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1 All authors: Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, White 270, 55 Fruit St., Boston, MA 02114.
Received March 22, 2002;
accepted after revision June 7, 2002.
Address correspondence to B. C. Lucey.
Abstract
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MATERIALS AND METHODS. We used our electronic database to perform a retrospective analysis of patients treated from January 1990 to December 2000. Thirty-nine imaging-guided percutaneous splenic procedures were performed in 38 patients: 27 men and 11 women who ranged in age from 17 to 83 years (mean age, 56.5 years). For 28 procedures, sonographic guidance was used, and for 11, CT guidance was used. Procedures performed included splenic biopsy (n = 24), fluid aspiration (n = 8), and fluid drainage (n = 7).
RESULTS. Splenic biopsy was successful in 91% of the procedures; fluid aspiration, in 100%; and fluid drainage, in 86%. The overall complication rate was 10.3%, with three patients requiring emergency splenectomy as a result of massive bleeding after the procedure. Two of these patients had previously unrecognized vascular tumors, and one had concomitant refractory thrombocytopenia.
CONCLUSION. This study suggests that splenic biopsy can be performed safely and is of considerable value in diagnosis. Our findings also show that percutaneous catheter drainage of splenic abscesses is successful and that splenectomy should be reserved for failed percutaneous drainage. The complications that occur after procedures on vascular tumors emphasize the importance of requiring normal coagulation parameters before the procedure because the vascular nature of the lesion may be difficult to recognize on imaging before the procedure.
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Before all procedures, written informed consent was obtained. The platelet count, prothrombin time, and activated partial thromboplastin time were reviewed and corrected, if necessary, before the procedure. The minimum platelet level acceptable was 50,000 platelets/mL, and the acceptable range for prothrombin time was 11.5-13.5 sec. After each procedure, all outpatients were monitored in an observation unit located in the radiology department; blood pressure and pulse rate were taken at 15-min intervals for 1 hr and at 30-min intervals for an additional 3 hr for a total of 4 hr. Monitoring was performed to evaluate for evidence of internal bleeding. Before outpatients were discharged, the skin entry site was inspected for evidence of bleeding or hematoma.
Biopsy
Twenty-four biopsies were performed in 23 patients, 19 with sonographic
guidance and five with CT guidance. Thirteen patients underwent fine-needle
aspiration biopsy only, three patients underwent core biopsy only, and eight
patients underwent both fine-needle aspiration biopsy and core biopsy. Ten of
the patients who underwent fine-needle aspiration biopsy or core biopsy had a
known primary extrasplenic malignancy with suspected metastasis. These
malignancies included patients with lymphoma (n = 4)
(Fig. 1), lung cancer,
leukemia, carcinoid tumor (Fig.
2A,2B),
angiosarcoma, melanoma (Fig.
3A,3B),
and ovarian cancer (n = 1). In each case, an uncharacterized splenic
lesion was documented on contrast-enhanced helical CT.
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In 12 patients, the procedure was performed after an incidental finding of a splenic lesion on a contrast-enhanced CT scan that was obtained for other reasons. The splenic procedure was therefore performed to obtain a primary diagnosis.
In one patient, a biopsy was performed after an incidental finding of splenomegaly without a focal splenic lesion being seen on contrast-enhanced CT. This patient was being assessed for lung transplantation, and the biopsy was performed to exclude a diagnosis of lymphoma.
The needle gauge used for biopsy and the number of passes made were at the discretion of the interventional radiologist performing the procedure. Core biopsies were performed with an 18-gauge needle (n = 8), 19-gauge needle (n = 1), or 20-gauge needle (n = 2).
The coaxial needle (Temno; Allegiance Health-care, McGaw Park, IL) technique was used in 10 of the 24 biopsies. This technique involves placing a hollow needle into the lesion through which multiple aspirates and cores can be obtained without repeatedly puncturing the spleen. In the remaining 14 cases, the tandem technique was used. This technique involves placing a needle into the lesion and repeatedly guiding a second needle parallel to the first needle to obtain samples.
Fine-needle aspiration biopsies were performed with 20-gauge (n = 3), 22-gauge (n = 14), or 23-gauge (n = 4) needles. Chiba needles (Cook, Bloomington, IN) were used for aspirates. Between one and five passes were made (mean, three passes).
Fluid Aspiration
Splenic fluid aspiration was performed in eight patients. In these cases, a
low-attenuation lesion was identified on a contrast-enhanced CT scan, and the
patients presented with a fever of unknown origin. The aspiration was
performed to differentiate between a simple splenic cyst and an abscess. Five
procedures were performed under direct sonographic guidance, and three were
performed using CT guidance. Fluid aspirations were performed using 19-gauge
(n = 1), 20-gauge (n = 2), or 22-gauge (n = 5)
needles. Samples were sent for cytology or culture and sensitivity as
clinically indicated.
Fluid Drainage
Seven drainage catheters were placed into splenic collections in seven
patients. Six of these were considered to be abscesses on the basis of imaging
criteria, and the catheters were placed after the initial needle aspiration.
The catheters used for abscess drainage ranged from 8- to 12-French (8-French,
n = 1; 10-French, n = 4; and 12-French, n = 1). The
size of the catheter used was at the discretion of the radiologist performing
the procedure. The more viscous the fluid that was initially aspirated, the
larger the catheter that was placed. For one fluid aspiration, a 7-French
catheter was used to facilitate more rapid drainage of a large fluid
collection after a 22-gauge needle was used for the initial aspiration.
Location
Each lesion was characterized by location as either peripheral or central.
A peripheral lesion was defined as a lesion that was adjacent to or within 1
cm of the splenic capsule. All the remaining lesions were classified as
central. Overall, 24 of the lesions were considered peripheral, and the
remaining 15, central. Sixteen biopsies were performed on peripheral targets
and eight biopsies on central targets. Of the fluid aspirations, three lesions
were located peripherally and five, centrally. Five of the seven catheters
were placed into collections that were within 1 cm of the splenic capsule.
We examined the procedure-related complications with respect to the location of the lesion to evaluate whether location affected the complication rate.
Technique
Conscious sedation was achieved in all patients using IV midazolam
hydrochloride (Versed; Roche Laboratories, Nutley, NJ) and fentanyl citrate
(Elkins-Sinn, Cherry Hill, NJ) according to standard protocols. All
sonographic procedures were performed using a 3.5-MHz sector transducer. The
lesion was initially localized, and the overlying skin was cleaned and draped.
If more than one lesion was present, the most peripheral accessible lesion was
selected for biopsy so that as little normal splenic tissue as possible was
traversed. Using real-time sonographic guidance, the interventional
radiologist directed the biopsy needle into the lesion while avoiding the
colon, pleura, lung, and kidney. A subcostal approach was used if possible,
and the needle was inserted during suspended respiration. A sonogram was
obtained after the procedure to exclude clinically relevant hemorrhage.
For CT-guided biopsies, a preliminary unenhanced CT scan was obtained to localize the lesion. Again, the largest and most peripheral accessible lesion was targeted in patients with multiple lesions, and an access route that avoided transgressing any normal anatomic structures was chosen. Real-time fluoroscopic CT was not used. An unenhanced CT scan was also obtained after the procedure to exclude potential complications.
If purulent material was present in the initial needle aspirate then a drainage catheter (8- to 12-French, Dawson-Mueller; Cook) was placed. Five catheters were placed under direct sonographic guidance, and two catheters were placed under CT guidance. All the drainage catheters were inserted using the trocar technique, guiding the catheter along the localizing needle pathway. After the catheters had been successfully placed, the abscesses were fully aspirated and irrigated with sterile saline; standard catheter care was observed during follow-up [7,8,9].
Biopsy was deemed successful if a diagnostic pathology specimen was obtained. Fluid aspiration was deemed successful if imaging after the procedure showed resolution of the collection. Catheter drainage was deemed successful if the abscess resolved without further intervention being required.
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Fluid Aspiration
All eight diagnostic and therapeutic fluid aspirations that were performed
were successful. No bacterial growth was shown in five cases that were
subsequently proven to be simple cyst (n = 4) or an infarct
(n = 1) (Fig.
5A,5B).
Purulent material was aspirated from three of eight abscesses. In one of these
three patients, a drainage catheter was subsequently placed. In the second of
three patients, the patient was brought directly to the operating room for
surgical drainage of the abscess. This patient had insulin-dependent diabetes
and had undergone kidney transplantation. In the third of three patients, the
aspiration was technically difficult because the patient was obese and the
abscess was small. The abscess was fully aspirated through an 18-gauge needle
and confirmed on imaging performed after the procedure. No subsequent
intervention was needed. No complications occurred in this patient group.
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Fluid Drainage Catheters
Of the seven catheters placed into splenic collections, six were inserted
in splenic abscesses that grew gram-positive rods, gram-negative rods,
gram-positive cocci, or a combination of these organisms. Five of the six
abscesses were successfully drained (Fig.
6A,6B,6C).
All patients were already taking broad-spectrum antibiotics before the
procedure. The patients were seen daily by the interventional radiology team.
Standard catheter care was used during follow-up. The catheters were flushed
every 8 hr with 10 mL of normal saline, and catheter output was recorded
daily. The decision to remove the catheters was based primarily on the
clinical status of the patient. Once a patient improved clinically, with a
return to normal temperature and WBC, and once the catheter output decreased
to less than 10 mL per 24 hr, then the catheter was removed.
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Complications
Four complications were encountered after the 39 procedures: three major
(7.7%) and one minor (2.6%). The minor complication was a small amount of
intraabdominal bleeding, confirmed on CT, for which no further intervention
was required. The three major complications consisted of large areas of
perisplenic bleeding that occurred after the procedure and were shown on
unenhanced CT. Two of these patients developed abdominal pain soon after the
procedure, and CT was performed within 2 hr of the procedure. One of these
patients, who was an inpatient at the time, complained of abdominal pain
almost 12 hr after the procedure. The three patients required emergency
splenectomy within 24 hr because of hemodynamic instability.
In one of these three patients, the biopsy result yielded a littoral cell angioma [6], and in another patient a metastatic angiosarcoma was diagnosed (Fig. 7). In the first patient, three passes with a 22-gauge needle were made. This patient had normal coagulation parameters before the procedure. In the second patient, three passes with a 23-gauge needle were made. This patient had a normal prothrombin time and normal activated partial thromboplastin time before the procedure. This patient, however, had thrombocytopenia before the procedure, with a platelet count of 27,000/mL. The patient was unresponsive to platelet transfusion, so corticosteroids and Rho Immune Globulin (Ortho Diagnostic Systems, Raritan, NJ) were administered, which elevated the platelet count to more than 100,000/mL before the procedure. It was therefore deemed safe to proceed with the procedure. Despite receiving 18 U of platelets and 6 U of packed RBCs after the procedure, the patient continued to hemorrhage and emergency splenectomy was required. The third patient required a splenectomy after a 10-French catheter was placed in a splenic abscess. This patient had normal coagulation parameters before the procedure, and the procedure was uncomplicated from a technical perspective.
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Location
Of the four complications encountered, two of the four lesions were
peripherally located and two were centrally located. The complications in the
peripheral lesions occurred after fine-needle aspiration biopsy and included
one case of minor bleeding that required no further intervention and a
splenectomy in a patient with a littoral cell angioma. The two central lesions
with complications included an angiosarcoma for which fine-needle aspiration
biopsy had been performed and an abscess for which a catheter had been placed;
both complications led to splenectomy. The complication rate was too low to
suggest any significant trend with regard to the location of the splenic
lesion.
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Traditionally, splenic abscesses have been drained surgically [15,16,17], but relatively high morbidity and mortality have been reported, with operative mortality varying from 13% to 28% [18, 19]. However, these series have been small (from two to five patients). Reported success rates in the literature for percutaneous splenic abscess drainage range from 60% to 77% [2, 12, 20]. The success rate for percutaneous splenic abscess drainage is lower than the success rate for percutaneous drainage of abscesses located in the remainder of the abdomen and pelvis, which varies from 80% to 90% [21,22,23,24,25]. The lower success rate for drainage of splenic abscesses may reflect both the multiloculated nature and multiplicity of these abscesses. It may also result from a tendency to use a smaller catheter for drainage of splenic abscesses. Successful percutaneous drainage of postoperative splenic abscesses in five attempted cases was reported by Dattola et al. [26]. The results of our report for drainage compare favorably with these previously reported series that achieved technically successful catheter placement in 100% and successful drainage in 86% of procedures. These results suggest that splenectomy should be reserved for selected cases for which percutaneous catheter drainage has failed.
Percutaneous fluid aspiration can be performed for therapeutic purposes in symptomatic patients who have a pseudocyst or a posttraumatic hematoma. More commonly, however, fluid aspiration is performed for diagnostic purposes, usually to differentiate among a simple splenic cyst, an infarct, and a splenic abscess. Few reports about aspiration of splenic cysts have been published in the literature, but one report describes 12 diagnostic fluid aspirations performed in 12 patients [2]. All the aspirations were technically successful, and no complications were encountered. Our results reflect these findings; no complications were encountered in the eight cases in our study.
A few small reports about percutaneous biopsy of the spleen have been published [2, 4,5,6]. In the absence of suspected malignancy or sepsis, splenic lesions detected on CT are usually benign and commonly prove to be cysts. In patients with known malignancy, isolated splenic metastases are infrequent. As a result, the diagnosis of metastatic disease seldom relies on splenic biopsy alone. If lesions are identified in both the spleen and another organ, the lesion in the spleen has generally not been biopsied because hemorrhagic complications are possible.
However, our results and those of other investigators suggest that percutaneous biopsy and fine-needle aspiration biopsy are both safe and useful. A specific diagnosis can be obtained in up to 91% of the cases. However, if lesions are present in both the spleen and another organ, biopsying the nonsplenic lesion is still prudent if the lesion is amenable to biopsy to avoid potential splenic complications. Recent series have shown similar findings. A study by Keogan et al. [4] showed a specific diagnosis after splenic biopsy using 18- to 22-gauge needles in 89% of patients with no reported complications. Other series have also reported successful biopsies, including a series by Caraway and Fanning [3] of 50 aspirates that yielded an 88% diagnostic accuracy rate. Another study of 11 splenic aspirates enabled a specific diagnosis in 10 of the 11 patients [27]. In a series of 35 patients by Venkataramu et al. [5], a definitive cytologic diagnosis was made in 63% of the patients.
Few complications have been reported in these series. Caraway and Fanning [3] reported that one pneumothorax occurred after 50 splenic biopsies. Venkataramu et al. [5] reported one small area of intraabdominal bleeding after 35 splenic biopsies, and Keogan et al. [4] reported no complications after 20 splenic biopsies. The complications due to hemorrhage after splenic biopsy have been documented in the literature as being between 0% and 2%. This complication rate is similar to that reported after biopsy of other abdominal and pelvic organs.
In conclusion, the ability of fine-needle aspiration biopsy to enable a specific diagnosis both in our series and in previously published data approaches 90%. This high percentage suggests that fine-needle aspiration biopsy of the spleen is of considerable value in diagnosis. This report and others have shown that catheter drainage of splenic abscesses is successful in selected patients and that splenectomy should be reserved for cases in which percutaneous drainage has failed. Although three patients required splenectomy in this series, two patients had unsuspected underlying vascular anomalies. These two lesions were biopsied with fine needles—only 22- and 23-gauge, respectively—but still bled extensively. We found no difference in the complication rate between interventions performed on peripheral lesions and on central lesions.
These cases remind us of the risks associated with performing interventional procedures involving the spleen because the vascular nature of splenic lesions may be difficult to determine before the procedure. These findings also emphasize the importance of requiring normal coagulation parameters before performing a procedure and highlight the increased risk associated with performing procedures in patients who require blood products to correct coagulation abnormalities.
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