Splenic Disease Research Articles

A prospective trial of involved field radiation (IFRT) + chemotherapy compared to extended field (EFRT) radiation for favorable Hodgkin disease: Survival differences and implications of mature follow-up for current combined modality therapy

8014 Background: We conducted a prospective randomized trial from 1980–88 comparing IFRT plus VBM (vinblastine, bleomycin, methotrexate) chemotherapy to extended field radiation (EFRT) in patients with favorable stage I-IIIA disease to limit radiation exposure and define an effective treatment regimen that preserved fertility and did not increase the risk of leukemia. Methods: Patients (pt) with favorable, laparotomy-staged disease were defined as those with no bulky mediastinal disease, no or minimal abdominal disease (<5 cm), no or minimal splenic disease, and <1 extranodal site. VBM was given for 6 cycles after 44 Gy IFRT. EFRT was subtotal lymphoid for stage I-IIA and total lymphoid irradiation for I-IIB, IIIA pt. We previously reported (J Clin Oncol 6:1822, 1988) no survival differences in this study. Follow-up was similar for both arms and was further supplemented by an approved SSA Epidemiologic Vital Status Data Record application. Results: 72 pt were randomized, 34 to IFRT + VBM and 38 to EFRT. Median follow-up is 20.8 yr (10.3–25.1) and just 8 pt were censored at <15 yr. Twenty-one yr freedom from progression is 96% for IFRT + VBM vs 74% for EFRT (p= 0.035). A single death at 18 yr was recorded in IFRT + VBM pt (3%) whereas 11 deaths occurred among EFRT pt (29%). Overall survival (OS) at 21 yr is 95% for IFRT + VBM vs 68% for EFRT (p=0.003). As previously reported, fertility was informally assessed, but premature menopause was not observed and both men and women conceived after IFRT + VBM. Conclusion: The reduction of radiation to IFRT, combined with a less toxic chemotherapy in our study, resulted in excellent long-term OS that was significantly superior to EFRT. The survival data with IFRT + VBM also compare favorably with our historical EFRT experience. Moreover, these results have implications for current combined modality therapy where much lower doses of RT, more limited fields and brief chemotherapy should lead to even less late morbidity and mortality. No significant financial relationships to disclose.

Recurrent endometrial cancer: patterns of recurrent disease and assessment of prognosis

To evaluate patterns of disease and identify factors predicting outcome in patients presenting with recurrent endometrial adenocarcinoma following primary surgery. A retrospective review was performed of the imaging and clinical data in 86 patients (median age 66 years, range 42-88 years) presenting with recurrent endometrial adenocarcinoma following primary surgery. Following primary surgery recurrent disease occurred within 2 years in 64% and within 3 years in 87%. Relapse was seen within lymph nodes in 41 (46%), the vagina in 36 (42%) the peritoneum in 24 (28%) and the lung in 21 (24%). Unusual sites of disease included spleen, pancreas, rectum, muscle and brain. Univariate survival analysis showed the factors significant for poor outcome were: multiple sites of disease, liver and splenic disease, haematogenous, peritoneal and nodal spread, poorly differentiated tumour, and early relapse. The presence of disease within the vagina, bladder or lung was not associated with poor prognosis. Multivariate analysis identified multiple sites of disease, liver and splenic metastases to be independent predictors of poor outcome. The most frequently observed sites of relapse are: lymph nodes, vagina, peritoneum and lung. Significant predictors of poor outcome in recurrent disease are multiple sites of disease and liver and splenic metastases.

Isolated skeletal and splenic hydatid disease

Isolated skeletal and splenic hydatid disease

An audit on pediatric hydatid disease of uncommon localization: incidence, diagnosis, surgical approach, and outcome

Background/Purpose Infestation of sites other than the liver and lungs by the parasite Echinococcus granulosus is rarely encountered in clinical practice. The present study aims to determine the incidence of hydatid disease of uncommon localization in children and to document the clinical and radiologic findings, the types of the operations performed, and the postoperative course of the disease. Methods A retrospective review of the demographical data as well as preoperative and postoperative clinical findings of children who underwent surgical treatment of hydatid disease was done. Results Hydatid disease of uncommon localization was encountered in 15 (7%) of 207 children reviewed. The sites in which the cysts were located were as follows: spleen (n = 4, 1.9%), kidney (n = 4, 1.9%), retroperitoneum (n = 3, 1.4%), omentum (n = 2, 1%), anterior abdominal wall (n = 1, 0.5%), and anterior thigh (n = 1, 0.5%). Radiodiagnostic tools such as ultrasonography were used in all. Partial pericystectomy was the surgical procedure of choice in most cases. There was 1 recurrence in a patient with splenic disease, with no mortality. Conclusions Pediatric hydatid disease can involve any body part. Radiologic imaging techniques are helpful in diagnosis. Surgery should aim to preserve as much tissue as possible while precautions to prevent recurrences are undertaken.

Isolated splenic granuloma: report of a case with an emphasis on ultrasound findings

There is a marked paucity of reports on contrast-enhanced ultrasonography (US) for focal splenic disease in the literature, and there are no previously reported contrast-enhanced US findings for splenic granuloma. We report the case of a 77-year-old cirrhotic woman with isolated splenic granulomas. We detail the diagnostic difficulty encountered in this case and briefly review the literature.

Upper Gastrointestinal Surgery

This book attempts to cover all aspects of management for oesophageal, gastric, splenic and small bowel disease. The editors have amassed an excellent portfolio of contributors who have written the 27 chapters. The page layout is double column, which makes for easy reading, and black and white lined drawings are interspersed throughout the text. This style works well and helps to make the information readily accessible, encouraging one to dip in and out of the various chapters. There are questions at the end of each of these that provide a useful ‘checking back’ function, which helps readers confirm that they have picked up the main learning points from each contribution. What I did not enjoy about this book was the organisation. It was novel to describe the anatomy and physiology of each organ in its own chapter and then discuss the benign diseases and malignant problems again in separate chapters. However, this resulted in considerable repetition. The spleen seems to have been given excessive prominence with over 20 pages devoted to the benign conditions of this organ whereas only 10 are given over to carcinoma of the oesophagus. There are some unusual chapters such as Chapter 23: ‘High risk lesions in the oesophagus and nuclear medicine’. This goes into the most extra-ordinary detail of how radionucleotide oesophageal transit studies are performed and interpreted. Unexpectedly, there is then no discussion about high-risk lesions of the oesophagus! This chapter is followed by the only colour illustration of the book, which consists of five pictures of radionucleotide oesophageal gastric and motility studies. I am not entirely sure who this book is aimed at but undergraduates and surgical trainees alike may find it useful to dip into for quick guidance. I think it would be most useful as a reference volume for some of its excellent chapters such as ‘Stromal upper GI tract neoplasms’ and ‘Surgical resection of oesophageal cancer: role of extended lymphadenectomy’.

Bildgebende Diagnostik bei Milzerkrankungen

Primary diseases of the spleen are relatively rare. More frequently, the spleen is involved secondarily in hematological, oncological, infectious, immunological, vascular, and other systemic diseases. The spleen is the most commonly injured organ in blunt abdominal trauma. Anatomical and physiological basics are explained, in addition to embryological facts with resulting abnormalities, such as accessory and "wandering" spleen, and polysplenia. The most frequent primary and secondary diseases of the spleen, including rare diagnoses, are presented and illustrated. Hemangioma represents the most common primary benign tumor, and lymphoma the most common primary malignant tumor of the spleen. Diagnostic imaging does not a allow safe differentiation between Hodgkin's and non-Hodgkin's lymphoma. One section deals with the clinical value and diagnostic workup of incidentally detected lesions. Simple cysts and calcifications need neither clarification nor a follow-up examination. Atypical cysts should be controlled within 3-6 months. Additional clarification using CT or MRT should be reserved for cases with a strong suspicion of clinically relevant primary or secondary splenic disease.

Characterisation of the signalment, clinical and survival characteristics of 41 cats with mast cell neoplasia

Mast cell tumours (MCTs) are relatively common tumours of cats, and are the second most common cutaneous tumours in cats in the USA. While the primary splenic form of the disease is far less common, it is usually associated with more severe clinical signs. Signalment, clinical and survival characteristics of mast cell neoplasia were characterised in 41 cats. The most common tumour location was cutaneous/subcutaneous head and trunk. Stage 1a was the most common tumour stage at first diagnosis (n=20), followed by stage 4 (both stage 4a and stage 4b; n=10). Of 22 cats that underwent excisional biopsy, mast cell neoplasia recurred in four cats during the study period. Three of the 41 cats presented with simultaneous cutaneous and either splenic or lymph node tumours. A comparison between cats with only cutaneous tumours (n=30) and those with tumours involving the spleen or lymph nodes (n=11) showed longer survival times for the cutaneous-only group (P=0.031). Twelve of the 41 cats died of mast cell neoplasia during the study period. When a subgroup of cats with only cutaneous tumours (no lymph node or visceral involvement) were divided according to whether there were multiple (five or more) tumours (n=6) or a single tumour (n=19), cats with single tumours survived longer than those with multiple tumours (P=0.001). Solitary cutaneous feline MCTs without spread to the lymph nodes usually manifest as benign disease with a relatively protracted course. However, multiple cutaneous tumours, recurrent tumours and primary splenic disease should receive a guarded prognosis due to the relatively short median survival times associated with these forms of the disease.

A case of splenic abscess after radiofrequency ablation

Radiofrequency ablation (RFA) is an innovative technique used primarily for the palliative treatment of unresectable liver tumors. Its therapeutic indications however, have been expanded and now include various other organs and diseases. There is a paucity of data regarding technical details and complications of the use of RFA in the spleen. We report a case of partial splenectomy using radiofrequency ablation for splenic hydatid disease, complicated by an abscess formation.

Low-Grade B-Cell Lymphomas With Plasmacytic Differentiation Lack PAX5 Gene Rearrangements

The chromosomal translocation t(9;14)(p13;q32) has been reported in association with lymphoplasmacytic lymphoma (LPL). Although this translocation involving the paired homeobox-5 (PAX5) gene at chromosome band 9p13 and the immunoglobulin heavy chain (IgH) gene at 14q32 has been described in approximately 50% of LPL cases, the actual number of cases studied is quite small. Many of the initial cases associated with t(9;14)(p13;q32) were actually low-grade B-cell lymphomas with plasmacytic differentiation other than LPL. Thus, we analyzed a series of low-grade B-cell lymphomas for PAX5 gene rearrangements. We searched records from the Department of Pathology, Stanford University Medical Center for low-grade B-cell lymphomas, with an emphasis on plasmacytic differentiation, that had available paraffin blocks or frozen tissue. We identified 37 cases, including 13 LPL, 18 marginal zone lymphomas (nodal, extranodal, splenic, and alpha-heavy chain disease), and 6 small lymphocytic lymphomas. A novel dual-color break-apart bacterial artificial chromosome probe was designed to flank the PAX5 gene, spanning previously described PAX5 breakpoints, and samples were analyzed by interphase fluorescence in situ hybridization. All cases failed to demonstrate a PAX5 translocation, indicating that t(9;14)(p13;q32) and other PAX5 translocations are uncommon events in low-grade B-cell lymphomas with plasmacytic differentiation. This study also confirms recent reports that found an absence of PAX5 rearrangements in LPL, suggesting the reassessment of PAX5 rearrangements in LPL.

Ultrasonography of the spleen in 50 healthy cows

This paper describes the ultrasonographic appearance, location and size of the spleen in 50 healthy commercial milk cows destined for slaughter. The intercostal spaces of the left thoracic wall were scanned with a 3.5 MHz linear transducer. In each intercostal space, the appearance of the splenic parenchyma, the dorsal and ventral margins and the distance between them, and the diameter of the splenic vessels were recorded. The spleen was seen in intercostal spaces 7–12. It was 2.0–5.0 cm thick, and tapered ventrally. The splenic capsule appeared as an echogenic line. The splenic parenchyma consisted of numerous small regularly spaced echoes, and vessels within the parenchyma appeared as anechoic round to oval or elongated images. The long axis was oblique, running caudodorsal to cranioventral. The distance from the dorsal margin of the spleen to the midline of the back was greatest in the 7th intercostal space (60.9 ± 6.81) and smallest in the 12th intercostal space (12.7 ± 2.85 cm). The extent of the spleen was greatest in the 8th intercostal space (24.9 ± 10.77 cm) and smallest in the 12th intercostal space (9.5 ± 5.38 cm). The mean diameter of the splenic vessels ranged from 0.66 ± 0.28 to 0.90 ± 0.65 cm, depending on the intercostal space scanned. Ultrasonography of the spleen in healthy cows provides information that can be used as a reference when examining cattle with suspected splenic disease.

Use of an Ultrasonically Activated Scalpel for Splenectomy in 10 Dogs with Naturally Occurring Splenic Disease

To evaluate the safety and efficacy of an ultrasonically activated scalpel for performing splenectomy, with minimal ligation, in dogs. Prospective clinical study. Dogs (10) with naturally occurring splenic disease. Between October 2003 and February 2004, splenectomy was performed using an ultrasonically activated scalpel and a double seal method, in 10 dogs with naturally occurring splenic disease. Time for splenectomy and number of ligatures required were recorded. Intraoperative hemostasis, device ease of use, postoperative hemorrhage, and short-term survival were evaluated. Mean operative time for splenectomy, exclusive of celiotomy and closure, was 18 minutes (range, 8-25 minutes). The mean number of ligatures needed to perform splenectomy was 1 (range, 0-2 ligatures). One dog hemorrhaged from the splenic vein after ultrasonic scalpel transection of a vessel >5-mm diameter and required a ligature. The ultrasonic scalpel was easy to use, with a minimal learning curve. None of the dogs had postoperative abdominal hemorrhage; 9 dogs were discharged and 1 dog was euthanatized because of septicemia. Ultrasonic activated scalpel may be used to achieve efficient and safe hemostasis of the splenic vascular pedicle in dogs with minimal need for vascular ligation. Ultrasonic scalpels can be used to perform splenectomy in dogs with naturally occurring splenic disease.

Efficacy and Late Effects of Stanford V Chemotherapy and Radiotherapy in Untreated Hodgkin's Disease: Mature Data in Early and Advanced Stage Patients.

From 5/89 to 5/01, 256 patients (pts) with classical Hodgkin's disease were treated on prospective trials with the weekly Stanford V (doxorubicin, vinblastine, mustard, vincristine, bleomycin, etoposide, prednisone) regimen +/− radiotherapy (RT). Pts with non-bulky stage I-IIA disease received 8 weeks Stanford V + 30 Gy involved field RT (G4 protocol, n=87) at Stanford (n=52) or Northern California Kaiser Permanente (n=35). Pts with bulky stage II (mediastinal mass > 1/3 intrathoracic diameter) or III,IV disease received 12 weeks Stanford V + 36 Gy to sites >=5 cm or macroscopic splenic disease (G2,3 protocol, n =169) at Stanford University. Bulky mediastinal pts received mediastinal, hilar and bilateral supraclavicular RT but no axillary or high neck RT to sites <5 cm. Chemotherapy was supported as needed by G-CSF to maintain dose intensity after the first dose reduction (absolute neutrophil count [ANC] < 1000/mm3) or treatment delay (ANC < 500/mm3). The median age was 29 years (range 16–60) and 134 pts were male. Two pts did not complete treatment: 1 due to sclerosing cholangitis not appreciated at diagnosis and 1 due to hyponatremia plus gastrointestinal toxicity. No cases of clinical bleomycin toxicity or radiation pneumonitis were observed. Major acute toxicities were grade 3–4 neutropenia and constipation. With a median follow-up of 5.7 years for early stage and 6.9 years for advanced stage pts, the outcome and late effects data are detailed in the table below. Among 24 pts with disease progression (4 with early stage and 20 {8 with international prognostic score >=4} with advanced stage disease, 16 (67%) were successfully treated with second-line therapy. Eleven pts have died: 6 from Hodgkin's disease and 1 each from suicide, complications of second-line transplantation, influenza, lung cancer, and unknown cause. No cases of secondary myelodysplasia/leukemia or non-Hodgkin's lymphoma have occurred. Second cancers included 1 prostate (no pelvic RT), 1 colon ( no abdominal RT but TBI used with second-line transplant), 1 lung (no RT) and 2 breast (1 with DCIS after mediastinal RT, 1 after axillary RT for >10 cm mass). To date, 72 post-treament conceptions (excluding pre-treament semen or embryo cryopreservation) were recorded with 65 live births (+ 4 current pregnancies) among 34 men and 30 women. In our hands, the Stanford V + RT regimen was effective with modest toxicity and 25% pts conceived post-treatment. An international score >=4 was the major adverse prognostic factor; the majority of relapses were successfully treated secondarily. These data support definitive testing of this treatment program as in the ongoing E2496 Intergroup Study for bulky and advanced stage disease.Efficacy and Late EffectsAll patientsFavorable I, IIBulky I, IIIII. IVn=256n=87n=61n=108FFP / 4 yr91% [87–95]*96% [92–100]92% [85–98]86% [79–93]FFP / 8 yr91% [91–94]96% [92–100]92% [85–98]86% [79–93]FFP / 12 yr89% [84–94]NA92% [85–98]83% [75–92]OS / 4 yr97% [94–99]98% [94–100]98% [93–100]95% [91–99]OS / 8 yr95% [92–98]98% [94–100]92% [82–100]95% [91–99]OS / 12 yr95% [92–98]NA92% [82–100]95% [91–99]AML/MDS0000Solid tumor5203*[95% confidence intervals]

The influence of splenic metastases on survival in FIGO stage IIIC epithelial ovarian cancer

The purposes of this study were to compare the survival of ovarian cancer patients with splenic metastasis to patients without it and to evaluate the complications of the procedure.A retrospective study was performed on 34 patients with ovarian cancer who underwent splenectomy for initial cytoreduction at gynecologic oncology unit of Hacettepe University Hospitals between 1989 and 2001. All patients had FIGO stage IIIC disease and were left with &lt;1 cm residual tumor after surgery. Eighteen patients (52.9%) had splenic metastasis. Patients with splenic metastasis tended poorer survival. Median survivals were 28.9 and 41.3 months for patients with splenic disease and for patients without it, respectively (P &gt; 0.05). Univariate analysis revealed that performance status and histologic type influenced survival. Histologic type and performance status were identified as independent risk factors by multivariate analysis. Postoperative complications were developed in ten (29.4%) patients and three of these (8.8%) died in 1 month after operation. None of the complications was attributed directly to the splenectomy procedure.Complete surgical cytoreduction confers a survival benefit whether the parenchyma was involved or not. The splenectomy should be considered with its acceptable morbidity in selected patients who have a chance to achieve optimal debulking.

The influence of splenic metastases on survival in FIGO stage IIIC epithelial ovarian cancer.

The purposes of this study were to compare the survival of ovarian cancer patients with splenic metastasis to patients without it and to evaluate the complications of the procedure. A retrospective study was performed on 34 patients with ovarian cancer who underwent splenectomy for initial cytoreduction at gynecologic oncology unit of Hacettepe University Hospitals between 1989 and 2001. All patients had FIGO stage IIIC disease and were left with <1 cm residual tumor after surgery. Eighteen patients (52.9%) had splenic metastasis. Patients with splenic metastasis tended poorer survival. Median survivals were 28.9 and 41.3 months for patients with splenic disease and for patients without it, respectively (P > 0.05). Univariate analysis revealed that performance status and histologic type influenced survival. Histologic type and performance status were identified as independent risk factors by multivariate analysis. Postoperative complications were developed in ten (29.4%) patients and three of these (8.8%) died in 1 month after operation. None of the complications was attributed directly to the splenectomy procedure. Complete surgical cytoreduction confers a survival benefit whether the parenchyma was involved or not. The splenectomy should be considered with its acceptable morbidity in selected patients who have a chance to achieve optimal debulking.

FDG-PET is Superior to Gallium Scintigraphy in Staging and More Sensitive in the Follow-up of Patients with de novo Hodgkin Lymphoma: A Blinded Comparison

Accurate staging of Hodgkin lymphoma (HD) allows for minimization of therapy and reduction of long-term toxicities. The present study prospectively compares FDG-PET with gallium/SPECT scintigraphy at time of diagnosis and in follow-up of 36 patients with HD. Prior to therapy, whole body FDG-PET and gallium/SPECT were performed. Follow-up scans were obtained after 3 cycles of chemotherapy (n = 22), and at the end of chemotherapy (n = 32). Two nuclear medicine physicians independently interpreted scans in blinded and random order and a consensus was obtained. Baseline scans revealed a greater number of supradiaphragmatic disease sites detected by PET, and 5 patients had splenic involvement on PET not noted by gallium (P = 0.05); 3 patients were upstaged on PET. Midway through therapy, 5 patients had positive PET (4 of whom relapsed), and 3 had positive gallium (1 relapsed). At conclusion of chemotherapy, 8 patients had a positive PET (4 relapsed) and 3 had a positive gallium (2 relapsed). In conclusion, diagnostic PET and gallium are largely concordant, with the exception of unique detection of splenic disease by PET. However, more patients have persistently positive PET at the end of chemotherapy compared with gallium (P = 0.04), although only half of these patients have relapsed.

Current treatment of follicular non-Hodgkin's lymphoma

56 200 new cases of NHL are expected to be diagnosed in the United States (US) per year. For reasons that are not fully understood, the number of new cases per year has nearly doubled in the past three decades. Most patients with follicular lymphoma are over 50 years of age and present with widespread disease at diagnosis. Nodal involvement is very common, often accompanied by splenic and bone marrow disease. Despite the advanced stage, the median survival ranges from 8 to 12 years. The vast majority of patients with advanced stage follicular lymphoma are not cured using the current therapeutic options. The rate of relapse is fairly consistent over time, even in patients who have achieved complete responses (CRs) to treatment. Therapeutic options in follicular NHL include watchful waiting, oral alkylating agents, purine nucleoside analogues, combination chemotherapy, interferon and monoclonal antibodies. Radiolabelled monoclonal antibodies, autologous or allogeneic bone marrow or peripheral stem cell transplantation are under current clinical evaluation. The approval of rituximab, an unconjugated chimeric antibody against the CD20 antigen for the treatment of relapsed follicular B-cell NHL marked a milestone in the development of antibody treatment. In addition, newer approaches like radioimmunoconjugates with myeloablative activity induced response rates of 80–100% in heavily pretreated patients. Various clinical trials combining monoclonal antibodies with conventional therapies are currently ongoing to determine whether these new biological agents will alter the natural history of follicular lymphoma.

Stanford V and Radiotherapy for Locally Extensive and Advanced Hodgkin's Disease: Mature Results of a Prospective Clinical Trial

PURPOSE: To provide more mature data on the efficacy and complications of a brief, dose-intense chemotherapy regimen plus radiation therapy (RT) to bulky disease sites for locally extensive and advanced-stage Hodgkin’s disease. PATIENTS AND METHODS: One hundred forty-two patients with stage III or IV or locally extensive mediastinal stage I or II Hodgkin’s disease received Stanford V chemotherapy for 12 weeks followed by 36-Gy RT to initial sites of bulky (≥ 5 cm) or macroscopic splenic disease. Freedom from progression (FFP), overall survival (OS), and freedom from second relapse (FF2R) were determined using life-table estimates. Outcomes were analyzed according to the international prognostic score. Late effects of treatment were recorded in follow-up. RESULTS: With a median follow-up of 5.4 years, the 5-year FFP was 89% and the OS was 96%. No patient progressed during treatment, and there were no treatment-related deaths. FFP was significantly superior among patients with a prognostic score of 0 to 2 c...

Minimally Invasive Surgery

In 1987, Mouret performed the first laparoscopic cholecystectomy - dramatically changing the history of surgical practice. No other aspect of surgery has developed with such vigor as laparoscopy. Previously, surgeons had attempted to define the maximum level of surgical intervention a patient could withstand - but as laparoscopic surgery developed, this paradigm was turned on its head. Minimally invasive surgeons are continuing to determine and redefine how much can be accomplished through smaller incisions and with minimal surgical stress. Laparoscopy is still only in its infancy. This article reviews current aspects of laparoscopic surgery in 1999-2000 in relation to gallbladder, gastric, colorectal, and splenic disease, as well as reviewing the current role of laparoscopic surgery in the treatment of abdominal wall hernias.

Factors of failure for nonoperative management of blunt liver and splenic injuries.

A review of the literature describing the management of hepatic and splenic injuries indicates that as many as 67% of exploratory celiotomies for blunt trauma are reported as nontherapeutic. Avoiding unnecessary surgery through nonoperative management offers an attractive alternative. Nonetheless, nonoperative management should not be considered unless the patient meets the following criteria: (1) hemodynamic stability, with or without minimal fluid resuscitation; (2) no demonstrable peritoneal signs on abdominal examination; and (3) the absence on computed tomography (CT) scan of any intraperitoneal or retroperitoneal injuries that require operative intervention. Although a patient may meet these criteria, several additional factors can serve as predictors of failure of nonoperative management. Such predictors among patients with hepatic injuries are hemodynamic instability, liver injury of American Association for the Surgery of Trauma grades IV and V (especially when accompanied by hemodynamic instability), and pooling of contrast on CT scan. Formerly thought to be a predictor of failure of nonoperative management, periportal tracking has not been cited as such in recent reports of hepatic injuries. Among patients with blunt splenic injuries, such predictors include hemodynamic instability, injury of grade IV or higher, large associated hemoperitoneum, and contrast blush on CT scan. Although preexisting splenic disease and age older than 55 years have traditionally been considered predictors of failure, recent reports have shown that these characteristics do not appear to be associated with an increased need for surgical intervention.