European Radiology

, Volume 29, Issue 1, pp 450–457 | Cite as

Diagnosis of diffuse spleen involvement in haematological malignancies using a spleen-to-liver attenuation ratio on contrast-enhanced CT images

  • Christian Philipp ReinertEmail author
  • Clemens Hinterleitner
  • Jan Fritz
  • Konstantin Nikolaou
  • Marius Horger



We aimed to test the hypothesis that the spleen-to-liver-attenuation ratio on portal-venous enhancement phase CT images can identify diffuse splenic infiltration in subjects with lymphoma.


A database search yielded 70 subjects with malignant haematological diseases who underwent contrast-enhanced CT (CECT) between December 2010 and March 2018. Additionally, consecutive control subjects were evaluated. We compared the splenic volume, splenic attenuation, spleen-to-liver, spleen-to-aorta and spleen-to-musculature ratios on portal-venous phase CECT images, pre- to post-treatment and between the different lymphoma entities. The standard of reference for splenic involvement was normalisation of the spleen volume following chemotherapy or normalisation of FDG-uptake.


In subjects with diffuse splenic involvement, the spleen attenuation was significantly lower before treatment (93.48 HU) compared to controls (112.39 HU; p < .01) and after successful treatment (113.39 HU; p < .01). The spleen-to-liver attenuation ratio significantly increased after treatment (p < .001) and proved significantly lower at baseline when compared to control subjects (p < .01). The spleen volume significantly decreased after successful treatment (from 586.14.87 cm3 to 284.90 cm3; p < .001). Spleen-to-liver ratio significantly increased in lymphoma patients after therapy, inversely correlating with the decline in FDG-uptake (n=10) even in patients with normal-sized spleens (2/10), staying unchanged at follow-up. The outcome variables were not significantly different between the lymphoma subtypes.


We suggest the additional use of spleen-to-liver attenuation ratio to splenic volume alone for detection of diffuse splenic infiltration in subjects with lymphoma. The course of spleen-to-liver attenuation ratio inversely correlated with that of FDG-uptake in a subgroup of patients working accurately in normal-sized diffusely involved spleens.

Key Points

Involvement of the spleen is frequent in haematological malignancies and is important for staging and appropriate treatment.

Diffuse splenic infiltration often results in only homogeneous splenomegaly without a focal lesion, but even no or only minimal increase in splenic volume is possible. In these cases diagnosis of spleen involvement is a challenge for the radiologist.

Our data support the use of the spleen-to-liver attenuation ratio in addition to size measurements for the detection of diffuse splenic infiltration in subjects with lymphoma.


Lymphoma Splenomegaly Haematological diseases Follow-up studies 



Chronic lymphoid leukaemia


Granulocyte colony stimulating factors


Region of interest



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Prof. Dr. Marius Horger.

Conflict of interest

Jan Fritz received institutional research funds and speaker's honorarium from Siemens Healthcare USA and is a scientific advisor of Siemens Healthcare USA and Alexion Pharmaceuticals, Inc

Marius Horger received institutional research funds and speaker's honorarium from Siemens Healthineers Germany and General Electrics

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• case-control study

• performed at one institution


  1. 1.
    Olweny CL (1990) Cotswolds modification of the Ann Arbor staging system for Hodgkin's disease. J Clin Oncol 8:1598CrossRefGoogle Scholar
  2. 2.
    Bhatia K, Sahdev A, Reznek RH (2007) Lymphoma of the spleen. Semin Ultrasound CT MR 28:12–20CrossRefGoogle Scholar
  3. 3.
    Saboo SS, Krajewski KM, O'Regan KN et al (2012) Spleen in haematological malignancies: spectrum of imaging findings. Br J Radiol 85:81–92CrossRefGoogle Scholar
  4. 4.
    Leite NP, Kased N, Hanna RF et al (2007) Cross-sectional imaging of extranodal involvement in abdominopelvic lymphoproliferative malignancies. Radiographics 27:1613–1634CrossRefGoogle Scholar
  5. 5.
    Cronin CG, Swords R, Truong MT et al (2010) Clinical utility of PET/CT in lymphoma. AJR Am J Roentgenol 194:W91–w103CrossRefGoogle Scholar
  6. 6.
    de Jong PA, van Ufford HM, Baarslag HJ et al (2009) CT and 18F-FDG PET for noninvasive detection of splenic involvement in patients with malignant lymphoma. AJR Am J Roentgenol 192:745–753CrossRefGoogle Scholar
  7. 7.
    Hoffmann M, Kletter K, Becherer A, Jager U, Chott A, Raderer M (2003) 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) for staging and follow-up of marginal zone B-cell lymphoma. Oncology 64:336–340CrossRefGoogle Scholar
  8. 8.
    Cheson BD, Pfistner B, Juweid ME et al (2007) Revised response criteria for malignant lymphoma. J Clin Oncol 25:579–586CrossRefGoogle Scholar
  9. 9.
    Juweid ME, Stroobants S, Hoekstra OS et al (2007) Use of positron emission tomography for response assessment of lymphoma: consensus of the Imaging Subcommittee of International Harmonization Project in Lymphoma. J Clin Oncol 25:571–578CrossRefGoogle Scholar
  10. 10.
    Nakachi S, Okada M, Morishima S et al (2017) Clinical usefulness of FDG-PET/CT for the evaluation of various types of adult T-cell leukemia. Hematology 22:536–543CrossRefGoogle Scholar
  11. 11.
    Kirchner J, Deuschl C, Grueneisen J et al (2017) (18)F-FDG PET/MRI in patients suffering from lymphoma: how much MRI information is really needed? Eur J Nucl Med Mol Imaging 44:1005–1013CrossRefGoogle Scholar
  12. 12.
    Weissleder R, Elizondo G, Stark DD et al (1989) The diagnosis of splenic lymphoma by MR imaging: value of superparamagnetic iron oxide. AJR Am J Roentgenol 152:175–180CrossRefGoogle Scholar
  13. 13.
    van Krieken JH, Feller AC, te Velde J (1989) The distribution of non-Hodgkin's lymphoma in the lymphoid compartments of the human spleen. Am J Surg Pathol 13:757–765CrossRefGoogle Scholar
  14. 14.
    Marx A, Muller-Hermelink HK, Hartmann M et al (2008) Lymphomas of the spleen. Pathologe 29:136–142CrossRefGoogle Scholar
  15. 15.
    Falk S (1991) Malignant lymphoma of the spleen. Histological and immunohistochemical studies of morphology and differential diagnosis. Veroff Pathol 136:1–265PubMedGoogle Scholar
  16. 16.
    Barrington SF, Kluge R (2017) FDG PET for therapy monitoring in Hodgkin and non-Hodgkin lymphomas. Eur J Nucl Med Mol Imaging 44:97–110CrossRefGoogle Scholar
  17. 17.
    Rini JN, Manalili EY, Hoffman MA et al (2002) F-18 FDG versus Ga-67 for detecting splenic involvement in Hodgkin's disease. Clin Nucl Med 27:572–577CrossRefGoogle Scholar
  18. 18.
    Paes FM, Kalkanis DG, Sideras PA, Serafini AN (2010) FDG PET/CT of extranodal involvement in non-Hodgkin lymphoma and Hodgkin disease. Radiographics 30:269–291CrossRefGoogle Scholar
  19. 19.
    Rueffer U, Sieber M, Josting A et al (1999) Prognostic factors for subdiaphragmatic involvement in clinical stage I-II supradiaphragmatic Hodgkin's disease: a retrospective analysis of the GHSG. Ann Oncol 10:1343–1348CrossRefGoogle Scholar
  20. 20.
    Sandrasegaran K, Robinson PJ, Selby P (1994) Staging of lymphoma in adults. Clin Radiol 49:149–161CrossRefGoogle Scholar
  21. 21.
    Jaffe ES (2009) The 2008 WHO classification of lymphomas: implications for clinical practice and translational research. Hematology Am Soc Hematol Educ Program.
  22. 22.
    Shirkhoda A, Ros PR, Farah J, Staab EV (1990) Lymphoma of the solid abdominal viscera. Radiol Clin N Am 28:785–799PubMedGoogle Scholar
  23. 23.
    Shi F, Zhou Q, Gao Y, Cui XQ, Chang H (2016) Primary splenic B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and classical Hodgkin lymphoma: a case report. Oncol Lett 12:1925–1928CrossRefGoogle Scholar
  24. 24.
    Lee JE, Cho JS, Shin KS et al (2016) Diffuse infiltrative splenic lymphoma: diagnostic efficacy of arterial-phase CT. Korean J Radiol 17:734–741CrossRefGoogle Scholar
  25. 25.
    Robertson F, Leander P, Ekberg O (2001) Radiology of the spleen. Eur Radiol 11:80–95CrossRefGoogle Scholar
  26. 26.
    Rini JN, Leonidas JC, Tomas MB, Palestro CJ (2003) 18F-FDG PET versus CT for evaluating the spleen during initial staging of lymphoma. J Nucl Med 44:1072–1074PubMedGoogle Scholar
  27. 27.
    Munker R, Stengel A, Stabler A, Hiller E, Brehm G (1995) Diagnostic accuracy of ultrasound and computed tomography in the staging of Hodgkin's disease. Verification by laparotomy in 100 cases. Cancer 76:1460–1466CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  • Christian Philipp Reinert
    • 1
    Email author
  • Clemens Hinterleitner
    • 2
  • Jan Fritz
    • 3
  • Konstantin Nikolaou
    • 1
  • Marius Horger
    • 1
  1. 1.Department of Diagnostic and Interventional RadiologyUniversity Hospital TuebingenTuebingenGermany
  2. 2.Department of Internal Medicine IIUniversity Hospital TuebingenTuebingenGermany
  3. 3.Russell H. Morgan Department of Radiology and Radiological ScienceJohns Hopkins University School of MedicineBaltimoreUSA

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