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British Journal of Radiology (2006) 79, 319-325
© 2006 British Institute of Radiology
doi: 10.1259/bjr/81529894
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Full Paper

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

C Görg, MD1, K Görg, MD1, T Bert, MD1 and P Barth, MD2

1 Medizinische Universitätsklinik, Baldingerstraße, 35043 Marburg/Lahn, Germany, 2 Institut für Pathologie der Universitätsklinik, Baldingerstraße, 35043 Marburg/Lahn, Germany


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 References
 
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.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 References
 
In recent years, B-mode ultrasound patterns of various common splenic lesions including infarction [1, 2] lymphoma [3], rupture [4, 5], metastases [6], cysts [7], haemangioma [8] and other tumours [9] have been described.

The poor correlation between ultrasound appearances and specific splenic pathology causes difficulty in clinical diagnosis. In liver lesions, colour Doppler ultrasound (CDS) as well as contrast enhanced ultrasound (CES) have improved diagnostic accuracy [10]. To date there are few data regarding CDS and CES patterns of splenic lesions [11–14].

This report reviews the spectrum of ultrasound findings and the clinical follow-up we have observed in 13 patients with incidentally found hypoechoic vascular splenic lesions.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 References
 
Between January 1990 and January 2005, 13 patients were found incidentally to have focal hypoechoic splenic lesions with an increased vascular pattern on CDS at an internal medicine centre. The patient ages ranged from 2 years to 76 years. The male–female ratio was 8:5. Ultrasound and clinical data of these 13 study patients were retrospectively evaluated.

The inclusion criteria for the study were:

The following B-mode and CDS ultrasound parameters were retrospectively evaluated: splenic size, sonomorphological pattern of the parenchymal lesions (homogeneous vs inhomogeneous vs central echoic), number (solitary vs multiple), configuration (round vs oval), margin (smooth vs irregular), maximal size of lesions and CDS patterns of vessels (diffuse vs radial).

Between 1990 and 1998, patients were examined by Acuson 128 XP (Acuson, Mountain View, CA). From 1998, all new study patients and follow up examinations were performed using an Acuson Sequoia (Acuson; Siemens Medical Solutions, Mountain View, CA) equipped with a 3.5 MHz curvilinear array and 8 MHz linear array transducer. All ultrasound studies were performed by a single observer CG with more than 20 years of experience. Colour Doppler settings were optimized to achieve the greatest sensitivity for allowing detection of low flow.

Since January 2004 all new study-patients and all follow-up study-patients were (re)examined by CES with a second generation contrast agent (SonoVue®; Bracco SpA, Milan, Italy). Informed consent according to legislation was obtained in each patient for CES examination and statement of the local internal review board was achieved.

Following baseline ultrasound, CES studies were performed using an Acuson Sequoia equipped with contrast-specific, continuous-mode software operating at a low acoustic pressure. Immediately after contrast medium injection, the splenic lesions were observed for evidence of contrast uptake over a 5 min period. CES studies were analysed on the basis of review of ultrasound unit-stored clips. CES parameters were determined by only one observer (CG). For characterization of potential interobserver variability, one other completely blinded observer (KG) with at least 20 years of ultrasound experience retrospectively analysed CES data on the basis of review of ultrasound unit-stored images. A third reviewer (TB) decided in cases of disagreement (2 of 18 CES patterns).

The following CES patterns of intrasplenic lesions using the normal splenic tissue as an "in vivo" reference were considered: extent of enhancement during the arterial phase between 1–30 s and parenchymal phase between 1 min and 5 min after injection (absent vs hypoechoic vs isoechoic vs hyperechoic vs mixed echogenicity). During the arterial phase, a distinction between a central filling and a peripheral filling was made.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 References
 
The ultrasound data of the study patients are shown in detail in Table 1Go. In all patients, splenic size was normal (less than 11 cm x 5 cm). Regarding echotexture, parenchymal lesions were homogeneous (n = 4), inhomogeneous (n = 2), and central echoic (n = 7) (star-like pattern). Lesions were solitary (n = 11), multiple (n = 2), round (n = 13) and with a smooth margin (n = 13). Two patients had two splenic lesions on primary diagnosis. Size of lesions ranged from 1 cm to 4 cm (Figures 1–3GoGoGo).


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  		Table 1. Clinical and ultrasound findings in high vascular splenic tumours

 

Figure 1
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  		Figure 1. Patient No. 9. (a) B-mode ultrasound shows a well-demarcated solitary homogeneous hypoechoic splenic tumour. (b) Colour-Doppler ultrasound shows a tumour with marked diffuse intratumoral flow signals. (c) The lesion is composed of small inconspicuous round lumina surrounded by broad strands of collagen fibre-rich connective tissue (haematoxylin and eosin x 200). (d) Immunohistochemistry (x 200) demonstrates a peculiar network of small capillaries lined by CD34 positive endothelia (sclerosing capillary haemangioma).

 

Figure 2
Figure 2
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  		Figure 2. Patient No. 5. (a) B-mode ultrasound shows a small well-demarcated hypoechoic central hyperechoic splenic tumour (arrows). (b) Power-Doppler ultrasound shows a vascular tumour with marked diffuse intratumoral flow signals (arrows). (c) In the early arterial phase (15 s), contrast enhanced ultrasound (SonoVue®) shows a central contrast filling indicating the increased vascular lesion (arrow). (d) In the late parenchymal phase (4 min) contrast enhanced ultrasound (SonoVue®) shows a hypoechoic contrast enhancement of the tumour in comparison with the surrounding normal splenic tissue (arrow). (e) Contrast CT shows a hyperintense vascular splenic tumour (arrow).

 

Figure 3
Figure 3
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  		Figure 3. Patient No.10.(a) B-mode ultrasound shows two well-demarcated hypoechoic central hyperechoic splenic lesions. (b) Colour-Doppler ultrasound shows two vascular tumours with marked radial intratumoral flow signals in both lesions. (c) In the early arterial phase (11 s), contrast enhanced ultrasound shows a peripheral contrast enhancement of both tumours in comparison with the surrounding normal splenic tissue (arrows). (d) In the parenchymal phase (1 min), contrast enhanced ultrasound shows a complete filling of both lesions with an isoechoic enhancement of both tumours in comparison with the surrounding normal splenic tissue. (e) In the late parenchymal phase (3 min), contrast enhanced ultrasound shows a wash out phenomenon of both lesions with a hypoechoic enhancement of both tumours in comparison to the surrounding normal splenic tissue (arrows). (f) Contrast CT shows a hyperintense peripheral ring enhancement of the splenic tumour (arrow). (g) Contrast CT shows a complete filling of the splenic tumour (arrow).

 
CDS of increased vascular lesions showed a diffuse vessel pattern (Figures 1 and 2GoGo) or a radial ("starfish-like") vessel pattern in the remaining 9 patients (Figure 3Go).

In two patients (Nos. 2 and 9) surgical diagnosis was performed (one splenectomy and one tumour resection) and confirmed capillary haemangioma. In patient 1, ultrasound-guided tumour biopsy was performed and the diagnosis of hamartoma was made. All non-surgically treated patients were subject to ultrasound follow-up investigations which were performed at 3 month intervals during the first year and then once every year (patient 3 was lost to follow-up after 2 years, patients 7 and 11 died).

In patient 9, the resection specimen consisted of macroscopically normal splenic tissue surrounding a well circumscribed but unencapsulated red-brown tumour with a maximum diameter of about 3.5 cm. Histologically the lesion showed evenly distributed capillaries with inconspicuous round lumina surrounded by a thick rim of connective tissue (Figure 1cGo). Immunostaining (standard avidin-biotin-complex peroxidase method) for CD 34 and CD 31 demonstrated the lumina to be outlined by slightly hyperplastic endothelia (Figure 1dGo). These findings prompted the diagnosis of a sclerosing capillary haemangioma.

In patient 2 the spleen weight was 160 g. The cut surface showed no abnormalities except for a soft spongy dark-red nodule measuring 6 mm in diameter. Histologically, the nodule consisted of irregularly thin walled anastomosing capillaries lined by slightly hyperplastic endothelia. Immunohistochemistry (standard avidin-biotin-complex peroxidase method) revealed the endothelia to be CD 34 positive, whereas CD 8 was negative. For these morphologic findings, diagnosis of a splenic capillary haemangioma was made.

Contrast enhanced ultrasound was performed in nine cases (Table 1Go). During arterial phase, hyperechoic enhancement was seen in seven patients, while an isoechoic pattern was seen in two patients. Three cases showed marked central filling with contrast (Figure 2Go), while the remaining patients demonstrated peripheral ("ring sign") filling (Figure 3Go). All patients showed complete filling in of the lesion by the end of the arterial phase. In the parenchymal phase, all but two lesions were hypoechoic in reference to the surrounding tissue (Figures 2 and 3GoGo). In patients 1 and 7 an isoechoic enhancement was observed during the parenchymal phase (Table 1Go).

Additional imaging diagnostic procedures which confirmed the intrasplenic tumour were MRI (n = 1) and contrast enhanced CT (n = 10). CT revealed an increased vascular lesion in 9 out of 10 patients. Patterns of arterial phase enhancement on CT were concordant to those seen with CES. No "parenchymal phase" was examined by CT. In patient 1, no tumour was seen on CT examination.

In all 11 patients without surgical treatment, ultrasound follow-up was performed and revealed stable lesions in 10 cases. In patient 4 the lesion increased in size from 1.0 cm to 1.5 cm and a second increased vascular lesion of 0.5 cm was seen. Splenectomy was recommended, but the patient refused surgery; treatment with ultrasound follow-up continued (Table 1Go).


   Discussion
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
References
 
The spleen is regarded as "the forgotten organ" of the abdomen because splenic pathology is relatively rare [15]. Secondary lesions to the spleen (i.e. lymphoma, infarction, rupture and metastasis) are more common and often demonstrate a hypoechoic pattern on B-mode ultrasound. On CDS, splenic infarction and splenic rupture are characterized by an absent vascularity. In patients with splenic lymphoma and splenic metastases a reduced vascularity is the preferred CDS pattern [2, 6, 9, 11]. On CES splenic infarction as well as rupture is characterized by an unenhanced pattern. Splenic lymphoma demonstrates irregular peripheral enhancement, while metastasis are as usually predominantly non-enhancing, typically with a rim of peripheral enhancement [13]. In all other lesions presented here CES showed a marked hyperechoic arterial phase with variable patterns of contrast filling and relatively hypoechoic enhancement during the parenchymal phase. Besides characteristic imaging patterns, clinical data and follow-up are important additives for definitive diagnosis.

A clinical problem occurs with the incidentally found focal hypoechoic intrasplenic tumour on ultrasound. B-mode ultrasound as well as CT and MRI are often non-specific and histological verification is often warranted.

The differential diagnosis of incidentally found hypoechoic splenic tumours includes hamartoma and haemangioma. Splenic hamartoma (also called splenoma or nodular hyperplasia of the spleen) is a rare, benign tumour which usually presents as a solitary lesion [16]. Splenic haemangioma presents histologically with two different types: the more common cavernous type and the rare capillary type.

For a better interpretation of increased vascular lesions found by CDS, CES or CT, it is helpful to review angiographic studies of splenic tumours. On angiography, hamartomas have a characteristic arteriographic pattern with irregular dilated tortuous vessels, with or without aneurysmal dilatation, within a well demarcated mass, with occasional vascular lakes or arteriovenous shunting [17–21]. In contrast to the more common cavernous haemangiomas, the capillary haemangiomas appear as multiple hypervascular nodules fed by dilated intrasplenic arteries without tumour vessels and vascular lakes [22]. Histologically, hamartomas resemble normal red pulp with slit like vascular spaces lined with endothelial cells [23]. In fact, some hamartomas with a distinctive lobular pattern have been reclassified as red pulp capillary haemangiomas [24].

On B-mode ultrasound, cavernous haemangiomas are described with a predominantly hyperechoic pattern and absent or reduced Doppler flow signals on CDS [9, 11, 13, 25]. Capillary haemangiomas as well as hamartomas present with a hypoechoic pattern on B-mode ultrasound [26, 27]. CES showed an increased vascular pattern in both the arterial and parenchymal phase with multiple radial blood-flow signals in the early arterial phase in a patient with a hamartoma [25]. In another case report, splenic hamartoma was markedly enhanced on CES [28].

In our series of hypoechoic increased vascular splenic lesions with clinical follow-up, the diagnosis of a benign splenic tumour was most likely. It should be noted that in one case, ultrasound follow-up examination revealed a mild increase in size of the vascular lesion was seen and an additional lesion found. In nine patients the increased vascular pattern was confirmed by contrast CT [29]. One lesion was not seen by CT (patient 1). In the same patient, CES also showed an isoechoic enhancement during the arterial and parenchymal phase. Catalano et al [30] reported about two patients with small capillary angiomas clearly visible in the conventional ultrasound and isoechoic in comparison with splenic parenchyma in all contrast phases of the CT examination (and therefore undetectable). In all other lesions presented here, CES showed a marked hyperechoic arterial phase with variable patterns of contrast filling and a hypoechoic enhancement during the parenchymal phase.

We suggest that with an incidentally found splenic tumour the hypoechoic increased vascular pattern on ultrasound indicates a benign vascular tumour. Capillary haemangioma/hamartoma seems to be the most likely diagnosis, but in all cases a careful ultrasound follow-up is warranted.

Received for publication February 1, 2005. Revision received June 11, 2005. Accepted for publication August 17, 2005.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

  1. Görg C, Schwerk WB. Splenic infarction: sonographic patterns, diagnosis, follow-up, and complications. Radiology 1990;194:803–7.
  2. Görg C, Zugmaier G. Chronic recurring infarction of the spleen: sonographic patterns and complications. Ultraschall in Med 2003;24:245–9.
  3. Görg C, Weide R, Schwerk WB. Malignant splenic lymphoma: sonographic patterns, diagnosis, and follow-up. Clin Radiol 1997;52:535–40.[CrossRef][Medline]
  4. McKenney KL, Nunez DB, McKenney MG, Asher J, Zelnick K, Shipshak D. Sonography as the primary screening technique for blunt abdominal trauma: experience with 899 patients. AJR Am J Roentgenol 1998;170:979–84.[Abstract/Free Full Text]
  5. Görg C, Cölle J, Görg K, Prinz H, Zugmaier G. Spontaneous rupture of the spleen: ultrasound patterns, diagnosis, and follow-up. Br J Radiol 2003;76:704–11.[Abstract/Free Full Text]
  6. Görg C, Schwerk WB. Sonographic findings of splenic metastases. Imaging/Bildgebung 1991;58:26–8.
  7. Dachman AH, Ros PR, Murari PJ, Olmstedt WW, Lichtenstein JE. Non parasitic splenic cysts: a report of 52 cases with radiologic-pathologic correlation. AJR Am J Roentgenol 1986;147:537–42.[Abstract/Free Full Text]
  8. Ros PR, Moser RP, Dachman AH, Murari PJ, Olmstedt WW. Hemangioma of the spleen: radiologic-pathologic correlation in 10 cases. Radiology 1987;162:73–8.[Abstract/Free Full Text]
  9. Görg C. The spleen. In: Meire M, Cosgrove D, Dewbury K, Farrant P, editors. Abdominal and general ultrasound, second edition. London, Edinburgh, New York: Churchill Livingstone .2001;17:379–445.
  10. Wermke W, Gassmann B. Tumor diagnostics of the liver with echo enhancers: colour atlas. Berlin, Heidelberg, New York: Springer Verlag, 1998
  11. Görg C, Schwerk WB. Color Doppler imaging of focal splenic masses. Eur J Radiol 1994;18:214–9.[CrossRef][Medline]
  12. Catalano O, Lobianco R, Sandomenico F. Splenic trauma: evaluation with contrast-specific sonography and a second-generation contrast medium. J Ultrasound Med 2003;22:467–70.[Abstract/Free Full Text]
  13. Peddu P, Shah M, Sidhu PS. Splenic abnormalities: a comparative review of ultrasound, microbubble-enhanced ultrasound and computed tomography. Clin Radiol 2004;59:777–92.[CrossRef][Medline]
  14. Catalano O, Sandomenico F, Matarazzo I, Siani A. Pictoral essay: sonography of the spleen. AJR Am J Roentgenol 2005;184:1150–6.[Abstract/Free Full Text]
  15. Mortelé KJ, Merjo PJ, Kunnen M. Tumoral pathology of the spleen. In: DeSchepper AM, Vanhoenacker F, editors. Medical imaging of the spleen. Berlin, Heidelberg, New York: Springer Verlag, 2000:101–23.
  16. Steinberg JJ, Suhrland MJ, Valensi OJ. The association of splenoma with disease. Lab Invest 1985;52:65A
  17. Kishikawa T, Numaguchi Y, Watanabe K, Matsuura K. Angiographic diagnosis of benign and malignant splenic tumors. AJR Am J Roentgenol 1978;130:339–44.[Abstract]
  18. Wexter L, Abrams ML. Hamartoma of the spleen. Angiographic observation. AJR Am J Roentgenol 1964;92:1150–5.
  19. Komaki G, Gombas OF. Angiographic demonstration of a calcified splenic hamartoma. Radiology 1976;121:77–8.[Abstract]
  20. Rösch J. Tumours of the spleen: the value of selective arterography. Clin Radiol 1966;17:183–90.[CrossRef][Medline]
  21. Teates CD, Seale DC, Allen MS. Hamartoma of the spleen. AJR Am J Roentgenol 1972;116:419–22.[Abstract]
  22. Tada S, Shin M, Takashima T, Noguchi M, Nishro I. Diffuse capillary hemangiomatosis of the spleen as a course of portal hypertension. Radiology 1972;104:63–4.[Medline]
  23. Silverman ML, LiVolsi VA. Splenic hamartoma. Am J Clin Pathol 1978;70:224[Medline]
  24. Krishnan J, Danon AD, Frizzera G. Use of anti-factor VIII-related antigen (F8) and Q Bend 10 (CD34) antibodies helps classify the benign vascular lesions of the spleen. Mod Pathol 1993;6:94A
  25. Niizawa M, Ishida H, Morikawa P, Naganuma H, Masamune O. Color Doppler sonography in a case of splenic hemangioma: value of compressing the tumor. AJR Am J Roentgenol 1991;157:965–6.[Free Full Text]
  26. Tang S, Shimizu T, Kikuchi Y, Shinya S, Kishimoto R, Fujioka Y, et al. Color Doppler sonographic findings in splenic hamartoma. J Clin Ultrasound 2000;28:249–53.[CrossRef][Medline]
  27. Fujii T, Obara T, Shudo R, Maguchi H, Saitoh Y, Ura H, et al. Splenic hamartoma associated with thrombocytopenia. J Gastroenterol 1997;32:114[CrossRef][Medline]
  28. Chou Y-H, Chiou H-J, Tui C-M, Chiou S-Y, Hsia C-Y, Tsay S-H. Splenic hamartoma: presentation on contrast-enhanced sonography. J Clin Ultrasound 2004;32:425–8.[CrossRef][Medline]
  29. Abbott RM, Levy AD, Aguilera NS, Gorospe I, Thompson WM. From the archives of the AFIP: primary vascular neoplasms of the spleen: radiologic-pathologic correlation. Radiographics 2004;24:1137–63.[Abstract/Free Full Text]
  30. Catalano O, Lobianco R, Sandomenico F, D'Èlia G, Siani A. Real-time contrast-enhancement ultrasound of the spleen: examination technique and preliminary clinical experience. Radio Med (Torino) 2003;106:338–56.




This Article
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