Management of splenic incidentalomas, a new evidence-based algorithm

•Lesions with typical imaging or criteria of benignity do not require follow-up.•A splenic cyst could require parasitological consultation and serology.•In cases of non-typical imaging and no previous imaging, history is essential.•Non-typical imaging with no benign features should benefit from a PET-CT.•Biopsy has a place in the diagnosis; it does not entail over complication. Incidental splenic lesions are common in daily practice and managing them presents challenges. There are no typical imaging features for splenic lesions and the non-invasive diagnosis includes clinical, radiological, and biological evaluation. Most studies published to date propose non-invasive diagnosis algorithms based on imaging features, but often with insufficient specificity. The aim of the present article is to propose an algorithm adapted to the management of all splenic incidentalomas, leading to a final and accurate diagnosis. The management of splenic incidentaloma should be based on a multimodal approach including benign imaging features, nuclear medicine, follow-up, and biopsy.