# ACR Incidental Pancreatic Cyst — ACR incidental pancreatic cyst management

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

**Situação:** vigente · **Órgão:** Pâncreas · **Órgão emissor:** American College of Radiology · **Versão:** 2017 · **Ano:** 2017

## Procedência e vigência
- Família: achado incidental
- Tipo de lógica: flat
- Modalidade: CT, MRI
- Fonte primária: Megibow AJ, Baker ME, Morgan DE, et al.. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.03.010
- Última verificação: 2026-07-24
- Última checagem: 2026-07-24

## Lógica de decisão
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.

## Categorias

| Código | Rótulo | Critérios | Conduta | Risco | Localizador | Verificado |
| --- | --- | --- | --- | --- | --- | --- |
| 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. | 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. | 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. | 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. | 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. | 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. | ✓ |

### Citações por categoria
- **small-cyst**: Megibow AJ, Baker ME, Morgan DE, et al.. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.03.010 · 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**: Megibow AJ, Baker ME, Morgan DE, et al.. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.03.010 · Megibow et al., JACR 2017, Fig. 2/Charts 2A-2B and legends; pp.9-10 Chart 2 explanation and follow-up horizon.
- **large-cyst**: Megibow AJ, Baker ME, Morgan DE, et al.. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.03.010 · 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**: Megibow AJ, Baker ME, Morgan DE, et al.. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.03.010 · 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**: Megibow AJ, Baker ME, Morgan DE, et al.. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee (2017) — https://doi.org/10.1016/j.jacr.2017.03.010 · 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 compartilhada_ → [ACR Incidental Adrenal — ACR incidental adrenal mass management](https://radcommons.laudos.ai/systems/acr-incidental-adrenal-2017.md) — Both 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. | confirmed |


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> Conteúdo de referência reescrito. Confira a publicação primária vigente. Não é dispositivo médico nem substitui o julgamento clínico. O radiologista responsável pelo laudo permanece o autor e o responsável.

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