Splenic volume model constructed from standardized one-dimensional MDCT measurements

Development and validation of a nomogram based on Lasso-Logistic regression for predicting splenomegaly secondary to acute pancreatitis

PURPOSE

Investigate the clinical characteristics of splenomegaly secondary to acute pancreatitis (SSAP) and construct a nomogram prediction model based on Lasso-Logistic regression.

METHODS

A retrospective case-control study was conducted to analyze the laboratory parameters and computed tomography (CT) imaging of acute pancreatitis (AP) patients recruited at Xuanwu Hospital from December 2014 to December 2021. Lasso regression was used to identify risk factors, and a novel nomogram was developed. The performance of the nomogram in discrimination, calibration, and clinical usefulness was evaluated through internal validation.

RESULTS

The prevalence of SSAP was 9.2% (88/950), with the first detection occurring 65(30, 125) days after AP onset. Compared with the control group, the SSAP group exhibited a higher frequency of persistent respiratory failure, persistent renal failure, infected pancreatic necrosis, and severe AP, along with an increased need for surgery and longer hospital stay (P < 0.05 for all). There were 185 and 79 patients in the training and internal validation cohorts, respectively. Variables screened by Lasso regression, including platelet count, white blood cell (WBC) count, local complications, and modified CT severity index (mCTSI), were incorporated into the Logistic model. Multivariate analysis showed that WBC count ≦9.71 × 109/L, platelet count ≦140 × 109/L, mCTSI ≧8, and the presence of local complications were independently associated with the occurrence of SSAP. The area under the receiver operating characteristic curve was 0.790. The Hosmer-Lemeshow test showed that the model had good fitness (P = 0.954). Additionally, the nomogram performed well in the internal validation cohorts.

CONCLUSIONS

SSAP is relatively common, and patients with this condition often have a worse clinical prognosis. Patients with low WBC and platelet counts, high mCTSI, and local complications in the early stages of the illness are at a higher risk for SSAP. A simple nomogram tool can be helpful for early prediction of SSAP.

Effectiveness and Safety of Avatrombopag in Liver Cancer Patients with Severe Thrombocytopenia: Real-World Data and Challenges

Background

Avatrombopag has been approved in patients who have severe thrombocytopenia (<50 × 10⁹/L) and chronic liver disease (CLD) while receiving invasive procedures. The real-world application and effectiveness of avatrombopag in the subgroup patients with liver cancer remain unknown.

Methods

Liver cancer patients (including primary liver cancer and colorectal cancer liver metastasis) who had severe thrombocytopenia and received avatrombopag were retrospectively enrolled. Avatrombopag dose, peak and absolute platelet count increase, combination treatment with other thrombopoietic agents, responder (peak count ≥50 × 10⁹/L with absolute increase ≥20 × 10⁹/L) rate, and anticancer treatment effect were analyzed. Thrombosis and bleeding events were assessed.

Results

In total, 93 patients were enrolled, with 72 and 21 in the CLD and non-CLD groups, respectively. Patients with CLD had hepatitis B or C, larger spleen volume, and a higher cirrhosis degree. Baseline platelet counts were similar between two groups (median, 37.0 × 10⁹/L vs. 39.0 × 10⁹/L; P=0.594), while patients without CLD had higher peak platelet (median, 134.0 × 10⁹/L vs. 74.0 × 10⁹/L; P=0.015) and absolute increase (median, 101.0 × 10⁹/L vs. 41.0 × 10⁹/L; P=0.020) after avatrombopag treatment. The responder rate was higher in patients without CLD (100% vs. 76.4%; P=0.010). Combined avatrombopag with other thrombopoietic agents significantly increased platelet count; repeated use of avatrombopag produced similar effects with that of initial treatment. Concerning anticancer treatment effect, patients who responded to avatrombopag had a higher disease control rate. No thrombosis or hemorrhagic events were observed, even in patients with portal vein tumor thrombosis.

Conclusion

Avatrombopag was safe and effective and ensured successful implementation of anticancer treatment in liver cancer patients with severe thrombocytopenia, accompanied with or without CLD.

Eight weeks of dry dynamic breath-hold training results in larger spleen volume but does not increase haemoglobin concentration

Purpose: It has previously been reported that repeated exposure to hypoxia increases spleen size and haemoglobin (HGB) level and recent reports on the effect apnoea has on spleen size and haematological parameters are contradictory. Therefore, this study aims to evaluate the effect apnoea training has on spleen size and haematological parameters.

Methods: The breath-holding (BH) group was comprised of 12 local student-athletes with no BH exercise experience who performed BH jogging and BH jumping rope dynamic apnoea protocols, five times weekly for 8 weeks. The BH event duration was progressively increased as the apnoea tolerance of the athletes improved (20 to 35 s). The same training task was performed by the control group (n = 10) without BH. Spleen sizes were measured with an ultrasound system and a complete blood cell analysis was performed on the median cubital venous blood.

Results: Spleen volume in the BH group increased from 109 ± 13 ml to 136 ± 13 ml (p < 0.001), and bulky platelets decreased from 70.50 ± 5.83 to 65.17 ± 5.87 (p = 0.034), but no changes were recorded for erythrocytes (p = 0.914), HGB (p = 0.637), PLTs (p = 0.346) and WBC (p = 0.532). No changes were recorded for the control group regarding spleen size or haematological parameters.

Conclusion: Eight weeks of dry dynamic apnoea training increased spleen size and decreased the number of circulating bulky platelets in the athletes who were assessed in this study. However, the baseline RBC counts and HGB levels of the athletes were not altered by the training programme.

Measurement of multiple spleen lengths is not necessary for non-invasive prediction of high-risk esophagogastric varices

AIM

To validate an appropriate spleen size measurement technique for the prediction of high-risk esophagogastric varices.

METHODS

This retrospective cross-sectional study included 369 patients who underwent ultrasonography and computed tomography (CT) of the spleen and esophagogastroduodenoscopy between January 2018 and December 2020. Maximum spleen length, width, and craniocaudal length were measured in a longitudinal view. The two-dimensional (2D) spleen index (maximum length × maximum width in the longitudinal view) was calculated. A three-dimensional (3D) spleen index was then defined as follows: 2D spleen index × maximum length in the transverse view. The similarity in spleen volume measured by CT and ultrasonography (spleen index) was assessed by the correlation coefficient. The diagnostic accuracies of the spleen index, platelet/spleen length, and platelet/spleen index were calculated to determine the overall diagnostic accuracy.

RESULTS

Compared to the other spleen indices, our 3D spleen index was significantly better correlated with spleen volume on CT (r = 0.91, 95% confidence interval 0.89-0.92, p < 0.001). Receiver-operating characteristic curve analyses revealed no significant difference between the 3D and 2D indices (p = 0.228) but did show a significant difference between the 3D and one-dimensional indices (p = 0.020). Although the area under the curve for the platelet count combined with the spleen index or length was higher than that for our 3D index, there was no significant difference between platelet count and spleen index or length (p = 0.078).

CONCLUSIONS

Platelet/spleen length has a reasonable ability to predict high-risk esophagogastric varices, even though measurement of two or three factors can be correlated with spleen volume.

[CME Sonography 96: Spleen Changes]

CME Sonography 96: Spleen Changes Abstract. The spleen is a somewhat neglected organ but there are some changes that must not be neglected. Splenomegaly, caused worldwide most commonly by malaria, can occur in other infections, in portal vein thrombosis or in portal hypertension in the context of liver cirrhosis. An accessory spleen is also often found. Sometimes after splenectomy, small remains are found which may later hypertrophy. Where focal changes are concerned, we differentiate between various forms of spleen cysts, lymphomas, metastases, and benign tumors.

Intraoperative hemorrhage and increased spleen volume are risk factors for conversion to open surgery in patients undergoing elective robotic and laparoscopic splenectomy

Objectives

Minimal invasive surgery is one of the most popular treatment approaches which is safe and effective in experienced hands in different clinical practices. In the present study, we aimed to evaluate the risks factors for conversion to open splenectomy and the performance of indirect hilum dissection technique.

Material and Methods

A total of 56 patients who underwent laparoscopic or robotic splenectomy for isolated spleen diseases were included into the study. Patients were divided into two groups as robotic or laparoscopic splenectomy (Group 1; n= 48) and conversion to open surgery (Group 2; n= 8). Patients were retrospectively evaluated according to clinical, biochemical, hematological and microbiological parameters and morbidity.

Results

No statistically significant difference was found between the groups in terms of age, gender, body mass index (BMI), ASA score, co-morbid disease, operation time, hospital stay, follow-up period, accessory spleen, diagnosis, international normalized ratio (INR), red cell distribution width (RDW), platelet distribution width (PDW), platelet to lymphocyte ratio (PLR), neutrophil to lymphocyte ratio (NLR), reapplication, splenosis, surgical site infection, vascular thrombus and incisional hernia (p> 0.05). On the other hand, intraoperative splenic hilum hemorrhage and increased spleen size (p <0.05) were higher in the conversion to open surgery group. In logistic regression analysis, intraoperative splenic hilum hemorrhage (B= 4.127) (OR= 61.974) (95% CI= 3.913-981.454) (p= 0.003) and increased spleen volume (B= 3.114) (OR= 22.509) (95% CI= 1.818-278.714) (p= 0.015) were found as risk factors for conversion to open surgery.

Conclusion

Intraoperative hemorrhage from the splenic hilum and increased spleen volume (> 400 cm3) are risk factors for conversion to open splenectomy in patients undergoing elective robotic or laparoscopic splenectomy. Indirect splenic hilum dissection can decrease intraoperative hemorrhage and conversion to open surgery.

Spleen and splenic vascular involvement in acute pancreatitis: an MRI study

BACKGROUND

To investigate the spleen and splenic vascular involvement in acute pancreatitis (AP) and their correlations with the severity of AP using magnetic resonance imaging (MRI).

METHODS

MRI of 239 patients with AP was retrospectively reviewed to assess splenic and splenic vascular complications, and the severity of AP. The severity of AP was graded by the MRI severity index (MRSI) and the New Revised Classification of AP 2012. The intravoxel incoherent motion (IVIM) parameters (D, D*, and f) of spleen were measured. Thirty-five subjects without pancreatic and splenic disorders were enrolled as controls for IVIM parameters.

RESULTS

Among the 239 patients with AP, splenomegaly (16.7%), splenic infarction (0.4%), splenic vein thrombosis (4.2%), phlebitis (7.5%) and arteritis (4.2%) were observed. Splenic vascular involvement was positively correlated with the severity of AP based on both the MRSI and the New Revised Classification of AP 2012 (P<0.05). In the control and AP groups, the splenic f values were (0.164±0.074) vs. (0.210±0.095) (P=0.023) respectively. In AP patients with and without splenomegaly, f = (0.240±0.091) vs. (0.203±0.095) (P<0.001).

CONCLUSIONS

Splenic vascular involvement and splenomegaly were common in AP. The vascular involvement was associated with the severity of AP. This complication should be considered when severity and prognosis of AP are assessed. Quantitative analysis of the spleen with IVIM might be a useful imaging biomarker for splenic perfusion changes in AP, especially in those with splenomegaly.

Does coronal oblique length of spleen on CT reflect splenic index?

AIMS AND OBJECTIVES

Splenic dimension of >12 cm on coronal plane on ultrasound is considered to represent splenomegaly. We sought to estimate the accuracy of similar coronal oblique length of spleen on CT in identifying splenomegaly by comparing it with CT splenic index. We also sought to establish the splenic width, craniocaudal dimension (CC), thickness, and coronal oblique length in both normal and splenomegaly groups.

MATERIALS AND METHODS

319 consecutive patients undergoing CT abdomen were included in the study and measurements of width (W), CC, thickness (T), and coronal oblique length (L) made. Splenic index was calculated based on the formula CC × W × T. Diagnostic accuracy of coronal oblique length in identifying splenomegaly on the basis of splenic index was assessed. Patients with splenic trauma were excluded. Patients with perisplenic collection that precluded proper measurement of spleen were excluded.

RESULTS

Of the 319 patients, 41 patients had splenomegaly with splenic index >480. 278 patients showed normal splenic index less than or equal to 480. Sensitivity and specificity of coronal oblique length as ≥12 cm in identifying splenomegaly were 97.8% and 34.1%, respectively. Positive and negative predictive values for the same were 91% and 70%, respectively (p value-0.000). There is overlap of numerical values for thickness and coronal oblique length in the normal and splenomegaly groups for a 95% confidence interval, whereas there is no significant overlap between these groups with respect to the craniocaudal length and width. Hence, craniocaudal length of 9.5 cm and width of 10.6 cm may be used as upper cutoff limit for normal spleen.

CONCLUSION

Coronal oblique dimension of spleen >12 cm is highly sensitive and shows good positive predictive value in diagnosing splenomegaly but has poor specificity and negative predictive value. Ideally, splenic index calculated using the CC, width, and thickness is the most reliable measurement for diagnosing splenomegaly. But if single measurements are to be used for identifying splenomegaly, craniocaudal length >9.5 cm, width of >10.6 cm, and coronal oblique dimension >12 cm may be used.

AnaFe: Visual Analytics of Image-derived Temporal Features-Focusing on the Spleen

We present a novel visualization framework, AnaFe, targeted at observing changes in the spleen over time through multiple image-derived features. Accurate monitoring of progressive changes is crucial for diseases that result in enlargement of the organ. Our system is comprised of multiple linked views combining visualization of temporal 3D organ data, related measurements, and features. Thus it enables the observation of progression and allows for simultaneous comparison within and between the subjects. AnaFe offers insights into the overall distribution of robustly extracted and reproducible quantitative imaging features and their changes within the population, and also enables detailed analysis of individual cases. It performs similarity comparison of temporal series of one subject to all other series in both sick and healthy groups. We demonstrate our system through two use case scenarios on a population of 189 spleen datasets from 68 subjects with various conditions observed over time.

Platelet count combined with right liver volume and spleen volume measured by magnetic resonance imaging for identifying cirrhosis and esophageal varices

AIM

To determine whether the combination of platelet count (PLT) with spleen volume parameters and right liver volume (RV) measured by magnetic resonance imaging (MRI) could predict the Child-Pugh class of liver cirrhosis and esophageal varices (EV).

METHODS

Two hundred and five cirrhotic patients with hepatitis B and 40 healthy volunteers underwent abdominal triphasic-enhancement MRI and laboratory examination of PLT in 10(9)/L. Cirrhotic patients underwent endoscopy for detecting EV. Spleen maximal width (W), thickness (T) and length (L) in mm together with spleen volume (SV) and RV in mm(3) were measured by MRI, and spleen volume index (SI) in mm(3) was obtained by W × T × L. SV/PLT, SI/PLT and RV × PLT/SV (RVPS) were calculated and statistically analyzed to assess cirrhosis and EV.

RESULTS

SV/PLT (r = 0.676) and SI/PLT (r = 0.707) increased, and PLT (r = -0.626) and RVPS (r = -0.802) decreased with the progress of Child-Pugh class (P < 0.001 for all). All parameters could determine the presence of cirrhosis, distinguish between each class of Child-Pugh class, and identify the presence of EV [the areas under the curve (AUCs) = 0.661-0.973]. Among parameters, RVPS could best determine presence and each class of cirrhosis with AUCs of 0.973 and 0.740-0.853, respectively; and SV/PLT could best identify EV with an AUC of 0.782.

CONCLUSION

The combination of PLT with SV and RV could predict Child-Pugh class of liver cirrhosis and identify the presence of esophageal varices.

Quantitative assessment of the presence and severity of cirrhosis in patients with hepatitis B using right liver lobe volume and spleen size measured at magnetic resonance imaging

OBJECTIVE

To determine whether right liver lobe volume (RV) and spleen size measured utilizing magnetic resonance (MR) imaging could identify the presence and severity of cirrhosis in patients with hepatitis B.

METHODS

Two hundred and five consecutive patients with clinically confirmed diagnosis of cirrhosis due to hepatitis B and 40 healthy control individuals were enrolled in this study and underwent abdominal triphasic enhanced scans using MR imaging. Spleen maximal width (W), thickness (T) and length (L), together with RV and spleen volume (SV), were measured utilizing MR imaging. Spleen multidimensional index (SI) was obtained by multiplying previously acquired parameters W×T×L. Then statistical assessment was performed to evaluate the ability of these parameters, including RV, SV, RV/SV and SI, to identify the presence of cirrhosis and define Child-Pugh class of this disease.

RESULTS

SV and SI tended to increase (r = 0.557 and 0.622, respectively; all P<0.001), and RV and RV/SV tended to decrease (r = -0.749 and -0.699, respectively; all P<0.001) with increasing Child-Pugh class of cirrhosis. All the parameters, including RV, SV, RV/SV and SI, might be the indicators used to discriminate the patients with liver cirrhosis from the control group, and to distinguish these patients between Child-Pugh class A and B, between B and C, and between A and C (area under receiver operating characteristic curve [AUC] = 0.609-0.975, all P<0.05). Among these parameters, RV/SV was the best noninvasive factor for the discrimination of liver cirrhosis between Child-Pugh class A and B (AUC = 0.725), between A and C (AUC = 0.975), and between B and C (AUC = 0.876), while SI was the best variable to distinguish the cirrhosis patients from the control group (AUC = 0.960, P<0.05).

CONCLUSION

RV/SV should be used to identify the severity of cirrhosis, while SI can be recommended to determine the presence of this disease.

Spleen size measured on enhanced MRI for quantitatively staging liver fibrosis in minipigs

PURPOSE

To investigate whether and how spleen size measured on magnetic resonance imaging (MRI) could be used to stage liver fibrosis.

MATERIALS AND METHODS

Sixteen minipigs were used to prospectively model liver fibrosis staged by biopsy. Abdominal gadolinium-enhanced MRI was performed on the 0, 5th, 9th, 16th, and 21st weekend after beginning of the modeling. Splenic maximal width (W), thickness (T), length (L), and area (S) together with spleen volume (SV) and liver volume (LV) were measured on enhanced MRI and the ratio of SV to LV (SV/LV) was calculated. Spleen multidimensional indexes 1 and 2 were obtained by W × T × L and S × L, respectively. Statistical analyses were performed to determine which parameter could best stage the fibrosis.

RESULTS

W, T, L, S, SV, index 1 and 2, and SV/LV tended to increase with increasing stages of fibrosis (r = 0.46-0.796, all P < 0.001), and might predict liver fibrosis stage ≥1, ≥2, ≥3, and 4 (area under receiver operating characteristic curve [AUC] = 0.697-1.0, all P < 0.05). Among the parameters, splenic index 1, SV, and SV/LV might be best for predicting stage ≥1 (AUC = 0.941), ≥2 or ≥3 (AUC = 0.875 or 0.978, respectively), and 4 (AUC = 1.0), respectively.

CONCLUSION

Spleen size measured on MRI could be used for staging liver fibrosis.

Spleen size in idiopathic and heritable pulmonary arterial hypertension

BACKGROUND

It is unknown whether the spleen size correlates with disease severity and outcome in patients with idiopathic and heritable pulmonary arterial hypertension (PAH).

OBJECTIVES

To determine the prevalence of splenomegaly in PAH and assess whether it correlates with severity of disease and outcome.

METHODS

We identified subjects with either heritable or idiopathic PAH who had Doppler echocardiography, right-heart catheterization and computed tomography (CT) of the chest and/or abdomen that included the spleen.

RESULTS

We included 62 subjects with a mean age (±SD) of 49 (±15) years; 82% were women. Spleen dimensions were 10 (±3), 6 (±2) and 9 (±2) cm for the craniocaudal length, thickness and width measurements, respectively. The median [interquartile range (IQR)] spleen volume was 344 (225-533) cm3. Splenomegaly was observed in 52-63% of the patients, depending on the formula used. The spleen volume was not associated with clinical, echocardiographic or hemodynamic variables. Spleen volume was not associated with adjusted mortality. We studied the characteristics of the spleen during autopsy in 9 patients with idiopathic PAH who died of right-heart failure. The mean (IQR) spleen weight was 220 (151-325) g. We observed early congestion in all but 2 patients who had chronic congestion.

CONCLUSIONS

Splenomegaly of predominantly mild degree is common in idiopathic and heritable PAH. However, spleen size was not associated with clinical, echocardiographic, hemodynamic and survival data in these patients.

Laparoscopic spleen-preserving distal pancreatectomy in elderly subjects: splenic vessel sacrifice may be associated with a higher rate of splenic infarction

BACKGROUND

Laparoscopic spleen-preserving distal pancreatectomy has gained popularity in recent years. Splenic preservation can be achieved with or without splenic vessel preservation (SVP). The potential morbidity of this approach in patients aged >70 years has not been well defined.

METHODS

Ten patients aged >70 years underwent attempted laparoscopic spleen-preserving distal pancreatectomy within a 2-year period. Multiple patient parameters were examined and chi-squared analysis was used to evaluate the association between the operative technique (SVP or splenic vessel division [SVD]) and splenic infarction. The Mann-Whitney test was used to compare the SVP and SVD groups with regard to age, estimated blood loss (EBL), operating time, splenic volume and length of stay (LoS).

RESULTS

Median age was 81 years (range: 71-92 years). Operating room time, LoS, EBL and complication rates were similar to those reported in published series of younger patients. In four patients, the splenic vessels were divided in a manner relying on short gastric collateral flow; SVP was achieved in all other patients. All four patients who underwent SVD developed splenic infarcts and three required splenectomy to manage this (P=0.002). Median LoS was increased in the SVD group (9.3 days vs. 4.3 days; P=0.053). Estimated blood loss was higher in the SVP group (200 ml vs. 100 ml; P=0.091). One pancreatic leak occurred. There were no mortalities.

CONCLUSIONS

Spleen-preserving laparoscopic distal pancreatectomy can be performed safely in elderly patients, with results comparable with those achieved in younger subjects. However, elderly patients undergoing division of the splenic artery and vein may be at higher risk for splenic infarct and the aetiology of this is unclear.