PMC3738359_01
Initial CT scan of abdomen in the portal venous phase (a) and the 4 min delayed excretory phase (b). A 6-cm mass was seen in the spleen with density of 42 Hounsfield units (HU) on portal venous phase image that did not change on delayed images. A subsequent CT scan of abdomen was performed without contrast and demonstrated the density of lesion was 28 HU (image not shown) indicating that there was mild enhancement in the splenic lesion retrospectively. L, liver; S, spleen; *, splenic mass
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PMC3738359_01_10.1258_arsr.2012.120033-fig1.jpg
ARSR-12-0033F1
CEA level was 15.1 ng/mL at presentation (normal healthy smoker <5.5 ng/mL). CT scan of the abdomen demonstrated a 1.0-cm left adrenal nodule and a 6-cm heterogeneous, ill-defined mass in the spleen (Fig. 1).
PET scan does not show any abnormal FDG uptake in the expected location of splenic lesion. Increased FDG is seen in renal collecting systems, bladder, and over the left lower quadrant of abdomen at the site of colostomy
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ARSR-12-0033F2
Axial SPECT image of the upper abdomen that was obtained 2 h after the intravenous injection of four mCi of Tc-99m labeled autologous RBCs. A photopenic region (*) is seen in the spleen (arrow) that corresponds to the splenic mass. Lack of RBC retention in the mass on delayed image excludes a hemangioma
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ARSR-12-0033F3
Given that the most common benign lesion of the spleen is a hemangioma, a radiolabeled red blood cell (RBC) scan was performed to further characterize this lesion (Fig. 3).
Axial contrast-enhanced MRI of splenic lesion (S, spleen; *, splenic mass). The lesion is well-defined and hyperintense on T2-weighted images and demonstrates centripetal fill-in of contrast on three-dimensional spoiled gradient echo pulse sequence with fat suppression (TE 1.96 ms, TR 4.36 ms) following the IV administration of 20 cc of Gadovist contrast agent. However, the most delayed images still do not show homogeneous filling. This pattern is commonly seen with hemangioma rather than lymphangioma
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ARSR-12-0033F4
Because the tagged RBC scan did not confirm the diagnosis of hemangioma, an MRI of the abdomen was performed with and without Gadovist IV contrast (Fig. 4).
(a) Gray-scale ultrasound showed a mildly hyperechoic mass in the spleen. (b) Color Doppler study showed some color signals inside of the lesion. (c, d) Immediately after intravenous injection of definity, the lesion showed internal straight vessels (arrow), and (e) heterogenous enhancement, to a slightly less degree than surrounding spleen, with early wash-out (f). The enhancement pattern is not typical for a lymphangioma and suggested benign lesions such as hamartoma or sclerosing antiomatoid nodular transformation (SANT)
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ARSR-12-0033F5
Philips iU 22 ultrasound machine (Philips Medical Systems, Bothell, WA, USA) with C5-1 and X6-1 transducers were used for contrast study with contrast specific mode (Fig. 5).
H&E staining of the core biopsy of spleen lesion. There are dilated lymphatic channels with attenuated single layer lining (arrow) that are filed with proteinaceous materials (*). No RBC is seen within these dilated channels. This pattern is consistent with lymphangioma
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ARSR-12-0033F6