Incidental Splenic Lesions: A Proposed Algorithm for Assessment and Management

Although incidental splenic lesions are typically benign, they present a diagnostic challenge in that they lack specific imaging features and rarely receive pathologic confirmation. Whereas CT can suggest a diagnosis, abdominal MRI provides superior characterization using standard pulse sequences, dynamic contrast enhancement, and DWI sequences. In most cases, establishing the indolent nature of a lesion is more important than determining an exact diagnosis. Building on the American College of Radiology’s white paper on incidental findings, this Pictorial Essay focuses on lesions 1 cm or larger that are encountered on abdominal CT without a known history of malignancy and proposes a simple classification algorithm for management. We group incidental splenic lesions into four categories, ranging from definitively benign to likely malignant, with follow-up or intervention recommendations based on malignancy risk. This clinically based classification system offers clearer guidance on managing incidental splenic lesions and assists the radiologist in suggesting appropriate management strategies.