltrating. The appearance suggest an infiltrating process and was consistent with Primary Splenic Lymphoma.  |
Splenic Lymphoma: Facts
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Splenic Lesions with Concurrent Liver Lesions: Differential Dx
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B-Cell Lymphoma Involves Liver and Spleen and Nodes  |
Pancreatic and Splenic Lymphoma  |
Primary Splenic Lymphoma  |
Diffuse Large B-Cell Lymphoma  Concurrent Adenopathy is the second finding of note. |
 The imaging with 2D and 3D mapping show involvement of the liver as well as adenopathy consistent with malignancy. Suspected diagnosis include lymphoma and metastases. In this AIDs patient the final dx was Kaposi’s Sarcoma involving the spleen and liver. |
Potential Pitfalls in Diagnosis
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Infarcted Spleen s/p Whipples  |
 Splenic Infarct with sequestration can be confused with a splenic mass or abscess in the absence of a clear clinical history in this case of Thalassemia |
Conclusion and Take Away Messages There are a range of large splenic masses ranging from simple cyst, to hamartoma, to lymphoma and to sarcoma. While many lesion have a classic “signature” there is still overlap with lesion including Littoral Cell Tumor, SANT and Sequestration that can prove to be a challenge. The integration of clinical history into the equation often proves valuable in patient management decision making. Hopefully a review of key CT imaging features are helpful in your daily practice. |