Color Doppler sonographic findings in splenic hamartoma

Algorithmic Approach to the Splenic Lesion Based on Radiologic-Pathologic Correlation

Splenic lesions are commonly discovered incidentally at imaging, without clinical signs or symptoms that may aid in diagnosis. As such, the differential diagnosis and subsequent management are based primarily on imaging characteristics. Much has been written about the myriad pathologic conditions that can occur in the spleen; however, there is little guidance on the approach to an incidental splenic mass. Applying an approach frequently used in imaging to the splenic mass-based on the number and consistency of lesions and refined by supplementary imaging features-allows formulation of a useful differential diagnosis. Solitary cystic masses include true cysts, pseudocysts, and parasitic cysts. When multiple cystic lesions are present, the differential diagnosis expands to include infectious lesions (abscess or microabscesses) and lymphangioma (a benign cystic neoplasm). Hemangioma is the most common solitary solid mass, although other vascular lesions (hamartoma, sclerosing angiomatoid nodular transformation) and nonvascular lesions (inflammatory pseudotumor, lymphoma) manifest as solitary and solid. When multiple solid masses are present, diffuse inflammatory disease (sarcoidosis), littoral cell angioma, and lymphoma should be considered. Malignancies, such as angiosarcoma or metastasis, can manifest as solitary or multiple and solid or cystic masses but are typically associated with symptoms or widespread primary malignancy. Careful assessment of the multimodality imaging characteristics of splenic lesions based on this approach aids the radiologist faced with the incidental splenic lesion. Online supplemental material is available for this article. Work of the U.S. Government published under an exclusive license with the RSNA.

A splenic hamartoma: Adding a new case to the literature: A case report

Introduction

Splenic tumours are relatively rare and include malignancies such as lymphomas, angiosarcomas, plasmacytomas, primary malignant fibrous histiocytomas, and splenic metastases. Benign tumours of the spleen such as hemangiomas, cysts, and inflammatory pseudotumours are very rare (Kaza et al., 2010, PisaniCeretti et al., 2012) [1], [2]. There are fewer than 160 cases of splenic hamartoma or splenomas having been reported in the literature (Basso et al., 2012) [3]. Only 20% of the cases were detected in children (Abramowsky et al., 2004) [4]. Although multi-modality imaging findings were described preoperatively, the final diagnosis was splenic hamartoma based on histology and immunohistochemistry.

Case report

Here, we report a case of a14 year old child left upper quadrant abdominal pain and worsening sickness. Multi-modality imaging detected a solid lesion of the spleen, who required splenectomy and was pathologically diagnosed as a splenic hamartoma. The postoperative course was uneventful.

Discussion

Splenic hamartoma is very rare. Only 20% of hamartomas occur in children. They are commonly found incidentally on imaging with no symptoms.

Conclusion

Splenic hamartoma is a benign vascular proliferative lesion that requires a multi-modality imaging studies for diagnosis and confirmed by histopathology. It must be included in the differential diagnosis of splenic mass forming lesions.

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There are fewer than 160 cases of splenic hamartoma having been reported in the literature. Only 20% of the cases were detected in children.

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Although imaging findings were described preoperatively, the final diagnosis was splenic hamartoma based on histology.

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We report a case of solid lesion of the spleen, who required splenectomy and was pathologically diagnosed as splenic hamartomas.

[Imaging of abdominal tumors in childhood and adolescence : Part I: Background, hepatic, splenic and pancreatic tumors]

In comparison to adult patients, other specific entities of abdominal tumors occur in childhood and adolescence. These include malignant tumors originating from embryonic tissue, such as hepatoblastoma. Some of the abdominal tumors are already diagnosed prenatally or in neonates. Sonography functions as the primary radiological basic diagnostics of pediatric abdominal space-occupying lesions, if necessary supplemented by administration of ultrasound contrast medium or the implementation of novel techniques (e.g. innovative Doppler and elastography procedures). Magnetic resonance imaging (MRI) is used for a comprehensive and detailed depiction of the tumors including the question of resectability and vascular supply. Various weighting and different MRI sequences are used in order to be able to assess the signal behavior of the tumor and therefore the possible presence of calcification, necrosis or hemorrhage, the behavior of dynamic contrast enhancement, and the presence and extent of diffusion disorders. This information is decisive in order to be able to assess the entity and malignancy of the abdominal space-occupying lesion. Rare but relevant tumors with respect to the entity occur in childhood and adolescence in the abdominal organs liver, spleen and pancreas.

[Splenic hamartoma, severe thrombocytopenia, and macrocrania in a neonate: A case study]

We report a case of splenic hamartoma associated with neonatal macrocrania diagnosed in a newborn. The diagnosis was made in the first 2 days of life upon the existence of an abdominal mass in the newborn infant. Abdominal ultrasound and abdominal computed tomography supported the diagnosis, but the histological study was inconclusive. The indication for surgery is still controversial. Through a literature review, the clinical, histological, and radiological aspects are discussed. The combination of neonatal hamartoma, thrombocytopenia, and macrocrania has never been reported.

Splenic hamartomas in two children

Hamartomas are extremely rare splenic benign tumours in children. We present two cases, both in boys (6 and 8 years old), with left upper quadrant abdominal pain that were otherwise asymptomatic. Both patients showed a splenic mass on preoperative ultrasonography and magnetic resonance imaging (MRI). One patient had a focal splenic mass that was identified preoperatively with contrasted computed tomography (CT) scans. Both patients underwent a total splenectomy. Although multi-modality imaging findings were described preoperatively, the final diagnosis in each case was splenic hamartoma based on histology and immunohistochemistry. The postoperative courses were uneventful.

Multi-modality imaging findings of splenic hamartoma: a report of nine cases and review of the literature

PURPOSE

To investigate the presentation of splenic hamartomas (SHs) on ultrasonography (US), CT and MRI.

METHODS

Nine patients (5 males and 4 females, mean age, 52.8 years) with pathologically proven SHs were included in this study. US, CT and MRI images were analyzed retrospectively, and imaging features were correlated with pathological findings.

RESULTS

SHs appeared solitary lesion (n = 8) and multiple lesions (n = 1) in the present study. (1) In 8 cases of solitary lesion, the lesions appeared as solid nodules or masses with well-defined margins and varying echogenicity (hyperecho = 5, hypoecho = 2, strong echo = 1) on ultrasound. The lesions showed iso-attenuation (n = 3) or slightly hypo-attenuation (n = 4) on unenhanced CT, and calcification were revealed in 3 lesions. MRI showed isointensity (n = 3) or hypointensity (n = 2) on the T1-weighted image, and heterogeneous hypointensity (n = 2), slightly hyperintensity (n = 2) and hyperintensity (n = 1) on the T2-weighted image. The enhanced patterns of SHs showed mild diffuse heterogeneous enhancement (n = 6) and prominent enhancement (n = 1) during arterial phase and above 7 lesions were demonstrated progressive enhancement at delayed phase on enhanced CT. One lesion without any enhancement was revealed in another patient. (2) One case of multiple lesions included 1 cystic lesion with irregular calcification and 7 solid lesions with progressive enhancement on CT images.

CONCLUSIONS

Combination of a variety of imaging modalities could more fully reflect the pathological characteristics and contribute to the diagnosis of SH.

Laparoscopic splenectomy for splenic hamartoma: a case report

Hamartoma is a rare splenic benign tumor usually accidentally detected as a radiologic finding. Preoperative diagnosis poses a challenge and thus surgery becomes necessary to confirm the clinical suspicion. Laparoscopic splenectomy has gained consensus as a standard surgical procedure particularly for autoimmune hematological diseases. This former experience has allowed this technique to be extended to other splenic pathologies. Here we report a case of total laparoscopic splenectomy for a bulky splenic hamartoma in a young male patient.

Gastrointestinal tumors in children

Although tumors arising from the spleen, pancreas, and gastrointestinal tract in the pediatric population are relatively uncommon, imaging plays an important role in diagnosis, staging, and treatment planning. Initial imaging with abdominal radiograph contributes to the evaluation for intestinal obstruction, constipation, and mass effect, and sometimes may reveal areas of calcification.

Laparoscopic splenectomy for splenic hamartoma: Case management and clinical consequences

Splenic hamartoma is a rare benign tumor, and although minimally invasive surgery may be suitable for this condition, there have only been 2 previous reports of laparoscopic surgery. Here we report the third case of splenic hamartoma managed by laparoscopic splenectomy. A 37-year-old male was incidentally diagnosed by abdominal ultrasonography with a hypoechoic mass measuring 2.5 cm × 2.4 cm in the spleen. Color Doppler sonography showed multiple flow signals within the mass and contrast-enhanced computed tomography revealed strong enhancement of the lesion. On T1- and T2-weighted magnetic resonance images, the splenic mass was demonstrated as isointense and hyperintense respectively. Although a malignant tumor could not be ruled out, a hand-assisted laparoscopic splenectomy was performed because the splenic mass was limited in size and had not invaded adjacent organs. The pathological diagnosis was splenic hamartoma. The postoperative course was uneventful and the patient was discharged by the seventh postoperative day. Although splenic hamartomas have some specific imaging features, more reports and analyses of these cases are required to increase the reliability of the diagnosis and management. Hand-assisted laparoscopic splenectomy may play a pivotal role in the postoperative diagnosis and management of this condition.

Sclerosing angiomatoid nodular transformation (SANT) of the spleen: sonographic finding

Sclerosing angiomatoid nodular transformation (SANT) is a recently recognized benign vascular lesion of the spleen. There is limited information regarding its imaging findings of this condition. Until now, the diagnosis was based on histopathologic examination of splenectomy specimens. We report the sonographic findings in a case of SANT of the spleen confirmed by ultrasound-guided core needle biopsy.

Colour Doppler ultrasound patterns and clinical follow-up of incidentally found hypoechoic, vascular tumours of the spleen: evidence for a benign tumour

Between January 1990 and January 2005, incidental hypoechoic, vascular tumours of the spleen were identified in 13 patients using B-mode and colour Doppler ultrasound (CDS). All lesions found were well demarcated, intrasplenically located, and ranged in size between 1 cm and 4 cm. The increased vascular pattern on CDS was confirmed in 9 of the 13 cases by contrast enhanced ultrasound (CES), while two patients showed reduced vascularity on CES. In 10 patients, lesions were confirmed by contrast enhanced CT. Histological examination was performed in three patients with the diagnosis of capillary haemangioma (n = 2) and hamartoma (n = 1). In the remaining cases, ultrasound follow-up was performed (range 4 months to 13 years) and demonstrated no evidence of tumour growth in all but one patient. During a 4 year follow-up, one lesion increased in size from 1.0 cm to 1.5 cm and in the same patient an additional 0.5 cm sized hypoechoic increased vascular lesion was also found. In the spleen a hypoechoic lesion with an increased vascular pattern incidentally found by ultrasound most likely indicates a benign tumour with capillary haemangioma/hamartoma as the most likely diagnosis. However, it should be emphasised that in all cases a careful ultrasound follow-up is warranted.

Spontaneous rupture of splenic hamartoma in a patient with hepatitis C virus-related cirrhosis and portal hypertension: A case report and review of the literature

Spontaneous rupture is a rare complication of splenic hamartoma. A review of the literature revealed only four such cases. To the best of our knowledge, this is the first report of spontaneous rupture of splenic hamartoma associated with liver cirrhosis and portal hypertension. A 53-year-old woman, who was followed up for aortic dissection and hepatitis C virus (HCV)-related liver cirrhosis, was referred with sudden left chest and shoulder pain. An abdominal ultrasound showed intraabdominal bleeding, and computed tomography indicated rupture of a splenic tumor. Emergent splenectomy was carried out. The postoperative course was uneventful, and the patient was discharged on the 13th postoperative day. Pathology revealed the tumor to be a ruptured splenic hamartoma. The non-tumorous splenic parenchyma revealed congestive changes. We consider that the presence of liver cirrhosis and portal hypertension are risk factors for spontaneous rupture of the splenic hamartoma.

Basket pattern blood flow signals discovered in a case of splenic hamartoma by power Doppler ultrasonography

We present the gray-scale ultrasonography (GSUS), power Doppler ultrasonography (PDUS), abdominal computed tomography (CT), and magnetic resonance imaging (MRI) findings for a case of splenic hamartoma in a 27-year-old man, showing a φ 50 mm homogeneous, iso- and hypo-echoic splenic mass with evidence of a small plural cystic lesion. This splenic hamartoma showed increased vascularity on power Doppler sonograms. PDUS showed multiple circular blood flow signals inside the mass (i.e. a basket pattern), which was consistent with the small plural cystic lesion shown by GSUS. Spectral analysis also confirmed arterial and venous flow. CT scans showed that the mass had low-density relative to the normal spleen and MRI showed that the mass was isodense, relative to the normal spleen. Therefore, CT and MRI are not useful for the diagnosis of splenic hamartoma. Ultrasonography can be used to diagnose splenic hamartoma without administration of a contrast material and therefore is an indispensable method for the diagnosis of splenic hamartoma.

Color Doppler sonographic findings in focal spleen lesions

Since focal lesions of the spleen are rare (0.2%), there is little data concerning color Doppler images of focal lesions of the spleen.

OBJECTIVE

The aim of this study is to describe the color Doppler images of 98 etiologically proved focal spleen lesions.

METHODS

In about 110,000 consecutive abdominal ultrasound examinations, which included the spleen, 600 patients with focal lesions of the spleen were identified. In 98 of these patients a color Doppler scan of the lesion was performed and documented. These scans were analysed retrospectively and classified as avascular, hypovascular, isovascular, hypervascular and arterio-venous "high flow", using the surrounding spleen tissue as an in vivo reference.

RESULTS

In color Doppler sonography (CDS) 68.4% (n=67) of the focal spleen lesions showed no flow. 15.3% (n=15) appeared hypovascular, 8.2% (n=8) isovascular, 5.1% (n=5) hypervascular, and in 3.1% (n=3) an arterio-venous "high flow"-pattern was found.

CONCLUSIONS

In CDS about two thirds (68%) of focal spleen lesions appear to be avascular. Except from diagnosis of intra-splenic pseudo-aneurysm, the practical utility of CDS in diagnosing focal spleen lesions has to be estimated as low.

Splenic abnormalities: a comparative review of ultrasound, microbubble-enhanced ultrasound and computed tomography

The ultrasound appearances of abnormalities of the spleen are reviewed and images compared with computed tomography. Focal lesions, both benign and malignant, trauma, infarction and congenital abnormalities are presented. The use of microbubble ultrasound contrast media as an aid to identifying and characterizing abnormalities is discussed.

From the Archives of the AFIP

Primary vascular neoplasms of the spleen constitute the majority of nonhematolymphoid splenic tumors. The benign primary vascular tumors include hemangioma, hamartoma, and lymphangioma, whereas those of variable or uncertain biologic behavior include littoral cell angioma, hemangioendothelioma, and hemangiopericytoma. The primary malignant vascular neoplasm of the spleen is angiosarcoma. Peliosis is a rare lesion of unknown cause that is usually found incidentally in asymptomatic patients but may be associated with hematologic or metastatic disease. Although these vascular neoplasms of the spleen are uncommon, their importance lies in that they must be differentiated from the more common neoplastic disorders of the spleen, such as lymphoma and metastasis. The most common echogenic solid or complex cystic mass in an asymptomatic patient is splenic hemangioma. However, the imaging appearance of splenic hemangiomas may be complex, and differentiation of these lesions from malignant disease may not be possible. The diagnosis of splenic hamartoma may be suggested when findings of increased blood flow on color Doppler images are seen in association with a homogeneous solid echogenic mass. A large subcapsular solitary cystic abnormality discovered incidentally in a child in association with internal septations and tiny mural nodules favors the diagnosis of lymphangioma. Any invasion of the surrounding splenic parenchyma by a splenic lesion should indicate a more aggressive or malignant process. Evaluation of a focal splenic abnormality identified on sonograms should be followed up with computed tomography or magnetic resonance imaging with and without contrast material enhancement. Splenectomy may be required for definitive evaluation of a splenic mass with atypical features.

"Hamartoma" of the spleen (splenoma) in children

Hamartomas of the spleen or splenomas, are uncommon benign tumorous growths in this organ which have not been well characterized in children. We report four patients, 4 to 11 years old, who had splenomegaly and splenic "hamartomas" associated with different hematologic conditions (refractory microcytic anemia, sickle cell anemia, hereditary spherocytosis, and dyserythropoietic hemolytic anemia). All patients had total splenectomy as a primary therapeutic approach or to lessen their transfusion requirements. In only one patient was a focal splenic mass identified preoperatively with contrasted computed tomography (CT) scans and magnetic resonance imaging (MRI). None of the patients showed a mass by ultrasonography. Gross examination showed enlarged spleens (315-724 g) which on cut surface revealed a single nodule in one and multiple bulging nodules in three specimens. The nodules varied from 1.3 to 7 cm and were indistinct from the surrounding nonlymphoid splenic (i.e., red pulp) parenchyma. Histology of the nodules showed red splenic pulp with variable histiocytic proliferation, focal extramedullary hematopoiesis, lympho-plasmacytosis, fibrosis, and siderotic-calcific deposits. Intranodular small T- and B-cell lymphoid aggregates but no organized secondary follicles or periarteriolar sheaths were seen. Proliferation antigen Ki-67 (Mib-1) immunostains showed a low (< 5%) proliferation index in the nodules and surrounding tissue. Reticulin stains did not show a capsule or border between the normal spleen and the nodules. The critical histologic differential diagnosis for these lesions is with benign vascular tumors. These can be identified by their more disorderly pattern, by immunohistochemistry and by their higher proliferation index. It is our contention that these splenic nodules are not true hamartomas, as they seem to result from remote ischemic or infectious/inflammatory insults, leading to the fibro-inflammatory reaction and deposition of calcium and hemosiderin that is better designated with the descriptive term of splenoma. Review of the literature and our own experience indicates that most children with splenic hamartomas or splenomas as we prefer to call them, have an underlying hematologic disorder likely made worse by a state of hypersplenism that explains the consistent improvement in the blood values after splenectomy.

[Preoperative selective embolization allowing a partial splenectomy for splenic hamartoma]

PURPOSE OF THE STUDY

To underline value of the preoperative splenic embolization with haemostatic aim to facilitate partial splenectomy.

MATERIAL

Observation of a 23-year-old woman, admitted for pain, anemia, and mass of the left hypochondrium. Sonography, helical CT and MRI showed that the bulky mass was developed from the upper pole of spleen, and dislodged the left kidney towards the pelvis. This mass had fibrous characteristics in favour of a primary lesion with recent bleeding and was compatible with a splenic hamartoma.

METHODS

Selective partial splenic embolization with haemostatic aim using metal coils, immediately followed by surgery.

RESULTS

Preoperative embolisation made possible to carry out under optimal surgical conditions a partial splenectomy with en-bloc resection of the splenic mass. Histologic diagnosis was splenic hamartoma of pulpar type.

CONCLUSION

This case illustrates the interest of accurate characterization of splenic lesions by several imaging techniques allowing indication for conservative surgery, and of preoperative embolization facilitating a partial splenectomy.