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Abdomen » Spleen
Splenic hemangiomas
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Presentation A 40 year old woman underwent an abdominal ultrasound for vague right upper quadrant pain. Incidental splenic findings were noted.
Caption: Sagittal section of the spleen
Description: A hyperechoic lesion (1) is demonstrated within the spleen.
Caption: Sagittal view of the spleen and kidney
Description: Two additional well-defined, rounded, hyperechoic masses (2, 3) are demonstrated within the splenic parenchyma.
Caption: Color Doppler of the spleen
Description: Using color (power) Doppler no flow was demonstrated within the mass.
Differential Diagnosis Multiple splenic hemangiomas, primary vascular tumors such as Littoral cell angioma [patient usually has massive splenomegaly and multiple nodular masses], splenic metastases [less likely as patient has no known primary].
Final Diagnosis Multiple splenic hemangiomas.
Discussion Splenic hemangiomas are rare, but are the most prevalent of all tumors of the spleen. These lesions are mostly asymptomatic and are often detected as incidental findings while performing abdominal ultrasounds for other reasons. Rarely are the patients symptomatic. When present, symptoms may be due to hemorrhage from spontaneous or traumatic rupture of a hemangioma. A few patients present with splenomegaly.

Splenic hemangiomas may be single or multiple and usually present as a hyperechoic mass in the spleen. By ultrasound their detection rate  is estimated to be around 1%. Autopsy studies have shown the incidence rate of splenic hemangiomas to range from 0.03-14%. Most of these are silent; however a few studies have reported spontaneous rupture of a splenic hemangioma in about one-fourth of patients in the series. In such a scenario, splenectomy is often necessary.

Ultrasound is often the initial modality used to diagnose splenic lesions, and when in doubt, a contrast enhanced CT or MRI scan is performed to characterize the lesions further. Studies have shown that color Doppler can sometimes demonstrate characteristic flow patterns in focal lesions [based on patterns of blood flow within and around the tumors] that can aid in diagnosing doubtful cases. In most cases the flow within the hemangiomas is so slow that they appear to be hypovascular.

The closest differential is splenic metastases, arising from a melanoma,  ovarian, pancreatic or any GI malignancy. Other rare hyperechoic appearing tumors include hemangiosarcoma and sometimes echogenic lymphomatous deposits [although classically the lymphomatous deposits are hypoechoic]. A recently discovered hyperechoic tumor to be considered is a Littoral cell angioma, which is a benign vascular tumor. Littoral cells are cells lining the splenic sinuses. No definite sonographic pattern of the tumor has been described, although a study reported that patients with these tumors typically present with splenomegaly and multiple focal nodular hyperechoic masses.

In the case discussed here, a contrast enhanced CT was performed, which demonstrated the typical contrast enhancement pattern for hemangiomas [peripheral enhancement followed by slow filling of the lesion with contrast].

Case References 1.Kohler M, Kubale R. Differential echogenic focal splenic lesion diagnosis. Schweiz Rundsch Med Prax. 2003 May 28; 92(22): 1037-42.
2.Willcox T, et al. Hemangioma of the spleen: presentation, diagnosis, and management. J Gastrointest Surg. 2000 Nov-Dec; 4(6): 611-3.
3.Goerg C, et al. Splenic lesions: sonographic patterns, follow-up, differential diagnosis. Eur J Radiol 1991 Jul-Aug; 13(1): 59-66.
4.Borner N, et al. Echogenic splenic lesions: incidence and differential diagnosis. Ultraschall Med. 1990 Jun; 11(3): 112-8.
5.Goerg C, Schwerk WB. Color Doppler imaging of focal splenic masses. Eur J Radiol 1994 Aug; 18(3): 214-9.
6.Dennhardt N, et al. Frequency, pattern and differential diagnosis of echogenic splenic changes: sonographic follow-up study. Ultraschall Med. 2000 Aug; 21(4): 151-9.
7.Gorg C, et al. Sonographic patterns of littoral cell angioma: case report and review of the literature. Ultraschall Med. 2001 Aug; 22(4): 191-4.
Follow Up CT scan confirmed the presence of multiple hemangiomas in the spleen, and periodic ultrasound follow up was recommended.
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