Approach to splenic masses: Clinical sciences

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Introduction 0:00–0:32

Splenic masses are abnormal growths or tumors of the parenchyma or vasculature of the spleen. They are broadly categorized into solid and cystic lesions.
Most splenic masses are benign and incidentally found. The patient’s history and the characteristics of the mass on ultrasound or CT scan are key factors in establishing the diagnosis.
Your first step in evaluating a patient presenting with a chief concern suggestive of a splenic mass is to obtain a focused history and physical examination.

Focused H&P 0:32–1:29

The patient might report a history of night sweats, unintentional weight loss, or fevers. However, keep in mind that some patients might be asymptomatic, in which case their splenic mass was probably discovered incidentally on imaging due to some other concern.
On the other hand, the exam might show left upper quadrant abdominal tenderness, a palpable left upper quadrant abdominal mass, petechiae, or ecchymoses.
With these findings you should consider a splenic mass and order imaging like a left upper quadrant abdominal ultrasound or CT scan of the abdomen.
These studies will determine if a splenic lesion is present and whether it is cystic or solid. First, let’s focus on cases where imaging shows cystic splenic masses.

Cystic splenic masses/Epithelial cyst 1:29–2:13

These are broadly divided into solitary lesions and multiple lesions. First up among solitary cystic splenic masses, are epithelial splenic cysts, also known as primary splenic cysts.
They got their name because these cysts are lined with epithelial cells. These patients might report vague abdominal pain or fullness, or they may be asymptomatic.
If the ultrasound or CT scan shows a thin-walled fluid-filled structure without internal debris or loculations you can make the diagnosis of epithelial splenic cyst.
On the other hand, you might be dealing with a pseudocyst, also known as a secondary cyst, which are not lined with epithelial cells.

Pseudocyst 2:13–2:44

These usually occur due to some damage to the spleen like trauma. Therefore, your patient might have a history of trauma or previous splenic infarct.
On ultrasound or CT, you will see a thick-walled cystic structure with rim calcifications. This will lead you to diagnose a splenic pseudocyst.
Next, you might be dealing with a splenic abscess. These patients might have a history of IV drug use or infective endocarditis.

Abscess 2:44–3:14

On CT you will see a hypodense round fluid collection with rim enhancement. There will be air-fluid levels with or without bubbles.
There may also be multiple or complex cysts. With these findings, think splenic abscess.
Lastly, in rare situations, a patient might have an echinococcal or hydatid cyst in the spleen. If this is the case, they may have recently traveled to Central or South America or were exposed to dogs or sheep.

Echinococcal cyst 3:14–3:56

On CT you will see multiloculated cysts with daughter cysts with or without eggshell calcifications within the cyst wall.
These patients typically have lung or liver lesions as well since splenic lesions are part of a more advanced disease. These findings will lead to the diagnosis of echinococcal or hydatid cyst.
Moving on, let’s talk about multiple cystic splenic masses. These lesions usually occur in the pediatric population.

Multiple cystic splenic masses 3:56–4:20

The ultrasound or CT will likely show multilobulated cysts with thin walls and sharply defined borders. This is characteristic of splenic lymphangiomas.
Alright, now that we have covered cystic splenic masses, let’s turn to solid splenic masses, which can also be subdivided into solitary or multiple lesions.

Solid splenic masses/Solitary masses 4:20–5:05

Solitary solid splenic masses can be vascular or non-vascular in origin. Vascular lesions have a characteristic contrast enhancement on CT from the IV contrast that pools within the mass.
Non-vascular lesions, on the other hand, look isodense or hypodense on CT. Let’s talk about vascular lesions first, which include splenic artery aneurysm, hamartoma, hemangioma, and angiosarcoma.
Splenic artery aneurysms occur due to weakening of the arterial wall, which can happen from atherosclerosis or from changes in blood flow dynamic, as seen with portal hypertension and pregnancy.

Splenic artery aneurysm 5:05–5:35

If history reveals portal hypertension, atherosclerosis, or pregnancy, and the CT shows a contrast-enhancing mass continuous with the splenic artery, you can make your diagnosis of a splenic artery aneurysm.
On the other hand, patients with hamartomas are usually asymptomatic or report only vague abdominal discomfort or fullness.

Hamartoma 5:35–6:00

The CT might show a lesion with a well-defined border without a capsule, often containing fibrosis or single or multiple cystic areas.
In this case, you can diagnose splenic hamartoma. Next up is hemangioma.
These patients might also be asymptomatic or report vague abdominal discomfort or fullness. However, their CT will show small isodense or hypodense lesions, with internal cystic components, and progressive or persistent contrast enhancement.

Hemangioma 6:00–6:56

There might also be areas of hemorrhage or infarct. If so, diagnose splenic hemangiomas.
= Here’s a clinical pearl. A condition called Kasabach-Merritt syndrome, which is more commonly seen in children, manifests with large hemangiomas, often in the spleen or liver.
It causes consumptive coagulopathy and thrombocytopenia, which often leads to high-output heart failure. This condition is an indication for urgent splenectomy.
Finally, patients with angiosarcoma might be asymptomatic or present with vague abdominal discomfort or fullness. In this case, CT reveals a heterogeneous lesion with irregular enhancement and possible splenomegaly.

Angiosarcoma 6:56–7:18

This indicates a splenic angiosarcoma. Alright, let’s turn to solitary splenic masses that are non-vascular on imaging.

Non-vascular masses/Lymphoma 7:18–8:23

Patients might report night sweats and unintentional weight loss. Physical exam typically reveals palpable lymphadenopathy in multiple lymph node beds.
The CT scan reveals well-defined, homogenous, spherical nodules. In this case, consider splenic lymphoma and order a PET/CT scan.
If the PET/CT reveals FDG-avid lesions with homogenous enhancement, diagnose splenic lymphoma. Here’s a clinical pearl!
In some cases, splenic lymphomas can present as multifocal lesions. However, isolated splenic lymphomas are rare, and most patients have other lymph node involvement.
The lymph node that is easiest to access is typically biopsied to confirm the diagnosis. Keep in mind that splenic biopsies are very rarely performed due to bleeding complications.
Okay, let’s go back to imaging and discuss patients with multiple solid splenic masses, which are usually inflammatory or metastatic lesions.

Multiple solid splenic masses 8:23–8:33

When it comes to inflammatory lesions, history reveals fever, dry cough, and left upper quadrant abdominal discomfort. The CT scan reveals numerous hypodense tiny lesions with central fibrous scarring which indicates granulomas.

Inflammatory lesions 8:33–8:57

If you see these findings, think of inflammatory lesions such as sarcoidosis. Finally, when it comes to metastases, patients usually have a past medical history of an extrasplenic malignancy.

Metastases 8:57–9:15

Their CT scan reveals multiple solid lesions. In this case, you are most probably dealing with metastatic lesions.
Alright, as a quick recap… When a patient presents with a splenic mass, start with a focused history and physical exam. Next, obtain imaging like an ultrasound or abdominal CT, which will help you make a diagnosis.

Review 9:15–10:08

Splenic masses can be broadly classified as cystic or solid lesions. If you are dealing with a solitary cystic mass, consider an epithelial cyst, pseudocyst, abscess, or echinococcal cyst, but if there are multiple cystic lesions, think lymphangiomas.
On the flip side, if there is a solitary solid mass, it might be a splenic artery aneurysm, hamartoma, hemangioma, angiosarcoma, or lymphoma.
However, with multiple solid masses, consider inflammatory lesions or metastases.
Approach to splenic masses: Video, Steps, and Uses | Osmosis