Incidental splenic lesion (an approach)

Last revised by Dr Jeremy Jones on 02 Nov 2015

The majority of splenic lesions are benign and when an incidental splenic lesion is found in an asymptomatic patient, it may pose a dilemma in workup because imaging findings are often nonspecific.

  • benign imaging features: no follow up
    • imperceptible wall
    • well-marginated
    • homogeneous
    • <10-20 HU
    • does not enhance after contrast
    • splenic hemangioma does not typically demonstrate peripheral nodular discontinuous enhancement
  • not definitely benign features
    • prior imaging
      • unchanged over one year: no follow up
      • changed over the past year: MRI, PET, or biopsy follow up
    • no prior imaging
      • history of cancer
        • <1 cm: follow up MRI in 6 and 12 months
        • ≥1 cm: MRI, PET, or biopsy follow up
      • no history of cancer
        • indeterminate features: follow up MRI in 6 and 12 months
          • smooth margins
          • enhancement after contrast
          • >20 HU
          • heterogeneous
        • suspicious features: MRI, PET, or biopsy follow up
          • marked enlargement
          • splenic or vascular invasion
          • necrosis
          • irregular margins
          • enhancement after contrast
          • heterogeneous

Practical points

  • even with a known malignancy, an incidental lesion <1 cm is thought to most likely represent a benign finding, although this is extrapolated from incidental hepatic lesion data
  • primary splenic lymphoma is uncommon, look for other enlarged nodes before suggesting splenic lymphoma as a diagnosis
  • splenic hemangiomas do not tend to enhance in a similar way to hepatic hemangiomas (peripheral nodular discontinuous enhancement) 2
  • primary malignancy of the spleen is rare

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