CEUS of Focal Splenic Lesions: Enhancement Patterns and Differentiation of Benign and Malignant Disease

Focal splenic lesions are uncommon, and diagnostic experience with splenic imaging is substantially more limited than that with focal liver lesions. Contrast-enhanced ultrasound (CEUS) has emerged as a valuable imaging modality for the detection and differentiation of splenic lesions because it allows real-time assessment of vascularization and enhancement behavior without ionizing radiation. This narrative review summarizes the current evidence regarding CEUS findings in focal splenic lesions, with particular emphasis on the differentiation between benign and malignant lesions. Benign vascular lesions typically demonstrate arterial hyperenhancement or isoenhancement with persistent enhancement or only mild late washout, whereas malignant lesions frequently show early and progressive washout with marked hypoenhancement in the parenchymal phase. Rapid washout, particularly within the first 60 s after contrast administration, represents one of the most important imaging features associated with malignancy. Although overlap of enhancement patterns exists and standardized diagnostic criteria are still lacking, CEUS represents a valuable, radiation-free, and cost-effective imaging modality for the evaluation of focal splenic lesions. CEUS may improve diagnostic confidence, support clinical decision-making and reduce the need for additional cross-sectional imaging in selected patients.