Primary lymphoma of the spleen mimicking simple benign cysts: contrast-enhanced ultrasonography and other imaging findings

Cystic splenic lesions: a sonographic approach-retrospective study in 111 patients

OBJECTIVES

To describe and categorize splenic cystic-appearing lesions (S-CAL) with B-mode and contrast-enhanced ultrasound (CEUS).

MATERIALS AND METHODS

This retrospective study investigated S-CALs in 111 patients between 2003 and 2023 in an interdisciplinary ultrasound center with B-mode ultrasound, color Doppler sonography (CDS), and CEUS. S-CAL was characterized by echogenicity, diameter, and shape, as well as additional features like septation, calcification, or wall thickening, and CDS/CEUS were used to identify perfusion. Histological examination or imaging follow-up was necessary to determine the nature of S-CAL. Moreover, 'S-CAL with risk' was defined, necessitating further procedures. Four types (0-III) of S-CALs were defined based on ultrasound parameters. Fisher's exact test was used to compare non-parametric data.

RESULTS

S-CAL of 111 patients (58 female, 53 men-average age: 58.6 years) was examined. Final diagnoses were: splenic cyst (n = 64, 57.7%); splenic abscess (n = 10, 9.0%); intrasplenic pseudoaneurysm (n = 10, 9.0%); splenic metastasis (n = 10, 9.0%); splenic infarction (n = 6, 5.4%); splenic hematoma (n = 4, 3.6%); other (n = 7, 6.3%). S-CAL groupings were type 0 (n = 11, 9.9%), type I (n = 33, 29.7%), type II (n = 24, 21.6%), and type III (n = 43, 38.7%). 'S-CAL with risk' was diagnosed in n = 41 (36.9%). Malignant S-CAL was only seen in type II (n = 2, 8.2%) and type III (n = 9, 20.9%) (p < 0.001). 'S-CALs with risk' were found more frequently in type 0 (n = 11, 100%), type II (n = 16, 66.7%) and type III (n = 13, 30.2%) than in type I (n = 1, 3%) (p < 0.001).

CONCLUSION

B-mode ultrasound, CDS, and CEUS are useful to further characterize and follow-up S-CAL and identify 'S-CAL with risk', requiring further procedures.

CLINICAL RELEVANCE STATEMENT

Ultrasound imaging is valuable for the detection, categorization, and monitoring of cystic-appearing lesions of the spleen, as well as for the identification of those with risk.

KEY POINTS

An S-CAL may introduce uncertainty in clinical practice as imaging-based risk stratification is missing. B-mode and CEUS, along with the clinical context and follow-up, assist in characterizing and identifying 'S-CAL with risk'. S-CALs encompass various lesions, including simple cysts, metastases, abscesses, and intrasplenic pseudoaneurysms.

Splenic cyst deroofing complicated with B lymphoma

BACKGROUND

Splenic cysts are uncommon and very rarely malignant therefore their treatment isn't standardized. In case of symptomatic cysts different surgical approaches have been suggested. Primary malignant lymphoma of the spleen comprises less than 1% of non-Hodgkin's lymphomas. To our knowledge, only 203 cases of splenic large B-cell lymphoma (LBCL) have been reported to date and only 2 of them were fibrin-associated splenic cysts.

CASE PRESENTATION

27-year-old model with a 19 × 13 cm splenic cyst without data of malignancy in the preliminary study and therefore treated with laparoscopic deroofing. After histological diagnosis of LBCL with a fibrin/EBV-associated splenic pseudocyst, the patient received 4 cycles of Rituximab and a laparoscopic splenectomy was performed due to resurgence of the pseudocyst. No evidence of malignancy has been found during follow up (EBV viral load every 3 months during the first year, PET-CT every 6 months during the first year and annual afterwards) performed after the splenectomy.

DISCUSSION AND CONCLUSIONS

The value of tumor markers and radiology for diagnosis of splenic cysts is put into question. Only 60 cases of Fibrin-associated LBCL (FA-LBCL) have been described in the literature therefore there are no treatment guidelines for them even though surgery together with systemic treatment has been the prevalent route with good results in most cases.

Laparoscopic partial splenectomy for a giant splenic pseudocyst with elevated CA19-9: a case report

Introduction and importance

Currently, there is a lack of reliable evidence on the management of splenic cysts, which are rare. Exploring the efficacy of laparoscopic partial splenectomy can aid in the accumulation of treatment-related evidence.

Case presentation

Here, we report the case of a 31-year-old female who was diagnosed with a giant splenic cyst with elevated serum CA19-9 and subsequently underwent laparoscopic partial splenectomy.

Clinical discussion

The effects of most treatment options for splenic cysts, including percutaneous aspiration and drainage, fenestration, and partial splenectomy, have not been confirmed by high-level evidence. With the development of minimally invasive surgery, laparoscopic partial splenectomy has drawn increasing attention. Additionally, the relationships between tumor markers and splenic cysts need to be further elucidated.

Conclusions

Laparoscopic partial splenectomy might be recommended for patients with splenic cysts, especially when the cysts are not completely covered by the splenic parenchyma.

The findings on the CEUS of diffuse large B cell lymphoma in abdomen: A case report and literature review

Background

PET-CT is the first choice for the imaging diagnosis of intraperitoneal lymphomas. Contrast-enhanced ultrasound (CEUS) is rare in the diagnosis of intraperitoneal nodal lymphoma.

Case summary

A 62-year-old man was admitted for examination with "right upper abdominal pain". Ultrasound was used to refer to the masses in the hilar region, spleen, and anterior sacral region respectively. The masses were all hypoechoic, and blood flow signals could be detected by CDFI. Laboratory tests of CA125 were within normal limits. CEUS examination was performed on the three masses respectively. The three masses showed different perfusion patterns. Thickened vessels appeared around the mass in the hilar region, a peripheral centrally directed perfusion pattern was observed in the splenic mass, and blood supply vessels appeared in the center of the presacral mass with a significant filling defect. They all showed a contrast pattern with rapid clearance and hypoenhancement compared with the surrounding areas. Ultrasound guided needle biopsy revealed non-Hodgkin's lymphoma, diffuse large B-cell lymphoma, non-germinal center origin. After biopsy, the patient was treated with R-CHOP regimen for chemotherapy, and the tumor disappeared by routine ultrasound review after 5 cycles of chemotherapy.

Conclusion

To the best of our knowledge, this report is the first to describe the findings of CEUS in intraperitoneal nodal lymphoma. CEUS has various manifestations in intraperitoneal nodal lymphoma. Future studies are still needed to explore the diagnostic features of CEUS in intraperitoneal nodal lymphoma.

Contrast-enhanced ultrasound of the spleen, pancreas and gallbladder in children

Gray-scale and color/power Doppler ultrasound (US) are the first-line imaging modalities to evaluate the spleen, gallbladder and pancreas in children. The increasing use of contrast-enhanced ultrasound (CEUS) as a reliable and safe method to evaluate liver lesions in the pediatric population promises potential for imaging other internal organs. Although CEUS applications of the spleen, gallbladder and pancreas have been well described in adults, they have not been fully explored in children. In this manuscript, we present an overview of the applications of CEUS for normal variants and diseases affecting the spleen, gallbladder and pancreas. We highlight a variety of cases as examples of how CEUS can serve in the diagnosis and follow-up for such diseases in children. Our discussion includes specific examination techniques; presentation of the main imaging findings in various benign and malignant lesions of the spleen, gallbladder and pancreas in children; and acknowledgment of the limitations of CEUS for these organs.

Giant epidermoid cyst of the spleen in a pediatric patient: A case report

RATIONALE

Splenic cysts (SCs) are rare findings in children, particularly the youngest. Here, we discuss a case that is useful for the differential diagnosis and treatment of SCs.

PATIENT CONCERNS

A 9-year-old Albanian boy was admitted for severe abdominal pain localized mainly in the left hypochondrium for approximately 24 hours. His medical history was without significant clinical problems.

DIAGNOSIS

Splenomegaly was diagnosed during the first clinical examination, and laboratory tests showed an increase in CA 125 and CA19-9. Abdominal ultrasonography showed splenomegaly with a large hypoechoic oval formation with well-defined margins and the presence of internal fine suspension spots; abdominal magnetic resonance imaging revealed a well-defined SC. The cystic lesion caused major effects on the neighboring organs, shifting them from their normal sites.

INTERVENTIONS

Considering the mass's volume, an open splenectomy was performed. Upon histopathological examination, the lesion was characterized by a stratified squamous keratinized thick lining and brownish liquid contents consisting of lymphocytes, erythrocytes, and hemosiderin-rich macrophages. These features informed the diagnosis of a giant epidermoid SC.

OUTCOMES

No complications occurred in the post-operative period, and blood exams revealed the quick normalization of CA 19.9 and CA 125 levels. The boy was discharged on the eighth post-operative day. No complaints were documented during the regular follow-up.

LESSONS

This case shows that modern imaging techniques are useful for the differential diagnosis between epithelial mass and SCs of different origins. Open splenectomy has been the treatment of choice for years, but future studies should clarify whether more conservative methods are associated with positive long-term outcomes and if they can also be used for large SCs.

Laparoscopic fenestration for a large ruptured splenic cyst combined with an elevated serum carbohydrate antigen 19-9 level: a case report

BACKGROUND

Non-parasitic splenic cysts are associated with elevated serum carbohydrate antigen (CA) 19-9 levels. We report a case in which a 23-year-old female exhibited a large ruptured splenic cyst and an elevated serum CA19-9 level.

CASE PRESENTATION

The patient, who experienced postprandial abdominal pain and vomiting, was transferred to our hospital and was found to have a large splenic cyst during an abdominal computed tomography (CT) scan. On physical examination, her vital signs were stable, and she demonstrated rebound tenderness in the epigastric region. An abdominal CT scan revealed abdominal fluid and a low-density region (12 × 12 × 8 cm) with enhanced margins in the spleen. The patient's serum levels of CA19-9 and CA125 were elevated to 17,580 U/mL and 909 U/mL, respectively. A cytological examination of the ascitic fluid resulted in it being categorized as class II. Finally, we made a diagnosis of a ruptured splenic epidermoid cyst and performed laparoscopic splenic fenestration. The patient's postoperative course was uneventful, and she was discharged on postoperative day 5. The cystic lesion was histopathologically diagnosed as a true cyst, and the epithelial cells were positive for CA19-9. Follow-up laboratory tests performed at 4 postoperative months showed normal CA19-9 (24.6 U/L) and CA125 (26.8 U/L) levels. No recurrence of the splenic cyst was detected during the 6 months after surgery.

CONCLUSION

Laparoscopic fenestration of a ruptured splenic cyst was performed to preserve the spleen, after the results of abdominal fluid cytology and MRI were negative for malignancy.