Incidental splenic lesion (an approach)

Last revised by Jeremy Jones on 2 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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