Spleen in haematological malignancies: spectrum of imaging findings

Abstract

Imaging morphology and metabolic activity of splenic lesions is of paramount importance in patients with haematological malignancies; it can alter tumour staging, treatment protocols and overall prognosis. CT, MRI and positron emission tomography (PET)/CT have been shown to be powerful tools for the non-invasive assessment of splenic involvement in various haematological malignancies. Since many haematological malignancies and non-neoplastic conditions can involve the spleen and imaging manifestations can overlap, imaging and clinical findings outside of the spleen should be looked for to narrow the differential diagnosis; confirmation can be obtained by pathological findings. Radiologists should be familiar with the cross-sectional imaging patterns of haematological malignancies involving the spleen as well as non-neoplastic splenic findings common in these patients to facilitate their care and follow-up. This pictorial review provides the common and uncommon imaging appearances and complications of various haematological malignancies involving the spleen on CT, MRI and PET/CT, and common pitfalls in diagnosis.

Figure 1

An axial contrast-enhanced CT image of a 65-year-old male with primary splenic marginal zone lymphoma. Image reveals multiple hypodense nodular lesions in the spleen (white arrows) without lymphadenopathy.

Figure 2

Images from a 65-year-old male with relapse of small lymphocytic lymphoma. (a) Axial and (b) coronal contrast-enhanced CT images reveal moderate hepatosplenomegaly with multiple low attenuation, subcentimetre micronodules in the spleen (white arrows). Associated bulky retroperitoneal (black arrows) and mesenteric lymphadenopathy are also seen.

Figure 3

Images from a 52-year-old male with diffuse large B-cell lymphoma of the spleen. (a) Axial and (b) coronal contrast-enhanced CT images reveal large heterogeneous mass with areas of low attenuation almost completely replacing the spleen (short black arrow) with extracapsular extension to involve stomach (long white arrow), pancreas and left adrenal gland. The mass is contiguous with the retroperitoneal lymphadenopathy (short white arrow) causing encasement of the splenic artery, coeliac axis (long black arrow) and left renal vein.

Figure 4

Coronal reformatted contrast-enhanced CT image from a 54-year-old female with relapsed and refractory secondary splenic indolent marginal zone lymphoma. Images reveal marked homogeneous splenomegaly without focal splenic lesion. Hepatomegaly, retroperitoneal lymphadenopathy (black arrows) and pleuropulmonary parenchymal masses (white arrow) are also noted.

Figure 5

Images from a 27-year-old female with recurrent classical Hodgkin’s lymphoma of nodular sclerosis type. (a) Axial contrast-enhanced CT images reveal diffuse heterogeneity of splenic enhancement (white arrow) with upper abdominal (black arrow) and retroperitoneal lymphadenopathy. (b) Axial fused positron emission tomography (PET)/CT and (c) coronal maximum intensity projection images from PET/CT data reveal intense fluorodeoxyglucose (FDG) uptake in the spleen (black arrow in (b)), which is significantly greater than the liver. Note the diffuse FDG-avid lymphadenopathy in the neck, mediastinum, right axilla, right hila (black arrow), upper abdomen, retroperitoneum (white arrow) and bilateral external iliac regions.

Figure 6

Images from a 46-year-old female with secondary hepatosplenic T-cell lymphoma. (a) Axial non-contrast CT, (b) axial fused positron emission tomography (PET)/CT and (c) coronal maximum intensity projection images from PET/CT data reveal moderate hepatosplenomegaly and heterogeneous, diffuse intense FDG uptake in the spleen (white arrows) without evidence of lymphadenopathy. Biopsy showed periportal infiltrate consistent with hepatosplenic T-cell lymphoma.

Figure 7

Images from a 67-year-old male with secondary splenic chronic lymphocytic leukaemia. (a) Coronal maximum intensity projection image from positron emission tomography (PET)/CT data before treatment showing moderately enlarged spleen with diffusely increased abnormal splenic fluorodeoxyglucose (FDG) uptake (black arrow), which is greater than hepatic uptake consistent with splenic involvement. Note the moderate to high uptake lymphomatous lymphadenopathy in bilateral cervical chain, supraclavicular, axillary (short white arrows), mediastinal, retroperitoneal (long white arrow), mesenteric and common iliac regions. (b) Coronal maximum intensity projection image from PET/CT following allogeneic transplant reveals complete resolution of abnormal FDG avid disease involving lymph nodes and the spleen suggesting complete remission.

Figure 8

Images from a 40-year-old male with secondary splenic highly aggressive precursor B-cell acute lymphoblastic leukaemia. (a) Coronal non-contrast CT, (b) coronal fused positron emission tomography (PET)/CT and (c) coronal maximum intensity projection images from PET data reveal mild splenomegaly with diffuse intense fluorodeoxyglucose (FDG) uptake (white arrow), which is greater than hepatic uptake and is consistent with splenic involvement. Diffusely increased FDG uptake in the bone marrow of the spine (black arrow) was secondary to bone marrow involvement proven by biopsy.

Figure 9

Images from a 64-year-old male with secondary splenic aggressive mantle cell lymphoma. (a) Axial non-contrast CT, (b) axial fused positron emission tomography (PET)/CT and (c) coronal maximum intensity projection PET images from PET/CT data reveal marked splenomegaly, mild diffusely increased splenic fluorodeoxyglucose (FDG) uptake and several high uptake splenic foci (white arrows). CT images show a homogeneous appearance of the spleen. There is mildly FDG-avid upper abdominal, retrocrural, retroperitoneal (short black arrow), mesenteric, hilar and mediastinal lymphadenopathy (long black arrow).

Figure 10

Images from a 65-year-old male with Waldenstrom’s macroglobulinaemia. (a) Coronal non-contrast CT, (b) coronal fused positron emission tomography (PET)/CT images from PET/CT data reveal moderate splenomegaly with diffuse intense fluorodeoxyglucose (FDG) uptake (long black arrow), which is greater than hepatic uptake and is consistent with splenic involvement. FDG-avid lymphadenopathy is noted in bilateral axillary (short black arrow) and right common iliac regions.

Figure 11

Images from a 65-year-old male with acute myelogenous leukaemia. (a) Axial contrast-enhanced CT image reveals mild hepatosplenomegaly with multiple well-defined low attenuation, non-enhancing, <1 cm micronodules (white arrows) in the spleen due to leukaemic deposits. An associated small linear area of splenic infarct (black arrow) is also noted. (b) Axial contrast-enhanced CT image of a 60-year-old patient with clinical suspicion of fungal microabscesses reveals multiple well-defined low attenuation, minimally enhancing, subcentimetre nodules (white arrows) in the normal-sized spleen making it difficult to differentiate from leukaemic lesions; however, hyperintense signal on T₂ weighted images with rim enhancement on MRI (not shown) were suggestive of fungal microabscesses.

Figure 12

Image from a 49-year-old female with Hairy cell leukaemia and severe left upper quadrant pain. Contrast-enhanced axial CT revealed a well-defined heterogeneously enhancing solitary exophytic splenic lesion (white arrows). Biopsy was consistent with hairy cell leukaemia involving the spleen.

Figure 13

Images from a 44-year-old female with aggressive systemic mastocytosis. Contrast-enhanced CT scan of the abdomen, (a) coronal soft tissue and (b) axial bone windows reveal moderate hepatosplenomegaly with multiple splenic calcifications (long black arrow), mesenteric and retroperitoneal adenopathy (short black arrow) and diffusely sclerotic bones (white arrow). The patient also had oesophageal varices due to portal hypertension (not shown), which is a reported finding in aggressive systemic mastocytosis.

Figure 14

Images from a 56-year-old male with primary myelofibrosis. (a) Axial and (b) coronal T₂ half-Fourier acquisition single-shot turbo spin-echo (HASTE) images reveal marked splenomegaly (long white arrow) with splenic infarct (short white arrow).

Figure 15

Images from a 59-year-old male with relapsed refractory IgG myeloma. (a) Axial T₁ post-contrast venous phase and (b) coronal T₁ post-contrast delayed phase MRI reveal moderate hepatosplenomegaly that was histopathologically proved to be a result of a combination of cirrhosis and multiple myeloma. Note the multiple tiny hypointense nodules in the spleen representing Gamna–Gandy bodies (long white arrow) due to underlying cirrhosis of liver with portal hypertension. Note the heterogeneous appearance of bone marrow of the lumbar spine (short white arrow) secondary to multiple myeloma.

Figure 16

Hepatosplenic fungal (candida) microabscesses in a 60-year-old male with acute myelogenous leukaemia. (a) Axial T₂ weighted and (b) post-contrast T₁ weighted images show multiple tiny (<1 cm diameter) T₂ high-signal intensity lesions with thin rim enhancement on post-contrast T₁ weighted images in the liver (long white arrow) and spleen (short white arrow) consistent with microabscesses. In contrast, focal lymphomatous lesions involving the spleen are usually larger lesions with isointense signal on T₁ (not shown), and (c) T₂ weighted images compared with the spleen (white arrow) and hypoenhancement on (d) post-contrast T₁ weighted images in an enlarged spleen (white arrow). Note the multiple enlarged lymph nodes in the portocaval (small black arrow) and retroperitoneal (long black arrow) regions due to small lymphocytic lymphoma.

Figure 17

Images of a 63-year-old male with chronic myeloid leukaemia and extramedullary haematopoiesis. (a) Axial T₂ and (b) T₁ axial dynamic venous MRI reveals a normal-sized spleen with a focal lobulated lesion in its anterior aspect appearing heterogeneously hyperintense on T₂ weighted images (black arrow), hypointense on T₁ (not shown) and with minimal enhancement on post-gadolinium fat suppressed gradient recalled echo T₁ weighted image (white arrow).

Figure 18

Images from a 65-year-old male with known pulmonary sarcoidosis. (a) Axial T₂ weighted and (b) delayed post-contrast T₁ weighted images reveal multiple <1 cm, T₂ hypointense lesions involving the spleen with uniform enhancement only on delayed post-contrast images (white arrows) and are suggestive of sarcoidosis. Similar lesions are noted in the liver (black arrow).