Sclerosing angiomatoid nodular transformation of the spleen: clinical, computed tomography, and magnetic resonance imaging characteristics

Introduction

Sclerosing angiomatoid nodular transformation (SANT), a benign, vasculogenic lesion, originates in the spleen but has an unknown pathogenesis (1). Despite a growing understanding of its imaging characteristics (2-5), SANT is associated with a relatively high rate of misdiagnosis on imaging and a high frequency of surgical removal. Additionally, it has been suggested that patients with SANT may be predisposed to various benign and malignant tumors (6). Therefore, in this study, we collected a larger patient sample and analyzed more comprehensive clinical data. We advocate for imaging follow-up in asymptomatic or slowly growing SANT cases to minimize unnecessary surgeries. By enhancing the understanding of SANT through this detailed dataset, our study aims to improve diagnostic accuracy, guide appropriate clinical management, and ultimately improve patient outcomes. We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-24-1660/rc).

Methods

Patients

The institutional review board of The First Affiliated Hospital, Zhejiang University School of Medicine (No. 2024-1525) approved this retrospective cohort study, and the requirement for individual consent was waived due to the retrospective nature of the analysis. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). We retrospectively review the clinical and image data of SNAT between January 2012 and June 2024 in The First Affiliated Hospital, Zhejiang University School of Medicine. The inclusion criteria were as follows: (I) histopathological confirmation of SANT; (II) availability of preoperative contrast-enhanced and non-contrast-enhanced magnetic resonance imaging (MRI) and/or computed tomography (CT) scans; and (III) complete clinical records. Meanwhile, the exclusion criteria were (I) suboptimal image quality and (II) incomplete clinical data (Figure 1).

Figure 1 Study flow chart. SANT, sclerosing angiomatoid nodular transformation.

Imaging methods

Among the 40 patients, 16 underwent both enhanced CT and magnetic resonance (MR) scans, 8 underwent only enhanced MR scans, and 16 underwent only enhanced CT scans.

For CT scans, a Brilliance 64-slice CT scanner (Philips, Amsterdam, The Netherlands) was employed. The scanning parameters were as follows: voltage, 120 kV; current 250 mAs; slice thickness, 5 mm; and pitch, 1.0. For contrast-enhanced scans, iohexol (containing 350 mg of iodine/mL) was administered intravenously through the elbow vein at a rate of 2.5 mL/s, with the dose ranging from 80 to 100 mL. An automatic trigger at a threshold of 100 Hounsfield units (HU) was set in order to capture the arterial phase images. Following this, images of the portal venous phase were obtained after a 25-second delay, and equilibrium-phase images were acquired after an additional 60 seconds.

MRI scanning was performed with a 3.0-Tesla Signa HDXT device (GE HealthCare, Chicago, IL, USA) equipped with an 8-channel abdominal phased-array coil. The sequences included transverse in-phase and opposed-phase breath-hold fast spoiled gradient-echo T1-weighted imaging (T1WI), respiratory-triggered fat-suppressed fast-recovery fast spin echo T2-weighted imaging (T2WI), and diffusion-weighted imaging (DWI). For the four-phase MRI scan, a volumetric ultrafast multiphase dynamic sequence was conducted during breath-hold at end expiration. Gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) was injected intravenously through the elbow vein at a rate of 2.5 mL/s at a dose of 0.2 mL/kg of body weight. Arterial phase images were obtained 20 seconds after injection, portal venous phase images after 25 seconds, and equilibrium phase images after a further 60-second delay.

Imaging analysis

Two experienced radiologists (X.L.X. and C.L.) who had 10 (X.L.X.) and 7 years (C.L.) experience in abdominal images independently conducted a retrospective analysis of the images, with final interpretations subsequently reaching a consensus. The feature observations were focused on lesion number, size, shape, boundary, presence or absence of calcification, attenuation (compared with surrounding splenic parenchyma), signal intensity (compared with surrounding splenic parenchyma), central scar, hemosiderin deposition (signal intensity decrease on chemical shift for in-phase sequence images compared to out-phase sequence images), and enhancement patterns. Wherein the boundary of the lesion was divided 3 types: well-defined margin (lesion with clear and sharp boundary that is easily distinguishable from the surrounding splenic parenchyma). Relatively indistinct border (lesion with boundary that are somewhat blurred or less clear, but still discernible from the surrounding splenic parenchyma) and ill-defined margin (lesion with very unclear or vague boundary that blends into surrounding tissues, making it difficult to delineate the lesion from the splenic parenchyma). Additionally, the attenuation of the lesion was divided 4 types: homogeneous hypodensity (lesion that appears uniformly less dense than the splenic parenchyma on imaging). Homogeneously slight hypodensity (lesion that appears slightly less dense than the splenic parenchyma, but with uniform density throughout). Inhomogeneous hypodensity (lesion that contains areas of varying low density) and mixed hyper- and hypodensity (lesion that contains both areas of higher density and lower density within the same lesion).

Pathologic analysis

Pathology reviews were conducted by an experienced pathologist with 10 years of experience, who examined the pathology reports and slides to confirm the diagnosis of SANT and evaluated the immunoreactivity of vascular markers, including CD8, CD31, and CD34.

Results

Clinical features

A total of 40 cases fulfilled the requirements, including 21 males and 19 females, with an age range of 18 to 71 years, an average age of 42.3 years, and a median age of 40.5 years. Among the 40 patients with SANT, 19 were detected incidentally during routine physical examination, while the remaining 21 patients had the following clinical symptoms or associated diseases. In our cases, 8 patients had the clinical symptom, 5 of them had abdominal pain and distension, 3 had platelet abnormalities (2 with thrombocytopenia, 1 with thrombocytosis). In addition, 13 patients had the history of other diseases, 3 of them had a history of malignancy (2 cases of colorectal cancer, 1 case of thyroid cancer), 4 cases had cholecystitis and gallbladder adenomyomatosis, 1 case had chronic myeloid leukemia, 1 case had pheochromocytoma of the adrenal gland, 1 case had immunoglobin A nephropathy, 1 case had pancreatic neuroendocrine tumor, 1 case had thalassemia, and 1 case had hemangioma of the buttock. Notably, in 3 cases, follow-up examinations prior to surgery revealed gradual enlargement of the masses. Preoperatively, 12 cases were accurately diagnosed as SANT by the radiologist, 10 cases were diagnosed as hemangioma, 5 cases were diagnosed as hamartoma, 9 cases were diagnosed as vascular tumor, 1 case was diagnosed as littoral cell angioma, 2 cases were diagnosed as metastatic tumor, and 1 case was diagnosed as lymphoma. The clinical presentations for all 40 patients are presented in Table 1.

Histopathologic findings

Among the 40 cases, 36 had solitary lesions and 4 had multiple lesions. The lesions were well-circumscribed and had a round-to-ovoid shape, and the maximum diameter ranged from approximately 2.0 to 11.4 cm. In sectioning, they appeared grayish-red to grayish-yellow in color, were relatively firm in consistency, and were clearly demarcated from the surrounding spleen tissue, without a capsule. A fibrous scar could be observed in the center of the tumors in all cases. Microscopically, all cases exhibited nodules resembling hemangiomas encapsulated by proliferative and collagenized fibrous tissue (Figure 2). The central portions of these nodules contained slit-like or sinusoidal vascular spaces, with some areas showing deposits of brownish hemosiderin. Immunohistochemically, positive expressions of CD31, CD34, and CD8 was observed in all cases. All lesions exhibited three types of small vessels within the angiomatous nodules: capillary type (CD34⁺/CD31⁺/CD8⁻), sinusoidal type (CD34⁻/CD31⁺/CD8⁺), and small venous type (CD34⁻/CD31⁺/CD8⁻). Specifically, 92.5% (37/40) were predominantly of the capillary type, 5% (2/40) were predominantly of the sinusoidal type, and 2.5% (1/40) was predominantly of the small venous type. Within the proliferating fibers, spindle cells were stained positively for CD68.

Figure 2 A 20-year-old male with SANT detected during a physical examination. (A,B) Microscopic examination (HE, ×50) show the normal spleen tissue (green triangles) and the formation of angioma-like nodule (yellow triangles) within a fibrosclerotic stroma (blue arrows). HE, hematoxylin and eosin; SANT, sclerosing angiomatoid nodular transformation.

Imaging features

Among the 40 cases in this group, 36 had solitary lesions. Among the remaining 4 cases with multiple SANT lesions, 3 had dozens of lesions of varying sizes, and so the largest lesion in diameter was selected for analysis. The longitudinal diameter of the lesions ranged from 2.0 to 11.4 cm. All lesions appeared round or oval in shape, with 65% (26/40) having well-defined margins, 27.5% (11/40) having relatively indistinct borders, and 7.5% (3/40) having ill-defined margins. On CT examinations (n=32), 65.6% (21/32) cases exhibited homogeneous hypodensity on noncontrast scans (Figure 3A), 12.5% (4/32) cases homogeneously slight hypodensity, 6.2% (2/32) cases inhomogeneous hypodensity, and 15.6% (5/32) cases mixed hyper- and hypodensity. Additionally, calcifications were observed within the lesions in 15.6% (5/32) cases. After CT contrast enhancement the typical “spoke-wheel” pattern of enhancement was observed in 59.4% (19/32) cases (Figure 3B-3F). The CT manifestations of the 32 patients are presented in Table 2. On MR examinations (n=24), 100% (24/24) showed low-signal scars (Figure 4A) on T2WI, and the specific distribution of features were as follows: 37.5% (9/24) cases showed isointensity with a central low-signal scar; 16.7% (4/24) cases showed low intensity with a centrally even, lower-signal scar; and 45.8% (11/24) cases showed a slightly higher peripheral signal with a central, low-signal scar. Six out of 24 (25.0%) cases exhibited isointensity on T1WI, 33.3% (8/24) cases exhibited hypointensity, 29.2% (7/24) cases exhibited mixed isointensity and hypointensity (Figure 4B), and 12.5% (3/24) cases exhibited mixed hyper- and hypointensity. On DWI, all lesions appeared hypointense (Figure 4C). After MR contrast enhancement the typical “spoke-wheel” pattern of enhancement was observed in 66.7% (16/24) cases (Figure 4D-4G). On the in-phase and out-phase of T1WI, 70.8% (17/24) cases were characterized by deposits of hemosiderin (Figure 4H,4I). The MR manifestations of the 24 patients are presented in Table 3. After contrast enhancement (both CT and MRI), central scar enhancement was evident in all cases (Figure 4G). The patterns of enhancement included progressive enhancement in 92.5% (37/40) cases and delayed enhancement in 7.5% (3/40) cases. As for the degree of enhancement, 67.5% (27/40) cases showed marked heterogeneous enhancement, 17.5% (7/40) cases mild heterogeneous enhancement, and 15% (6/40) cases moderate heterogeneous enhancement. Furthermore, the typical “spoke-wheel” pattern of enhancement was observed in 65% (26/40) cases, nodular enhancement in 35% (14/40) cases, and traversing branches of the splenic artery in 40% (16/40) cases.

Figure 3 Plain and contrast-enhanced CT images of a 26-year-old female with SANT detected during a physical examination. (A) A slightly low-density mass within the spleen on noncontrast CT. (B) Mild enhancement during the arterial phase. (C) Increased enhancement in the venous phase with a characteristic “spoke-wheel” pattern. (D) Delayed enhancement in the delayed phase. (E,F) Coronal views of the venous phase and delayed phase, respectively. CT, computed tomography; SANT, sclerosing angiomatoid nodular transformation.

Figure 4 Liver and gallbladder MR images of a 37-year-old male detected with SANT during a physical examination, including noncontrast sequences, DWI, and contrast-enhancement. (A,B) The lesion appearing with a mixed low signal on T2WI and an iso-to-low signal on T1WI. (C) DWI showing a heterogeneous low signal. (D-G) Progressive enhancement with central scar enhancement, featuring a “spoke-wheel” pattern on sequential contrast phases. (H,I) Deposits of hemosiderin apparent on in-phase and out-phase images. DWI, diffusion-weighted imaging; MR, magnetic resonance; SANT, sclerosing angiomatoid nodular transformation; T1WI, T1-weighted imaging; T2WI, T2-weighted imaging.

Discussion

Pathological features

SANT is a rare, benign splenic lesion with an unknown etiology and was first distinguished by Martel et al. in 2004 (1). The mechanism underlying the development of SANT remains uncertain; it has been proposed that SANT represents as a peculiar polyclonal, nonneoplastic, vascular condition of the spleen, characterized by distinct pathological features (3,6-9); however, other theories hold that CTNNB1 exon 3 is fundamentally involved in the pathogenesis of SANT, which could account for its neoplastic nature, suggesting that SANT is a true vascular neoplasm of the spleen (10). The defining pathological characteristics of SANT include the formation of multiple angioma-like nodules within a fibrosclerotic stroma (11), with these nodules being separated by fibrosclerotic septa appearing as a central scar in a stellate pattern. The angiomatoid nodules are composed of sinusoidal, slit-like, or irregular vascular spaces lined by plump endothelial cells, with densely fibrous connective tissue apparent between the nodules. According to immunohistochemical staining, there are three types of small blood vessels within these angiomatoid nodules: the capillary type (CD34⁺, CD31⁺, CD8⁻), the sinusoidal type (CD34⁻, CD31⁺, CD8⁺), and the small venous type (CD34⁻, CD31⁺, CD8⁻).

SANT can be identified across all age groups and exhibits no established correlation with either gender or age (12). In our study, we found a slight prevalence of middle-aged males, which could have been a product of sample bias. In addition, all lesions exhibited three types of small vessels within the angiomatous nodules in our cases, and the majority of them were predominantly of the capillary type.

Clinical features

In the literature, the majority of patients with SANT are either asymptomatic or have their condition incidentally discovered during evaluations for other disorders (8). However, in recent years, it has been proposed that a portion of patients with SANT have clinical manifestations akin to those of von Hippel-Lindau syndrome, making them susceptible to various benign and malignant tumors (6). In our study, only 20% patients had nonspecific clinical symptom, and 47.5% of cases were detected through physical examination, while in the remaining 52.5% of patients, a review of the medical history indicated concurrent diseases affecting multiple organs and systems, including those of the gastrointestinal tract, hematological system, biliary tract, and adrenal glands. These findings suggest that SANT patients should undergo comprehensive systemic examinations to rule out diseases in other organs. Research suggests that SANT typically remains stable or grows slowly, and thus serial imaging follow-up is recommended; meanwhile, for those lesions that exhibit rapid enlargement, laparoscopic splenectomy can be considered for achieving both diagnostic and therapeutic objectives (12). Among the 40 cases examined in our study, apart for the 3 cases showing gradual enlargement during preoperative follow-up, extended radiological follow-ups were not conducted, which we attribute to the limitations of retrospective analysis. Furthermore, by reviewing the clinical histories, we found that 2 patients experienced thrombocytopenia preoperatively, which was resolved after splenectomy. Conversely, in patients with normal platelet counts preoperatively, a transient increase in platelets was observed following splenectomy, a phenomenon generally considered a normal physiological response to splenectomy. Therefore, we propose that for patients with SANT showing stable or slow growth and lacking clinical symptoms, imaging follow-up is advisable. For those experiencing rapid growth or demonstrating clinical symptoms, active surgical intervention, with laparoscopic splenectomy being a favorable option, should be pursued.

Imaging findings

SANT of the spleen typically manifests as solitary, well-circumscribed, round or oval masses, although occasionally they may be multifocal or present with lobulated lesions, with sizes ranging from 1.2 to 17 cm (median 5.2 cm) (8). In our study, 36 cases had solitary lesions, while 4 cases showed multiple lesions, with sizes varying approximately between 2.0 and 11.4 cm, which is consistent with previous literature (8). SANT typically appears on noncontrast CT scans as a clearly demarcated, low or slightly low-density mass, with occasional calcifications being visible. When hemorrhage occurs within the lesion, it may appear with high density (8). Among the CT images of the 32 cases of SANT in our study, the majority had low or slightly low density, while 5 cases had mixed high and low densities due to internal hemorrhage or calcification, which was consistent with a previous study (8). Most SANT lesions presented with an isointense-to-low signal on T2WI, with some peripheries showing a slightly higher signal. Owing to high fibrous content in their central scars, these areas demonstrate a more pronounced central low signal. In our study, the lesions predominantly displayed heterogeneous isointense-to-low signals on T2WI, with scattered, slightly lower signal strands, which is consistent with other published findings (4). As the spleen exhibits the most prominent diffusion restriction among abdominal solid organs, analyzing DWI and apparent diffusion coefficient (ADC) values of splenic lesions remains a substantial challenge; in our study, no obvious diffusion restriction was observed.

On the T1WI in-phase and out-phase sequence, a locally elevated signal on out-phase compared to in-phase images suggests iron deposition due to prior hemorrhaging (4). Of the 22 MR cases in our study, 17 demonstrated signals indicative of hemosiderin, partly in agreement with previous reports (4). The representative imaging feature of SANT is the spoke-wheel sign (5,13,14). On T2WI, with the peripheral angioma-like nodules exhibiting an isointense or slightly low signal and the central stellate fibrous stroma having an even lower signal. During the arterial phase of contrast enhancement, the peripheral angioma nodules are enhanced early, whereas the central fibrous stroma is not enhanced. At this stage, a spoke-wheel pattern of enhancement is also discernible. From the portal venous phase onward, the central fibrous stroma is gradually enhanced, and the signal difference between it and the peripheral angioma-like nodules gradually reduce over time, even eventually disappearing during the delayed phase. In our study, the spoke-wheel pattern was less conspicuous on T2WI. On contrast-enhanced MR images, lesions primarily demonstrated progressive enhancement, with varying degrees of delayed enhancement observed in the central fibrous stroma region. The typical spoke-wheel sign was observed in 16 cases during the arterial phase. Among the 32 cases with enhanced CT scans, progressive enhancement dominated, and the spoke-wheel sign was evident in 19 cases. The detection rate of the spoke-wheel sign was lower on enhanced CT compared to enhanced MR, and areas of the fibrous stroma region showed delayed enhancement within the lesions on CT, which were less conspicuous than that on MR. We speculate that this might be related to the fewer scanning phases in CT and the inadequate duration of the delay times. Consequently, for cases where typical SANT features are insufficiently depicted on CT, contrast-enhanced MR imaging is recommended. If necessary, an extension of the delayed scan time may be appropriate to better visualize the delayed enhancement of the central scar, thereby significantly increasing the confidence in diagnosing SANT.

Differential diagnosis

SANT is frequently differentiated from hemangioma, hamartoma, littoral cell angioma, and inflammatory pseudotumor-like follicular dendritic cell sarcoma (IPT-like FDCS). (I) Hemangioma is more common than is SANT, and although both conditions may exhibit progressive enhancement, most hemangiomas appear hyperintense on T2WI and have a high signal on DWI and high ADC values. SANT demonstrates lower signal scars on T2WI, typically presenting with a spoke-wheel pattern of enhancement, which makes differentiation diagnosis straightforward. (II) Hamartomas characteristically contain mature fat and often show calcifications, whereas SANT lacks fat and calcifications are uncommon in the lesions. (III) Littoral cell angiomas tends to present as multiple lesions, whereas SANT is usually solitary. Moreover, sinusoidal littoral cell angioma appears hyperintense on T2WI, while SANTs predominantly show an inhomogeneous low signal. (IV) IPT-like FDCS is exceedingly rare and primarily affects older adult females (15). SANT and IPT-like FDCS both may show progressive enhancement, but inflammatory pseudotumor-like dendritic cell sarcomas frequently exhibit necrosis, which is uncommon in SANT. These differential diagnoses are essential for radiologists when evaluating potential cases of SANT.

Our study involved certain limitations that should be motioned. First, due to the low incidence of SANT in the spleen, the number of patients included in this retrospective study was limited. Second, in this study, the vast majority of patients did not undergo long-term imaging follow-up of the splenic lesions preoperatively, and thus the growth rate of the splenic SANT lesions remains unknown.

Conclusions

SANT of the spleen is a rare disease. It typically manifests on T2WI as an isointense or low signal with a centrally even lower-signal scar. Enhancement is often progressive, and the characteristic spoke-wheel pattern is observable in most cases. Furthermore, in patients in whom SANT is suspected, prolonging the MR delayed-phase scanning time can significantly improve the diagnostic accuracy for SANT.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-24-1660/rc

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-24-1660/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The institutional review board of The First Affiliated Hospital, Zhejiang University School of Medicine (No. 2024-1525) approved this study, and the requirement for individual consent was waived due to the retrospective nature of the analysis. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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