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.
{
"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."
}