How to manage a splenic nodule?

Catherine Ridereau-Zins Department of Radiology University Hospital of ANGERS - FRANCE

Not so easy…

? many etiologies: congenital epidermoid or endothelial cysts

infectious bacterial abscess , hydatidis, candidosis, tuberculosis inflammatory sarcoidose, SANT, inflammatory pseudotumor hemopathies lymphoma vascular hemangioma, angiosaroma, infraction trauma hematoma, pseudocyst, pseudo aneurysm metastases breast, colon, lung, melanoma, ovary .. other Gandi-Gamna nodules, hamartoma, Gaucher’s disease,

Castelman, drepanocytosis, amylose, extra medullary hematopoiesis …

? Spleen nodule is fortuitously discovered, on US or CT ? no specific features on imaging

How to manage?

? Take into account clinical and biological data associated lesions prior exams ? Try to characterise the nodule on different imaging : � US +/- contrast � CT � MRI � FDG TEP CT

unique or multiple cystic or solid

?

? Be able to biopsy When ?

In oncologic context: � suspicion of splenic metastasis: changing treatment ? � suspicion of benign lesion: avoiding a splenectomy

Out oncologic context: atypical lesion � if benign: stop follow-up � if malignant: diagnosis before splenectomy � suspicion of granulomatosis (TB, sarcoidosis)

How to manage?

US-guided splenic biopsy

Contra-indications

Hemostasis troubles Suspicion of hydatidosis

Fine needle aspiration (22 G) or biopsy with a 18 G needle - 2 samples at most

How?

Complications ?

bleeding (2-8% of biopsy, ì number of samples) pneumothorax; pleural effusion

? Be able to biopsy

US-guided splenic biopsy

How to manage?

Keogan, AJR 1999; Kang, M Eur J Radiol. 2007; Singh AK, Radiographics 2012

How far to go?

1st level: know the 2 or 3 most common pathologies è hemangioma, epidermoid cyst, endothelial cyst

3rd level: know very rare pathologies (-1% of cases !)

2nd level: take into account clinical and biological data be able to perform a biopsy è metastasis, lymphoma, infection

How far to go?

1st level: know the 2 or 3 most common pathologies è hemangioma, epidermoid cyst, endothelial cyst

3rd level: know very rare pathologies (-1% of cases !)

2nd level: take into account clinical and biological data be able to perform a biopsy è metastasis, lymphoma, infection

Gilles Genin

Characterise on imaging

☛  On US: hypo or anechoic septa ? if doubt: contrast

Cystic nodule

endothelial cyst

☛  On US: hypo or anechoic septa ? if doubt: contrast

☛  On CT: more difficult hypodense mass

Characterise on imaging Cystic nodule

☛  On CT: more difficult hypodense mass

☛  On US: hypo or anechoic septa ? if doudt: contrast

☛  On MRI: easy ! hyper T2, hypo T1

Characterise on imaging Cystic nodule

? BENIGN (more often): � epidermoid cyst, mesothelial cyst � cystic lymphangioma � hydatid cyst � false cyst ( history of trauma, pancreatitis or spleen infarction)

Cystic nodule Characterise on imaging

Tunisian man: cyst with septa and calcifications èhydatid serology +

Hydatic cyst

Characterise on imaging Cystic nodule

BE CAREFUL: cystic metastasis!

Cystic nodule Characterise on imaging

49 year old man, lung cancer screening

Cystic metastasis

BE CAREFUL: cystic metastasis!

Characterise on imaging

è normal spleen examination 3 years ago

Cystic nodule

Hypervascular

? BENIGN: common • hemangioma, hemangiomatosis • hamartoma • pseudo aneurysm

? Malignant : rare • epithelioid hemangioendothelioma • angiosarcoma

Hemangioma

Pseudo aneurysm

Characterise on imaging Solid nodule

NON Hypervascular

? MALIGNANT : common • lymphoma • metastasis • sarcoma

Lymphoma

Mets stomach cancer

clinical data associated lesions

Characterise on imaging Solid nodule

NON Hypervascular

? But also: • infectious • granulomatosis

Toxocarosis

Characterise on imaging Solid nodule

clinical data biological data

NON Hypervascular

? But also: • infectious • granulomatosis

Toxocarosis

History of colon cancer è biopsy : tuberculosis

Characterise on imaging Solid nodule

clinical data biological data FDG TEP CT biopsy ?

Things are not so easy …

52 year old woman, lung cancer screening

ènon contributory biopsy èsplenectomy HAMARTOMA

52 year old woman, lung cancer screening

Things are not so easy …

Take home messages

? Diagnosis is not easy without clinical data

? Some lesions can be identified easily: cysts, hemangioma

? All rare etiologies: think about them … rarely they can be seen in literature.

? US-guided splenic biopsy can be performed, if doubt

Thank you 谢谢