1. How to manage a splenic nodule?
Catherine Ridereau-Zins
Department of Radiology University Hospital of ANGERS - FRANCE

2. Not so easy…
? Spleen nodule is fortuitously discovered, on US or CT
? no specific features on imaging
? many etiologies:
congenital
epidermoid or endothelial cysts
infectious
bacterial abscess , hydatidis, candidosis, tuberculosis
inflammatory
sarcoidose, SANT, inflammatory pseudotumor
hemopathies
lymphoma
vascular
hemangioma, angiosaroma, infraction
trauma
hematoma, pseudocyst, pseudo aneurysm
metastases
breast, colon, lung, melanoma, ovary ..
other
Gandi-Gamna nodules, hamartoma, Gaucher’s disease,
Castelman, drepanocytosis, amylose, extra medullary
hematopoiesis …

3. How to manage?
? Take into account clinical and biological data
associated lesions
prior exams
? Try to characterise the nodule on different imaging :
Ÿ US +/- contrast
Ÿ CT
Ÿ MRI
Ÿ FDG TEP CT
unique or multiple
cystic or solid
?

4. How to manage?
? Be able to biopsy
When ?
In oncologic context:
Ÿ suspicion of splenic metastasis:
changing treatment ?
Ÿ suspicion of benign lesion:
avoiding a splenectomy
US-guided splenic biopsy
Out oncologic context: atypical lesion
Ÿ if benign: stop follow-up
Ÿ if malignant: diagnosis before splenectomy
Ÿ suspicion of granulomatosis (TB, sarcoidosis)

5. How to manage?
? Be able to biopsy
Contra-indications
Hemostasis troubles
Suspicion of hydatidosis
How?
US-guided splenic biopsy
Fine needle aspiration (22 G)
or biopsy with a 18 G needle - 2 samples at most
Complications ?
bleeding (2-8% of biopsy, ì number of samples)
pneumothorax; pleural effusion
Keogan, AJR 1999; Kang, M Eur J Radiol. 2007; Singh AK, Radiographics 2012

6. How far to go?
1st level:
know the 2 or 3 most common pathologies
è hemangioma, epidermoid cyst, endothelial cyst
2nd level:
take into account clinical and biological data
be able to perform a biopsy
è metastasis, lymphoma, infection
3rd level:
know very rare pathologies (-1% of cases !)

7. How far to go?
1st level:
know the 2 or 3 most common pathologies
è hemangioma, epidermoid cyst, endothelial cyst
Gilles Genin
2nd level:
take into account clinical and biological data
be able to perform a biopsy
è metastasis, lymphoma, infection
3rd level:
know very rare pathologies (-1% of cases !)

8. Characterise on imaging
☛
On US:
hypo or anechoic
septa ? if doubt: contrast
Cystic nodule
endothelial cyst

9. Characterise on imaging
☛
On US:
hypo or anechoic
septa ? if doubt: contrast
☛
On CT: more difficult
hypodense mass
Cystic nodule

10. Characterise on imaging
☛
On US:
hypo or anechoic
septa ? if doudt: contrast
☛
On CT: more difficult
hypodense mass
☛
On MRI: easy !
hyper T2, hypo T1
Cystic nodule

11. Characterise on imaging
Cystic nodule
? BENIGN (more often):
Ÿ epidermoid cyst, mesothelial cyst
Ÿ cystic lymphangioma
Ÿ hydatid cyst
Ÿ false cyst ( history of trauma, pancreatitis or spleen infarction)

12. Characterise on imaging
Cystic nodule
Tunisian man: cyst with septa and calcifications
èhydatid serology +
Hydatic cyst

13. Characterise on imaging
Cystic nodule
BE CAREFUL: cystic metastasis!

14. Characterise on imaging
Cystic nodule
BE CAREFUL: cystic metastasis!
49 year old man, lung cancer screening
è normal spleen examination 3 years ago
Cystic metastasis

15. Characterise on imaging
Hypervascular
Solid nodule
Hemangioma
? BENIGN: common
• hemangioma, hemangiomatosis
• hamartoma
• pseudo aneurysm
? Malignant : rare
• epithelioid hemangioendothelioma
• angiosarcoma
Pseudo aneurysm

16. Characterise on imaging
Solid nodule
NON Hypervascular
Lymphoma
? MALIGNANT : common
• lymphoma
• metastasis
• sarcoma
clinical data
associated lesions
Mets stomach cancer

17. Characterise on imaging
NON Hypervascular
? But also:
• infectious
• granulomatosis
clinical data
biological data
Solid nodule
Toxocarosis

18. Characterise on imaging
NON Hypervascular
Solid nodule
Toxocarosis
? But also:
• infectious
• granulomatosis
History of colon cancer
è biopsy : tuberculosis
clinical data
biological data
FDG TEP CT
biopsy ?

19. Things are not so easy …
52 year old woman, lung cancer screening

20. Things are not so easy …
52 year old woman, lung cancer screening
ènon contributory biopsy
èsplenectomy
HAMARTOMA

21. Take home messages
? Diagnosis is not easy without clinical data
? Some lesions can be identified easily:
cysts, hemangioma
? US-guided splenic biopsy can be performed, if doubt
? All rare etiologies:
think about them … rarely
they can be seen in literature.

22. Thank you
谢谢