MALIGNANT SPLENIC DISEASE

Ultrasound images Lymphoma
Lymphoma is the most common malignant disease affecting the spleen. Lymphomas comprise a number of diseases, all malignant, which affect the lymphocytes. Malignant cells can infiltrate the spleen, lymph nodes, bone marrow and thymus and can also involve the liver, gastrointestinal tract, kidney
and other organs. Approximately 3% of malignant diseases are lymphomas. Splenic involvement may be found in up to 60% of lymphomas as a result of dissemination of the disease. Primary splenic lymphoma, limited to the spleen, is very rare, and accounts for less than 1% of lymphomas. There are two main groups: Hodgkin’s and non-Hodgkin’s lymphomas.
Clinical features and management lymphoma
Patients may present with a range of non-specific symptoms which include lymph node enlargement, anaemia, general fatigue, weight loss, fever, sweating and infections associated with decreased immunity.
If the disease has spread to other organs, these may produce symptoms related to the organs in question.
Prognosis depends upon the type of the disease, which must be determined histologically, and its stage. Both ultrasound and CT may be used in staging: ultrasound demonstrates splenic involvement with greater sensitivity than CT, and CT is superior in demonstrating para-aortic and iliac lymph nodes. Bone scintigraphy and MRI are further supplementary techniques in staging. Depending upon the type of lymphoma, chemotherapy regimes may be successful and, if not curative, can cause remission for lengthy periods. High-grade types of lymphoma are particularly aggressive with a poor survival rate.

Ultrasound images lymphoma
The range of possible ultrasound appearances in lymphoma is varied (Fig. below). In many cases the spleen is not enlarged and shows no acoustic abnormality. In a study of 61 patients with Hodgkin’s disease involving the spleen, the organ was usually normal in size and showed no acoustic abnormality in 46% of cases.3
Lymphoma may produce a diffuse splenic enlargement with normal, hypo- or hyperechogenicity.
Focal lesions may be present in up to 16% of lymphomas. They tend to be hypoechoic and may be single or multiple, and of varying sizes.
In larger lesions the margins may be ill-defined and the echo contents vary from almost anechoic to heterogeneous, often with increased through-transmission.
In such cases, they may be similar in appearance to cysts, however, the well-defined capsule is absent in lymphoma, which has a more indistinct
margin.
Smaller lesions may be hyperechoic or mixed. Tiny lymphomatous foci may affect the entire spleen, making it appear coarse in texture.
Lymphadenopathy may be present elsewhere in the abdomen. If other organs, such as the kidney or liver, are affected, the appearances of mass
lesions vary but are commonly echo-poor or of mixed echo pattern.
A differential diagnosis of metastases should be considered in the presence of multiple solid hypoechoic splenic lesions, but most cases are due to
these are microscopic and not amenable to radiological imaging. The most commonly found splenic metastases on ultrasound are from lymphoma, but may occur with any primary cancer. Intrasplenic deposits are more likely in later-stage disease and favour melanoma, pulmonary, ovarian or breast primaries.
As with liver metastases, the ultrasound appearances vary enormously, ranging from hypo- to hyperechogenic or of mixed pattern (Fig. below).
They may be solitary, multiple or diffusely infiltrative,giving a coarse echo-pattern.  lymphoma.

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Ultrasound images limphoma  Small, focal lesion in a normal-sized spleen
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Enlarged, hyperechoic spleen with a hypoechoic focal lesion (arrow).
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Enlarged, coarse-textured spleen containing multiple tiny lymphomatous lesions.
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Extensive lymphadenopathy in the epigastric region
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