Download Spleen Fine Needle Aspiration

Spleen Fine
Needle
Aspiration
Nothing to be afraid of
A. A. Pérez Martínez, M. Adán-Martín
B. R. Juárez Tosina,
C. Y. Herrero Gómez
D. A. Enríquez Puga,J. Pinto Varela
Objetives
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To review the basic anatomy and CT
imaging findings of spleen abnormalities
To review the main indications,
contraindications and potential
complications of spleen fine-needleaspiration (FNA) guided by CT.
To highlight the adecuate interventional
procedures to obtain enough cytologic
material.
Gross Anatomy
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The spleen is an oblong or
ovoid organ in the left upper
abdomen.
The contour of the superior
lateral border of the spleen is
convex, conforming to the
shape of the adjacent
abdominal wall and left
hemidiaphragm.
The hilum is concave where it
conforms to the shape of the
adjacent left kidney. The
medial surface anterior to the
hilum is in contact with the
stomach.
Microscopic Anatomy
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White Pulp: lymphoid compartment. Consists of both follicular Bcell-rich areas as well as T-cell-rich periarteriolar lymphoid sheaths.
Red Pulp: large volume of erythrocytes. Four vascular structures:
slender and nonanastomosing arterial vessels; splenic cords; large,
thin-walled venous vessels called sinusoids; pulp veins which drain
the sinusoids.
CT Anatomy

On images
performed without
intravenous
contrast material,
the spleen has
homogeneous
density (55-65
Hounsfield units).
Normal size: 12x7x4cm.
150g of weight.
CT Anatomy
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The splenic artery
and vein and their
branches enter the
spleen in the hilum
The spleen has
smooth margins
sharply
demarcated from
the adjacent fat
Imaging findings
Technique
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5mm slice thickness with
5mm reconstruction
interval
The use of intravenous
contrast material is
essential.
Normal heterogeneous
enhancement during the
parenchymal phase of
opacification.
Imaging findings
Infectious diseases

Bacterial abscess
may be due to metastatic
infection, contigous infection,
embolic noninfectious events,
iatrogenic, immunodeficiency
conditions and trauma. Lowattenuation center of fluid or
necrotic tissue with minimal
peripheral contrast enhancement.
The presence of gas inside the
collection is diagnostic.
 Fungal Microabscess: multiple
small lesions of low attenuation.
 Tuberculosis: irregular areas of
low density. May produce septic
emboli and infaction.
Imaging findings
Cysts

Incidental. Primary (true)
and secondary (false) are
difficult to differenciate
 Typically seen as round, well-defined cystic
lesions with water attenuation with a thin or
imperceptible wall and no rim enhancement.
Imaging findings
Infarction
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Key imaging finding: wedgeshaped, peripheral,
hypoattenuating lesion.
Many appear round or
irregular. Also as
hypoattenuating lesion with
poor defined margins,
indistinguishable from other
lesions (abscesses, tumors).
Imaging findings
Splenomegaly

There are a lot of causes:
congestion (portal
hypertension), infiltrative
diseases (histiocytosis)
hematologic disorders
(polycytemia vera),
inflamatory diseases
(infectious mononucleosis),
cysts or tumors (metastases,
lymphoma, leukemia).
Imaging findings
Benign tumors

Hemangioma
usually an indicental finding.
They appear as solid or cystic
mass, and may enhance with
contrast material in a similar
fashion to that of hepatic
hemangioma.
Hamartoma: incidentally found.
Iso- or hypoattenuating mass.
Imaging findings
Malignant tumors
 Angiosarcoma: may manifest with
well-defined nodules or difusse
splenic involvement. CT shows an
enlarged spleen with
hypoattenuating lesions on nonenhanced scans and contrast
enhancement is variable.

Lymphoma: most common
spleen malignancy. The CT
appearances is similar to a variety
of splenic pathologies:
homogeneus enlargment without
a discrete mass, solitary mass,
multifocal mass and diffuse
infiltration.
Imaging findings
Malignant tumors

Metastatic disease:
up to 7% of patients
with malignancy.
50% melanoma.
CT images show
slighty hypoattenuating
areas, that may be
solid or cystic.
The role of Interventional
Radiology in Spleen Diagnosis
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As stated before, many pathologies
affecting the spleen have a similar
appearance on CT imaging.
Characterization of spleen lesions only by
imaging techniques may be impossible.
Spleen FNA and microbiopsy may help to
achieve a final diagnosis.
Clinical Indications of
FNA
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Suspected lymphoma
Known primary malignancy with suspected
metastases
Immunosuppressed patients with splenic
lesions
Incidental splenic lesion with uncertain
diagnosis.
Contraindications
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Abnormal coagulation status
Infectious mononucleosis
Polycythemia vera
Megakaryocytic myelosis with
thrombocytosis
Complications
 Low rate of complications
(0-2% reported in the literature)
 Potentially:
-- Subcapsular hematoma (most common)
-- Peritoneal hemorrhage
-- Infection
-- Pneumothorax
-- Pleural effusion
-- Colonic, renal or pancreatic injure
FNA procedure
Prerrequisites:
 Signed informed consent form
 Normal platelet count and coagulation screen
-- platelet count: 150-450x109/l
-- prothrombin time:11.3 -13.3 sec.
-- activated partial thromboplastin time:
20-33sec.
FNA procedure
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Unenhanced CT scan is performed
Contrast enhanced CT scan is performed if no
previous diagnostic study is available.
FNA procedure
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A radiopaque grid is
placed on the skin of the
patient, to define the
entry point
The path is chosen
trying to cross the lowest
volume of normal
splenic tissue.
FNA procedure
 The skin is cleaned with a bactericidal agent and
infiltrated with a local anesthesic agent (1-2% lidocaine).
FNA procedure
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Fine-needle aspirations are performed with 20gauge or 22-gauge self-aspirating Crown needle.
FNA procedure
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The needle is placed
at the periphery of the
splenic lesion, and
then rapidly and
repeatedly advanced
and withdrawn 1-2cm.

Each biopsy is performed during
suspended respiration
FNA procedure

Biopsy material is sent
for histologic
examination preserved
in a tube containing
formalin and for
cytologic examination
smeared on a slide
and immersed in 96%
ethyl alcohol.
Our Experience
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27 Spleen FNA 2002-2009
All were CT guided
 FNA: 20-g
 Microbiopsy: 19-g
Only FNA: 14 cases
FNA and microbiopsy : 13 cases
Stains: HE, Giemsa, Papanicolau
Aditional techniques:
Inmunohistoquímic
Molecular techincque
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8 patients underwent splenectomy (diagnostic / therapeutic)
RESULTS
Patients
27
Women
13
Men
14
Complaint
Abdominal pain + constitutional syndrome
14
Constitutional syndrome
1
Incidental
12
Imaging findings
Splenomegaly + nodule/s
18
Nodules/s
5
Cyst
2
Difuse splenomegaly
1
RESULTS
DIAGNOSIS
NEOPLASMS
NON TUMORAL
LESIONS
INSUFICIENT
Nº
Linfoid
12
Non linfoids
4
Cysts
2
Granulomes
2
Negative
6
1
RESULTS
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The spleen-FNA combined with
microbiopsy was diagnostic in 96% of the
cases.
In 1 case (3,7%) there wasn´t enough
cytologic material for diagnosis.
COMPLICATIONS
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We only had 1 case with complications (3,7%).
The patient developed a splenic abscess, which was
succesfully treated with percutaneous drainage and
antibiotherapy
Our Cases
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Patient admitted to complete splenomegaly
study.
A bone-marrow biopsy was performed. It
was normocellular, without evidence of
lymphoproliferative process.
Spleen FNA and microbiopsy were
performed.
FNA
Microbiopsy
CD20
Our Cases
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Abdominal CT: homogeneous
splenomegaly.
FNA and microbiopsy were performed.
FNA: monomorphic proliferation of small
lymphoid cells.
Microbiopsy: diffuse proliferation of small
lymphoid cells : cd20+, bcl2+
Diagnosis: SMALL CELLS B LYMPHOMA.
Our Cases
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Patient admitted due to anemia and possible GI
bleeding.
CT findings: hepatic hypodense nodules, with
multiple lymphadenopaties in hepatic hilium
compressing the vena porta. Retroperitoneal
mass involving pancreatic body and tail.
Splenomegaly with multiple hypodense nodules.
Lymphoma was the first diagnostic possibility.
CT guided FNA and
Microbiopsy were
performed.
ACT
DESM
Microbipsy
ACT
 FNA: fibrosis, isolated
grups of atipyc cells with
fusiform and
hypercromatic nuclei:
actine and desmine +.
 Microbiopsy: elongated
cells with fusiform,
pleomorphic and
hypercormatic nuclei,
and atipycal mitosis .
Actine, desmine and
vimentin +. s100, cd34,
ckit,alc, cd68-.
 Diagnosis:
Leiomyosarcoma
Summary
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Characterization of spleen lesions only by
imaging techniques may be impossible.
The FNA is a usefull and safe procedure to
diagnose infections and tumorals diseases
of the spleen.