Spleen: Focal Lesions

Spleen in Trauma

This was the first one in which you can see there is no
chapter dedicated to the spleen,
but the spleen is inside the trauma.

These are the typical features
of contrast ultrasound.

Something can give us,
but the vascularization is quite the same of
CT and MRI in the early phases of
contrast ultrasound.

You can see that the heterogeneity,
heterogenicity in arterial phase is due to dual circulation,
and there is a fast hyperenhancing low,
high, high poncing in the 10 seconds phase.

This is a well known
appearance of the spleen in the arterial phase for radiologists.

The zebra part, this one
that you can see here on CT in the arterial is typical,
nobody during our reporting,
they will look with the suspicious on this spleen.

What is different that the persistent enhancement
in the late, very late phase is very important.

A lot of paper then appears in the literature
and you can see that the first are dedicated to the trauma
and the appearance of ischemic slash traumatic lesion is the same.

Hyperenhancing area
inside the spleen better visible in the late phase.

Traumatic Patient Paper

Let me show you this paper on the
traumatic patient.

You can see that contrast ultrasound misses a large
CEUs of solid lesion,
and cannot be recommended to replace CT.

This is the conclusion
of a paper published in the literature.

Then we move to this other paper,
and you can see that CUS may replace CT
in many patient in traumatic patient.

There is no consensus in my idea.

However, what is very important is this multicenter
study, other study that proved that CS is better than US.

This is the real message.

If I performed an ultrasound examination in a traumatic
patient, it's not the same.

If I inject contrast, I will have more information of
parenchymal injuries
and homogeneity
of the enhancement in the late phase liver
and spleen and so on.

This is the conclusion of this paper.

CS is more sensitive than US
and is almost as sensitive CT in the detection of
lesion in traumatic patient.

Guidelines for Spleen

These are the new guidelines,
and you can see that there is a chapter
dedicated to the spleen.

These are the three recommended uses
and indications, characterize splenic suspected lesion,
to confirm suspected splenic infection, so hypovascular area
during the late phase
and to characterize a accessory spleen.

We will speak at the end of this
third point.

Characterization of Splenic Focal Lesions

First characterization of a splenic focal
lesion is not the same in respect to liver.

Even if the enhancement can be the same,
that cure is not the same,

because in this paper you can see that in Iman,
only two third of the cases will show
the typical global enhancement in the early phase.

You can see in two third of the cases that we have
less enhancement than the spleen lesion is lightly
hypo in the late phase.

There is no typical
enhancement in this lesion.
That was Iman at the end.

Again, in this paper that is focused on characterization
of splenic Iman Zoma, you can see that filling
enhancement is present only in 7% of the cases.

It's not so easy to be sure about the final diagnosis.

We can be sure about the absence
of malignancy in this case.

This important paper, in my opinion, is
in which you can see that more generally speaking,
CS can improve the differential diagnosis
between benign
and malignant lesion in the spleen is more easy.

Hyper ISO enhancement at CS is a
predictor of benign.

This is what we can say in my opinion.

The diagnostic accuracy is absolutely
better after contrast media injection respect
to Basel ultrasound
and also the agreement will be improved.

Malignant Lesions

Moving to malignant lesion is very easy
to understand that this lesion is malignant
because of the hypo aspect
in the late phase.

Moving to our published paper, we can see that
the reduced enhancement,
so the hypoechoic aspect in the late phase is the typical
sign of metastasis.

Again, also in this paper, hypo enhancement
in the parenchymal phase is predictive
for malignancy in very high percent of the cases.

We can use this.

Also in lymphoma, the same sign the lesion is hypo,
the lesion is hypo, and we can detect more lesion in respect
to CT.

We can also better understand if the lesion is really a lesion
or not in respect to Basel.

We can have also better results in respect
to PET in this paper that is published in radiology.

On the contrary,
we can find in literature also these other paper in which
the conclusion is contrast
resound has no clear advance for the diagnosis of PLE
lymphoma involvement
because you can see that the lesion,
the spleen was homogeneous
and no added values of contrast media injection
and the visualization of focal
splenic lymphoma lesion in the spleen was equal, better
or worse in this case in respect to Basel ultrasound.

This was the conclusion at the end.

This is a table
for the characterization of lesion in the spleen.

For sure we hope to find the central filling
of the man, but there are a lot of atypical cases.

Please remember that with the T two weighted imaging,
we have the diagnosis.

These are the typical appearance
of malignant lesion hypo.

We can use this sign for the definition of the malignancy
of a focal lesion detecting the spleen.

Abscess Clinical Scenario

What about the abscess clinical scenario?
What about a OC caucus?

There is no enhancement of the inclusion inside.

This is typical on the in the liver everywhere.

This a good conclusion.
This paper that contrast ultrasound is effective in the
characterization of a focal lesion in the spleen.

The CS findings are consistent
with the benign CT is not necessary,

but I will suggest not CT in every case it's better MRI
because we have more parameter to evaluate.

I will show you some examples.

Accessory Spleen

Moving to the last indication accessory spleen,
this is a paper dedicated on this finding on this
scenario.

You can see the enhancement have to be similar
to the spleen, obviously in all phases.

What I want to add that we can need to have
a concordance between different imaging modality.

CT MRI has to be the same.

If it is really accessory spleen,
this in example was suspected to be an accessory spleen,
but you can see the morphology is not typical,
even if the density is good, is the same.

This is the lesion on BMO in homogeneous enhancement,
black in the late phase in respect to the spleen.

Completely different in respect to the CT finding it was a rine tumor,
the pancreatic tail in this case.

What I want to tell you that
using CT, we have only the density during the dynamic phase is the same of CS even if the distribution
of contrast is different.

With MRI, we have more parameters.

We can just lesion on T two, T one per contrast.

We can jet contrast and saw the same of CT SUS,
but we can also diffusion with the imaging.

You can see here this was an accessory spleen
in the pancreatic tail.

You can see that lesion is ISO to the spleen
in the early arterial phase on CT, late phase on CT
T two, dynamic phase on MRI,
but also on the fusion.

We have more parameters to judge the lesion.

What about this patient?

During ultrasound examination, we can have the arterial in one
scan in one place and not in the other one.

We know this is a problem.

In this patient you can see a lesion that
it was at the end an accessory spleen,
but also another lesion in the table of pancreas.

This lesion is iso, this lesion is light hyper ONT two.

This lesion is iso ondy phase to the spleen.

This lesion is light hyper in the arterial
phase in respect to the spleen.

This was a tumor
was a metastasis from kidney cancer,
and this is accessory spleen.

We need also to be panoramic enough to study different lesion in the same site.

Conclusion

The conclusion can be very simple in my opinion.

Contrast ultrasound is more sensitive than the US in the
detection of solid organ injury and blood trauma.

CUS improves differential diagnosis between benign
and malignant lesion in the spleen
because it's very easy to judge as malignant lesion
that appears to be hypoechoic
after contrast media injection.

And thank you.