Case Report
Color Doppler Sonographic Findings in
Splenic Hamartoma
Shaoshan Tang, MD,1 Tadashi Shimizu, MD,1 Yoichi Kikuchi, MD,1 Sumiyo Shinya, MD,1
Riwa Kishimoto, MD,1 Yasunori Fujioka, MD,2 Kazuo Miyasaka, MD1
1
Department of Radiology, Hokkaido University School of Medicine, North-5, West-7, Kita-ku,
Sapporo 060-8638, Japan
2
Department of Pathology, Kyorin University School of Medicine, Shinkawa 6-20-2, Mitaka,
Tokyo 181-8611, Japan
Received 28 June 1999; accepted 2 December 1999
ABSTRACT: We present the gray-scale and color
Doppler sonographic findings in a case of a splenic
hamartoma in a 40-year-old man. Gray-scale sono-
grams showed a 2 × 2 cm, hypoechoic splenic mass
that was homogeneous without evidence of cystic
change or calcification. Color Doppler sonograms
showed multiple radial blood-flow signals inside
the mass, and spectral analysis confirmed arterial
and venous flow. Arteriograms showed multiple
small, hypervascular masses with fine tumor vessels
and tumor stains within the spleen. Histologic analy-
sis following a splenectomy showed dilated vessels
and congestion consistent with the color Doppler
sonographic findings. © 2000 John Wiley & Sons, Inc.
J Clin Ultrasound 28:249–253, 2000.
Keywords: spleen; hamartoma; ultrasonography;
magnetic resonance imaging; computed tomography
S plenic hamartoma is a rare, benign tumor
usually discovered incidentally during a lap-
arotomy or autopsy.1 The sonographic appear-
ance of a splenic hamartoma is usually a solid,
homogeneous mass with various echogenicity
relative to the normal splenic parenchyma.2–4
The splenic hamartoma is occasionally heteroge-
neous and may contain cystic areas5 or, in rare
cases, calcification. To our knowledge, the color
Doppler sonographic findings in splenic hamarto-
mas have not been reported. We present a case of
splenic hamartoma that showed increased vascu-
larity on color Doppler sonograms. The radiologic
features and pathologic findings are described.
Correspondence to: S. Tang
© 2000 John Wiley & Sons, Inc.
VOL. 28, NO. 5, JUNE 2000
CASE REPORT
A 40-year-old man presented with a 1-month his-
tory of diarrhea and sweating. Results of physical
examination and routine blood studies were un-
remarkable.
Gray-scale abdominal sonography performed
using a LOGIQ 500 scanner (GE Yokogawa Medi-
cal Systems, Tokyo, Japan) and a 3.5-MHz con-
vex-array transducer showed a 2 × 2 cm, hy-
poechoic mass (Figure 1) at the lower pole of the
spleen. The mass was homogeneous without evi-
dence of cystic change or calcification. Color
Doppler sonograms showed multiple radial blood-
flow signals inside the mass (Figure 2). Arterial
and venous flow were confirmed by spectral
analysis (Figure 3). The peak systolic velocity
noted in the tumor was 71.4 cm/second, with a
resistance index of 0.525 and a pulsatility index of
0.776.
Abdominal CT scans taken before and after ad-
ministration of a contrast material revealed no
mass in the spleen. MRI also did not show the
mass in the spleen on standard T1-weighted or
T2-weighted images. During the arterial phase of
contrast-enhanced dynamic MRI, however, the
mass enhanced earlier than did the normal
splenic parenchyma (Figure 4). During the de-
layed phase, the intensity of the mass was the
same as that of the splenic parenchyma. Arteri-
ography revealed multiple small, hypervascular
masses with fine tumor vessels and tumor stains
within the spleen (Figure 5). The largest mass on
the arteriogram was presumed to represent the
mass detected on the sonograms. There was no
evidence of vascular encasement by the mass.
249
 TANG ET AL
FIGURE 1. Gray-scale sonogram shows a grossly homogeneous, hy-
poechoic mass (arrows) at the lower pole of the spleen.
A splenectomy was performed because a malig-
nant splenic neoplasm or metastasis could not be
ruled out. On gross examination, there were mul-
tiple solid nodules in the spleen ranging from 0.5
cm to 2 cm and slightly grayer in color than the
surrounding splenic parenchyma. Histologic ex-
amination of the lesions showed dilated vessels
and congestion. The masses were composed of red
pulp; they lacked fibrous trabeculae and white
pulp (Figure 6). The normal splenic parenchyma
FIGURE 2. Color Doppler sonogram shows multiple vessels within the mass (arrows).
250
was compressed, and no true capsule was found.
The final pathologic diagnosis was a splenic ham-
artoma of the red-pulp type.
DISCUSSION
Splenic hamartoma, variously termed splenoma,
spleno-adenoma, fibrosplenoma, and nodular hy-
perplasia of the spleen, is a rare, benign tumor
with an autopsy incidence of 0.13%.1 Since the
first description by Rokitansky in 1861,6 more
than 100 cases have been reported. In none of
these cases was a definite diagnosis made preop-
eratively.
Two histologic types of splenic hamartoma
have been described: the white-pulp (lymphoid)
type and the red-pulp (pulposal) type. The white-
pulp type is composed entirely of lymphoid tissue.
The red-pulp type, defined by the Armed Forces
Institute of Pathology as a hamartoma in 1995,7
is composed of sinuses and structures histologi-
cally similar to that of normal splenic red pulp.1
A splenic hamartoma shows expansive growth
and compresses the surrounding splenic tissue
without a true capsule. The hamartomas were
red-pulp type in most of the reported cases and in
all of the reported cases in which the hamartomas
were symptomatic.1,2 It is sometimes difficult to
delineate the red-pulp type hamartoma from nor-
mal splenic tissue because this hamartoma con-
sists of abnormal mixtures of normal splenic ele-
ments. Fine-needle aspiration biopsy is not
recommended as a diagnostic tool because there is
JOURNAL OF CLINICAL ULTRASOUND
 SPLENIC HAMARTOMA
FIGURE 3. Duplex Doppler sonogram shows arterial flow in the mass (arrows). The peak systolic velocity was
71.4 cm/second, with a resistance index of 0.525 and a pulsatility index of 0.776.
FIGURE 4. MR image obtained during the early enhancement phase
of dynamic MRI shows that the mass (arrow) enhanced earlier than
did the rest of the splenic parenchyma (S).
a risk of hemorrhage and because it is difficult to
diagnose splenic hamartoma based on such a
small tissue sample.5,8
Splenic hamartoma is not more prevalent in
VOL. 28, NO. 5, JUNE 2000
FIGURE 5. Arteriogram reveals multiple hypervascular masses with
fine tumor vessels and tumor stains within the spleen (arrowheads).
Arrow points to the larger lesion that correlates with the sonographi-
cally detected lesion.
either sex and has been reported in all age
groups. In a study of 18 cases of splenic hamar-
tomas, 8 patients had multiple lesions.9 Although
patients with splenic hamartomas are usually
asymptomatic, it was reported that 50% of pedi-
atric patients with a splenic hamartoma had
clinical findings such as pancytopenia, anemia, or
thrombocytopenia.2 Spontaneous rupture of the
hamartoma with acute abdominal pain in adults
has also been reported.6,10
The radiologic findings in cases of splenic ham-
251
 TANG ET AL
FIGURE 6. Photomicrograph shows that the mass is composed of red
pulp (arrowheads) (hematoxylin-eosin stain; original magnification,
10×).
artoma have been described.3–5,11,12 On sonograms,
most splenic hamartomas are homogeneous and
solid2–4,11; some, however, are heterogeneous
with cystic changes or calcification,3,5 indicating
secondary ischemia or hemorrhage.
Contrast-enhanced abdominal CT scans in cases
of splenic hamartoma usually show a low-density,
enhanced mass after administration of contrast
material.11 Zissin et al5 reported that, as in our
case, the mass was isodense relative to the nor-
mal parenchyma before and after administration
of the intravenous contrast material.
The appearance of a hamartoma on MR images
has rarely been reported. One report described
the appearance as isointense relative to the nor-
mal spleen on T1-weighted images and hyperin-
tense on T2-weighted images; the lesion on T1-
weighted images enhanced after administration
of gadopentetic acid.11
Splenic hamartomas are usually detected as
hypervascular tumors using arteriography. An-
giograms of the mass show tumor vessels with
aneurysmal dilatation, arteriovenous shunts,
vascular lakes, and tumor blush, presenting a
typically malignant vascular pattern.12 The mul-
tiple Doppler signals in our case might be ex-
plained by the dilated vessels and congestion
found on histologic analysis; the red-pulp type of
hamartoma is a tumor-like malformation or hy-
perplasia composed of normal splenic red-pulp el-
ements in abnormal quantities and with faulty
structural arrangement. The hypervascularity
detected with the use of arteriography and color
Doppler sonography in our case was thought to be
a reflection of the characteristic hypervascularity
of red pulp itself.
The differential diagnosis in cases in which a
vascular tumor of the spleen is detected includes
252
hemangioma, metastatic tumor, malignant lym-
phoma, and angiosarcoma as well as hamartoma.
A splenic hemangioma is a benign tumor that in
many cases is hyperechoic on gray-scale sono-
grams.4,13 Color Doppler sonograms of a splenic
hemangioma show few color echoes,13 similar to
the finding in hepatic hemangiomas. Splenic
hemangiomas demonstrate prolonged enhance-
ment on contrast-enhanced CT scans and MR im-
ages, and these lesions show strong hyperinten-
sity on T2-weighted MR images, providing a
useful tool for differentiating them from other tu-
mors.14 Goerg et al4 reported color Doppler sono-
graphic findings in cases of metastatic tumor and
malignant lymphoma of the spleen. In 8 of 10 of
these cases, color Doppler sonograms showed an
avascular pattern. Metastatic tumors may also be
differentiated based on the patient’s clinical his-
tory, multiplicity of the tumor, and rapid tumor
growth. Angiosarcoma has hemodynamic charac-
teristics on angiography similar to those of hem-
angioma.12 On non–contrast-enhanced CT scans,
angiosarcoma is hyperdense and shows minimal
or no enhancement after administration of contrast
material. Both T1-weighted and T2-weighted MR
images of angiosarcoma reveal low-intensity ar-
eas in an enlarged spleen caused by hemorrhage
or iron deposition. Sonograms of angiosarcoma
show multiple hyperechoic masses15; in 1 case,
color Doppler sonograms demonstrated a fluctu-
ating low-velocity flow pattern.16
In conclusion, a preoperative diagnosis of a
splenic hamartoma in an asymptomatic case may
obviate splenectomy. The multiple Doppler sig-
nals on color Doppler sonograms in our case were
consistent with the hypervascularity on angio-
grams and with the histologic findings. Although
splenic hamartoma does not always show hyper-
vascularity,3 it should be included in the differen-
tial diagnosis in cases in which color Doppler
sonograms show abundant blood flow in a splenic
tumor.
REFERENCES
1. Silverman ML, LiVolsi VA. Splenic hamartoma.
Am J Clin Pathol 1978;70:224.
2. Iozzo RV, Haas JE, Chard RL. Symptomatic
splenic hamartoma: a report of two cases and re-
view of the literature. Pediatrics 1980;66:261.
3. Komaki S, Gombas OF. Angiographic demonstra-
tion of a calcified splenic hamartoma. Radiology
1976;121:77.
4. Goerg C, Schwerk W-B. Color Doppler imaging of
focal splenic masses. Eur J Radiol 1994;18:214.
5. Zissin R, Lishner M, Rathaus V. Case report: un-
usual presentation of splenic hamartoma; com-
JOURNAL OF CLINICAL ULTRASOUND
 SPLENIC HAMARTOMA
puted tomography and ultrasonic findings. Clin
Radiol 1992;45:410.
6. Morgenstern L, McCafferty L, Rosenberg J, et al.
Hamartomas of the spleen. Arch Surg 1984;119:
1291.
7. Warnke RA, Weiss LM, Chan JK, et al. Tumors of
the lymph nodes and spleen. In: Rosai J, Sobin LH,
editors. Atlas of tumor pathology. Series 3, Fascicle
14. Washington, DC: Armed Forces Institute of Pa-
thology; 1995.
8. Kumar PV. Splenic hamartoma. A diagnostic prob-
lem on fine needle aspiration cytology. Acta Cytol
1995;39:391.
9. Wirbel RJ, Uhlig U, Futterer KM. Case report:
splenic hamartoma with hematologic disorders.
Am J Med Sci 1996;311:243.
10. Ferguson ER, Sardi A, Beckman EN. Spontaneous
rupture of splenic hamartoma. J La State Med Soc
1993;145:48.
11. Ohtomo K, Fukuda H, Mori K, et al. CT and MR
VOL. 28, NO. 5, JUNE 2000
appearances of splenic hamartoma. J Comput As-
sist Tomogr 1992;16:425.
12. Kishikawa T, Numaguchi Y, Watanabe K, et al.
Angiographic diagnosis of benign and malignant
splenic tumors. AJR Am J Roentgenol 1978;130:
339.
13. Niizawa M, Ishida H, Morikawa P, et al. Color
Doppler sonography in a case of splenic hemangi-
oma: value of compressing the tumor. AJR Am J
Roentgenol 1991;157:965.
14. Ito K, Mitchell DG, Honjo K, et al. MR imaging of
acquired abnormalities of the spleen. AJR Am J
Roentgenol 1997;168:697.
15. Ha HK, Kim HH, Kim BK, et al. Primary angio-
sarcoma of the spleen. CT and MR imaging. Acta
Radiol 1994;35:455.
16. Aytac S, Fitoz S, Atasoy C, et al. Multimodality
demonstration of primary splenic angiosarcoma. J
Clin Ultrasound 1999;27:92.
253