Managing a splenic nodule can be challenging as there are many possible etiologies. Imaging with ultrasound, CT, and MRI can help characterize nodules as cystic or solid and hypervascular or not. Common benign cystic nodules include epidermoid cysts while hemangiomas are a common benign solid hypervascular nodule. Malignant nodules such as metastases or lymphomas are also possible. A biopsy may be needed if imaging is non-diagnostic but carries risks. Taking clinical context into account is important for diagnosis.

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