ACR Incidental Pancreatic Cyst · Pâncreas

ACR Incidental Pancreatic Cyst management

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Management pathway for incidentally detected pancreatic cysts based on size and worrisome features.

Índice de referência, não é suporte à decisão clínica. O RadCommons apresenta conteúdo de referência reescrito a partir de critérios publicados e com link para a fonte primária. Confira sempre a publicação primária vigente. Não é um dispositivo médico nem substitui o julgamento clínico. O radiologista responsável pelo laudo permanece o autor e o responsável.

Escala de categorias

small-cyst intermediate-cyst large-cyst worrisome-features main-duct-involvement

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Procedência e vigência

Órgão emissor: American College of Radiology
Versão: 2017
Ano: 2017
Família: achado incidental
Tipo de lógica: flat
Modalidade: CT, MRI
Fonte primária: Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee · doi:10.1016/j.jacr.2017.03.010
Última verificação: 2026-07-24
Última checagem: 2026-07-24

Lógica de decisão

Forma estruturada (flat). Uma futura calculadora a lê; as categorias abaixo são a superfície legível.

Return one primary size branch plus any applicable duct or worrisome-feature flags. Preserve age, growth, MPD communication and surgical candidacy; do not turn this consensus flowchart into an automatic procedure order.

Mostrar a lógica estruturada (JSON)

{
  "applicability": {
    "use_for": "Incidentally detected pancreatic cyst in an asymptomatic adult (age >=18 years).",
    "stop_algorithm_when": [
      "jaundice",
      "anorexia_or_weight_loss",
      "palpable_mass",
      "steatorrhea",
      "relevant_abnormal_laboratory_value_such_as_elevated_amylase",
      "pain_attributable_to_the_cyst",
      "new_related_symptoms_during_surveillance"
    ],
    "surgical_candidacy_rule": "Do not pursue surveillance in a patient who is not a surgical candidate; incorporate overall health and preferences.",
    "default_histology_assumption": "Presume mucinous unless definitive imaging or aspiration establishes another histology."
  },
  "categories": [
    {
      "outcome_code": "small-cyst",
      "role": "primary_size_branch",
      "size": "<1.5_cm"
    },
    {
      "outcome_code": "intermediate-cyst",
      "role": "primary_size_branch",
      "size": "1.5_to_2.5_cm"
    },
    {
      "outcome_code": "large-cyst",
      "role": "primary_size_branch",
      "size": ">2.5_cm"
    },
    {
      "outcome_code": "worrisome-features",
      "role": "escalation_flag",
      "coexistence": "emit_alongside_the_size_branch_when_present"
    },
    {
      "outcome_code": "main-duct-involvement",
      "role": "duct_flag_and_branch_selector",
      "coexistence": "emit_alongside_the_size_branch_when_present"
    }
  ],
  "reporting_requirements": [
    "cyst_morphology_and_location",
    "single_long_axis_size_with_series_and_image_number",
    "possible_MPD_communication",
    "worrisome_features_and_high_risk_stigmata",
    "growth",
    "multiplicity_and_index_lesion"
  ],
  "growth_definition": [
    {
      "initial_size": "<5_mm",
      "significant_growth": "100_percent_increase_in_long_axis"
    },
    {
      "initial_size": ">=5_mm_and_<15_mm",
      "significant_growth": "50_percent_increase_in_long_axis"
    },
    {
      "initial_size": ">=15_mm",
      "significant_growth": "20_percent_increase_in_long_axis"
    },
    {
      "growth_rate": ">2_mm_per_year",
      "interpretation": "rapid_growth_feature"
    }
  ],
  "escalation_features": {
    "worrisome_features": [
      "cyst_>=3_cm",
      "thickened_or_enhancing_wall",
      "nonenhancing_mural_nodule",
      "MPD_>=7_mm"
    ],
    "high_risk_stigmata": [
      "obstructive_jaundice_with_cyst_in_pancreatic_head",
      "enhancing_solid_component_or_enhancing_mural_nodule",
      "MPD_>=10_mm_without_obstruction"
    ],
    "action": "EUS_with_FNA_and_surgical_consultation",
    "size_only_exception": "A cyst >=3 cm with no other worrisome feature or high-risk stigma may alternatively be followed.",
    "output_codes": [
      "worrisome-features",
      "main-duct-involvement"
    ]
  },
  "size_branches": {
    "small_cyst": {
      "outcome_code": "small-cyst",
      "size": "<1.5_cm",
      "age_<65": {
        "initial": "reimage_every_1_year_x5",
        "if_stable": "reimage_every_2_years_x2",
        "stop": "if_stable_for_minimum_9_years"
      },
      "age_65_to_79": {
        "initial": "reimage_every_2_years_x5",
        "stop": "if_stable_for_10_years"
      },
      "white_dot_<5_mm": "one_CT_or_MRI_at_2_years_then_stop_if_stable",
      "after_growth_still_<1.5_cm": "reimage_every_1_year_or_consider_EUS_FNA",
      "after_growth_>=1.5_cm": "move_to_intermediate_chart_or_EUS_FNA"
    },
    "intermediate_cyst_with_MPD_communication": {
      "outcome_codes": [
        "intermediate-cyst",
        "main-duct-involvement"
      ],
      "size": "1.5_to_2.5_cm",
      "size_1.5_to_1.9_cm": {
        "schedule": "reimage_every_1_year_x5_then_every_2_years_x2",
        "stop": "if_stable_for_9_years"
      },
      "size_2.0_to_2.5_cm": {
        "schedule": "reimage_every_6_months_x4_then_every_1_year_x2_then_every_2_years_x3",
        "stop": "if_stable_for_10_years"
      },
      "alternative_at_detection": "EUS_FNA",
      "growth_to_>2.5_cm": "EUS_FNA"
    },
    "intermediate_cyst_without_or_unknown_MPD_communication": {
      "outcome_code": "intermediate-cyst",
      "size": "1.5_to_2.5_cm",
      "imaging_path": {
        "schedule": "reimage_every_6_months_x4_then_every_1_year_x2_then_every_2_years_x3",
        "stop": "if_stable_for_10_years"
      },
      "alternative_path": "EUS_FNA_to_classify_mucinous_status_and_guide_management",
      "after_growth_still_<=2.5_cm": "reimage_every_6_months_x2_then_every_1_year_x5_then_every_2_years_or_EUS_FNA",
      "after_growth_>2.5_cm": "EUS_FNA",
      "after_EUS_FNA": {
        "SCA_cPNET_or_pseudocyst": "management_depends_on_diagnosis",
        "mucinous_or_indeterminate": "reimage_every_6_months_x4_then_every_1_year_x2_then_every_2_years_x3",
        "growth": "surgical_consultation"
      }
    },
    "large_cyst": {
      "outcome_code": "large-cyst",
      "size": ">2.5_cm",
      "SCA": "If >4 cm or symptomatic, surgical consultation for possible resection; otherwise diagnosis-specific management.",
      "low_risk_by_imaging": {
        "features": [
          "no_mural_nodule",
          "no_wall_thickening",
          "normal_caliber_MPD",
          "no_peripheral_calcification"
        ],
        "schedule": "reimage_every_6_months_x4_then_every_1_year_x2_then_every_2_years_x3",
        "stop": "if_stable_for_10_years"
      },
      "high_risk_by_imaging": {
        "features": [
          "mural_nodule",
          "wall_thickening",
          "MPD_>=7_mm",
          "peripheral_calcification"
        ],
        "action": "EUS_FNA_plus_surgical_consultation"
      },
      "alternative_at_detection": "EUS_FNA",
      "pre_resection": "EUS_FNA_is_advised_before_resection_to_reduce_unnecessary_surgery"
    },
    "age_>=80_at_presentation": {
      "principle": "Base workup on overall health, preferences and surgical candidacy.",
      "cyst_<=2.5_cm": {
        "schedule": "reimage_every_2_years_x2",
        "stop": "if_stable",
        "after_growth_still_<=2.5_cm": "reimage_every_1_year_then_stop_if_stabilized_or_no_longer_surgical_candidate",
        "after_growth_>2.5_cm": "EUS_FNA"
      },
      "cyst_>2.5_cm_low_risk": {
        "schedule": "reimage_every_2_years_x2",
        "stop": "if_stable",
        "growth": "EUS_FNA_plus_surgical_consultation"
      },
      "cyst_>2.5_cm_high_risk": "EUS_FNA_plus_surgical_consultation_if_surgical_candidate"
    }
  },
  "duct_logic": {
    "communication": "CT_with_3D_reconstructions_or_MRI_MRCP_can_establish cyst-MPD communication and a branch-duct or combined IPMN pattern.",
    "record": "Report the widest MPD diameter even when it is away from the cyst.",
    "thresholds": [
      {
        "finding": "MPD_>=7_mm",
        "outcome_code": "main-duct-involvement",
        "level": "worrisome"
      },
      {
        "finding": "MPD_>=10_mm_without_obstruction",
        "outcome_code": "main-duct-involvement",
        "level": "high_risk_stigma"
      }
    ]
  },
  "multiplicity": "Use the largest cyst as the index lesion but assess every cyst for growth, worrisome features and high-risk stigmata.",
  "follow_up_horizon": "Generally 9-10 years and stop at age 80; when a patient approaches 80, transition case-by-case to the age-80 chart rather than restarting a new surveillance clock.",
  "missing_input_behavior": [
    "Do not recommend a surveillance interval until age, exact size, symptoms, surgical candidacy and worrisome/high-risk features are known.",
    "For a 1.5-2.5 cm cyst, report whether MPD communication is present, absent or cannot be determined; do not assume it.",
    "When prior imaging is unavailable, state that growth cannot be assessed rather than labeling the cyst stable."
  ],
  "version_context": {
    "implemented_system": "ACR Incidental Findings Committee pancreatic cyst white paper, 2017",
    "current_adjacent_document": "Current ACR Appropriateness Criteria Pancreatic Cyst topic continues to cite the 2017 white paper for incidental-cyst management.",
    "rule": "Keep the 2017 flowchart version explicit and do not silently merge Fukuoka or another society's thresholds into it."
  },
  "source_locator": "Megibow et al., JACR 2017;14:911-923: Figs. 1-4 (Charts 1, 2A, 2B, 3 and 4), Table 1, pp.7-10 reporting, applicability, common principles and chart explanations. ACR Appropriateness Criteria Pancreatic Cyst reviewed for current version context."
}

Categorias num relance

Cat.	Significado	Conduta	Risco	Fonte
small-cyst	Small cyst Incidental pancreatic cyst <1.5 cm in an asymptomatic adult. Chart 1 separates age <65 from age 65-79; a T2-hyperintense 'white dot' <5 mm is a special subgroup. Worrisome features, high-risk stigmata or related symptoms supersede routine size surveillance.	For age <65, reimage yearly five times, then every 2 years twice if stable, stopping after at least 9 stable years. For age 65-79, reimage every 2 years five times and stop after 10 stable years. After significant growth while still <1.5 cm, reimage yearly or consider EUS/FNA; if size reaches >=1.5 cm, move to Chart 2 or EUS/FNA. For a <5 mm white-dot lesion, one CT or MRI at 2 years is enough to stop if stable. Surveillance generally ends at age 80.	Most small presumed mucinous cysts are expected to be indolent, but the paper states that accurate malignant-transformation rates for small incidental cysts are unknown. Size alone is not a calibrated individual risk estimate.	okfonte Megibow et al., JACR 2017, Fig. 1/Chart 1 and legend; pp.6-9 length of follow-up, reporting, applicability and Chart 1 explanation.
intermediate-cyst	Intermediate size cyst Incidental pancreatic cyst 1.5-2.5 cm in an asymptomatic adult. Chart 2A applies when cyst-main-pancreatic-duct communication is established; Chart 2B applies when communication is absent or cannot be determined. Worrisome features or high-risk stigmata trigger the escalation pathway regardless of the routine schedule.	With MPD communication, a 1.5-1.9 cm cyst is reimaged yearly for 5 years then every 2 years twice; a 2.0-2.5 cm cyst is reimaged every 6 months four times, yearly twice, then every 2 years three times. EUS/FNA at detection is an alternative. Without or with unknown MPD communication, either use EUS/FNA or reimage every 6 months four times, yearly twice, then every 2 years three times. Growth to >2.5 cm prompts EUS/FNA; result-dependent paths distinguish SCA/cPNET/pseudocyst from mucinous or indeterminate aspiration.	The 1.5-2.5 cm band has no single malignancy percentage. Risk assessment depends on duct communication, growth, mural or wall findings, duct caliber, symptoms and sampling rather than size alone.	okfonte Megibow et al., JACR 2017, Fig. 2/Charts 2A-2B and legends; pp.9-10 Chart 2 explanation and follow-up horizon.
large-cyst	Large cyst Incidental pancreatic cyst >2.5 cm. Chart 3 separates a diagnosed serous cystadenoma, low-risk imaging, high-risk imaging and direct EUS/FNA. Low-risk imaging means no mural nodule, no wall thickening, normal-caliber MPD and no peripheral calcification; high-risk imaging includes the converse features, with the standardized worrisome/high-risk definitions assessed separately.	For low-risk imaging, reimage every 6 months four times, then yearly twice and every 2 years three times, stopping after 10 stable years. High-risk imaging prompts EUS/FNA plus surgical consultation. A symptomatic SCA or SCA >4 cm merits surgical consultation; any cyst should undergo EUS/FNA before contemplated resection. For a patient >=80 at presentation, use the separate 2.5 cm Chart 4, generally reimaging a low-risk lesion every 2 years twice and pursuing EUS/FNA only when health, preferences and surgical candidacy support it.	A >2.5 cm cyst receives closer evaluation, but this size branch is not a numeric malignancy probability. High-grade dysplasia or malignancy can occur below 3 cm, which is why the ACR chose 2.5 cm for this management chart.	okfonte Megibow et al., JACR 2017, Fig. 3/Chart 3 and Fig. 4/Chart 4 with legends; pp.9-10 Chart 3-4 explanations.
worrisome-features	Worrisome features present ACR 2017 worrisome features are cyst >=3 cm, thickened or enhancing cyst wall, nonenhancing mural nodule, or MPD caliber >=7 mm. High-risk stigmata are obstructive jaundice with a pancreatic-head cyst, an enhancing solid component or enhancing mural nodule, or MPD >=10 mm without obstruction.	A worrisome feature or high-risk stigma prompts EUS with FNA and surgical consultation. The stated exception is size >=3 cm as the only worrisome feature: if no other worrisome feature or high-risk stigma is present, imaging follow-up is an alternative. New symptoms terminate the incidental-cyst algorithm and require clinical evaluation.	These are qualitative escalation features rather than calibrated malignancy probabilities. An enhancing component, obstructive jaundice or MPD >=10 mm carries the stronger high-risk-stigma label; cyst size >=3 cm alone has an explicit surveillance alternative.	okfonte Megibow et al., JACR 2017, Table 1; pp.7-9 reporting consideration 4, applicability and common principle 4; Charts 1-4 escalation footnotes.
main-duct-involvement	Main pancreatic duct involvement Cyst-MPD communication and/or main pancreatic duct dilation. Communication establishes a branch-duct or combined IPMN pattern; record the widest MPD diameter even away from the cyst. MPD >=7 mm is a worrisome feature and MPD >=10 mm without obstruction is a high-risk stigma.	Use CT with 3D reconstructions or MRI/MRCP to assess communication. In a 1.5-2.5 cm cyst, confirmed communication selects Chart 2A; absent or indeterminate communication selects Chart 2B. Dilated MPD prompts EUS/FNA and surgical evaluation according to the 7 mm and 10 mm escalation thresholds rather than routine surveillance alone.	The paper cites disease-level malignancy rates of 38%-65% for combined-form and 38%-68% for main-duct IPMN, but those cohort ranges are not an individual risk estimate for every cyst with duct communication or dilation.	okfonte Megibow et al., JACR 2017, pp.4-5 clinical-importance histology context; pp.7-8 reporting consideration 3 and Table 1; Fig. 2/Charts 2A-2B.

Referências cruzadas

fronteira compartilhadaACR Incidental Adrenal. ACR incidental adrenal mass managementBoth are ACR Incidental Findings Committee white papers in the same series.

Histórico de versões

Data	Evento	Detalhe	Situação
2017-07-01	published	ACR Incidental Findings Committee pancreatic cyst white paper published. evidência	confirmado

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