J Korean Soc Radiol JKSR Journal of the Korean Society of Radiology 1738-2637 2288-2928 The Korean Society of Radiology 10.3348/jksr.2017.76.5.303 Abdominal Radiology Original Article Ultrasound-Guided Percutaneous Core Needle Biopsy of Splenic Lesions Park Sangik MD Shin Yong Moon MD Won Hyung Jin MD Kim Pyo Nyun MD Lee Moon-Gyu MD Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea. Corresponding author: Yong Moon Shin, MD. Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. Tel. 82-2-3010-4352, Fax. 82-2-476-0090, cjimage@amc.seoul.kr 05 2017 24 04 2017 76 5 303 309 02 09 2016 18 10 2016 27 10 2016 Copyrights © 2017 The Korean Society of Radiology 2017 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose

To evaluate the safety and efficacy of ultrasound-guided percutaneous core needle biopsy of splenic lesions.

 Materials and Methods

This retrospective study included 30 patients who underwent percutaneous core needle biopsy of their splenic lesions using 18- or 20-gauge needles between January 2001 and July 2016 in a single tertiary care center. The characteristics of the splenic lesions were determined by reviewing the ultrasound and computed tomography examinations. Acquisition rate and diagnostic accuracy were calculated, using pathologic results of the splenectomy specimen, clinical course and/or imaging follow-up as a reference standard. Post-procedure complications were identified from electronic medical records, laboratory findings and computed tomography images. Seventy-three specimens were obtained from the 30 patients and splenectomy was performed in 2 patients.

 Results

Twenty-nine of the 30 patients had focal splenic lesions, while the remaining patient had homogeneous splenomegaly. Acquisition rate and diagnostic accuracy were 80.0% (24/30) and 76.7% (23/30), respectively. Perisplenic hemorrhage without hemodynamic instability developed in one patient.

 Conclusion

Ultrasound-guided percutaneous core needle biopsy of splenic lesions is a safe method for achieving a histopathologic diagnosis and can be considered as an alternative to splenectomy in patients with a high risk of splenectomy-related complications.

 Core Needle Biopsy Spleen Lymphoma Tuberculosis Hemangioma Compérat E Bardier-Dupas A Camparo P Capron F Charlotte F Splenic metastases: clinicopathologic presentation, differential diagnosis, and pathogenesis Arch Pathol Lab Med 2007 131 965 969 Cadili A de Gara C Complications of splenectomy Am J Med 2008 121 371 375 Lehne G Hannisdal E Langholm R Nome O A 10-year experience with splenectomy in patients with malignant non-Hodgkin's lymphoma at the Norwegian Radium Hospital Cancer 1994 74 933 939 Machado NO Grant CS Alkindi S Daar S Al-Kindy N Al Lamki Z Splenectomy for haematological disorders: a single center study in 150 patients from Oman Int J Surg 2009 7 476 481 Keogan MT Freed KS Paulson EK Nelson RC Dodd LG Imaging-guided percutaneous biopsy of focal splenic lesions: update on safety and effectiveness AJR Am J Roentgenol 1999 172 933 937 Quinn SF vanSonnenberg E Casola G Wittich GR Neff CC Interventional radiology in the spleen Radiology 1986 161 289 291 Solbiati L Bossi MC Bellotti E Ravetto C Montali G Focal lesions in the spleen: sonographic patterns and guided biopsy AJR Am J Roentgenol 1983 140 59 65 Gómez-Rubio M López-Cano A Rendón P Muñoz-Benvenuty A Macías M Garre C Safety and diagnostic accuracy of percutaneous ultrasound-guided biopsy of the spleen: a multicenter study J Clin Ultrasound 2009 37 445 450 Lieberman S Libson E Maly B Lebensart P Ben-Yehuda D Bloom AI Imaging-guided percutaneous splenic biopsy using a 20- or 22-gauge cutting-edge core biopsy needle for the diagnosis of malignant lymphoma AJR Am J Roentgenol 2003 181 1025 1027 Muraca S Chait PG Connolly BL Baskin KM Temple MJ US-guided core biopsy of the spleen in children Radiology 2001 218 200 206 Venkataramu NK Gupta S Sood BP Gulati M Rajawanshi A Gupta SK Ultrasound guided fine needle aspiration biopsy of splenic lesions Br J Radiol 1999 72 953 956 Olson MC Atwell TD Harmsen WS Konrad A King RL Lin Y Safety and accuracy of percutaneous image-guided core biopsy of the spleen AJR Am J Roentgenol 2016 206 655 659 McInnes MD Kielar AZ Macdonald DB Percutaneous image-guided biopsy of the spleen: systematic review and meta-analysis of the complication rate and diagnostic accuracy Radiology 2011 260 699 708 Liang P Gao Y Wang Y Yu X Yu D Dong B US-guided percutaneous needle biopsy of the spleen using 18-gauge versus 21-gauge needles J Clin Ultrasound 2007 35 477 482 Patel N Dawe G Tung K Ultrasound-guided percutaneous splenic biopsy using an 18-G core biopsy needle: our experience with 52 cases Br J Radiol 2015 88 20150400 Civardi G Vallisa D Bertè R Giorgio A Filice C Caremani M Ultrasound-guided fine needle biopsy of the spleen: high clinical efficacy and low risk in a multicenter Italian study Am J Hematol 2001 67 93 99 Kim SH Min YI Lee IC Lee MG Auh YH Hyun CD Fine-needle aspiration of splenic lesions J Korean Radiol Soc 1994 31 921 924 Lindgren PG Hagberg H Eriksson B Glimelius B Magnusson A Sundström C Excision biopsy of the spleen by ultrasonic guidance Br J Radiol 1985 58 853 857 A 66-year-old male with perisplenic hemorrhage after core needle biopsy.

A. Axial computed tomography (CT) obtained for evaluation of fever shows mild splenomegaly (maximal diameter, 13 cm).

B. Axial fused positron emission tomography-CT image shows mildly increased 18F-fluorodeoxyglucose uptake in the spleen (maximum standardized uptake value, 3.0). The differential diagnoses included infection and hematologic malignancy.

C. Percutaneous ultrasound-guided core needle biopsy of the spleen was performed using an 18-G needle. The arrowheads indicate the tip of the biopsy needle. Histopathologic examination showed inflammatory infiltrates without evidence of malignancy.

D. Follow-up CT scan obtained 1 day after the procedure to evaluate a decrease in blood hemoglobin levels (8.0 g/dL to 6.3 g/dL) shows perisplenic hemorrhage (arrowheads) and probable active extravasation of contrast media (arrow). The patient showed no hemodynamic instability and improved with supportive management.

 A 66-year-old female patient with known lung cancer: case with a nondiagnostic histopathologic result.

A. Axial CT shows multiple low density lesions in the spleen, which were considered as possible splenic metastases.

B. US examination shows a 1.4-cm hypoechoic lesion in the spleen. The index mass and other lesions were poorly visualized owing to poor sonic window. Needle approach was hindered by narrow intercostal space of the patient. The histopathologic result was nondiagnostic, and splenectomy revealed sclerosing angiomatoid nodular transformation.

CT = computed tomography, US = ultrasound

 A 43-year-old male patient with splenic hemangiomas: case with a favorable result.

A. Axial CT shows numerous hypointense lesions in the spleen.

B. US examination shows multiple hyperechoic lesions in the spleen, one of which was biopsied using an 18-G core needle. The histopathologic diagnosis was hemangioma.

CT = computed tomography, US = ultrasound

 Clinical and Radiological Characteristics of 30 Patients and Their Splenic Lesions
Number of Patients
Symptoms at presentation
 Fever 7
 Left flank pain 5
 Generalized weakness 3
 Hematemesis 1
 Asymptomatic 14
Clinical impression
 Lymphoma 11
 Primary benign mass 8
 Infection 5
 Metastasis 4
 Sarcoidosis 1
 Sarcoma 1
Characteristics of splenic lesions
 Number of splenic lesions Number of patients*
  Solitary 10
  2–5 6
  6 or more 13
 Margin Number of patients*
  Ill-defined 9
  Well-defined 20
 Internal attenuation (homogeneity) Number of patients*
  Homogeneous 22
  Heterogeneous 7
Internal attenuation (CT number) 81.4 ± 23.5 HU*
Maximal diameter of largest splenic lesions 3.6 ± 2.2 cm*
Maximal diameter of spleen 11.6 ± 2.4 cm

*n = 29 (excluding one patient with splenomegaly without focal lesions).

CT = computed tomography, HU = Hounsfield unit

 Histopathologic Results of Ultrasound-Guided Core Needle Biopsy of Splenic Lesions in 30 Patients
Result Number of Patients
Malignant
 Non-Hodgkin’s lymphoma (B cell) 8
 Non-Hodgkin’s lymphoma (T cell) 2
 Angiosarcoma 1
 Pleomorphic rhabdomyosarcoma 1
Benign
 Hemangioma 3
 Lymphangioma 2
 Tuberculosis 2
 Sclerosing angiomatoid nodular transformation 2
 Total necrosis and fibrosis 1
 Sarcoidosis 1
 Inflammatory infiltration 1
Nondiagnostic* 6
Total 30

*Nondiagnostic results include normal splenic parenchyma (n = 2), splenic congestion (n = 2), reactive mesothelial cells (n = 1) and normal renal parenchyma (n = 1).

 Radiologic Impression, Histopathologic Results, Modalities of Further Evaluation and Final Diagnosis in 6 Patients with Nondiagnostic Results on Ultrasound-Guided Percutaneous Core Needle Biopsy
Patient Number Impression Histopathology Further Evaluation Final Diagnosis
1 Lymphoma Splenic congestion Bone marrow biopsy Tuberculosis
2 Metastasis Reactive mesothelial cells None (follow-up) NA
3 Pancreatic tail cancer with splenic invasion Normal splenic parenchyma EUS-guided FNA Poorly differentiated carcinoma
4 Metastasis Normal renal parenchyma Splenectomy SANT
5 Hamartoma Splenic congestion None (follow-up) NA
6 Tuberculosis Normal splenic parenchyma None (follow-up) NA

EUS = endoscopic ultrasound, FNA = fine needle aspiration, NA = not available, SANT = sclerosing angiomatoid nodular transformation