0:02

Hello and welcome to Noon Conference, hosted

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by Modality Noon Conference connects the global radiology

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community through free live educational webinars

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that are accessible for all.

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It's an opportunity to learn alongside top

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radiologists from around the world.

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You can access the recording of today's noon conference

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and previous noon conferences by creating a free account.

0:20

Today we're honored to welcome Dr.

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Deborah Baumgarten for a lecture entitled Case-Based Review

0:24

of Splenic Abnormalities.

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Dr. Baumgarten completed medical school

0:28

and all of her radiology training at Emory University.

0:31

She was on staff at Emory for over 25 years

0:33

before moving to the Mayo Clinic in Jacksonville, Florida,

0:35

where she specializes in abdominal imaging

0:37

with a special interest in ultrasound and GU imaging.

0:41

At the end of the lecture, please join Dr.

0:42

Baumgarten in a q and A session

0:44

where we'll address questions you may have on today's topic.

0:47

Please remember to use the q

0:48

and a feature to submit your questions so we can get to

0:50

as many as we can before our time is up.

0:53

With that, we are ready to begin today's lecture. Dr.

0:55

Baumgarten, please take it from here.

0:58

Awesome. Great.

1:00

So I know that normally q and A occurs at the end,

1:03

but I do have both the chat function opened and the q

1:06

and a open and another screen on my computer.

1:09

So if there are questions that seem relevant to try

1:12

to answer as we go along, I will do my best to answer those.

1:16

So a few months ago I was asked to, uh,

1:18

give a lecture on the spleen.

1:20

I, I guess that's one of the topics

1:21

that Modality didn't have in its arsenal.

1:24

So I've put together this case-based review

1:26

of splenic abnormalities.

1:29

I have no financial disclosures

1:30

that are relevant to this presentation.

1:33

I will say that I am the, uh, section editor for UpToDate

1:37

or one of the section editors for UpToDate.

1:39

And I do a bunch of, uh, GU topics.

1:42

I am the current president of the American Rent

1:44

and Raise Society and I serve on the editorial board

1:47

of both radiology and radiology imaging cancer.

1:51

The relevance of the presidency of the rank

1:53

and Ray, uh, well I'll get back to that in a second.

1:57

Uh, by learning objectives, first I'm gonna go

1:59

through what's normal and then an approach

2:01

to splenic lesions and I'll highlight some features that

2:05

will make you worried or not so worried.

2:08

Uh, looking at stability is a very important factor

2:11

to determine whether something's important in

2:13

the spleen or not.

2:15

The use of MRI as a problem solver.

2:18

And then here's where that, uh, presidency comes in handy.

2:21

There was a paper published in our new journal,

2:24

the radiology, uh, the R three Rank

2:26

and Ray Review that is published

2:28

by the American Rank and Ray Society.

2:30

And it is an article

2:34

based on the spleen, incidental splenic lesions

2:37

and they propose an algorithm

2:39

for their assessment and management.

2:41

Um, this article is free if you're a member of the rank

2:44

and Ray and if any of you are in training either medical

2:47

students, uh, in residency

2:50

or in fellowship, you can join the rank and write for free

2:53

and get access to this uh, uh, this um, particular inter uh,

2:58

article as well as many other articles.

3:00

However, I've gotten permission

3:02

for everyone who's watching this noon conference now

3:06

and probably for about the next 30 days

3:09

to have this spleen article for free.

3:10

So this is the QR code that you can use

3:12

that will take you directly to an open access, full version

3:16

of this article.

3:18

And then this is the um, rank

3:20

and Ray membership application website.

3:22

If you are interested

3:24

as a trainee in having a free membership

3:27

or if you're not a trainee and would like to join the rank

3:30

and Ray, uh, you can go to the website as well.

3:33

So let's start with what's normal.

3:36

Uh, I consider about 13 centimeters in greatest dimension

3:40

to be upper limits of normal for spleen size.

3:42

And I'll measure the spleen either in a coronal image,

3:45

cranial coddle, or occasionally if the greatest dimension is

3:49

actually anterior posterior,

3:51

I'll measure it on an axial image.

3:54

On ct, the spleen should be slightly less dense than the

3:58

normal liver on a non-contrast ct

4:00

and you've gotta make sure you're dealing

4:02

with a normal liver, not one that's fatty, infiltrated,

4:05

or one that's too dense

4:07

because of hemochromatosis or something like that.

4:10

And in this case, this liver is measuring about 59 hound

4:13

field units and the spleen is measuring about

4:16

49 hounds field units.

4:17

So that's the normal ratio

4:19

between the liver and spleen density.

4:22

You can have a very modeled appearance

4:24

or sometimes described as zebra stripes

4:27

on an arterial phase.

4:29

The spleen is highly vascular

4:31

and will enhance more than the liver on an arterial phase.

4:35

But by the venous and later phases you have more homogeneous

4:38

enhancement and it's more similar

4:40

to the liver on mr.

4:44

The spleen is slightly

4:45

or a little bit more bright on T two weighted imaging

4:48

compared to the liver on T one.

4:51

It's slightly darker than the liver

4:54

and has the same enhancement pattern as ct

4:57

and I think we can appreciate that sort

4:59

of zebra striping a little bit better in this particular

5:02

patient on the arterial phase.

5:04

And then the homogeneous enhancement

5:07

on the portal venous phase,

5:12

there is restricted diffusion in the spleen,

5:14

meaning it stays dark on that diffusion weighted mapping.

5:21

So let's get into some of these cases.

5:24

So our first case is an 83-year-old female who presented

5:27

with abdominal pain

5:29

and her physicians ordered an upper abdominal ultrasound

5:34

as her first study.

5:37

So here we have selected images from the

5:39

left upper quadrant.

5:40

They're labeled long and transverse spleen

5:43

and what we see is a rounded lesion within the spleen.

5:47

This is normal splenic parenchyma.

5:49

Here the lesion is slightly hypoechoic with areas

5:54

that look a little more liquified,

5:56

necrotic perhaps, or just cystic.

5:59

This lesion is fairly large, it's about seven

6:02

and a half centimeters.

6:04

And when we put color doppler on the limb I on the uh area,

6:09

we see that the areas

6:10

that look more solid don't actually have any discernible

6:14

flow, whereas the spleen next

6:16

to the lesion does have discernible flow.

6:19

So if anybody would like

6:20

to type into the chat box if they have any ideas about

6:23

what this might be, that would be great.

6:25

As we're going along, um, I'm, I would love to hear

6:28

what you guys have to say about these lesions,

6:33

but if not this patient then

6:35

because this was rather nonspecific, the patient went on

6:38

to have an MRI and on the T two weighted image we see

6:42

that the lesion is very heterogeneous.

6:44

There are a few areas of bright signal that might correspond

6:48

to those areas of fluid,

6:49

but the majority of the lesion has a very dark T two signal

6:53

which may indicate blood products or hemosiderin.

6:56

This is a pre contrast T one weighted image

6:59

and a later phase post contrast T one weighted image.

7:03

And there is no, uh, distinct enhancement within this area.

7:07

If we did subtracted imaging,

7:09

this would not show enhancement at all.

7:12

So given the appearance at ultrasound of this rounded area

7:17

with these sort of quote solid areas that don't have flow

7:20

and the fact that it looks a little bit like blood products

7:23

here, a splenic hematoma which somebody has typed in there,

7:27

which is great, um,

7:31

works is perfect.

7:32

This is an old hematoma.

7:33

Now unfortunately this patient did not have a history

7:35

that we could discern of trauma,

7:37

but she probably at some point had had trauma.

7:40

All right, so this was a hemorrhagic cyst which is a benign

7:43

finding and for which no further imaging

7:45

follow-up is needed.

7:48

Our next case is a 41-year-old male

7:51

who did actually have a history of trauma about a week

7:54

before he presented to the emergency room

7:56

with some vague left upper quadrant discomfort.

8:00

He had initially been cleared

8:01

after his motor vehicle collision, so he got a CT scan

8:06

and this is an image that's showing you portions

8:09

of the liver, the left kidney, right kidney,

8:12

and the spleen here.

8:15

So what we're seeing is an area of decreased enhancement.

8:19

Uh, this may be a little vessel coming in from the hilum.

8:22

There's a little bit of blush of enhancement here.

8:24

Maybe a little enhancement along the edge of this lesion,

8:28

some modeled appearance

8:29

of the more peripheral spleen in this patient.

8:33

Now, does anybody have any ideas of

8:35

what might be really important to get next in this patient,

8:39

especially while we have them on the uh, CT scanner?

8:43

Is there anything else that might be very helpful?

8:46

I've seen somebody has put laceration

8:49

suggesting a CT angiogram that might be very helpful

8:52

to see if there's active bleeding.

8:54

What might also be useful without actually having

8:57

to get okay, a fast

8:59

interventional embolization get a delayed image.

9:02

Excellent. The person who suggested a delayed image,

9:05

and this is what we've got, this is a little bit lower,

9:07

the original area looked similar in this image

9:10

and then we see that there is bright enhancement similar

9:13

to the blood pool in this case.

9:16

So does anybody know what this is then?

9:21

This is a pseudo aneurysm following trauma in this patient.

9:25

This is not an incidental hemangioma,

9:27

this is actually a pseudo aneurysm

9:29

and the person who suggested interventional embolization

9:32

is absolutely correct.

9:34

There is a very large risk

9:35

of rupture from pseudo aneurysms in the spleen after trauma.

9:41

Um, and these need to be embolized.

9:42

If they're really large

9:44

or embolization does not include, does not uh, take care

9:48

of the problem, then splenectomy would be the next choice,

9:50

which is not optimal

9:52

but could be done to avoid the risk

9:54

of massive hemoperitoneum.

9:56

This person's very lucky that they had some vague symptoms.

9:59

They could have had a silent rupture of the spleen

10:02

and not made it to the emergency department for a second.

10:05

Look. Okay, we have a 57-year-old female who's coming in

10:10

for restaging.

10:11

I'm not gonna mention what cancer this patient has,

10:13

but just know that she does have a history of cancer.

10:17

So I've got two images at the top here showing you both the

10:20

liver and the spleen.

10:22

This is in an arterial phase.

10:23

This is in a portal venous phase

10:26

and we can see that there are some

10:27

lesions here in the liver.

10:29

This one has a little rind

10:31

of slightly high attenuation on the arterial phase.

10:34

The lesions become more homogeneously hypo enhancing

10:38

on the portal venous phase.

10:40

And these are two separate lesions, so there's more than one

10:42

but of course this is a le a lecture on the spleen.

10:45

So we see that there is this large lesion here in the spleen

10:49

and maybe another smaller one here.

10:52

And the imaging characteristics are somewhat similar

10:54

to the lesion in the liver.

10:56

So these are additional metastatic lesions.

10:59

What's also really important though is to note

11:03

that this patient has a similar lesion in a large spleen.

11:09

Now most splenic uh, metastases

11:14

are from hematogenous spread.

11:15

So through the generalized arterial system they are filtered

11:20

through the spleen and some do set up shop there.

11:22

They're very rarely by retrograde flow

11:26

through the splenic vein or through lymphatics.

11:30

One of the most common is breast for a metastatic lesion.

11:33

And someone mentioned that in the chat function

11:36

other in a large series breast was the most common followed

11:39

by lung, ovary, stomach

11:42

and melanoma as well as prostate.

11:45

So what you'll notice aside from stomach, the kinds

11:49

of cancers that spread to the spleen are not the GI cancers.

11:54

GI cancers tend to go to the liver first

11:56

because they go through the portal vein

11:58

because the stomach is right adjacent to the spleen.

12:00

It might explain why there is a little bit more metastatic

12:03

disease from the stomach than other GI cancers.

12:06

If you have a GI cancer in the spleen metastatic, it means

12:10

that it's very widespread, probably late stage and has

12:13

and should already have had liver metastases.

12:17

A lot of splenic metastases are microscopic

12:20

and asymptomatic so we don't actually see them at all

12:24

when we are scanning our patients

12:26

and they might only be discovered if the patient undergoes

12:29

autopsy for some reason they tend to be hypodense

12:33

to the spleen following contrast administration.

12:36

This one turned out to be a melanoma metastasis

12:39

and something important to consider when you are thinking

12:43

about metastases in the spleen is

12:46

that if s splenectomy is being considered as a treatment,

12:49

which of course it wouldn't be in this case

12:51

'cause we have widespread mets in other areas,

12:53

but if splenectomy is going to be a treatment choice,

12:58

you need to make sure you look very carefully

13:00

for any other splenic tissue

13:02

and make sure that those spleen needles are also

13:05

removed at the same time.

13:08

This is another patient also with metastatic melanoma

13:11

who has a solitary very large mass.

13:14

This is extremely nonspecific in appearance as I'll show you

13:18

as we go along to some of our other cases.

13:20

And knowing this patient's history is paramount in making

13:23

the correct diagnosis.

13:28

Okay, our next case is a 62-year-old male

13:32

and he presented with left chest and shoulder pain.

13:37

So here is the ct, I have an axial and a coronal CT scan

13:42

and this looks a lot like our last patient, very irregular

13:46

shaped hypodense mass,

13:49

occupying a large portion of the spleen.

13:52

There may be a second smaller satellite lesion here.

13:56

There was no other disease in the abdomen

13:58

and the patient did not have a history

14:00

of any known malignancy.

14:04

The reason they probably presented with shoulder pain is

14:06

because this lesion is getting very close to the diaphragm

14:10

and is irritating the diaphragm which may

14:14

refer to the shoulder.

14:16

There also might be a capsular breach

14:18

as someone in the chat function mentioned.

14:20

There's a little bit of artifact through here so it's hard

14:22

to know if this is actually breaching,

14:24

but it does look like it is

14:26

and it looks like it may be breaching the capsule here.

14:30

So thoughts about this, somebody says abscess,

14:32

that's an absolutely great thought.

14:34

One would wanna make sure that patient didn't have fever,

14:36

chills, a white count, that sort of thing.

14:38

There were no signs of sepsis in this patient.

14:42

Lymphoma is also excellent to put in the differential

14:46

and one of the things I'd like to show you though is

14:48

that the patient happened to have an

14:50

outside chest CT five months earlier.

14:54

I don't have the report that came with the ct.

14:56

I tried looking through all

14:57

of this patient's medical records

14:59

but I am going to assume that this lesion here

15:03

was not reported because the patient was being scanned for a

15:08

primary chest purpose.

15:10

The spleen is very heterogeneous in its enhancement pattern

15:14

normally because this is an arterial phase scan.

15:17

So this may have been overlooked.

15:19

It was also not contoured deforming the spleen at that time.

15:23

I think if it had been noted it would've been

15:25

worked up a little bit sooner.

15:28

Now given the fact

15:29

that this lesion changed from this smaller size

15:32

to this very large size in only five months,

15:36

we've gotta really consider things

15:38

that are malignant and not benign.

15:40

So although putting hemangioma in the differential would be

15:44

fine if this were a long time lesion, it is a little bit big

15:47

for most angios I've seen in the spleen.

15:50

We really have to think about something malignant

15:53

and one of the primary malignant tumors in the spleen

15:57

is an angiosarcoma.

15:59

Now they're extremely rare, which is a good thing

16:02

because they have an incredibly poor prognosis.

16:05

They tend to be hypodense both before and

16:07

after contrast material.

16:10

They are associated, uh, traditionally

16:12

with tho rast injection,

16:14

although that's not an agent we inject anymore.

16:17

So that's kind of an old thing that people are taught.

16:20

But fortunately they are very rare.

16:23

Um, in this case, if this were the only site of disease

16:27

you would try splenectomy as a primary cure.

16:30

Um, unfortunately this patient did succumb to their disease

16:33

after uh, presenting later with metastases.

16:39

Okay, our next case is a 64-year-old female

16:43

who again also had some left upper quadrant pain

16:46

and she initially got a CT at an outside institution,

16:49

which I don't have,

16:51

but showed a mass of some sort on her ct.

16:54

Very nonspecific and as we know, MRI is often great

16:58

as a problem solver.

17:00

So she then got an MRI and this is her MRI.

17:05

So we can see some heterogeneity in this region

17:08

of the spleen on the T two fat sat weighted image,

17:12

T two fat sat T two weighted fat SAT imaging.

17:16

Here's a T two without fat sat, also very heterogeneous.

17:20

Our T one pre contrast,

17:22

the lesion is slightly hypo intense to the spleen.

17:26

And then as we give contrast material

17:28

and go from an arterial to a portal to a later phase, we is

17:33

where we really can see the the lesion.

17:35

Well it's got a lobulated contour, it does show some late

17:40

enhancement and this is the diffusion weighted imaging.

17:45

So it's bright on the diffusion weighted

17:49

and does show restricted diffusion except for a couple

17:52

of spots here, just like the rest of the spleen.

17:54

So this is a lesion showing restricted diffusion.

17:57

So that is also going to lead us away from things

18:00

that are benign even though we might like to think

18:03

that the enhancement pattern is somewhat like a hemangioma.

18:07

So we've already talked about some differential diagnoses

18:10

for malignant things like angiosarcoma,

18:13

but I wouldn't show you two cases of that right in a row.

18:16

People mentioned lymphoma as a differential diagnosis,

18:20

not only for the metastatic lesion I showed you

18:22

but also for the sarcoma.

18:25

And that is indeed what this turned out

18:27

to be was a lymphoma.

18:31

This patient was treated with splenectomy and

18:34

because of some of the features

18:37

of her particular lymphoma was also treated

18:39

with systemic chemotherapy and is now disease free

18:43

after several years.

18:47

This is another patient with a similar lesion on ct

18:52

and this patient didn't have an MRI

18:54

but instead had a PET scan

18:56

as the next step in their evaluation.

18:59

And you can see that there is intense uptake of pet

19:02

radio tracer on the PET scan here.

19:05

And this was another example of a lymphoma.

19:09

Um, if there is no other disease elsewhere

19:12

and there is the thought that this is a malignant process,

19:15

the patient may or may not have a biopsy prior

19:18

to just having a splenectomy as the definitive therapy.

19:25

Okay, our next patient is a 67-year-old female

19:29

and she was undergoing screening

19:30

for hepatocellular carcinoma

19:32

because she had a diagnosis of cryptogenic cirrhosis.

19:37

And this is uh, are some images from her later phases

19:42

of her CT scan.

19:43

She did have multi-phase ct

19:46

but this lesion looked the same on pretty much all phases.

19:50

So we have a lesion with a very thick calcified rind

19:54

and fluid attenuation,

19:56

which is relatively homogeneous throughout the lesion.

20:00

Does anybody have any ideas about what this may be due

20:03

to or what it might be?

20:06

I'll also just for fun, show you

20:08

that on a plain film you can really easily see this lesion

20:11

and the extent of it.

20:14

Amania, somebody says calcified hematoma. Excellent.

20:18

So this was a, an an older lady

20:20

but she did not remember any trauma.

20:22

Now it is possible that she had trauma as a child and

20:25

and didn't know, but this is indeed yes,

20:28

a benign calcified cyst.

20:30

The fact that the rind

20:32

of calcium is very thick doesn't lead you one way

20:35

or the other in terms of benign

20:36

or malignant, the homogeneous content is very helpful.

20:41

Um, these are usually due to trauma.

20:43

So a prior hematoma, they can also be due to um,

20:47

prior pancreatitis

20:48

and a pseudocyst

20:50

that's been sitting in there for a long time.

20:51

Those can also calcify.

20:54

So if we had old imaging of this patient,

20:56

even a chest x-ray showing just the top

20:58

of it might help us feel more comfortable knowing

21:00

that it was there for a long time.

21:04

Okay, rapid fire cases here.

21:08

All right, our next case is a 68-year-old male

21:10

and the history that was given in his requisition was blood

21:13

in stool but he wasn't having acute GI bleeding.

21:17

It was more like screening

21:18

to see if we could see anything in his colon.

21:22

And this is what we see here are a series of images

21:26

through the upper abdomen and axial and coronal.

21:29

And the first thing you'll notice is

21:30

that the spleen is enlarged.

21:32

So it's extending well below the, uh,

21:34

bottom contour of the liver.

21:36

So this I would guess was at least probably 19

21:39

or 20 centimeters in craniocaudal length.

21:43

We are not in an arterial phase.

21:45

This is a portal venous phase.

21:46

So this is not normal modeled enhancement of the spleen,

21:50

but rather innumerable small lesions, most

21:53

of which have relatively homogeneous um,

21:58

hypo attenuation compared to the background spleen.

22:03

This patient also underwent an MRI

22:06

and I am pointing out the fact

22:08

that on this T two weighted image there are areas of

22:12

decreased signal intensity within these lesions indicating

22:17

the presence of hemosiderin, which is something

22:19

that is helpful for this particular diagnosis.

22:23

After IV contrast administration on an arterial,

22:27

a portal venous and a delayed phase, these fill in

22:32

and become almost iso dense to the spleen here.

22:35

So these also have um, delayed enhancement.

22:43

So anybody have any thought about this?

22:49

The fact that there's hemo citrin in them coupled

22:52

with the innumerable number of them, the enlargement

22:55

of the spleen and the delayed enhancement

23:01

is one they, this patient actually had a biopsy though

23:04

to absolutely prove that this is what this is.

23:06

So I know it's what it is.

23:08

You can see here our needle coming through

23:10

and going for that larger lesion here,

23:12

which we cannot see on the non-contrast imaging,

23:16

but this is literal cell angios.

23:18

So these are, um, literal cells line, the red pulp

23:22

of the spleen, they form these cystic channels vascular

23:26

channels, they often bleed cau, you know,

23:30

asymptomatically bleed causing that hemo citrin deposition.

23:33

The enhancement pattern is very similar on most of these

23:37

that I've shown you also, again, if they're going

23:39

to present, they present with splenomegaly,

23:41

but a lot of these patients are asymptomatic

23:44

as in case the patient did not present

23:46

because of any left upper quadrant symptoms.

23:48

But rather an unrelated symptom to his bowel is biopsy safe?

23:53

Um, we have found that in the correct hands

23:56

and done cautiously, yes, biopsy of the spleen is safe

23:59

and I will show you that there are several of these cases

24:02

where biopsy made the definitive diagnosis.

24:05

So yes, biopsy of splenic lesions, it's not things

24:09

that thing that people traditionally like to do

24:12

but is very safe.

24:16

Our next case again is a patient

24:17

who has a primary liver problem cirrhosis

24:21

and she was undergoing ultrasound screening as part of her

24:25

workup for hepatocellular carcinoma.

24:27

A lot of our patients alternate between ultrasound and MRI.

24:33

So in the left upper quadrant we can see her spleen here

24:37

and we see a very well-defined

24:39

slightly lobulated hyper coic lesion without any perceptible

24:44

flow on the Doppler image.

24:47

This lesion measured almost three centimeters.

24:51

Any thoughts about

24:53

what this is based solely on the ultrasound

25:00

hemangioma?

25:01

Someone mentioned yeah, this, if this were in the liver,

25:05

I think most people would have absolutely no trouble saying

25:07

this as a hemangioma

25:08

and the spleen, it's a little different,

25:10

but I'll show you this is the patient 18 months later,

25:15

the lesion is stable in size, we don't really see it at all.

25:19

On the non-contrast image, you'll note

25:21

that her spleen does look a little bit, uh, plump.

25:25

I don't know if it measured greater than 13 centimeters,

25:27

but might, we can see on the arterial phase a little bit

25:31

of peripheral enhancement here on the venous phase it's

25:35

slightly less, um, apparent,

25:38

but on a delayed phase it fills in.

25:41

And given this the stability as well as the appearance on

25:45

the ultrasound, a diagnosis of hemangioma was made.

25:49

Someone suggested an infarction.

25:53

I don't think I've ever seen an infarction look hyper

25:56

a coic on a, on a, an ultrasound.

25:59

Um, they tend to be more wedge shaped

26:01

and not quite so round and mass like.

26:04

But I agree with you that the location is really good

26:06

for an infarction and, and stay tuned.

26:08

We might have one of those later.

26:13

This is another example here.

26:14

We do not see the lesion on the non-contrast

26:18

on the arterial phase we can see brisk

26:21

filling of a small lesion.

26:23

And on the portal venous phase we can see enhancement

26:26

that's similar to the blood pool

26:28

and smaller lesions can have flash filling

26:31

like they do in the liver.

26:33

So something else to keep in mind,

26:36

hemangiomas are the most common benign primary

26:39

neoplasm of the spleen.

26:40

So they're, they are encountered

26:43

although not as frequently as in the liver.

26:48

Okay, our next patient does have a history of carcinoma.

26:51

They have a Ewing sarcoma of the right leg

26:53

and they were undergoing staging

26:58

and this was their first scan

27:00

and there are actually two lesions,

27:02

this one here toward the top of the spleen

27:04

and this one a little bit lower in the spleen.

27:07

They have very similar characteristics.

27:10

Again, a little bit lobulated, low density,

27:14

maybe some small septations

27:15

or enhancing areas within the lesion,

27:18

maybe a little nodularity.

27:21

This patient underwent a PET scan

27:23

as their next step in staging.

27:25

And if I show you the area here where that first lesion is

27:29

and the area here where that second lesion is,

27:31

there's really not any increased uptake, maybe a signal

27:36

that's similar to the spleen.

27:39

Now despite this,

27:41

these were called potentially still malignant

27:43

because the patient did have a very serious primary

27:47

and the patient underwent a third study, an MRI,

27:51

I'm only showing one of the lesions,

27:53

but I assure you they looked exactly identical.

27:55

So this is that lower lesion,

27:57

it is bright on the T two weighted imaging.

28:01

It is slightly hypo intense to the spleen on the T one.

28:05

And then as we gave contrast here is the arterial phase,

28:10

the portal venous phase and the delayed phase.

28:13

And so far everything I've shown you seems

28:15

to enhance in a delayed fashion.

28:17

And in this case this kind of sticks

28:18

around a little bit longer.

28:20

So your first thought might be, oh,

28:22

I wonder if this is a hemangioma.

28:24

Okay, that would be a really good thought.

28:26

This is what the diffusion weighted imaging look like.

28:30

And you can see on the a DC map, this is not

28:33

restricting diffusion, the normal spleen

28:35

is restricting in dark.

28:36

This is bright, this indicates this is

28:40

probably a benign lesion.

28:41

But despite that

28:43

because she had a very serious primary, which

28:47

otherwise would have been just confined to the right leg,

28:50

this would've been the only site of metastatic disease.

28:54

The patient underwent a biopsy based on ultrasound.

28:58

You can see this is labeled pass number one,

29:00

this is labeled pass number two,

29:02

we're sticking a needle in the lesion

29:04

and then following the biopsy, whoops, we can see

29:09

that there's flow around this lesion.

29:11

They didn't see a hematoma, they didn't see any,

29:14

any increased, um, vascularity in the lesion itself.

29:18

It had not expanded because of hematoma or anything.

29:21

So it looked like the patient

29:22

did pretty well from the biopsy.

29:25

This is the patient. Two years later

29:27

she was getting again staging studies

29:29

because of her earing sarcoma

29:32

and the both of the lesions were exactly stable

29:34

and looked exactly the same

29:35

with this nodular enhancement here.

29:38

And this was a biopsy proven lymph angio.

29:41

Now this is a little unusual for a lymph angio.

29:44

I I, I'll question this a little bit

29:46

because it was biopsied, I was like hmm,

29:49

okay it's a lymph angio.

29:51

I still wonder if it couldn't have been a um,

29:54

a he angio based on its impinging characteristics.

29:57

But in any case it is a benign lesion.

30:00

These are usually seen in children.

30:02

But keep in mind that this is a very young patient.

30:04

She was only 23, which is barely out of childhood.

30:08

Um, they are usually a little bit more cystic looking

30:11

and with less enhancements.

30:12

So this was a little bit atypical in appearance but whether

30:15

or not you call this a hemangioma or a lymph angio

30:20

or an unknown lesion, it's still benign

30:23

based on its imaging characteristics and its stability.

30:26

So this can be pretty much ignored.

30:31

All right, our next patient is 66-year-old female.

30:34

She presented with left upper quadrant pain

30:38

and she had had some decreased appetite, a little bit

30:42

of nausea and importantly she was also experiencing chills

30:46

although she did not take her temperature

30:49

and this is what she looks like.

30:52

So we have a portal venous or late phase CT scan.

30:56

Actually pretty late phase 'cause we're already excreting

30:58

here in the kidneys and we can see

31:00

that there are two collections, one at the edge

31:03

of the superior spleen

31:05

and then one a little bit lower in the spleen.

31:08

There's very heterogeneous looking, um,

31:11

little infiltrative looking

31:12

and there is some inflammation around the spleen here

31:16

and we can see a little bit of thickening

31:18

of the fascial planes near the spleen.

31:20

So absolutely right, several of you have written in abscess.

31:24

So then what are we gonna do with this abscess?

31:26

How are we gonna treat this?

31:28

Well we're gonna put a drain in.

31:30

So here is a drain here that is extending into

31:34

that lower aspect here of the part that was in the spleen

31:39

and this grew strep viridans.

31:41

So this was indeed a pretty serious abscess.

31:44

And this is the patient. Six weeks later the drain has been

31:47

removed and all we see is a little bit

31:48

of residual inflammation

31:50

and a little residual uh, wall of the abscess basically.

31:55

But at this point there was nothing left to drain.

31:58

There is still a little bit of residual inflammation

32:01

and this may take a little while to go away.

32:03

The patient was on IV antibiotics through her course

32:07

and then discharged with oral antibiotics.

32:09

So it was a fairly long course until this drain was removed

32:13

but she was cured of her abscess.

32:16

Um, I don't know what her particular risk factor was.

32:19

These are hemat spread

32:22

so abscesses can set up pretty much anywhere they went to.

32:25

Once you get that kind of uh, septic

32:29

material in your bloodstream.

32:33

Okay, another cirrhotic.

32:35

We do a lot of imaging on cirrhotics where I work

32:38

and again screening for hepatocellular carcinoma.

32:42

So here we have a four-phase CT scan.

32:45

We have what looks like a kind of cirrhotic morphology,

32:48

enlargement of the lateral left and the caudate lobe.

32:51

A little bit of a macro nodular contour.

32:54

The spleen is large on the non-contrast looks

32:58

very homogeneous.

32:59

We have that zebra pattern

33:01

of enhancement on the arterial phase

33:04

or homogeneous on the portal venous phase

33:06

and this is our five minute delayed.

33:09

And on that portal venous phase,

33:10

you can see a couple very tiny

33:12

but very well-defined low density lesions.

33:17

Oh, somebody asked me if there was ascites

33:19

and a plural fusion on the last case.

33:20

And yes there was a little bit

33:22

of ascites and a plural effusion.

33:23

Not in this case, but the last one anyway.

33:27

Anybody have any thoughts about

33:28

what these tiny little things are?

33:32

Okay, it's a possibility that they are cysts,

33:35

but in my experience I find

33:38

that cysts still remain relatively low attenuation

33:41

to the spleen

33:42

or any other organ they're in on delayed imaging

33:44

so they don't become iso dense

33:46

to the organ but they remain lower.

33:50

Yeah, somebody mentioned gam gandy bodies.

33:52

That is exactly correct. These are gamma gandy bodies.

33:56

They're also called retic nodules

33:58

and they are associated not only with cirrhosis,

34:02

which is probably the most recognized

34:04

but also patients with sickle cell disease can get them And

34:07

some uh, patients with hemochromatosis, even some patients

34:11

with lymphoma or leukemia can have nagani bodies.

34:15

They are little areas

34:16

of hemosiderin deposition they can calcify.

34:20

So they may mimic calcified granulomas

34:23

and it's impossible to tell them apart from a calcified

34:26

granuloma other than the clinical context.

34:29

Although patients with cirrhosis can also have calcified

34:33

granulomas, they are of no consequence in terms of

34:37

of doing anything about them

34:38

or biopsying them or anything else.

34:40

So just something to note.

34:42

You can also see them on MRI

34:44

and they can cause some artifact on T two weight images,

34:48

a little bit of of streak or something with them.

34:51

But you can also see them on the T one weighted images

34:54

and patients may have variable numbers of them depending,

34:58

but they are best seen once contrast material has been given

35:01

on the T one weighted images.

35:06

Now somebody asked if gamma ga gam D body should be high

35:09

attenuation on CT

35:10

and if they're not calcified they may not be.

35:13

And again we're seeing them after we give contrast material.

35:16

So relatively speaking they're a little bit lower

35:19

than the spleen in the background.

35:20

They have a very variable appearance depending upon whether

35:23

they have calcium in them or not.

35:29

Okay, our next patient is a 57-year-old male with back

35:32

and abdominal pain

35:35

and here are images through his upper and mid spleen

35:41

and we can see two areas of abnormality.

35:45

This area is sort of geographic and peripheral here

35:50

and hypo attenuating compared to the spleen.

35:53

And here's another kind of wedge-shaped area

35:56

again along the periphery if that wasn't enough

35:59

to help you with this diagnosis.

36:01

We can also look at this patient's kidneys

36:04

and we can see that there are abnormalities bilaterally.

36:07

Again wedge-shaped decreased

36:10

attenuation without enhancement here

36:14

and both the right and left kidney.

36:15

And yes these are infarctions.

36:17

Now infarctions in this particular case the patient

36:21

was then worked up for an A,

36:23

an occult malignancy which was not found.

36:25

So you're looking for something

36:26

that might give somebody a hypercoagulable state.

36:29

You also have to look very carefully at the heart.

36:33

So I'm gonna show you this case.

36:35

So this is a patient you can clearly see

36:38

that they are fluid overloaded.

36:40

So there are pleural effusions, there's ascites.

36:43

The liver has a kind

36:44

of very modeled enhancement pattern maybe from some issue

36:47

with heart output.

36:49

But we have this area in the spleen here

36:53

again an infarction

36:54

and then a very large infarction in the kidney.

36:58

But if you look very carefully at the base of the heart,

37:01

we can see that there are multiple filling defects in the

37:04

left ventricle and these are the source

37:07

of the embolic event here to this spleen and kidney.

37:11

It's very common to have

37:13

renal infarcts when you have splenic infarcts

37:15

or vice versa splenic infarc when you have renal infarcts

37:18

because these are showers of small emboli

37:21

that get trapped in the small vessels

37:23

and will cut off blood supply

37:25

and support to uh, make sure

37:29

that the this is taken care of.

37:30

You know, you wanna anticoagulate the patient if

37:32

they're a candidate for that.

37:34

You might consider revascularization if it would help the

37:37

patient's renal function.

37:38

So there are a variety of ways these may be treated,

37:41

but this was again infarction in this case we could see the

37:44

source on the CT scan.

37:49

Okay, this patient's ex,

37:51

her history is a little more extensive.

37:53

They came in with left upper quadrant pain

37:55

and noted that they had been bruising very easily.

37:58

And on their initial exam when they had some laboratory

38:01

values in a physical exam, they were noted to be anemic

38:04

and thrombocytopenic

38:05

and their spleen was noted to be enlarged.

38:11

So I'm showing you two axials

38:14

and one coronal image.

38:16

And again the most striking thing is

38:18

that the spleen is very large,

38:20

so again much larger than the liver.

38:24

And we have all these areas that are not enhancing well.

38:27

And again, this is not an arterial phase

38:29

so we expect the spleen to homogeneously enhance.

38:33

If we look really closely, there may be some areas

38:36

that look almost liquified in the center

38:38

of a couple of these lesions.

38:40

So maybe some areas of necrosis.

38:43

So someone is expecting is saying, you know,

38:46

maybe leukemia, that's a good thought.

38:48

Are these lots of infarctions in the liver

38:50

as the whole thing infarct?

38:53

Potentially this looks a little bit like one

38:56

of the cases I showed you earlier,

38:57

but the fact that there's some necrosis

39:00

makes me a little more suspect

39:01

that this could be a more malignant process.

39:03

Plus the patient is presenting with symptoms.

39:06

The thrombocytopenic, their anemic, they have pain,

39:11

this is this patient's PET scan

39:13

and you can see that there are areas

39:15

of uptake in the spleen corresponding

39:17

to a lot of those lesions.

39:19

And these are areas of increased uptake,

39:22

again pointing toward higher metabolism.

39:24

So again, something more malignant.

39:26

And this turned out to be a, a malignant form

39:30

of literal cell angios

39:32

or literal cell angiosarcoma.

39:35

Again, the literal cells are those that line the sinus

39:38

of the red pulp and they usually do form benign angios if

39:42

they're gonna form anything at all.

39:45

So a malignant transformation

39:47

or malignancy in the literal cells are even more rare

39:50

than angiosarcoma.

39:53

It is a form of sarcoma.

39:55

It's again extremely rare and and very, very fatal.

39:59

So again, this is not a good prognosis.

40:04

All right, I'm gonna show you a couple of cases highlighting

40:06

that R three paper algorithm.

40:09

So this is the algorithm that's in that paper

40:12

and this I wanna stress is for incidental splenic lesions.

40:16

So these are lesions in patients who

40:18

are without any signs of infection.

40:21

They have no history of malignancy

40:23

and they have no imaging signs

40:25

of any metastatic disease elsewhere.

40:27

So if this is a patient

40:28

that you discover a liver lesion in conjunction

40:31

with the splenic lesion, you cannot use this algorithm

40:34

and you wanna be able to put the lesion in one

40:37

of four buckets, whether the lesion is definitively

40:40

or almost certainly benign,

40:42

in which case you don't need to do anything about it.

40:44

In's probably benign, in which case you can choose

40:48

to do a 12 month follow up.

40:50

And once you do that you can push it into the no

40:52

follow-up required bucket.

40:55

It's truly indeterminate and you need to do something else.

40:58

So maybe a short-term follow-up or a pet CT

41:01

or it's likely malignant, in which case you wanna go

41:04

to tissue sampling or splenectomy.

41:06

So let's work our way through a few of these.

41:09

Each of these buckets has some uh, descriptors

41:12

that will help you decide where to put something.

41:15

So here's our next case.

41:16

It's a 52-year-old male

41:17

with an incidental lesion on a chest ct.

41:20

So the patient had a non-contrast chest ct

41:23

and the person reading it astutely noted

41:25

that there was a contour abnormality

41:27

of this anterior spleen here

41:30

and kind of a lower density lesion in that area.

41:36

So at this point we have no idea what this is.

41:40

So the patient underwent an ultrasound first

41:49

and we can see that the lesion is of

41:54

decreased echogenicity compared to the normal spleen.

41:59

It's a little lobulated.

42:01

There might be some areas

42:02

that are a little more heterogeneous

42:04

and there's definitely flow in it.

42:05

So it is a solid lesion, it's not uh, a cystic or

42:09

or hemorrhagic lesion.

42:15

So what are we thinking?

42:20

It's heterogeneous, it's got irregular margins.

42:22

Those little areas of of more cystic

42:25

or liquified areas could be necrosis

42:28

and there was definitely splenic parenchymal invasion.

42:31

So these are concerning features. So what do we wanna do?

42:34

We want a tissue sample or go to splenectomy.

42:37

So here you can see this is labeled as pass number two.

42:40

We've put a needle in there and you can see it fired

42:45

and got a core biopsy and then the

42:46

needle's being pulled out there.

42:48

So we have a definitive diagnosis in this particular patient

42:52

a a couple of people have suggested lymphoma

42:57

and that's exactly what this was.

42:58

This was that SP four malignant lesion

43:01

and biopsy proven lymphoma.

43:05

Okay, this is a 47-year-old female who presented just

43:08

with bloating and we have a small lesion here in the spleen.

43:17

It's mostly very low attenuation.

43:19

There may be a couple of tiny little SEPTA

43:22

that may be showing a little bit of enhancement.

43:27

It's about two centimeters in size.

43:30

So what are we gonna do with this one?

43:34

It's probably or almost certainly benign,

43:38

it's any fluid filled structure with thin walls.

43:41

We could barely see the walls.

43:43

Thin enhancing SEPTA are fine, thick,

43:46

non enhancing SEPTA are fine

43:48

and rim calcifications are also fine.

43:50

These do not increase the suspicion for anything else.

43:54

So this doesn't need any follow up.

43:56

So again, here's that lesion again.

43:59

There are some tiny little thin SEPTA in it,

44:02

A barely perceptible wall.

44:05

It's an SP one, it may be a lymph angio.

44:08

It's a little bit lobulated to be just a simple cyst.

44:12

So again, an SP one.

44:13

And we can ignore this again here,

44:18

another 23-year-old male, again an incidental finding.

44:22

And here we have a CT multi-phase.

44:25

In this particular case on the relatively arterial phase,

44:29

it's low attenuation,

44:31

it remains low attenuation on the portal venous phase

44:34

and is actually slightly hyperdense

44:36

to this spleen on the delayed phase.

44:39

And here it is again on the portal venous and the delayed.

44:43

So what do we wanna do with this solution?

44:45

It's clearly not a cyst, it's small, it's a young patient.

44:51

Maybe we wanna do an MRI. Maybe it's a hamartoma.

44:55

I haven't shown you one of those. They did get an MRI.

44:59

So that was a good thought.

45:00

It is dark on T two,

45:03

pretty much ISO on pre contrast T one

45:06

and then shows all these little cystic spaces,

45:09

these little septa

45:10

and then a little bit more enhancement on a delayed phase.

45:14

And here is the diffusion weighted imaging

45:16

and there is no restricted diffusion.

45:19

So this maybe was a SAN

45:20

or a sclerosis adenoid nodular transformation.

45:24

Um, they are most commonly heterogeneous on T one

45:29

on load intermediate signal,

45:31

which I guess this fits on T two.

45:33

They're typically low signal

45:36

and following contrast material,

45:38

they might have some peripheral

45:40

and septal enhancement, which this is kind of showing.

45:43

So we thought well maybe it's a sand.

45:45

They also do not show any restricted diffusion.

45:47

So that could fit. And a few people suggested it's an SP two

45:51

and exactly that it's probably benign.

45:54

So these are lesions with features

45:56

that lead you in one direction.

45:58

Is it a hamartoma, is it a sand, is it a hemangioma?

46:01

And if you're confident,

46:03

then you don't need to do anything else.

46:05

If you're not confident, you can do a 12 month follow up.

46:09

And what is defined

46:10

as stability is if it grows less than three millimeters per

46:13

year and then you can, once you've determined

46:16

that it's stable for that year, you can reclassify it

46:19

as an SP one and then you don't need to follow it at all.

46:23

So that's what happened in this case, the original scan

46:26

one year later completely stable

46:29

and we think it's probably a san

46:31

but in any case it's now an SP one

46:33

and we don't need to worry about it.

46:36

So a couple of conclusions about focal lesions.

46:40

Splenic lesions are don't seem to be

46:41

as common incidental findings as in other organs.

46:45

Um, in large series they're only in about 2% of cases.

46:49

Most incidental lesions are small and benign.

46:53

And again, small size and slow growth

46:55

or stability will lead you toward benign.

46:59

The malignant lesions grow faster

47:01

and they tend to be symptomatic.

47:04

Metastasis are rare compared to the liver only three

47:07

to 9% on autopsy and a lot of those we don't see

47:10

because they're microscopic.

47:12

And you usually have disease elsewhere if you have an

47:15

isolated splenic metastasis.

47:17

Again, do not think about GI primaries,

47:20

think about things like melanoma, breast,

47:23

ovary, that kind of thing.

47:25

And that R three paper will help you

47:27

and with patients that have incidental lesions

47:30

without a cancer history or symptomatology.

47:33

So again, I apologize if this isn't working we'll try it

47:36

again or I will send another code to modality

47:39

and let them publish it for their members.

47:43

I would like to do in the last couple of minutes since I,

47:46

I think, um, I've answered most of the questions

47:50

as we've gone along, show you a couple of bonus cases.

47:53

But let me just quick, quickly just check here

47:56

why not a hi dad cyst in the hematoma case.

47:58

Is it about the thick wall?

48:00

I have not actually made a diagnosis of Ahy dad cyst.

48:03

Personally, I think they're probably

48:04

because they're more common in other parts of the world.

48:07

So the one with a thick rind, um, could be a,

48:10

could have been a HY cyst.

48:13

And how come the spleen he mania doesn't restrict diffusion,

48:15

but liver he mania can restrict diffusion.

48:18

Um, I think that the, the,

48:22

I I'm probably not the best person to answer

48:25

that question to be honest with you.

48:27

Um, I have not really thought

48:28

that much about why spleen hemangiomas wouldn't restrict

48:31

but a liver hemangioma might, um,

48:34

because they basically should be the same,

48:36

um, type of tissue.

48:38

So I'm sorry that I can't give you a better

48:40

explanation for that.

48:43

How does, uh, how

48:44

to differentiate a PSA from a hemangioma?

48:48

Um, I think the history of trauma in

48:50

that case was very helpful

48:52

because in that particular case, um,

48:54

we knew the patient had had, um, a motor vehicle collision

48:58

and it would be unlikely.

49:01

I mean an incidental hemangioma will be much less likely

49:04

than a pseudo aneurysm in that particular case.

49:07

Plus the patient came back with symptoms

49:09

of left upper quadrant discomfort,

49:11

which would be also unusual in a case of he angio.

49:16

All right, so our few bonus cases, again,

49:18

this is just a patient for restaging

49:21

and this is a quick case just to notice that as you're going

49:24

through your axial images, I can see spleen,

49:28

I'm almost out of the liver.

49:29

I'm still slinging quite a bit of spleen here.

49:32

Now I know most of us do coronal reconstructions,

49:35

but it never hurts to go ahead

49:37

and look at the coronal reconstruction

49:39

because we might have overlooked the fact

49:42

that this patient had quite massive

49:44

splenomegaly if we didn't do a coronal for one.

49:48

The diaphragms also elevated.

49:49

So this spleen extended not only above

49:52

but also below the bottom of the liver.

49:55

So things you need to think about for splenomegaly.

49:58

Um, portal hypertension is probably one

50:00

of the most common things I see, but sickle cell patients

50:04

before they have functional asplenia could have acute

50:06

sequestration causing splenomegaly.

50:10

You can have extramedullary hematopoiesis,

50:12

which is associated with multiple different diagnoses.

50:15

Infections like mononucleosis.

50:19

Hepatitis aids can also cause splenomegaly.

50:22

There are a number of collagen vascular diseases like lupus

50:27

or storage diseases like ahas, amyloidosis,

50:31

congestive heart failure is also in the differential.

50:34

So the differential includes both mostly benign findings.

50:39

Lymphoma is also another in the differential for

50:43

a homogeneously enlarged spleen

50:46

which may only have lymphoma.

50:47

That's involvement noted on microscopic views,

50:50

but there are a lot of benign causes.

50:55

Okay, patient came in with left upper quadrant pain

50:58

and she had had a colonoscopy four days previous.

51:04

So any thoughts about this one? Uh, last or laceration?

51:08

Good. So unfortunately the patient had, like I said,

51:13

a colonoscopy four days previously

51:14

and they had a little bit of trouble getting

51:16

around the splenic flexor I imagine

51:18

and poked a little bit too hard.

51:20

And because the spleen is gonna be sitting right next

51:22

to the splenic flexor

51:24

before this hematoma came into play,

51:27

you can see this is not simple fluid.

51:29

It has 61 house with units.

51:31

Indeed, this was splenic injury from a colonoscopy

51:36

at this point the patient was hemodynamically stable,

51:39

so they admitted her for observation for serial hematocrits

51:42

and she ended up doing fine without any intervention.

51:47

This is another patient who has a similar finding

51:50

with a little bit more heterogeneity of the spleen.

51:53

Here you can see again that there is a sentinel clot here,

51:57

45 hounds field units.

51:59

And this was a patient who, um, was 61.

52:02

She had four days of pain. She had absolutely no trauma.

52:07

She also stabilized with just, um, conservative management

52:12

and she was felt to have a spontaneous splenic rupture.

52:16

Now they're, they're very rare.

52:18

They can be caused by infections such as mononucleosis

52:21

or other viral diseases.

52:23

You can have bacterial

52:24

or parasitic infestation that might cause splenic rupture.

52:28

Lymphomas and leukemias can also have it.

52:30

The same things that cause splenomegaly can also cause

52:34

be a risk factor

52:36

for splenic rupture if it's spontaneous splenic rupture.

52:40

Also, of course the waist basket category of idiopathic.

52:44

If you can find no other reason why the patient might have

52:46

had a splenic rupture.

52:48

So this was an idiopathic splenic rupture.

52:53

Uh, this next patient is a 25-year-old female

52:56

and she has pain and comes in with a known chronic disease.

53:01

So right off the bat you can see that she has

53:04

pretty large liver here.

53:06

She has a little bit of ascites, but what about her spleen?

53:14

Any ideas for this one?

53:21

Yeah, sickle cell disease.

53:22

So this is actually not enhancement,

53:25

but rather multiple small calcifications in an auto,

53:31

um, auto infarction

53:32

or auto splenectomy in sickle cell disease.

53:35

She also has the typical bony changes with ning

53:38

or widening of the trabecula.

53:41

This is another patient. This is their spleen.

53:46

This little tiny pancake back here

53:48

with calcifications in it.

53:49

This is a non-con, uh, a, a late contrast scan.

53:52

So it shouldn't be enhancing like this.

53:55

So again, another patient with sickle cell disease,

53:57

an autos splenectomy, okay,

54:02

56-year-old man with left lower quadrant pain

54:09

had ingested some contents in their stomach.

54:11

Maybe a diverticulum back here,

54:14

but I don't see a spleen where it's supposed to be sitting.

54:20

However, I see a couple of little things

54:24

that look similar to spleen tissue.

54:29

So how about this one?

54:33

Well, this patient had had

54:35

a splenectomy some years previously for trauma.

54:38

They tried to preserve spleens now more than

54:40

you know, more than they used to.

54:42

Um, and this patient has some residual splenic tissue.

54:46

It may not be enough to replace the entire function

54:49

of the spleen, but if there is residual splenic tissue

54:52

in these patients, that's fine.

54:53

Here's another area right here of osis.

54:59

So they can wander all over the place.

55:01

They can also be up in the chest,

55:02

they can be in the body wall depending

55:04

upon the type of trauma.

55:06

So stenosis, here's another patient, similar findings.

55:11

These lobulated soft tissue lesions here

55:16

up in the left upper quadrant is the most common location.

55:21

And another one here with an lesion behind the stomach next

55:24

to the stomach in the left upper quadrant.

55:30

Okay, another patient with pain and a chronic disease.

55:35

This is a relatively late phase

55:37

or late portal phase CT scan.

55:39

At this point, the spleen should be enhancing

55:41

homogeneously, but it's not.

55:46

And you can see multiple tiny little rounded lesions.

55:53

Again, another patient with a chronic disease.

55:55

And in this case, this is an example of sarcoidosis.

55:59

They have multiple small hypodensities through the spleen.

56:02

It's helpful to know this history.

56:04

You can also have a similar finding in the liver.

56:07

And if you see it both in the liver

56:08

and spleen, it, you know,

56:10

it really helps you cinch that diagnosis.

56:12

They can also have had an adenopathy and their spleen may

56:17

or may not be enlarged.

56:20

And I think this may be the last case I have.

56:22

I've got a couple of minutes.

56:24

This patient was undergoing a CTA for an aneurysm workup

56:28

and we have non-contrast images

56:30

and then post contrast images.

56:32

And these are in the arterial phase.

56:35

And you can see the spleen modeled,

56:38

which it should be on the arterial phase,

56:41

but there's a mass in the tail of the pancreas.

56:47

And it looks kind of similar to the spleen,

56:49

but maybe not exactly.

56:51

Somebody says, is this a lenal?

56:53

Well, the differential would be a lenal intra pancreatic

56:56

lenal versus a perhaps a neuroendocrine tumor

56:59

or eyelet cell tumor.

57:01

So one of the best ways that we can prove

57:03

that this is actually splenic tissue, there's a couple ways.

57:05

One might be a nuclear medicine scan showing uptake,

57:10

but the other is showing that it has similar properties

57:12

to the splenic tissue on an MRI.

57:15

So here is a T one non-con looks similar to the spleen.

57:19

This is in phase out of phase drops like the spleen

57:24

on the T two weighted images similar

57:27

on the arterial phase has that funky modeled.

57:31

Zebra stripe becomes more homogeneous.

57:34

And then again, so this is indeed a spleen,

57:39

but it was large and there was worried,

57:42

so people were worried about it.

57:43

So it got an an, an endoscopic ultrasound.

57:46

It looks very homogeneous like splenic tissue

57:49

and it actually got a biopsy.

57:51

And this was a biopsy proven spleen,

57:54

quite the workup for that.

57:56

And another case here where we have

58:01

tissue similar to the spleen,

58:03

and this is another, again,

58:06

showing similar characteristics to the spleen on all phases

58:10

of MR and another intra pancreatic senal.

58:15

So without its 1259, that's all my cases.

58:19

I appreciate your, uh, attention

58:21

and I'm sorry I didn't really answer

58:23

that hepatic angio versus sp angio question very well.

58:27

Somebody we put in the notes

58:28

that perhaps it's a venous malformation in the

58:33

liver and maybe it's not the same exact pathology in the

58:38

spleen, but I I don't really, I'm sorry that

58:40

that is not something I'm up on.

58:42

So I rather than make up an answer,

58:44

I'm just gonna, uh, defer.

58:46

But in any case, you're welcome to join the rank

58:48

and Ray as a trainee member

58:50

and you'll have free access to all

58:51

of the articles in R three.

58:53

Thank you very much

58:55

Dr. Baumgarten. Thank you

58:56

so much for your lecture today.

58:58

And thank you to all of you for participating in our noon

59:00

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59:02

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59:12

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