Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

General Assessment

The manuscript summarizes the imaging findings of common and rare splenic lesions. Since most splenic lesions are detected incidentally and may occasionally pose diagnostic challenges in differentiating benign from malignant entities, the topic is radiologically relevant. The inclusion of ultrasonography, CT, MRI, and, in some cases, PET/CT images is valuable.

However, in its current form, the manuscript requires revision before it can be considered for publication. My comments are provided below.

Major Comments

The manuscript lacks a clear diagnostic algorithm for splenic lesions. A structured algorithm should be added based on whether the lesion is cystic or solid, solitary or multiple, its enhancement pattern, the presence of diffusion restriction, the patient’s history of malignancy, and the presence of systemic symptoms.

A summary table should also be included. The educational value of the manuscript would be significantly improved if, for each lesion, the typical age group, clinical context, ultrasonographic findings, CT findings, MRI findings, enhancement pattern, diffusion characteristics, and key differential diagnoses were presented in tabular form.

There are numerous spelling and language errors throughout the text. For example, expressions such as “furious trabeculae,” “gallodium contrast,” “T2 hypersensitivity,” and “metastatic rumors” should be corrected. In addition, several sentences are grammatically problematic, and the manuscript requires professional language editing for academic English.

The figure legends should be carefully reviewed, as there are obvious errors. For instance, the phrase “incidental enlarging causing pain” in the legend of Figure 6 is grammatically incorrect. In Figure 11, the term “Noninfectious microabscess” is used, although the relevant section is titled “abscess/microabscess.” This terminology should be clarified.

 

Minor Comments

The list of abbreviations should be reviewed. For “PET,” the correct expansion is “Positron Emission Tomography,” not “Positron Emitted Tomography.”

The terminology for contrast phases and MRI sequences should be used appropriately and consistently. Standardization is needed for terms such as arterial phase, portal venous phase, delayed phase, T1-weighted, T2-weighted, fat-suppressed, and diffusion-weighted imaging.

Some statements are written in an overly definitive manner. Since imaging findings of splenic lesions frequently overlap, more cautious terms such as “suggestive” or “highly suggestive” should be preferred instead of “specific” in many instances.

The manuscript would be strengthened by adding more up-to-date references on contrast-enhanced ultrasonography, diffusion-weighted MRI, and the current management of incidental splenic lesions.

Comments on the Quality of English Language

Na

Author Response

Thank you for the feedback for our review article about common and uncommon splenic lesions.

Comment 1: The manuscript lacks a clear diagnostic algorithm for splenic lesions. A structured algorithm should be added based on whether the lesion is cystic or solid, solitary or multiple, its enhancement pattern, the presence of diffusion restriction, the patient’s history of malignancy, and the presence of systemic symptoms.

Response 1: Thank you for this comment. We agree there was a lack of a diagnostic algorithm hence we have added figure 11 on page 16 for an approach to diagnosing splenic lesions. Alongside this on page 16 we have added a written approach to splenic lesions based on characteristics seen here “The current management will depend on the characteristics of the splenic lesion of being either cystic or solid and solitary or multiple. Imaging will be one of the initial investigations. Depending on the characterization of the mass benign lesions would be sufficient for observation alone. If diagnosis continues to be uncertain after imaging a core needle biopsy would provide definitive diagnosis. If there is a strong suspicion for malignancy such as with angiosarcoma a splenectomy would be considered [58]”.

 

Comment 2: A summary table should also be included. The educational value of the manuscript would be significantly improved if, for each lesion, the typical age group, clinical context, ultrasonographic findings, CT findings, MRI findings, enhancement pattern, diffusion characteristics, and key differential diagnoses were presented in tabular form.

Response 2: We agree a summarized table would provide an organized tabular format. Thus on page 18-22 we have added a summary table with each lesion.

Comment 3: There are numerous spelling and language errors throughout the text. For example, expressions such as “furious trabeculae,” “gallodium contrast,” “T2 hypersensitivity,” and “metastatic rumors” should be corrected. In addition, several sentences are grammatically problematic, and the manuscript requires professional language editing for academic English.

Comment 4: The figure legends should be carefully reviewed, as there are obvious errors. For instance, the phrase “incidental enlarging causing pain” in the legend of Figure 6 is grammatically incorrect. In Figure 11, the term “Noninfectious microabscess” is used, although the relevant section is titled “abscess/microabscess.” This terminology should be clarified.

Response 3&4: We corrected all spelling and language errors noted in these comments and more so. As on page 2 paragraph 1 “or cuboidal epithelium. The cysts are filled with internal coarse fibrous trabeculae containing serous or proteinaceous fluid. The key pathologic feature is the presence of”. Page 3 paragraph 1 “This lesion does not show enhancement with contrast enhanced ultrasound [60]. With no”. Page 7 “On CT lesions are well circumscribed and have low attenuation. These lesions do not show significant enhancement following contrast administration [27].” Page 10 “hypo enhancement in the arterial and portal venous phase, with a distinctive progressive enhancement pattern known as a ‘spoke wheel’ pattern [28]. On MRI the T2 weighted images of the lesion are hypointense reflecting fibrous tissue and hemosiderin deposition, with variable T1 signal. The central scar is especially hypointense. The spoke wheel pattern appears with peripheral and septal enhancement following gadolinium contrast administration [31].” Page 11 “In summary the well-defined borders, peripheral nodular enhancement with centripetal fill in, marked T2 hyperintensity,”.

Comment 5: The list of abbreviations should be reviewed. For “PET,” the correct expansion is “Positron Emission Tomography,” not “Positron Emitted Tomography.”

Response 5: Fixed this abbreviation of page 17.

The terminology for contrast phases and MRI sequences should be used appropriately and consistently. Standardization is needed for terms such as arterial phase, portal venous phase, delayed phase, T1-weighted, T2-weighted, fat-suppressed, and diffusion-weighted imaging.

Response 6: Standiarzed approach now used throughout the article.

Some statements are written in an overly definitive manner. Since imaging findings of splenic lesions frequently overlap, more cautious terms such as “suggestive” or “highly suggestive” should be preferred instead of “specific” in many instances.

Response 7: Switched all instances of the use specific to suggestive on page 11 twice in paragraph 1 and page 19 in the conclusion.

The manuscript would be strengthened by adding more up-to-date references on contrast-enhanced ultrasonography, diffusion-weighted MRI, and the current management of incidental splenic lesions.

Response 8: Removed older references and added more up to date references with majority being recent literature now.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

This is a well written review article.

The coverage is balanced in terms of gross pathology, histopathology, clinical context and imaging features. 

Images are good.

Suggestions:

1. The lesions are listed in a random manner. Some kind of categorization would lend more structure to the manuscript. Simplest would be to group as per etiology e.g. infectious, vascular, neoplastic etc.
2. Splenic AV malformation, Gamma gandy bodies, splenic tuberculosis pose diagnostic challenge and should find mention in the manuscript.

Author Response

Thank you for taking the time read our article and for the feedback.

Comment 1: The lesions are listed in a random manner. Some kind of categorization would lend more structure to the manuscript. Simplest would be to group as per etiology e.g. infectious, vascular, neoplastic etc.

Response 1: The lesions were reorganized in manner of presentation throughout the article by cystic vs fluid, solitary vs multiple, and vascularity.

Splenic AV malformation, Gamma gandy bodies, splenic tuberculosis pose diagnostic challenge and should find mention in the manuscript.

 

Response 2: This is a good point but after further discussion as a team we have a variety of common and uncommon lesions and the associated diagnostic uncertainty is discussed in the conclusion. There are multiple other lesions that could be discussed but a comprehensive approach to emphasize the diagnostic challenge has already been emphasized.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Manuscript ID: Diagnostics-4344941

Type of manuscript: Review

Title: Common and Uncommon Splenic Lesions: A Review

Authors: Rajvir Teja, Evan Allarie, and Christopher Fung

 

Strengths

• Well-structured manuscript.
• Comprehensive overview of common and uncommon splenic lesions.
• Illustrative imaging examples.
• Extensive reference list.

 

The manuscript addresses a relevant topic and is easy to read. However, in its current form it primarily summarizes established knowledge and lacks sufficient critical analysis, methodological transparency, and practical guidance for clinical decision-making. The authors should clearly define the novelty of the review, provide a search methodology, strengthen the discussion of ultrasound and CEUS, include diagnostic performance data, and develop practical diagnostic algorithms and summary tables.

 

General Comments

Focal splenic lesions are relatively uncommon and often represent a significant diagnostic challenge, particularly when detected incidentally. Therefore, the topic of this review is clinically relevant and of interest to a broad readership. The manuscript is well organized, easy to read, and supported by a comprehensive set of illustrative images.

 

However, several review articles addressing the diagnosis and differential diagnosis of focal splenic lesions have already been published in recent years, including papers in Diagnostics itself. The authors should clearly define the novelty of the present review and explain how it advances existing knowledge or differs from previously published reviews.

 

In its current form, the manuscript is primarily a narrative overview and resembles a textbook chapter rather than a critical, evidence-based review. The article systematically describes common and uncommon splenic lesions, including epidemiology, pathology, and imaging findings, with emphasis on CT and MRI. While this information is useful, the scientific analysis remains limited, and the review does not sufficiently address diagnostic performance, current controversies, or practical clinical decision-making.

 

A literature search strategy is not provided. Even for a narrative review, the authors should describe the databases searched, search terms used, and the time period covered to improve transparency and reproducibility.

 

Major Comments

1. Novelty and scientific contribution: The authors should clearly explain what distinguishes this review from previously published reviews on focal splenic lesions. At present, the manuscript largely summarizes established knowledge without providing a novel perspective, updated evidence synthesis, or practical diagnostic framework.
2. Insufficient evidence-based analysis: The review primarily lists imaging characteristics of individual lesions but provides limited discussion of diagnostic accuracy, strengths, weaknesses, and limitations of the various imaging modalities. Whenever available, data regarding sensitivity, specificity, predictive values, and diagnostic performance should be included.
3. Limited discussion of ultrasound: Since focal splenic lesions are frequently first detected by ultrasound, sonographic findings deserve a more detailed discussion. In addition, contrast-enhanced ultrasound (CEUS) is not addressed despite its increasing role in the characterization of focal splenic lesions and its inclusion in international recommendations. A dedicated section on CEUS would substantially improve the manuscript.
4. Lack of diagnostic algorithms: The review would benefit greatly from a practical diagnostic algorithm. The reader is left without guidance regarding the recommended diagnostic pathway when an incidental splenic lesion is identified. A structured approach incorporating ultrasound, CEUS, CT, MRI, PET/CT, and biopsy would enhance the clinical utility of the article.
5. Benign versus malignant lesions: One of the most important clinical questions is how to distinguish benign from malignant splenic lesions. The manuscript should provide a dedicated discussion of imaging criteria suggestive of malignancy, including lesion morphology, enhancement patterns, diffusion restriction, multiplicity, associated lymphadenopathy, and clinical context.
6. Histological confirmation and biopsy: Although biopsy is mentioned in the conclusion, its role is not adequately discussed. A section addressing image-guided biopsy, indications, diagnostic yield, limitations, safety considerations, and histopathological confirmation would be valuable.

 

Minor Comments

1. A summary table comparing the key imaging features of the various lesions across ultrasound, CEUS, CT, and MRI would significantly improve readability.
2. The challenges and pitfalls associated with the diagnosis of individual lesions should be discussed in greater detail. In particular, the overlap between imaging findings and important differential diagnoses deserves further attention.
3. References should be checked carefully, as there appear to be inconsistencies in the reference list.
4. The manuscript should undergo careful language editing, as several grammatical and typographical issues remain.

 

 

Comments on the Quality of English Language

NA

Author Response

Thank you for the feedback to allow us to improve our article.

 

Comment 1: Novelty and scientific contribution: The authors should clearly explain what distinguishes this review from previously published reviews on focal splenic lesions. At present, the manuscript largely summarizes established knowledge without providing a novel perspective, updated evidence synthesis, or practical diagnostic framework.

 

Response 1: We have created figure 11 on page 19 and discussed in the conclusion an algorithmic approach to splenic lesions that allows for further management. Furthermore, we have created a summarized table on page 21 that focuses on an organized approach to classifying splenic lesions. Both of which are lacking in existing literature. Furthermore for each lesion we have discussed the relevance of contrast enhanced ultrasound.

Comment 2: Insufficient evidence-based analysis: The review primarily lists imaging characteristics of individual lesions but provides limited discussion of diagnostic accuracy, strengths, weaknesses, and limitations of the various imaging modalities. Whenever available, data regarding sensitivity, specificity, predictive values, and diagnostic performance should be included.

 

Response 2: Diagnostic accuracy of various imaging modalities and the difficulties associated for  diagnosis has been added to the conclusion on page 19 noted by “ PET scans of splenic lesions demonstrate the highest diagnostic accuracy with sensitivity of 93% and specificity of 82.8%. Contrast enhanced ultrasound, contrast enhanced CT, and contrast enhanced MRI also demonstrate high diagnostic accuracy [57]. The current management will depend on the characteristics of the splenic lesion of being either cystic or solid and solitary or multiple. Imaging will be one of the initial investigations. Depending on the characterization of the mass benign lesions would be sufficient for observation alone. If diagnosis continues to be uncertain after imaging a core needle biopsy would provide definitive diagnosis”

 

Comment 3: Limited discussion of ultrasound: Since focal splenic lesions are frequently first detected by ultrasound, sonographic findings deserve a more detailed discussion. In addition, contrast-enhanced ultrasound (CEUS) is not addressed despite its increasing role in the characterization of focal splenic lesions and its inclusion in international recommendations. A dedicated section on CEUS would substantially improve the manuscript.

 

Response 3: We had a discussion of contrast enhanced ultrasound to each splenic lesion along side with a discussion of the diagnostic accuracy compared to other imaging modalities in the conclusion here “Contrast enhanced ultrasound, contrast enhanced CT, and contrast enhanced MRI also demonstrate high diagnostic accuracy”

 

Comment 4: Lack of diagnostic algorithms: The review would benefit greatly from a practical diagnostic algorithm. The reader is left without guidance regarding the recommended diagnostic pathway when an incidental splenic lesion is identified. A structured approach incorporating ultrasound, CEUS, CT, MRI, PET/CT, and biopsy would enhance the clinical utility of the article.

 

Response 4: we have added figure 11 on page 16 for an approach to diagnosing splenic lesions. Alongside this on page 16 we have added a written approach to splenic lesions based on characteristics seen here “The current management will depend on the characteristics of the splenic lesion of being either cystic or solid and solitary or multiple. Imaging will be one of the initial investigations. Depending on the characterization of the mass benign lesions would be sufficient for observation alone. If diagnosis continues to be uncertain after imaging a core needle biopsy would provide definitive diagnosis. If there is a strong suspicion for malignancy such as with angiosarcoma a splenectomy would be considered [58]”.

 

Comment 5: Benign versus malignant lesions: One of the most important clinical questions is how to distinguish benign from malignant splenic lesions. The manuscript should provide a dedicated discussion of imaging criteria suggestive of malignancy, including lesion morphology, enhancement patterns, diffusion restriction, multiplicity, associated lymphadenopathy, and clinical context.

 

Response 5: Response 2: We have created summarized table distinguishes the splenic lesions based on benign and malignant . Thus on page 18-22 we have added a summary table with each lesion.

 

Comment 6: A summary table comparing the key imaging features of the various lesions across ultrasound, CEUS, CT, and MRI would significantly improve readability.

 

Response 6: Summary table as mentioned above ages 18—22/

 

The challenges and pitfalls associated with the diagnosis of individual lesions should be discussed in greater detail. In particular, the overlap between imaging findings and important differential diagnoses deserves further attention.

 

Response 6: Discussed further in conclusion and with figure 11.

 

References should be checked carefully, as there appear to be inconsistencies in the reference list.

 

Response 7: references are organized an relevant to literature now.

 

The manuscript should undergo careful language editing, as several grammatical and typographical issues remain.

 

Response 8: through grammatical changes made.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

All revisions have been made accordingly, and I have no further comments. Congratulations on your work.

Author Response

Comments 1: All revisions have been made accordingly, and I have no further comments. Congratulations on your work.

Reply 1: Thank you!

Reviewer 2 Report

Comments and Suggestions for Authors

Revised manuscript does not contain the suggested changes. 

As a result, there seems to be undue emphasis on rare entities while common ones are missing altogether. 

The algorithm advises CEUS, which is not illustrated in the figures anywhere.

Author Response

Comments 1: Revised manuscript does not contain the suggested changes. As a result, there seems to be undue emphasis on rare entities while common ones are missing altogether. 

Response 1: We respectfully disagree.  Common entities such as epithelial cysts, pseudocysts, hemangiomas, and hamartomas are all included in the current manuscript. We suspect that the reviewer may have been evaluating the previous submission rather than the most recent one.

Comments 2: The algorithm advises CEUS, which is not illustrated in the figures anywhere.

Response 2: We agree that figures with CEUS would be ideal, however these were not available at our institution.  This specific addition to the manuscript was made as part of the prior feedback to include more recent references, some of which include CEUS in the evaluation for splenic lesions. 

Reviewer 3 Report

Comments and Suggestions for Authors

Despite the improvements ultrasound and CEUS remains underrepresented. This is still the principal weakness, particularly for a journal such as Diagnostics. The manuscript is largely a CT/MRI review with relatively brief ultrasound descriptions. Important ultrasound features are often summarized in only one or two sentences, whereas CT and MRI receive much more detailed discussion.

Lack of a dedicated differential diagnosis section.

The manuscript still contains numerous small grammatical issues, for example: uniocular, several repetitive sentences, occasional awkward wording.

Comments on the Quality of English Language

NA

Author Response

Comment 1: Despite the improvements ultrasound and CEUS remains underrepresented. This is still the principal weakness, particularly for a journal such as Diagnostics. The manuscript is largely a CT/MRI review with relatively brief ultrasound descriptions. Important ultrasound features are often summarized in only one or two sentences, whereas CT and MRI receive much more detailed discussion.

Response 1: Ultrasound of splenic lesions is represented in several figures, including 

Lack of a dedicated differential diagnosis section.

Comment 3: The manuscript still contains numerous small grammatical issues, for example: uniocular, several repetitive sentences, occasional awkward wording.

Response 3: Thank you for drawing attention to these concerns. We agree, and have reviewed and corrected the entire publication for clarity.  This included removing the references to immunohistochemistry, clarifying findings for various modalities, and combining several sentences across the various cases. 

Author Response File: Author Response.docx