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The Best Single Measurement for Assessing Splenomegaly in Patients with Cirrhotic Liver Morphology

Posted Nov 30, 2017 Updated Apr 10, 2023
By Zachary Nuffer MD , Thomas Marini BS , Andrey Rupasov DO , Stephen Kwak BS , Shweta Bhatt MD
9 min read

Rationale and Objectives

There is little agreement within the radiology literature as to the best single measurement for assessing splenomegaly. In this study, we evaluate the correlation of multiple unidirectional measurements of the spleen with splenic volume in patients with cirrhotic liver morphology on computed tomography (CT).

Materials and Methods

Splenic volume was retrospectively calculated from CT examinations of 179 adult patients, 47 of whom were approved as renal donors, and 132 of whom were referred for various other indications, and were found to have cirrhotic liver morphology on CT. Seven unidimensional measurements (long-axis, cranial-caudal, width, and four measures of thickness) of each spleen were evaluated to identify which most closely correlated with the calculated volume.

Results

The splenic width had the best correlation with splenic volume for mild-to-moderate splenomegaly, and the splenic cranial-caudal measurement had the best correlation with splenic volume for massive splenomegaly. Receiver operating characteristic analysis demonstrates that a splenic width measurement of approximately 10.5 cm has a sensitivity of 89% and a specificity of 78% for mild-to-moderate splenomegaly, and a cranial-caudal measurement of 14.6 cm has a sensitivity of 92% and a specificity of 91% for massive splenomegaly.

Conclusions

A splenic width threshold of 10.5 cm is the most sensitive (89%) and specific (78%) single measurement for mild-to-moderate splenomegaly in patients with cirrhotic liver morphology, whereas a cranial-caudal height threshold of 14.6 cm is the most sensitive (92%) and specific (91%) single measurement for massive splenomegaly.

Introduction

Although nonspecific, splenomegaly is an important finding in a variety of disease processes, including portal hypertension, hematologic disorders, and chronic inflammatory conditions . In patients who have cirrhosis or who are at risk of cirrhosis, identification of splenomegaly is of particular value, as splenomegaly is the most sensitive imaging finding of portal hypertension, and correlation between splenomegaly and the subsequent development of cirrhosis, as well as between splenomegaly and the severity of esophageal varices, has been established . However, determining splenomegaly on computed tomography (CT) imaging has long vexed the radiology community, and there is no established consensus for when or how to diagnose it. The gold standard for determining splenomegaly requires calculating the splenic volume, although this is rarely performed, as it is both technically challenging and time-consuming . Rather, radiologists commonly rely on unidimensional proxy measurements, including cranial-caudal (CC) and long-axis (LA) measurements, as seen in Figure 1 . Despite the common use of these measurements, no single unidimensional measurement has been established in the literature with both a high sensitivity and a high specificity for all cases of splenomegaly, owing largely to the complex and varied shape and orientation of the spleen. For example, the commonly accepted LA and CC measurements of the spleen, ranging from 10 to 13 cm, have been demonstrated to have a low sensitivity (33%–68%) and specificity (68%–76%) for sub-massive splenomegaly, resulting in both underdiagnosis and misdiagnosis .

Figure 1, Unidirectional measurements.

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Materials and Methods

Study Patients

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Segmentation

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Figure 2, Semiautomatic segmentation in itk-SNAP. Depiction of the process of semiautomatic segmentation in itk-SNAP. Bubbles (red) are placed within the spleen, which then expand to the edges of the spleen according to a “level set” segmentation algorithm. This requires some guidance from the user, and errors can be manually corrected. A three-dimensional image is shown in the final frame. (Color version of figure is available online.)

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Definition of Splenomegaly and Volumetric Thresholds

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TABLE 1

Studies of Normal Splenic Volume on Computed Tomography

Study Inclusion Criteria Population Volume Linguraru et al., 2013 45 renal donors American Mean: 237 cm 3 Harris et al., 2010 230 consecutive patients who underwent computed tomography (CT) scans for various indications. Patients with conditions that have a known effect on the spleen size were excluded. Japanese Mean: 127 cm 3

Range: 22–417 cm 3 Kaneko et al., 2002 150 liver donors Japanese Mean: 112 cm 3

Range: 32–209 cm 3 Prassopoulos et al., 1997 140 patients referred for an indication unrelated to splenic disease European Mean: 215 cm 3

Range: 107–315 cm 3

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Statistical Analysis

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Results

Study Patients

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TABLE 2

Splenic Volume Statistics of the Renal Donor and Cirrhotic Liver Morphology Populations

Population Mean Volume (cc) St. Dev. (cc) Range (cc) Renal donors (48) 251 88 117-462 Cirrhotic liver morphology (132) 742 474 87-2745 <5 St. Dev (64) \* 385 135 87-606 ≥ 5 St. Dev (68) \* 1134 430 631-2745

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Segmentation

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Figure 3, Bland-Altman volumetric measurement agreement. Bland-Altman volumetric measurement agreement plots between two observers. The mean error is shown as the central dashed line, and the 95% limits of agreement (±1.96 standard deviation [SD]) are shown as the peripheral dashed lines.

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Relationship Between Splenic Volume and Unidirectional Measurements

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Figure 4, Bland-Altman unidirectional measurement agreement. Bland-Altman unidirectional measurement agreement plots between two observers. The mean error is shown as the central dashed line and the 95% limits of agreement (±1.96 standard deviation [SD]) are shown as the peripheral dashed lines.

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TABLE 3

Correlation Between Unidirectional Measurements and Splenic Volume

R Value Dimension <5 St. Dev. ≥5 St. Dev. Long axis 0.68 0.76 Cranial-caudal 0.69 0.86 Width 0.75 0.69 Transverse 1 0.62 0.59 Transverse 2 0.62 0.60 Transverse 3 0.74 0.74 Transverse 4 0.66 0.70

Correlation coefficients for each of the unidirectional measurements obtained in the cirrhotic liver morphology population. Correlation is greatest for width within 5 standard deviations of the mean (mild-to-moderate splenomegaly), and greatest for cranial-caudal above 5 standard deviations (massive splenomegaly).

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Figure 5, Receiver operating characteristic curves. Width has both the greatest area under the curve for the population of patients with cirrhotic liver morphology and mild-to-moderate splenomegaly (splenic volume less than 5 standard deviations [SD] above the mean) ( left ), as well as for the entire population of patients with cirrhotic liver morphology ( right ). Note that only the line corresponding to the W measurement is labeled in each figure.

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Discussion

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Academic Radiology, Volume 24, Issue 12
Journals General Radiology
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