Primary angiosarcoma of the spleen: in vivo and in vitro MRI findings

Gadoxetate disodium (Gd-EOB-DTPA) contrast-enhanced magnetic resonance imaging for differentiation between benign and malignant splenic lesions in dogs

Malignant splenic lesions in dogs are common, with hemangiosarcoma diagnosed most frequently, and there have been no consistent clinicopathologic, gross, or imaging characteristics identified that differentiate malignant from benign splenic lesions. Histopathology is required for definitive diagnosis, and given the poor long-term prognosis of malignant splenic lesions, a noninvasive tool to aid in diagnosis would be valuable. This prospective cohort study utilized gadoxetate disodium, a liver-specific contrast agent (Gd-EOB-DPTA; Eovist), to identify the general lesion and pre- and postcontrast signal characteristics of benign and malignant splenic and hepatic lesions in dogs with naturally occurring disease. Twenty-five dogs were enrolled, Eovist-enhanced MRI was performed, and dogs were taken to surgery for splenectomy and other organ biopsy. All histopathology and MRI studies were evaluated by a single pathologist and a single radiologist, respectively. The associations between the tumor type and numerous variables defined on MRI were evaluated using Fisher's exact tests, and the significance was identified at a P-value of .05. Malignant splenic masses were identified in 11/25 (44%) dogs, and 5/11 malignancies represented hemangiosarcoma. The presence of abdominal effusion (P = .017) and the presence of hepatic nodules on MRI (P = .009) were associated with splenic malignancy. There were no benign T2 hyperintense and no malignant T2 hypointense lesions (P = .021). Utilization of the T2 W MRI sequence may aid in the identification of malignant splenic lesions, particularly when accompanied by abdominal effusion and hepatic lesions.

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.

Imaging features of primary sites and metastatic patterns of angiosarcoma

Angiosarcomas are rare, aggressive soft tissue sarcomas originating from endothelial cells of lymphatic or vascular origin and associated with a poor prognosis. The clinical and imaging features of angiosarcomas are heterogeneous with a wide spectrum of findings involving any site of the body, but these most commonly present as cutaneous disease in the head and neck of elderly men. MRI and CT are complementary imaging techniques in assessing the extent of disease, focality and involvement of adjacent anatomical structures at the primary site of disease. CT plays an important role in the evaluation of metastatic disease. Given the wide range of imaging findings, correlation with clinical findings, specific risk factors and patterns of metastatic disease can help narrow the differential diagnosis. The final diagnosis should be confirmed with histopathology and immunohistochemistry in combination with clinical and imaging findings in a multidisciplinary setting with specialist sarcoma expertise. The purpose of this review is to describe the clinical and imaging features of primary sites and metastatic patterns of angiosarcomas utilising CT and MRI.

Spleen angiosarcoma: a world review

Introduction: Spleen angiosarcoma (SA) is a rare malignant neoplasm that arises from the splenic vascular endothelium, with only around 300 cases reported to date. Due to a limited number of reported cases, there is a paucity of data and a lack of understanding of its presentation, diagnosis, and management. In this study, we aim to provide a comprehensive review of SA.Areas covered: On 27 February 2021, a literature search was done in PubMed and Embase database. The search yielded 122 articles involving 205 patients. The focus was on patient demographics, risk factors, clinical presentations, investigation results, preliminary diagnoses, therapies provided, and patient outcomes. These factors were analyzed to identify possible risk factors, diagnostic modalities, and therapeutic principles that were not mentioned before.Expert opinion: The clinical presentation or investigation results of patients with SA are often nonspecific. Hence, they may not be sufficient to clinch the diagnosis of SA if used alone. The authors recommend a triple assessment of clinical examination, imaging findings, and pathology to diagnose SA with high accuracy. Splenectomy should be the mainstay of management, with chemotherapy and radiotherapy considered as adjuncts, especially in the presence of metastases.

Long-Term Survival due to Chemotherapy including Paclitaxel in a Patient with Metastatic Primary Splenic Angiosarcoma

A primary splenic angiosarcoma is a rare type of soft tissue sarcoma and is associated with an extremely poor prognosis. In this study, we describe the case of a patient who was diagnosed with metastatic primary splenic angiosarcoma and survived for about 2 years. A 62-year-old female was referred to us for the treatment of splenic angiosarcoma with disseminated intravascular coagulation (DIC) and multiple liver and bone metastases. Paclitaxel therapy resulted in recovery from DIC and enabled her to continue sequential treatment through to sixth-line chemotherapy. We reviewed all splenic angiosarcoma case reports which were described as stage IV to date and compared with our case. From these data, we found that the median overall survival was 105 days, and the prognosis of splenic angiosarcoma of stage IV was worse than conventional case series. Splenectomy was performed in more patients than chemotherapy as a treatment. Moreover, various chemotherapeutic regimens were used. These data suggest that administering chemotherapy including paclitaxel to patients with splenic angiosarcoma might improve their prognosis.

A review of anatomy, pathology, and disease spread in the perisplenic region

The perisplenic region is a complex anatomical area involving multiple peritoneal and subperitoneal structures, which influence the presentation and behavior of various pathologic processes. This review is a comprehensive resource for perisplenic anatomy and pathology with associated clinical presentations and imaging findings. Understanding the pathophysiologic intricacies of the perisplenic region assists the radiologist in building a helpful differential diagnosis and recognizing predictable disease patterns.

Presurgical assessment of splenic tumors in dogs: a retrospective study of 57 cases (2012-2017)

The purpose of this study was to evaluate the clinical and imaging characteristics of canine splenic tumors and to establish guidelines for the presurgical assessment of splenic tumors in dogs. Fifty-seven dogs that underwent total splenectomy for the treatment of splenic tumors were evaluated by examining medical records, hematologic results, diagnostic imaging results, and histopathologic results. The maximum lesion size from ultrasonography was significantly different between malignant and benign tumors (p = 0.002). There was a correlation between tumor margination and type of splenic tumors (p = 0.045). Precontrast lesion attenuation on computed tomography was significantly different between splenic malignant and benign tumors (p = 0.001). The mean ± SD precontrast lesion attenuation of malignant tumors was 40.3 ± 5.9 Hounsfield units (HU), and for benign tumors, it was 52.8 ± 6.8 HU. In conclusion, some variables of the imaging examination could be used to distinguish the type of splenic tumor. Based on the study results, using a diagnostic flowchart would be effective in increasing the survival rate of patients with splenic malignant tumors. In addition, fine needle aspiration or magnetic resonance imaging prior to surgical exploration and histopathologic examination may be useful in achieving a more accurate diagnosis.

Angiosarcoma: clinical and imaging features from head to toe

Angiosarcoma is a rare, aggressive subtype of soft-tissue sarcoma with a propensity for local recurrence and metastasis associated with a generally poor prognosis, unless diagnosed early. Given the vascular endothelial cell origin of angiosarcoma, tumours may develop in essentially any organ; however, there is a predilection for the skin where half of all tumours arise, increasing in prevalence with age. The most common risk factors are chronic lymphoedema and history of radiation. We review the most important radiological findings along the spectrum of angiosarcoma from head to toe throughout the body, including uncommon and rare locations. Key imaging features of angiosarcoma across multiple organ systems will be described, as well as the impact on management and prognosis.

Diagnosis of a large splenic tumor in a dog: computed tomography versus magnetic resonance imaging

This study demonstrated magnetic resonance imaging (MRI) and computed tomography for large-sized splenic hemangiosarcoma. Radiography and ultrasonography revealed the presence of a large-sized soft-tissue mass in the cranial abdomen. Computed tomography showed hypoattenuating mass. The mass was located in contact with liver, spleen and stomach, and the origin of the mass remained ambiguous. The mass was T2-hyperintense and T1-hypointense with mild contrast enhancement. MRI allowed a differentiation between large-sized tumor and neighboring normal structure, and the mass was consequently identified as arising from spleen. These results suggested that MRI might be a useful tool to visualize large-sized splenic tumors and improve the accuracy of diagnosis.

Primary angiosarcoma of the spleen as depicted on computed tomography

Primary angiosarcoma of the spleen is rare, usually widespread or has a splenic rupture by the time of presentation, and almost always has poor prognosis; early radiological diagnosis is necessary for improving the survival rate. We report two special cases of this disease. Both patients did not have pathologic metastasis or splenic rupture, but their computed tomography (CT) manifestations were distinct from each other and had uncommon characteristics. We compared the CT features with pathological findings.

Sarcomas of abdominal organs: computed tomography and magnetic resonance imaging findings

Sarcomas originating from abdominal organs are extremely rare, and literature in which investigators focus on their imaging features is scarce. This article aims to review the computed tomography and magnetic resonance imaging features of these rare tumors and to help in clinical diagnosis. Various sarcomas (eg, angiosarcoma, undifferentiated embryonal sarcoma, leiomyosarcoma, carcinosarcoma, rhabdomyosarcoma) originating, respectively, from different abdominal visceral organs (liver, pancreas, spleen, kidney, adrenal gland, uterus, and prostate gland) are reviewed along with cases we encountered.

MR imaging of the spleen: spectrum of abnormalities

The spleen has the same relationship to the circulatory system that the lymph nodes have to the lymphatic system. A wide range of diseases can affect the spleen. Pathologic conditions of the spleen can be classified into the following categories: congenital diseases (accessory spleen, polysplenia, and asplenia); trauma; inflammation (abscess, candidiasis, histoplasmosis, and sarcoidosis); vascular disorders (infarction, diseases affecting the splenic vasculature, and arteriovenous malformation); hematologic disorders (sickle cell disease and extramedullary hematopoiesis); benign tumors (cysts, hemangioma, diffuse hemangiomatosis of the spleen, and hamartoma); malignant tumors (sarcoma, lymphoma, and metastases); and other disease processes that affect the spleen diffusely (portal hypertension, Gaucher disease, and sickle cell disease) or focally (Gamna-Gandy nodules). New magnetic resonance (MR) imaging techniques have increased the role of MR imaging in detection and characterization of splenic diseases. MR imaging is an excellent tool for diagnosis and evaluation of focal lesions and pathologic conditions of the spleen.

Angiosarcoma of the spleen clinically presenting as metastatic ovarian cancer. A case report and review of the literature

Primary angiosarcomas of the spleen are rare and almost always fatal. With no more than 200 cases reported in the literature worldwide, no specific risk factors are strongly associated with the disease. The mean age of patients at presentation is 59 years and the major clinical findings include abdominal pain, splenic rupture, and splenomegaly. Grossly, this neoplasm appears as hemorrhagic and/or cystic nodules, with a low-density signal seen on computed tomographic scans. Histologically, the tumor is characterized by neoplastic proliferation with diffuse or focal areas of a vasoformative component with cavernous and arborizing channels. The vascular spaces are lined by endothelial cells with variable degree of atypia. The differential diagnosis includes a variety of benign and malignant vascular proliferations (littoral cell angioma and Kaposi's sarcoma) as well as metastatic tumors. The worst prognostic factor is splenic rupture with early metastasis. The liver is the most common site. We report a case of the 43-year-old woman with a long-standing history of recurrent ovarian carcinoma treated with surgery and multiple courses of radiation therapy and chemotherapy who clinically appeared to have a metastatic ovarian cancer to the spleen and treated with partial resection of stomach and splenectomy. However, histopathologic examination of the specimen showed the tumor to be of a primary angiosarcoma. We believe that the lengthy exposure to radiation may have played a role in the histopathogenesis of this neoplasm in this patient.

Angiosarcoma of the spleen: imaging characteristics in 12 patients

PURPOSE

To retrospectively review clinical, pathologic, and imaging features of angiosarcoma of the spleen in 12 patients.

MATERIALS AND METHODS

Institutional review board approval was obtained, and informed consent was not required. Records of 12 cases of proved angiosarcoma of the spleen were accessed from the files of the Armed Forces Institute of Pathology. Clinical, pathologic, and imaging findings were reviewed. Presenting signs and symptoms were recorded, and the pathologist confirmed the diagnosis and determined gross and microscopic morphologic findings in each spleen. Radiologists reviewed available images to determine the size of the spleen and mass, amount of splenic involvement by the tumor (if enhanced at computed tomography [CT] and magnetic resonance [MR] imaging), and amount of nonviable tumor determined as decreased echogenicity at ultrasonography (US) and lack of enhancement at CT and MR imaging. Imaging and pathologic findings were compared. Five US, 10 CT, three MR, and two angiographic images were reviewed by two experienced abdominal radiologists.

RESULTS

There were seven men and five women (age range, 36-86 years; mean, 55 years). The most common symptom was upper abdominal pain in eight (67%) patients: Pain was acute for 24 hours prior to admission in one patient and chronic (range, 1-6 months) in seven patients. At imaging, the spleen was enlarged (>12 cm in length) in nine patients. The most common finding, seen in seven (58%) patients, was a complex mass or masses in an enlarged spleen. Four of these patients had evidence of metastases and one had intraperitoneal hemorrhage. Two patients had solitary hypervascular tumors and liver metastases. One patient had a normal-sized spleen with multiple lesions that ranged 2-3 cm in size, as well as metastases to the spine. The 11th patient had two small lesions, with small calcifications in the periphery of one lesion. The 12th patient had intraabdominal hemorrhage around the spleen and no obvious mass at CT. Tumor necrosis was confirmed at histologic evaluation in nine patients.

CONCLUSION

The most common clinical finding was upper abdominal pain. Angiosarcoma of the spleen could be suggested in the majority of cases (83%) by using the imaging features of splenic mass with evidence of metastatic disease.