CASE 15630 Published on 07.04.2018

Splenic lymphoma: Radiologic–pathologic correlation

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Stella Ioakeimidou MD, Nikos Courcoutsakis MD D(Med)Sci, Anastasios Karayiannakis MD, Kostas Frigkas MD and Panos Prassopoulos MD.

University Hospital of Alexandroupolis,
Medical School Democritus University of Thrace,
Radiology and Medical Imaging;
Dragana, 68100 Alexandroupolis, Greece;
Email:ncourcou@med.duth.gr

Patient

64 years, female

Categories

Area of Interest Spleen ; Imaging Technique Ultrasound, CT, MR, PACS

Procedure Education ; Special Focus Lymphoma ;

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Clinical History

Sixty-four-year-old woman presented with fatigue and LUQ sensation of bulk for two months, with no fever or weight loss and otherwise free medical history. No enlarged lymph nodes or hepatomegaly were found on physical examination. The spleen was enlarged (seven cm below the left subcostal line).

Imaging Findings

US: Spleen appeared enlarged and contained a round-shaped mass. The lesion was hypoechoic and heterogeneous and a “target sign” was noted.
CT: A round-shaped mass was found on the spleen which was hypodense in the centre with unclear borders. The spleen was enlarged and had heterogeneous density parenchyma in the portal phase of the examination.
MRI: On T2 sequence a round mass, heterogeneous in signal intensity with decreased signal intensity in the centre was demonstrated. “Target-sign” was also seen.
Pathology: The lymphomatous mass protruded and invaded the splenic capsule. Lesion margins were well defined. In the centre of the mass a cavity due to necrosis was noted.

Discussion

Patients with HL have adenopathy and are asymptomatic. Splenic lymphoma tends to have systemic symptoms like fever, night sweats and weight loss. [1] NHL of the spleen is usually found incidentally manifested as a peripheral lymphocytosis. Simultaneously, NHL characteristics are referred to be symptomatic splenomegaly in advanced stages and a rare manifestation is an autoimmune characteristic like autoimmune haemolytic anaemia, immune thrombocytopaenia, circulating anticoagulants.
The main imaging patterns are splenomegaly (without a discrete mass), splenomegaly with diffuse infiltration, solitary mass (with necrosis or invasion of the splenic capsule), 2-10 cm miliary lesions, multifocal nodules (which differentiate from splenic infarcts and fungal abscesses). [2, 3]
The most-used imaging methods for evaluation of splenic pathology are US and CT. Characteristic findings in US are enlarged spleen with hypoechoic, heterogeneous mass and the presence of “target sign”. [4] On CT splenic lymphoma appears as splenomegaly containing a round mass which is usually hypodense and also one or more nodules. Sometimes infiltration of splenic artery is seen. MRI has a similar accuracy to CT, but with decreased sensitivity. [5] The low sensitivity of MRI is due to the similar relaxation times of normal splenic tissue and lymphoma. [5]

Differential Diagnosis List

NHL of the spleen

Splenomegaly (any cause)

Splenic abscess(-es) (rarely occur with lymphadenopathy)

Diffuse infiltration

Multifocal nodules

Final Diagnosis

NHL of the spleen

References

[1] Gobbi PG, Ferreri AJM,Ponzoni M, Levis A (2013) Hodgkin Lymphoma. Crit Rev Oncol Hematol 85(2):216-37 (PMID: 22867814)

[2] Anis M, Irshad A (2008) Imaging of abdominal lymphoma. Radiol Clin N Am 46:265–285 (PMID: 18619381)

[3] Li M, Zhang L, Wu N, Huang W, Lv N (2013) Imaging Findings of Primary Splenic Lymphoma: A Review of 17 Cases in Which Diagnosis Was Made at Splenectomy. PLoS One 8(11): e8026 (PMID: 24278265)

[4] Kaushik C, Relia N, Jambhekar K, Pandey T (2011) Unusual CT and MR Imaging Characteristics of Splenic Lymphoma. Case Rep Oncol Med 298357 (PMID: 22606442)

[5] Gaetke-Udager K, Wasnik AP, Kaza RK, Al-Hawary MM, Maturen KE, Udager AM, Azar SF, Francis IR (2014) Multimodality imaging of splenic lesionsand the role of non-vascular, image-guided Intervention. Abdom Imaging 39(3):570-87 (PMID: 24525666)

Case information

URL:	https://www.eurorad.org/case/15630
DOI:	10.1594/EURORAD/CASE.15630
ISSN:	1563-4086

License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Sonogram of splenic lymphoma

US (sagittal section): demonstrates enlarged spleen. Inside the spleen a round-shaped lesion with hypoechoic center—probably due to necrosis—and thickened hyperechoic borders creates ”target sign”.

Figure 2

CT of splenic lymphoma

CT (transverse section): Splenomegaly with a round-shaped mass which has low density in the center—due to necrosis—with hyperindense thickened bordes. Splenic artery is infiltrated, because it appears vague.

Figure 3

MRI of splenic lymphoma

MRI (axial MRI T2-weighted image): Round-shaped, heterogenous mass with low intensity in the centre. Splenomegaly is obvious. Small nodules around the splenic artery in the hilum are seen, correlating to lymphadenopathy.

Figure 4

Pathology gross pathology