What is the management approach for a splenic mass?

Management Approach for Splenic Mass

The management of a splenic mass should begin with contrast-enhanced CT scan as the gold standard for evaluation, followed by a systematic approach based on imaging characteristics to determine the appropriate treatment strategy, which may include observation, non-operative management, angioembolization, or surgical intervention depending on the patient's hemodynamic stability and the nature of the lesion. 1, 2

Diagnostic Evaluation

• Contrast-enhanced CT is the gold standard for evaluating splenic masses, providing detailed information about pattern, distribution, and associated abnormalities 1
• Doppler ultrasound and contrast-enhanced ultrasound are useful adjuncts to evaluate splenic vascularization and can be used for follow-up 1
• The diagnostic approach should be based on imaging characteristics including:
  • Number of lesions (solitary vs. multiple)
  • Consistency (cystic vs. solid)
  • Enhancement patterns
  • Presence of calcifications 2, 3

Management Algorithm Based on Clinical Presentation

For Incidental Asymptomatic Splenic Masses:

• For stable patients with incidental findings of splenic calcification or masses, clinical observation with serial examinations is appropriate if the patient is asymptomatic 1
• Further management depends on imaging characteristics:
  • Benign-appearing lesions (simple cysts, hemangiomas with typical enhancement) can be managed conservatively with follow-up imaging 2, 3
  • Indeterminate or potentially malignant lesions require further evaluation, which may include MRI or image-guided biopsy 3

For Traumatic Splenic Masses/Injuries:

• Non-operative management (NOM) is recommended as first-line treatment for hemodynamically stable patients with blunt splenic trauma, regardless of injury grade 4
• NOM should only be attempted in facilities with capability for continuous patient monitoring, angiography, trained surgeons, immediately available operating room, and immediate access to blood products 4
• Consider angiography/angioembolization (AG/AE) for patients with contrast blush on CT scan, though this finding alone is not an absolute indication for intervention in stable patients 4, 5
• Operative management should be performed when:
  • Patient is hemodynamically unstable despite resuscitation
  • NOM fails with significant drop in hematocrit or continuous transfusion requirements
  • Peritonitis or other indications for laparotomy are present 4, 5

Special Considerations for Different Types of Splenic Masses

• For calcifications related to prior splenic trauma, assess hemodynamic stability and consider non-operative management if stable 1
• For calcifications or masses associated with infectious or inflammatory conditions, treat the underlying cause with appropriate antimicrobial therapy 1
• For malignant-appearing lesions or when diagnosis remains uncertain after imaging:
  • Image-guided biopsy should be preferred over splenectomy when possible 3
  • Splenectomy may be necessary for definitive diagnosis, with studies showing high diagnostic yield (95% of cases) for unexplained splenomegaly or splenic mass 6

Follow-up Recommendations

• For low-grade splenic injuries or benign lesions, routine post-discharge follow-up imaging may not be necessary 1
• For moderate to severe injuries, consider CT follow-up before discharge 1
• In patients with underlying splenic pathology, coagulopathy, or neurological impairment, post-discharge CT follow-up should be considered 1
• Activity restriction may be advised for 2-6 weeks for minor injuries and up to 2-4 months for moderate and severe injuries 1

Complications and Precautions

• Perioperative mortality of splenectomy ranges from 5-10%, with complications occurring in approximately 50% of patients 1
• Patients undergoing non-operative management should be counseled about warning signs and advised not to remain alone during the first weeks after discharge 1
• Patients with splenomegaly should refrain from participating in contact sports to decrease risk of rupture 7
• Any patient with limited splenic function requires increased vaccination and prophylactic antibiotics for procedures involving the respiratory tract 7