Splenic Biopsy Research Articles

Large cell neuroendocrine carcinoma in pancreatoblastoma with TP53 and SMAD4 mutations: a clinicopathologic study of a rare entity

Abstract Pancreatoblastoma, a rare pancreatic tumor, exhibits diverse differentiation pathways, including acinar, ductal, and neuroendocrine lineages, often with distinct squamoid nests [3]. We present a notable case of pancreatoblastoma coexisting with large cell neuroendocrine carcinoma in a 10-year-old boy, presenting with abdominal discomfort, weight loss, and lesions in the pancreas, spleen, and liver visible on imaging. A liver biopsy revealed a poorly differentiated carcinoma with neuroendocrine features, while a splenic biopsy showed acinar cell differentiation, raising possible diagnoses of pancreatoblastoma or acinar cell carcinoma. Subsequent surgical resection after chemotherapy revealed diverse components within the pancreatoblastoma, including well-differentiated acinar and neuroendocrine cells, squamoid nests, and a high-grade neuroendocrine carcinoma. Genetic analysis detected pathogenic variants in TP53 and SMAD4, rarely found in pancreatoblastomas. This juxtaposition of large cell neuroendocrine carcinoma and pancreatoblastoma suggests a potential evolution from well-differentiated neuroendocrine tumors to poorly-differentiated carcinomas within pancreatoblastomas.

Epstein-Barr virus-positive inflammatory follicular dendritic cell sarcoma: A brief report of a rare neoplasm diagnosed with cytopathology on a splenic biopsy.

Splenic biopsies for cytology remain challenging due to the inherent difficulty in obtaining adequate samples and the paucity of literature on rare entities arising in the spleen. Among these, are tumors arising from blood vessels, lymphomas and rarely, mesenchymal dendritic cell neoplasms. An important but rarely considered entity primarily arising in the spleen is Epstein-Barr virus-positive inflammatory follicular dendritic cell sarcoma (EBV+ IFDCS). EBV+ IFDCS is an indolent neoplasm with useful cytomorphologic and distinct biologic characteristics that can be evaluated on fine-needle aspiration (FNA) cytology and small biopsies. In this report, we present a challenging case with the final diagnosis facilitated by cytomorphology and diagnostic markers in an ambiguous initial presentation.

Laparoscopic Partial Splenectomy May Be Valuable for the Diagnosis of Malignant Lymphoma: A Case Report.

Diagnosing primary splenic malignant lymphoma (PSML) is challenging due to the non-specific nature of splenomegaly, necessitating splenic biopsy for confirmation. However, performing partial splenic resection for diagnostic purposes is an elective procedure due to the risk of major hemorrhage. Despite the longstanding practice of splenectomy over the past few decades, it remains invasive and may result in severe early or late complications. Hence, we present laparoscopic partial splenectomy (LPS) in a patient suspicious of PSML for diagnostic purposes in this study. An 81-year-old woman presented to our hospital with a one-month history of fever and dry cough. Atypical cells had been detected in her peripheral blood nine months ago. However, at that time, a bone marrow examination did not reveal any atypical cells. The laboratory tests revealed a soluble interleukin receptor-2 levels of 4,667 U/dl and atypical cells were also found in peripheral blood. Abdominal computed tomography showed splenomegaly without any other relevant findings. These findings are suspicious of PSML and LPS without vessel ligation was performed and a small fraction of the spleen from the inferior pole measuring 1.8×1.0 cm was resected. The operation lasted for 63 min with minimal estimated blood loss. Histopathological findings were compatible with the diagnosis of diffuse B-cell lymphoma. The postoperative clinical course was uneventful, and splenomegaly demonstrated improvement six months after the operation. LPS without vessel ligation for biopsy may be valuable for the diagnosis of malignant lymphoma, particularly when there are no swollen lymph nodes, as it offers a less invasive approach.

A case report on para-kala-azar dermal leishmaniasis: an unresolved mystery

BackgroundPost-kala-azar dermal leishmaniasis (PKDL) is a dermatosis that occurs 2–3 years after an apparently successful treatment of visceral leishmaniasis (VL). In rare cases, PKDL occurs concurrently with VL and is characterized by fever, splenomegaly, hepatomegaly or lymphadenopathy, and poor nutritional status and is known as Para-kala-azar dermal leishmaniasis (Para-KDL). Co-association of active VL in PKDL patients is documented in Africa, but very few case reports are found in South Asia.Case summaryWe present a case of Para-kala-azar Dermal Leishmaniasis (Para-KDL) in a 50-year-old male patient with a history of one primary Visceral Leishmaniasis (VL) and 2 times relapse of Visceral Leishmaniasis (VL). The patient presented with fever, skin lesions, and hepatosplenomegaly. Laboratory tests revealed LD bodies in the slit skin smear and splenic biopsy. The patient was treated with two cycles of Amphotericin B with Miltefosine in between cycles for 12 weeks to obtain full recovery.ConclusionThis case report serves as a reminder that Para-kala-azar dermal leishmaniasis can develop as a consequence of prior visceral leishmaniasis episodes, even after apparently effective therapy. Since para-kala-azar is a source of infectious spread, endemics cannot be avoided unless it is effectively recognized and treated.

Exploration of predictors associated with bleeding in computed tomography-guided core needle splenic biopsy: A retrospective study.

Splenic diseases may be caused by infections and can be either malignant, such as lymphoma and lung cancer, or benign, such as hemangioma. In some cases, diagnostic uncertainty of imaging persists, and image-guided splenic needle biopsy is a useful diagnostic tool to avoid the disadvantages of incorrect diagnosis, including performing unnecessary splenectomy or not giving the necessary treatment. Splenic biopsies can be divided into ultrasound-guided, computed tomography (CT)-guided fine-needle aspiration, or core needle biopsy (CNB). However, few studies have focused exclusively on complications associated with CT-guided CNB of the spleen. Therefore, we assessed bleeding, the most common complication of CT-guided CNB of the spleen, and evaluated factors associated with the bleeding. Using the biopsy database maintained at the institution, all patients who underwent CT-guided CNB of the spleen between May 2012 and September 2022 were identified retrospectively. The 18 identified patients were divided into post-biopsy bleeding and non-bleeding groups for analysis. In total, 17 patients (94.4%) could be diagnosed accurately with CT-guided CNB. Bleeding complications occurred in 7 cases of CT-guided CNB; of these, 2 patients with Common Terminology Criteria for Adverse Events grade 4 disease required transcatheter arterial embolization. The bleeding group was characterized by diffuse spleen tumors in all cases, with significantly more diffuse spleen tumors than the non-bleeding group. CT-guided CNB is a useful option for neoplastic lesions of the spleen that are difficult to diagnose using imaging alone. However, consideration should be given to post-biopsy bleeding in patients with diffuse splenic tumors.

Acoustic Radiation Force Impulse (ARFI) Elastography of Focal Splenic Lesions: Feasibility and Diagnostic Potential.

Nontraumatic focal splenic lesions (FSL) are rare, and the need for tissue diagnosis must be weighed against the very high risk of bleeding after a splenic biopsy. The aim of this study was to explore the feasibility and diagnostic potential of acoustic radiation force impulse (ARFI) elastography as a noninvasive method for different benign and malignant FSLs. No human studies on the elastographic characteristics of FSL exist. This was a retrospective analysis of 34 patients with FSLs, who underwent abdominal B-mode ultrasound (B-US), contrast-enhanced ultrasound (CEUS), and standardized ARFI examinations between October 2021 and December 2022 at our university hospital. The inclusion criteria were: (i) FSL size ≥ 1 cm; (ii) 10 valid ARFI measurements of the FSL, as well as of the normal splenic parenchyma (NSP) as an in vivo reference; and (iii) diagnostic confirmation of FSL etiology based on histological examination (8/34; 23.5%) or clinical evaluation, which included a clinical and sonographic follow-up (FU), CEUS morphology, and/or morphology on cross-sectional imaging (26/34; 76.5%). CEUS was performed on all patients and the FSLs were classified according to the current guidelines; cross-sectional imaging was available for 29/34 (85.3%). The mean FU duration was 25.8 ± 30.5 months. The mean ARFI velocity (MAV) of the FSL (MAVL), the NSP (MAVP), and the ratio of the MAVL to the MAVP (MAVL/P) were calculated and compared. Of the 34 FSLs, 13 (38.2%) were malignant (mFSL) and 21 (61.8%) were benign (bFSL). The MAVL of all 34 FSLs (2.74 ± 0.71 m/s) was lower than the MAVP (3.20 ± 0.59 m/s), p = 0.009, with a mean MAVL/P ratio of 0.90 ± 0.34. No significant differences in the MAVL were observed between the mFSL (2.66 ± 0.67 m/s) and bFSL (2.79 ± 0.75 m/s). There were also no significant differences between the MAVP in patients with mFSL (3.24 ± 0.68 m/s) as compared to that in the patients with bFSL (3.18 ± 0.55 m/s). Likewise, the MAV L/P ratio did not differ between the mFSL (0.90 ± 0.41 m/s) and bFSL (0.90 ± 0.30 m/s) groups. ARFI elastography is feasible in evaluating the stiffness of FSLs. The lesions' stiffness was lower than that of the NSP, regardless of the FSL etiology. However, differentiation between benign and malignant FSL with the help of this elastographic method does not appear possible. Larger prospective studies are needed to validate these findings.

Hemophagocytic Lymphohistiocytosis Associated with Diffuse Large B-Cell Lymphoma: A Case Report

Abstract Introduction/Objective Secondary hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome of immune hyperactivation and dysregulation that has been observed in some malignancies. In HLH, natural killer (NK) cells and cytotoxic T-cells fail to control activated macrophages, leading to cytokine-mediated tissue injury and multiorgan failure. Persistent tumor antigenic stimulation and cytokine hypersecretion can trigger HLH. Diffuse large B- cell lymphoma (DLBCL) is uncommonly associated with HLH. Methods/Case Report A 50-year-old woman presented with daily fevers and malaise of one-month duration. Imaging showed marked hepatosplenomegaly with no lymphadenopathy. Laboratory studies were significant for pancytopenia (WBC: 3.8 K/µL, Hb: 6.8 g/dL, Plt: 74 K/µL), hypertriglyceridemia (330 mg/dL), hyperferritinemia (1460 ng/mL), and elevated soluble interleukin-2 receptor (CD25) (42351.5 pg/mL). These findings, along with NK cell activity level (not obtained in this case), fever, splenomegaly and hemophagocytosis (bone marrow, spleen or lymph nodes) represent the eight diagnostic criteria by Histiocyte Society HLH-2004. A splenic biopsy showed a nodular proliferation of medium-to-large neoplastic lymphocytes with CD20, PAX5, BCL6, MUM1, BCL2, CD5 (dim) and CD10 (dim) expression and negative for cyclin D1 and p53. CD21 did not highlight any dendritic cell meshwork. The bone marrow biopsy provided similar results. Overall, these findings were consistent with a DLBCL, germinal center subtype. Rearrangements of MYC, BCL2 or BCL6 genes were not detected. Although hemophagocytosis was not noted in the bone marrow or spleen, the patient met six of the eight HLH-2004 criteria (minimum five are required). The H-score was 174 reflecting up to 70% probability of HLH. Treatment with daily intravenous dexamethasone 10 mg/m2 was initiated as a temporizing measure prior to R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy which resulted in complete remission. Results (if a Case Study enter NA) NA Conclusion Physicians should be cognizant of secondary HLH as a rare complication of DLBCL. Prompt initiation of the appropriate therapy could result in rapid and complete resolution.

Safety and efficacy of percutaneous plugged splenic biopsy as an alternative to splenectomy for diagnosing disorders of the spleen

Category: Interventional radiology

The great masquerade: A rapidly growing pulmonary nodule

We present a case in which the patient had left-sided chest pain and was found to have an enlarged spleen with a necrotic mass and multiple pulmonary nodules. The splenic biopsy was nondiagnostic and repeat imaging showed rapid enlargement of the pulmonary nodules with high standardized uptake value (SUV) uptake. Spindle cells present on the lung pathology initially led to the diagnosis of sarcomatoid lung cancer. However, further review showed CD20 staining on the specimen and the final diagnosis was diffuse large B-cell lymphoma (DLBCL), spindle cell variant. The patient was successfully treated with rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride, vincristine and prednisone (R-CHOP) after the diagnosis was confirmed. This is a very rare form of DLBCL that is commonly misdiagnosed and is often not on the differential for spindle cell tumors. To our knowledge, DLBCL spindle cell variant has never presented or been diagnosed from pulmonary nodules.

Primary splenic lymphoma discovered on massive splenomegaly: A case report.

Introduction and importanceMalignant lymphoma occurs in all the systemic organs. Rarely, large B-cell lymphoma is located in the spleen, making the diagnosis difficult.Herein, we report a patient presenting with massive splenomegaly due to LBCL. Splenectomy was essential to assess the diagnosis and to guide postoperative therapeutics.Presentation of a caseA 47-year-old woman, with no comorbidities, complained of weight loss and abdominal pain. She had a palpable spleen that extended below the navel.CT scan revealed massive splenomegaly and lymph nodes in the spleen hilum. Splenectomy was performed.Histopathological examination confirmed the diagnosis of large B-cell lymphoma.The postoperative course was uneventful. Three courses of chemotherapy were given. The patient was in remission after a follow-up of 8 months.DiscussionMassive splenomegaly can be one of the circumstances of the discovery of large B-cell lymphoma.Splenectomy was then essential to confirm the diagnosis and to guide postoperative therapeutics. It also permits reducing hypersplenism and preventing spleen rupture.In patients with high operative risk, splenic needle biopsy should be taken into consideration.Splenic artery embolization before surgery can also be performed in patients having massive splenomegaly to reduce the spleen volume.We highlight the importance of splenectomy to confirm the diagnosis and to relieve the symptoms. Postoperative chemotherapy is essential to prevent relapses.ConclusionSplenectomy is essential in spleen localized large B-cell lymphoma. It permits to confirm the diagnosis, relieve symptoms, and treatment of underlying hematologic malignancies. Postoperative chemotherapy is essential to prevent relapses.

Top tips regarding EUS-guided liver biopsy

Top tips regarding EUS-guided liver biopsy

Spleen biopsy: "pros and cons" or better "when and when not?"

Due to the relatively high complication rate, the necessity of a spleen biopsy is controversially discussed. In establishing its indication, the clinical background and performed diagnostics must be considered. Based on the medical history, imaging procedures and sonographic course, different clinical scenarios are conceivable. The aim of this review is to describe theindications of splenic biopsy considering various clinical scenarios.

Usefulness of endoscopic ultrasound-guided fine needle aspiration for splenic parenchyma in patients suspected of having primary splenic malignant lymphoma.

Background and study aims The diagnosis of malignant lymphoma (ML) is sometimes difficult, especially in patients with primary splenic malignant lymphomas (psML) which have no lymph nodes capable of acting as the biopsy target. We carried out endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for “splenic parenchyma” in patients suspected of having a psML, even without any obvious neoplastic lesions in the spleen. Patients and methods A retrospective study using medical records was conducted of eight patients suspected of having a psML that received EUS-FNA for the splenic parenchyma between January 2016 and January 2019. Data analyzed included clinical background, EUS-FNA procedure (puncture needle/route), diagnostic ability (pathological/flow cytometry [FCM]), and complications. Results EUS-FNA was performed from the stomach in all eight cases, and no patients had complications. As a result of splenic parenchymal biopsy found on EUS-FNA, 75 % of patients (6/8) were histologically diagnosed with MLs, monoclonality of B-cells was identified in all cases (8/8) with FCM, and all patients (8/8) were definitively diagnosed with psMLs. Conclusion EUS-FNA for “splenic parenchyma” is useful for patients with spML, even if they have no obvious neoplastic lesions in the spleen.

Massive splenomegaly due to splenic marginal zone B‐cell lymphoma

A 73-year-old man presented with an abdominal mass that gradually swells over 3months. He denied any subjective symptoms. Physical examination revealed massive enlargement of the spleen-the spleen had crossed the midline and its lower margin extended into the lower abdomen.

B-cell neoplasms and Hodgkin lymphoma in the spleen

B-cell lymphoma of spleen may be primary (most commonly splenic diffuse large B-cell lymphoma) or secondary (typically low-grade non-Hodgkin lymphoma). Depending on the specific lymphoma subtype, there may be a predominantly white pulp pattern of involvement, a predominantly red pulp pattern or a focal nodular pattern. Splenectomy is the ideal specimen for a multiparametric integrative diagnosis of splenic lymphoma, as it allows for a combined study of morphology, immunohistology, flow cytometry, cytogenetics, and molecular genetic techniques. This review article describes the clinicopathologic characteristics of all the relevant B-cell neoplasms that may be encountered in a splenic biopsy or a splenectomy specimen.

Percutaneous Image-Guided Biopsy of the Spleen: Experience at a Single Tertiary Care Center.

The purpose of this study is to assess the complication rate of percutaneous image-guided biopsy of the spleen at our institution and to evaluate for variables associated with complication rate. This is a Research Ethics Board approved retrospective study of consecutive patients who underwent image-guided biopsy of the spleen at our institution from January 2010 to November 2019. Complications, imaging findings, and pathologic diagnosis were reviewed. Complications (major and minor) were classified per Society of Interventional Radiology Guidelines, and complication rate was calculated. Logistic regression was applied to determine factors associated with complications. Diagnostic yield was calculated. In all, 55 patients (28 female) underwent splenic biopsy using ultrasound guidance. The most common indication was possible lymphoma in 41 (71.7%) patients followed by query metastasis 18 (31.5%) patients. Core biopsies (18 g/20 g) were done in 53 (92%) cases, and fine-needle aspiration (22 g) was performed in 4 (8%). The median number of samples collected was 4 (range: 2-9). The results were diagnostic in 54 cases (94.7%, 95% confidence interval [CI]: 88.7-100.0). There were 12 (21%, 95% CI: 10.1-31.9) patients with minor complications and 2 (3.5%, 95% CI: 0.0-8.4) with major complications (2 splenic bleeds requiring embolization, no splenectomy, or deaths). No variables (needle size, lesion size, and number of passes) were associated with complication rate. Percutaneous image-guided biopsy of the spleen at a single tertiary care institution demonstrates major complication rate comparable to that in the literature with no variables associated with complication rate; there were no cases of splenectomy or death.

Percutaneous and endoscopic ultrasound-guided splenic biopsies are both safe procedures with a high diagnostic accuracy.

Splenic biopsy is a necessary diagnostic procedure. It has been proved that it is a safe procedure with a high diagnostic accuracy. However, the decision of percutaneous or endoscopic ultrasound-guided approach should be assessed taking into consideration patients' characteristics and the experience of each center.

Training rhesus macaques to take daily oral antiretroviral therapy for preclinical evaluation of HIV prevention and treatment strategies.

BackgroundMacaque models of simian or simian/human immunodeficiency virus (SIV or SHIV) infection are critical for the evaluation of antiretroviral (ARV)-based HIV treatment and prevention strategies. However, modelling human oral ARV administration is logistically challenging and fraught by limited adherence. Here, we developed a protocol for administering daily oral doses of ARVs to macaques with a high rate of compliance.MethodsParameters of positive reinforcement training (PRT), behavioral responses and optimal drug delivery foods were defined in 7 male rhesus macaques (Macaca mulatta). Animals were trained to sit in a specified cage location prior to receiving ARVs, emtricitabine (FTC) and tenofovir alafenamide (TAF), in a blended food mixture, which was followed immediately with a juice chaser. Consistency of daily oral adherence was evaluated in 4 trained macaques receiving clinically equivalent doses of FTC and TAF (20 and 1.5 mg/kg, respectively) in a short-term (1 month) and an extended (6 month) trial. Adherence was monitored using medication diaries and by quantifying intracellular FTC-triphosphate (FTC-TP) and tenofovir-diphosphate (TFV-DP) concentrations in peripheral mononuclear blood cells (PBMCs).ResultsTrained macaques quickly and consistently took daily oral ARVs for 1 month with an average 99.8% observed adherence. Intracellular concentrations of TFV-DP (median = 845.8 fmol/million cells [range, 620.8–1031.3]) and FTC-TP (median = 367.0 fmol/million cells [range, 289.5–413.5) in PBMCs were consistent with high adherence. Extended treatment with select subjects yielded similar observations for three months (99.5% adherence, 352/356 complete doses taken), although a sudden drop in adherence was observed after splenic biopsy surgery.ConclusionsWe demonstrate that trained macaques reliably adhere to a daily oral ARV regimen, although unexpected adherence issues are possible. Our approach, using clinical doses of oral FTC and TAF daily, further refines macaque models of HIV treatment and prevention by mimicking the human route and timing of ARV administration.

Descriptive Study of Hemophagocytic Lymphohistiocytosis (HLH) Admissions in Adult Population: Data from Nationwide Inpatient Sample (NIS) Database

Background: Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe immune activation and dysregulation, characterized by hyperactive macrophages and lymphocytes, resulting in multi-organ damage and high mortality. Epidemiologic data of HLH in the adult population is limited. The aim of our study is to characterize HLH admissions in the US adult population. Methods: We performed a retrospective study using the Nationwide Inpatient Database for the year 2016. 330 admissions with principal diagnosis of HLH in adults were identified, using ICD code specific for HLH. Using ICD 10 codes for malignancies and rheumatologic conditions, we subdivided HLH admissions into malignancy-associated HLH, autoimmune disease-related HLH and non-malignancy, non-autoimmune HLH. Statistical analyses were performed using STATA. One-way ANOVA was used to compare means of continuous variables and chi-square test was used to compare proportions of categorical variables. Results: Mean age of our study group was 50.1, with women making up 44% of the population. 15% of the patients had an underlying malignancy, most common type being mature T/NK cell lymphoma. Also, 15% of the patients had a rheumatologic diagnosis, SLE constituting half of this sub-group. 47% of the total population under study underwent either bone marrow, liver or splenic biopsy. Mortality rate was 21.2% and average length of stay was 17 days. 25.8% received systemic chemotherapy during the admission. Within the subgroups, we did not find a statistically significant difference in the age, gender, race, percentage undergoing biopsy or inpatient chemotherapy. There was also no statistically significant difference in mortality or length of stay between the three groups. Discussion: HLH is a life-threatening condition of immune hyper-activation and may be divided into primary HLH, which is an autosomal recessive condition, caused by mutations impairing the cytotoxic function of NK cells and cytotoxic T lymphocytes. Secondary HLH is the more frequent presentation in adults, and frequently identified triggers include hematologic malignancies, infections and autoimmune conditions. Autoimmune-associated HLH is usually termed as macrophage activation syndrome (MAS). Mortality in secondary HLH varies based on underlying condition, around 8% when associated with JIA, compared to more than 80% in malignancy associated HLH in some studies. Our study sample was underpowered to detect notable differences between the study groups. This can be attributed to the rarity of this condition. HLH is primarily a pediatric disease. Incidence of HLH in the pediatric age group has been estimated to be around 1 in 100,000 children. Incidence in the adult population is less clear. In our study, we were able to represent the epidemiologic aspects of adults with HLH in the real world. We need large observational studies to further characterize HLH in the adult population. Disclosures No relevant conflicts of interest to declare.

2126 Endoscopic Ultrasound-Guided Splenic Mass Biopsy. an Accessible Technique for Differential Diagnosis of Lymphoma

INTRODUCTION: Traditional methods for splenic mass biopsy includesurgical or percutaneous technique, however there is an increased risk of hemorrhage, hematoma or cutaneous infection associated with these techniques. In addition, these techniques do not allow us to evaluate adjacent organs. Endoscopic ultrasound (EUS) provides a novel method for splenic mass biopsy and should be considered for such procedures. Our case highlights technique for a successful and safely done EUS guided splenic mass biopsy. CASE DESCRIPTION/METHODS: Case: 68-year-old female with history of non-Hodgkin lymphoma in remission, stage IIIbsquamous cell carcinoma of anus treated with chemoradiation and on surveillance referred to GI after a surveillance CT abdomen/pelvis revealed spleen enlargement with hypodensities. This was followed by PET/CT with increased uptake on anal region, spleen, stomach and supraclavicular node. Endoscopy with EUSwas performed. Biopsies were obtained from stomach and duodenum. EUS imaging showed splenic lesion. Fine Needle Biopsy was performed with 22-gauge needle with a slow pool technique. 4 needle passes were made into the mass. Specimen was sent for pathology and flow cytometry. Patient tolerated procedure without complications. Biopsy report showed evidence of B cell lymphoma on all samples with diagnosis of relapsed B cell Non-Hodgkin lymphoma. DISCUSSION: EUS can provide a feasible and safer technique to obtain splenic mass biopsies. This technique utilizes the proximity of gastrointestinal tract and therefore a readily accessible path to obtain splenic biopsies. Endoscopic ultrasound can also provide a safe way to evaluate adjacent organs during the work up of disease extent involvement, all in one minimally invasive procedure,reducing the amount of risks and complications associated with traditional biopsy techniques.