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Gastrointestinal ❯ R/O Splenic Mass

CT Protocol for R/O Splenic Mass

Problem	The study is done to rule out suspected splenic pathology. The typical history is either FUO, LUQ pain or palpable spleen. The study may also be part of a workup for suspected lymphoma or myeloproliferative disorder. Evaluation of the spleen can also be a focus of evaluation of a patient with sickle cell disease or one of its variants.
Protocol	In most cases except when you are concerned for an aneurysm or pseudoaneurysm an arterial phase adds little to the evaluation of suspected splenic pathology. Therefore in most cases we will do a venous phase with 60-70 delay following injection of 100-120 cc of iodixanol-350. Occasionally a delayed phase at 3-4 minutes may be useful but that is rare. As for arterial phase imaging it would surely be helpful if the mass was vascular but they are usually angiosarcomas and are rare.
Pearls	The spleen is a very challenging organ because of the wide range of pathologies but the limited CT techniques available are a problem at times. Some rules that I follow are included under pearls. The most common vascular lesions are hemangiomas and hamartomas. The most common malignant vascular lesion is an angiosarcoma which usually are irregular and multifocal. The CT appearance of primary splenic lymphoma and splenic abscess can be nearly identical. If a lesion has air bubbles and an air fluid level than it is nearly always an abscess. Multiple splenic lesions can be seen in a range of pathologies ranging from hemangiomas, to sarcoidosis, to fungal abscesses to lymphoma. When I evaluate a splenic mass I always look at the extra-splenic findings including other organ involvement (i.e. liver or spleen) and the presence or absence of adenopathy The spleen may be involved by pathology extending from adjacent organs. A good example is the pancreas where we can see direct splenic involvement from pancreatic cancer or pancreatitis. Various splenic anomalies like accessory spleen can be confused with primary splenic or even pancreatic pathology. In cases of possible accessory spleen vs PNET I recommend scans in the non-contrast, arterial and late venous phase. Accessory spleens enhance identical to the normal spleen The spleen is involved in a range of sickle cell disease and its variants. The presence of splenic sequestration can simulate a tumor or an abscess. The clinical history is especially important in the evaluation of splenic pathology