APPROPRIATE USE CRITERIA

ACR Appropriateness Criteria
Pancreatic Cyst

Expert Panel on Gastrointestinal Imaging: Kelly Fábrega-Foster, MD, MA a,
Ihab R. Kamel, MD, PhD b , Jeanne M. Horowitz, MD c, Hina Arif-Tiwari, MD d,
Mustafa R. Bashir, MD e, Victoria Chernyak, MD, MS f, Alan Goldstein, MD g, Joseph R. Grajo, MD h,
Nicole M. Hindman, MD i, Aya Kamaya, MD j, Michelle M. McNamara, MD k,
Kristin K. Porter, MD, PhD l, James M. Scheiman, MD m, Lilja Bjork Solnes, MD, MBA n,
Pavan K. Srivastava, MD o, Atif Zaheer, MD p, Laura R. Carucci, MD q

Abstract

Incidental pancreatic cysts are increasingly detected on imaging studies performed for unrelated indications and may be incompletely characterized
on these studies. Adequate morphological characterization is critical due to the small risk of malignant degeneration associated with neoplastic
pancreatic cysts, as well as the risk of associated pancreatic adenocarcinoma. For all pancreatic cysts, both size and morphology determine
management. Specifically, imaging detection of features, such as pancreatic ductal communication and presence or absence of worrisome features
or high-risk stigmata, have important management implications. The recommendations in this publication determine the appropriate initial
imaging study to further evaluate a pancreatic cyst that was incidentally detected on a nondedicated imaging study. The recommendations are
designed to maximize the yield of diagnostic information in order to better risk-stratify pancreatic cysts and assist in guiding future management.
The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are
reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current
medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness
Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of
imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion
may supplement the available evidence to recommend imaging or treatment.
Key Words: Appropriate Use Criteria, Appropriateness Criteria, AUC, Incidental pancreatic cyst, Intraductal papillary mucinous
neoplasm, Neoplastic pancreatic cyst, Pancreatic cyst, Pancreatic cyst associated malignancy

J Am Coll Radiol 2020;17:S198-S206. Copyright ª 2020 American College of Radiology

a o
Research Author, University of South Florida, Tampa, Florida. University of Illinois College of Medicine, Chicago, Illinois; American
b
Panel Chair, Johns Hopkins University School of Medicine, Baltimore, College of Physicians.
p
Maryland. Johns Hopkins Hospital, Baltimore, Maryland.
c q
Panel Vice-Chair, Northwestern University, Chicago, Illinois. Specialty Chair, Virginia Commonwealth University Medical Center,
d
University of Arizona, Banner University Medical Center, Tucson, Arizona. Richmond, Virginia.
e
Duke University Medical Center, Durham, North Carolina. Corresponding author: Ihab R. Kamel, MD, PhD, Johns Hopkins Hospital, 600
f
Montefiore Medical Center, Bronx, New York. North Wolfe St, MRI 143, Baltimore, MD 21287; e-mail: ikamel@jhmi.edu.
g
UMass Medical School, Worcester, Massachusetts. The American College of Radiology seeks and encourages collaboration with
h
University of Florida College of Medicine, Gainesville, Florida. other organizations on the development of the ACR Appropriateness Criteria
i
New York University Medical Center, New York, New York. through society representation on expert panels. Participation by representatives
j
Stanford University Medical Center, Stanford, California. from collaborating societies on the expert panel does not necessarily imply
k
University of Alabama Medical Center, Birmingham, Alabama. individual or society endorsement of the final document.
l
University of Alabama Medical Center, Birmingham, Alabama. Reprint requests to: publications@acr.org.
m
University of Virginia Health System, Charlottesville, Virginia; American Dr Horowitz reports other support from Perspectum Diagnostics, outside the
Gastroenterological Association. submitted work. The other authors state that they have no conflict of interest
n
Johns Hopkins Bayview Medical Center, Baltimore, Maryland. related to the material discussed in this article.

Disclaimer: The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations
for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in
making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the
selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other
imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The
availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as
investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged.
The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and
radiologist in light of all the circumstances presented in an individual examination.

Copyright ª 2020 American College of Radiology

S198 1546-1440/20/$36.00 n https://doi.org/10.1016/j.jacr.2020.01.021

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ACR Appropriateness Criteria Pancreatic Cyst. Variants 1 to 5 and Tables 1 and 2.

Variant 1. Incidentally detected pancreatic cyst less than or equal to 2.5 cm in size. Initial evaluation.

Procedure Appropriateness Category Relative Radiation Level

MRI abdomen without and with IV contrast Usually Appropriate O

with MRCP
CT abdomen with IV contrast multiphase May Be Appropriate ☢☢☢☢
MRI abdomen without IV contrast with MRCP May Be Appropriate O
CT abdomen without and with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢☢
US abdomen endoscopic Usually Not Appropriate O

Variant 2. Incidentally detected pancreatic cyst greater than 2.5 cm in size. No high-risk stigmata or worrisome features.
Initial evaluation.

Procedure Appropriateness Category Relative Radiation Level

MRI abdomen without and with IV contrast Usually Appropriate O

with MRCP
CT abdomen with IV contrast multiphase May Be Appropriate ☢☢☢☢
MRI abdomen without IV contrast with MRCP May Be Appropriate O
US abdomen endoscopic May Be Appropriate O
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢
CT abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant 3. Incidentally detected pancreatic cyst greater than 2.5 cm in size. High-risk stigmata or worrisome features. Initial
evaluation.

Procedure Appropriateness Category Relative Radiation Level

US abdomen endoscopic Usually Appropriate O

MRI abdomen without and with IV contrast Usually Appropriate O
with MRCP
CT abdomen with IV contrast multiphase May Be Appropriate ☢☢☢☢
MRI abdomen without IV contrast with MRCP May Be Appropriate O
CT abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢

Variant 4. Incidentally detected main pancreatic duct dilation greater than 7 mm in size. Suspected main duct intraductal
papillary mucinous neoplasm (IPMN). Initial evaluation.

Procedure Appropriateness Category Relative Radiation Level

US abdomen endoscopic Usually Appropriate O

MRI abdomen without and with IV contrast with MRCP Usually Appropriate O
MRI abdomen without IV contrast with MRCP Usually Appropriate O
CT abdomen with IV contrast multiphase May Be Appropriate ☢☢☢☢
CT abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢

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 Variant 5. Follow-up imaging of pancreatic cyst.

Procedure Appropriateness Category Relative Radiation Level

CT abdomen with IV contrast multiphase Usually Appropriate ☢☢☢☢

MRI abdomen without and with IV contrast with MRCP Usually Appropriate O
MRI abdomen without IV contrast with MRCP Usually Appropriate O
CT abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢
US abdomen endoscopic Usually Not Appropriate O

Table 1. Appropriateness category names and definitions

Appropriateness Category Appropriateness

Name Rating Appropriateness Category Definition

Usually Appropriate 7, 8, or 9 The imaging procedure or treatment is indicated in the specified

clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate 4, 5, or 6 The imaging procedure or treatment may be indicated in the
specified clinical scenarios as an alternative to imaging
procedures or treatments with a more favorable risk-benefit ratio,
or the risk-benefit ratio for patients is equivocal.
May Be Appropriate 5 The individual ratings are too dispersed from the panel median. The
(Disagreement) different label provides transparency regarding the panel’s
recommendation. “May be appropriate” is the rating category
and a rating of 5 is assigned.
Usually Not Appropriate 1, 2, or 3 The imaging procedure or treatment is unlikely to be indicated in the
specified clinical scenarios, or the risk-benefit ratio for patients is
likely to be unfavorable.

Table 2. Relative radiation level designations

Adult Effective Dose Pediatric Effective Dose

RRL Estimate Range (mSv) Estimate Range (mSv)

O 0 0

☢ <0.1 <0.03

☢☢ 0.1-1 0.03-0.3

☢☢☢ 1-10 0.3-3

☢☢☢☢ 10-30 3-10

☢☢☢☢☢ 30-100 10-30

Note: Relative radiation level (RRL) assignments for some of the examinations cannot be made, because the actual patient doses in these
procedures vary as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is
used). The RRLs for these examinations are designated as “varies.”

SUMMARY OF LITERATURE REVIEW detection of progressively smaller cysts [4-6]. The most
Introduction/Background commonly encountered pancreatic cysts include intraductal
Incidental pancreatic cysts are now increasingly detected on papillary mucinous neoplasms (IPMNs), serous cystadenoma,
imaging studies performed for unrelated indications. [1-3]. mucinous cystic neoplasm (MCN), and pseudocysts [6,7].
Both increased imaging utilization and improved cross- There is a very small risk that an incidental pancreatic
sectional technique are responsible for the more frequent cyst may be malignant [8]. For instance, an incidental

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pancreatic cyst on MRI has a 10 in 100,000 chance of being unrelated indications. The recommendations below apply
a mucinous invasive malignancy and a 17 in 100,000 chance irrespective of the imaging modality in which the cyst was
of being a ductal carcinoma [8]. The risk of malignant initially detected. CT abdomen, MRI abdomen with
transformation in pancreatic cysts is estimated to be MRCP, and US abdomen endoscopic are included in the
0.24% per year [9], varying according to histologic discussion. These are the three conventional imaging mo-
subtype [7,10]. Yet there is considerable overlap in the dalities used in the workup of pancreatic cysts. Although we
imaging appearance of histologically distinct pancreatic acknowledge the added value of US (especially contrast-
cysts, particularly those <3 cm in size, with over 60% of enhanced US) in select cases in which workup with con-
cysts lacking a specific radiologic appearance on CT or ventional imaging is inconclusive or incomplete, US has
MRI [6]. Another important feature in the natural history been omitted from the discussion because it is not routinely
of pancreatic cysts is the small risk of pancreatic used in this setting.
adenocarcinoma developing at a separate site within the
pancreas [4,7,11-13]. Although the risk of cyst-related or
concomitant pancreatic malignancy is small, there is a need DISCUSSION OF PROCEDURES BY VARIANT
to characterize incidental pancreatic cysts effectively at initial Variant 1: Incidentally detected pancreatic
imaging in order to guide management. cyst less than or equal to 2.5 cm in size. Initial
evaluation
CT Abdomen. MRI is preferred over contrast-enhanced
Consensus Guidelines and Special
CT in this setting. The sensitivity and specificity of CT
Morphologic Considerations
for distinguishing IPMN from other cystic pancreatic lesions
There are several expert consensus guidelines for manage-
is 80.6% and 86.4% compared with 96.8% and 90.8% for
ment of incidental pancreatic cysts. These have defined
MRI [3,18]. Advantages of CT include its ease of
specific morphologic features to stratify cysts into two cat-
implementation and excellent spatial resolution.
egories based on whether or not they possess “worrisome
Multidetector CT provides critical diagnostic information
features” or “high-risk stigmata.” Worrisome features
pertaining to the presence or absence of calcifications
include 1) cyst size 3 cm, 2) thickened or enhancing cyst
(both in the background parenchyma and in the cyst
wall, 3) nonenhancing mural nodule, and 4) main pancre-
proper), ductal dilation, intralesional septations, mural
atic duct caliber 5 to 9 mm (simplified to 7 mm here in
nodules, and pancreatic duct communication [6,15].
accordance with the ACR White Paper on Management of
When CT is performed instead of MRI, a dual-phase
Incidental Pancreatic Cysts [7]). High-risk stigmata include
contrast-enhanced pancreatic protocol CT (including late
1) obstructive jaundice with cyst in the head of the pancreas,
arterial and portal venous phases with multiplanar refor-
2) enhancing solid component within a cyst, and 3) main
mations) is recommended. Intravenous (IV) contrast in-
pancreatic duct caliber 10 mm in the absence of
creases sensitivity for detecting worrisome features and high-
obstruction. Cysts lacking these features are stratified based
risk stigmata and improves characterization of a cyst’s in-
on size. The association between cyst size and risk of high-
ternal architecture as well as its relationship to adjacent
grade dysplasia or invasive carcinoma is well recognized;
anatomic structures [1,7-10,13,19-21]. If clearly discerned
however, there is no specific size threshold to quantify risk
on CT, communication with the main pancreatic duct
[1,7,13-15]. Generally, invasive carcinoma is rare in
suggests a diagnosis of IPMN [1,13,19-21]. The relative
asymptomatic cysts <3 cm in size [16,17].
sensitivity of pancreatic protocol multidetector CT for
Appropriate imaging evaluation of incidental pancreatic
detecting internal septations, mural nodules, and
cysts is critical because morphology determines manage-
communication with the pancreatic duct have been
ment. As an example, surveillance is generally recommended
reported to be 73.9% to 93.6%, 71.4%, and 86%,
for cysts <3 cm in size without worrisome features or high-
respectively [6,15,22].
risk stigmata [7,13]. Cysts with worrisome features undergo
sampling with endoscopic ultrasound fine-needle aspiration MRI Abdomen With MRCP. Contrast-enhanced MRI
(EUS-FNA) [8-10] and those with high-risk stigmata are with MR cholangiopancreatography (MRCP) is considered
typically resected [8-10]. For management the procedure of choice in this setting because of its superior
recommendations please refer to the ACR White Paper on soft-tissue contrast and superior ability to demonstrate
Management of Incidental Pancreatic Cysts [7]. ductal communication [6-10]. The reported sensitivity of
The following recommendations refer to the initial im- thin-slice 3-D MRCP acquisitions for demonstrating
aging evaluation of pancreatic cysts incidentally detected and communication of a cyst with the pancreatic duct is as high
incompletely evaluated on imaging studies performed for as 100% [6,22]. Communication with the main pancreatic

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duct is suggestive of IPMN, although this may also be seen nonmalignant lesions ranges from 73.2% to 91%
in the setting of pseudocysts [6]. The sensitivity of MRI for [6,23,24]. Its accuracy at diagnosing the specific type of
detection of internal septations is 91% [6,22], and its cyst is slightly lower at 50% [23]. However, an exception
diagnostic accuracy for distinguishing between malignant may be the distinction of IPMN from other cystic lesions,
and nonmalignant lesions ranges between 73.2% and 91% in which studies have reported a sensitivity of 96.8% and
[6,23,24]. In distinguishing IPMN from other cystic specificity of 90.8% [3,18].
lesions, studies have reported a sensitivity of 96.8% and a
US Abdomen Endoscopic. Because of its invasive
specificity of 90.8% [3,18].
approach, the decision to perform EUS-FNA in this setting
US Abdomen Endoscopic. EUS-FNA is not recom- must depend upon a careful consideration of the diagnostic
mended for initial characterization of pancreatic cysts 2.5 benefits and risks. A cyst size of 3 cm alone is considered a
cm in size. With EUS, morphologic characterization is worrisome feature associated with a 3-times greater risk of
achieved at the cost of a more invasive approach. The cyst-related malignancy [9] and may prompt EUS-FNA
unique advantage of EUS is its ability to perform FNA of even in the absence of other worrisome features [17]. For
cyst fluid and soft tissue [6,17,25]. At least 2 mL of this reason, many centers perform EUS-FNA in lieu of
aspirated fluid, corresponding to a cyst size of 1.7 cm, is MRI with MRCP as the initial imaging step in this setting
necessary to perform cytology and biomarker analysis [14,26]. Although worrisome features may be undetectable
using FNA [26]. Because the risk of malignant or absent in smaller cysts, they should prompt evaluation
transformation in cysts <3 cm in size is extremely low with EUS-FNA when present. Some authors have sug-
[17,27], the risks of performing EUS-FNA in this setting gested that EUS-FNA should be reserved for cysts demon-
may outweigh the diagnostic benefits. strating at least two worrisome features, with the specific aim
of increasing diagnostic specificity [9]. However, because
Variant 2: Incidentally detected pancreatic each worrisome feature confers a unique relative risk of
cyst greater than 2.5 cm in size. No high-risk malignancy (such that each feature must be weighed
stigmata or worrisome features. Initial separately in any assessment of overall risk), others have
evaluation reported that EUS-FNA should be considered for any cyst
2.5 cm with at least one other worrisome feature [7]. This
CT Abdomen. MRI is preferred over contrast-enhanced
approach recognizes the inherent complexity in risk
CT in this setting because of its superior sensitivity and
calculations for individual cysts and acknowledges that
specificity in differentiating cystic pancreatic lesions. Studies
even cysts slightly <3 cm may possess worrisome features
comparing the sensitivity and specificity of CT versus MRI
and still contain sufficient fluid for EUS-FNA. A cyst size
in distinguishing IPMN from other cystic pancreatic lesions
of 1.7 cm contains sufficient fluid to perform FNA with
report values of 80.6% to 86.4% for CT and 96.8% to
cytology and carcinoembryonic antigen and amylase levels
90.8% for MRI [3,18]. In cases in which contrast-enhanced
[7]. Cytological evaluation may identify atypia, dysplasia, or
MRI with MRCP cannot be performed, a dual-phase
neoplasia in these cysts [7,13,25]. The presence of high-
contrast-enhanced pancreatic protocol CT (including late
grade epithelial atypia in IPMN detects approximately
arterial and portal venous phases with multiplanar refor-
30% more cancers than the presence of worrisome imaging
mations) may be of value. The use of IV contrast improves
features alone [13]. Although it is true that a 3-times
detection of worrisome features and high-risk stigmata and
increased risk of malignancy is modest in absolute terms
better demonstrates a cyst’s relationship to surrounding
given the low baseline risk of adenocarcinoma [9], this is still
anatomy [1,7-10,13,19-21]. If clearly discerned on CT,
substantial given the dismal survival rate for adenocarcinoma
communication with the main pancreatic duct suggests a
and the potential survival benefit of enabling an early
diagnosis of IPMN [1,13,19-21]. The relative sensitivity
diagnosis of dysplasia rather than malignancy.
of pancreatic protocol multidetector CT for detecting
In a study of over 300 patients with pancreatic cysts, the
internal septations, mural nodules, and communication
addition of EUS-FNA to the diagnostic workup significantly
with the pancreatic duct are 73.9% to 93.6%, 71.4%,
altered the management strategy in nearly 72% of patients
and 86%, respectively [6,15,22].
[28]. Management algorithms integrating clinical data,
MRI Abdomen with MRCP. Because of its superior soft- imaging, and fluid analysis have reported cyst classification
tissue resolution and noninvasive approach, contrast- sensitivities of 90% to 100% and specificities of 92% to
enhanced MRI with MRCP is generally favored over CT 98% [7,25]. The addition of EUS-FNA to management
or EUS-FNA in this setting [6-10]. The diagnostic accuracy algorithms combining clinical history and imaging may also
of MRI for distinguishing between malignant and reduce unnecessary surgeries by 91% [7].

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Variant 3: Incidentally detected pancreatic expertise in EUS-FNA, cytological evaluation can identify
cyst greater than 2.5 cm in size. High-risk atypia, dysplasia, or neoplasia [7,13,25]. Studies have
stigmata or worrisome features. Initial demonstrated that the presence of high-grade epithelial
evaluation atypia in IPMN detects approximately 30% more cancers
than the presence of worrisome imaging features alone [13].
CT Abdomen. The presence of high-risk stigmata or
Although worrisome features may be undetectable or
worrisome features significantly increases the risk of malig-
absent in smaller cysts, they should prompt evaluation with
nancy, and therefore EUS-FNA is favored over CT in this
EUS-FNA when present. It is worth noting that a cyst size
setting [8,9,14]. In cases in which EUS-FNA cannot be
of 3 cm alone is considered a worrisome feature associated
performed and the patient is not a candidate for MRI with
with a 3-times greater risk of cyst-related malignancy [9],
MRCP, a dual-phase contrast-enhanced pancreatic protocol
prompting EUS-FNA even in the absence of other worri-
CT may still be of value for cyst characterization or pre-
some features. The presence of additional worrisome fea-
surgical planning [1,7-10,13,19-21]. The use of IV contrast
tures, such as a solid component, further increases the risk of
improves detection of worrisome features and high-risk
malignancy by up to eight times [9,31]. Some authors have
stigmata and the assessment of surrounding anatomy [1,7-
suggested that EUS-FNA should be reserved for cysts
10,13,19-21].
demonstrating at least two worrisome features, with the
MRI Abdomen With MRCP. The presence of high-risk specific aim of increasing diagnostic specificity [9].
stigmata or worrisome features significantly increases the risk However, because each worrisome feature confers a
of malignancy, and therefore EUS-FNA is favored over MRI unique relative risk of malignancy (such that each feature
in this setting [8,9,14]. In equivocal cases or cases in which must be weighed separately in any assessment of overall
EUS-FNA cannot be performed, MRI with and without IV risk), EUS-FNA should be considered for any cyst 2.5
contrast with MRCP may be of value, potentially allowing cm with at least one other worrisome feature [26]. This
further characterization of a cyst’s internal architecture and a approach recognizes the inherent complexity in risk
more specific diagnosis. When performed in conjunction calculations for individual cysts and acknowledges that
with MRCP, the reported sensitivity for detection of even cysts slightly <3 cm may possess worrisome features
worrisome features, such as enhancing internal septations, is and still contain sufficient fluid for EUS-FNA. Although
approximately 91% [6,22]. The diagnostic accuracy for it is true that a 3 to 8 times increased risk of malignancy is
distinguishing between malignant and nonmalignant modest in absolute terms given the low baseline risk [9], this
lesions ranges between 73.2% and 91% [6,23,24]. is still a substantial risk given the dismal survival rate for
Contrast-enhanced MRI with MRCP may also be per- pancreatic carcinoma and the potential survival benefit of
formed as a complement to EUS-FNA in this setting, enabling an early diagnosis of dysplasia rather than
establishing a baseline for future follow-up and facilitating malignancy.
detection of additional worrisome features or synchronous
lesions.
Variant 4: Incidentally detected main
US Abdomen Endoscopic. When high-risk stigmata or
pancreatic duct dilation greater than 7 mm in
worrisome features are present, the appropriate initial im-
size. Suspected main duct intraductal
aging study is EUS-FNA [7-10]. The unique advantage of
papillary mucinous neoplasm (IPMN). Initial
EUS-FNA is its ability to distinguish mucinous from non-
evaluation
mucinous lesions by means of biochemical markers assayed
from cyst fluid samples. This facilitates a specific diagnosis CT Abdomen. Although contrast-enhanced CT may also
in many cases [25,28-30]. For instance, the presence of assist in detection of synchronous lesions, it is not the
nongut mucin supports a diagnosis of mucinous preferred imaging modality in this setting. The presence of
neoplasm. Carcinoembryonic antigen levels <5 ng/mL main pancreatic ductal dilation is considered a “worrisome
suggest pseudocyst or serous cystadenoma. A feature” (5-9 mm) or one of several “high-risk stigmata” (1
carcinoembryonic antigen threshold level in the range of cm) [7,8,10,13]. In the absence of ancillary evidence of
192 to 200 ng/mL is 80% accurate for diagnosis of a chronic pancreatitis or main pancreatic duct obstruction,
mucinous cyst [13,29]. Amylase levels of >250 IU/L this feature should raise concern for main duct IPMN.
suggest a pseudocyst. Molecular assays for markers such as Main duct IPMN carries a risk of malignant degeneration
K-ras, GNAS, PTEN, VHL, TP53, and PIK3CA may of approximately 57% to 92% compared with 25% for
also assist in differentiating neoplastic cystic lesions and branch duct IPMN [1,7-10,32]. The presence of main
predicting cyst behavior. When performed in centers with duct dilation 1 cm should prompt surgical referral, and

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pancreatic ductal dilation between 5 to 9 mm should size, and whether or not there has been prior surgical
prompt EUS-FNA [7-10]. resection of a pancreatic cyst. For patients with a nonspecific
pancreatic cyst without a history of prior surgery, the sur-
MRI Abdomen with MRCP. Although MRI with and
veillance plan will depend upon patient age and the cyst size.
without IV contrast with MRCP is highly sensitive for
Follow-up intervals are generally in the range of 6 months to
delineating pancreatic ductal anatomy [6,22], the presence
every 2 years for a minimum of 5 to 10 years [7-9].
of pancreatic ductal dilation >7 mm is a worrisome
Development of high-risk stigmata or worrisome features
feature that should raise the question of main duct IPMN.
during the surveillance period should prompt EUS-FNA or
Given the high associated rates of malignancy (57%-
surgical evaluation. For patients with a previous history of
92%), pancreatic ductal dilation between 5 to 9 mm
surgery for IPMN or invasive MCN without residual dis-
should prompt EUS-FNA [1,7-10,32]. Nonetheless,
ease, continued surveillance is recommended, in view of the
contrast-enhanced MRI with MRCP may assist in detec-
small yearly risk of pancreatic ductal adenocarcinoma of
tion of additional worrisome features, including enhancing
0.7% to 0.9% [8]. For patients with known IPMN in the
mural nodule or thick septation or synchronous lesions, and
remnant pancreas, residual IPMN at the surgical margins,
should be performed prior to EUS-FNA for this reason.
or new postoperative recurrence of IPMN, surveillance
US Abdomen Endoscopic. EUS-FNA is the procedure of recommendations are less well defined [8]. To date, there
choice when main duct IPMN is suspected but degree of is no evidence basis for the recommended size threshold
ductal dilation does not meet criteria for surgical referral to follow-up cysts. Based on limited clinical and published
(1 cm) [1,7-10,32]. The presence of main pancreatic experience, a cyst <5 mm may require one follow-up CT
ductal dilation >7 mm is considered a worrisome feature or MRI at 2 years. Demonstrating stability at 2 years is
that should prompt EUS-FNA given the high risk of ma- sufficient to stop surveillance.
lignancy associated with main duct IPMN (57%-92%) [7-
10]. High spatial resolution imaging and the ability to MRI Abdomen with MRCP. The risk of malignant
perform fluid analysis or tissue sampling render EUS-FNA transformation of a pancreatic cyst is approximately 0.24%
superior to MRI and CT in this setting. However, MRI per year [9]. Once a pancreatic cyst has been characterized
with and without IV contrast with MRCP is recommended on a dedicated baseline examination, subsequent follow-up
prior to EUS-FNA because MRI provides morphologic in- may be performed with either CT or MRI. There is no
formation to complement FNA findings and establishes a evidence to suggest that MRI is superior to CT for detection
baseline for future follow-up if needed. If an alternative of new or developing worrisome features or pancreatic
cause for main duct dilation is found, such as a stricture or ductal adenocarcinoma [7], although modality concordance
mass, it may obviate the need for FNA. between baseline and follow-up examinations may facilitate
comparison.
The issue of whether IV contrast is necessary for MRI
Variant 5: Follow-up imaging of pancreatic
follow-up of pancreatic cysts remains controversial. Non-
cyst
contrast MRI is associated with shorter scan times, with some
CT Abdomen. The risk of malignant transformation of a sources citing little difference in the ability to detect evolving
pancreatic cyst is approximately 0.24% per year [9]. Once a dysplastic changes compared with a contrast-enhanced study
pancreatic cyst has been characterized on a dedicated [7,33,34]. However, the use of IV contrast may permit
baseline examination, subsequent follow-up may be per- detection of high-risk stigmata such as enhancing mural
formed with either CT or MRI. There is no evidence to nodules. An abbreviated protocol MRI, including T2-
suggest that MRI is superior to CT for detection of new or weighted sequences and dual-phase (late arterial and portal
developing worrisome features or pancreatic ductal adeno- venous phase) contrast-enhanced acquisitions, has been
carcinoma, and cysts that change at follow-up typically do so shown to be equivalent to standard pancreatic protocol MRI
by increasing size, which is well assessed by either modality for detection of evolving dysplasia [7,34].
[7], although modality concordance between baseline and The frequency and duration of follow-up is controversial
follow-up examinations may facilitate comparison. For CT and depends on multiple factors, including patient age,
follow-up, a dual-phase contrast-enhanced pancreatic pro- family history of pancreatic ductal adenocarcinoma, cyst
tocol CT, including late arterial and portal venous phases, size, and whether or not there has been prior surgical
should be performed [7,8]. resection of a pancreatic cyst. For patients with a nonspecific
The frequency and duration of follow-up is controversial pancreatic cyst without a history of prior surgery, the sur-
and depends on multiple factors, including patient age, veillance plan will depend upon patient age and the cyst size.
family history of pancreatic ductal adenocarcinoma, cyst Follow-up intervals are generally in the range of 6 months to

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every 2 years for a minimum of 5 to 10 years [7-9].
abdomen without IV contrast with MRCP are usually
Development of high-risk stigmata or worrisome features
appropriate for the initial evaluation of incidentally
during the surveillance period should prompt EUS-FNA or
detected main pancreatic duct dilation >7 mm in
surgical evaluation [8,9,14,26]. For patients with a previous
size with suspected main duct IPMN. US abdomen
history of surgery for IPMN or invasive MCN without
endoscopic and either dual-phase or noncontrast MRI
residual disease, continued surveillance is still
abdomen with MRCP are complementary (ie, more
recommended in view of the small yearly risk of
than one procedure is ordered as a set or simulta-
pancreatic ductal adenocarcinoma [8]. For patients with
neously where each procedure provides unique clinical
known IPMN in the remnant pancreas, residual IPMN at
information to effectively manage the patient’s care).
the surgical margins, or new postoperative recurrence of
n Variant 5: CT abdomen with IV contrast multiphase,
IPMN, surveillance recommendations are less well defined
[8]. To date, there is no evidence basis for the MRI abdomen without and with IV contrast with
recommended size threshold to follow-up cysts. Based on MRCP, and MRI abdomen without IV contrast with
limited clinical and published experience, a cyst <5 mm MRCP are usually appropriate for the follow-up im-
may require one follow-up CT or MRI at 2 years. aging of pancreatic cyst. CT abdomen with IV contrast
Demonstrating stability at 2 years is sufficient to stop multiphase and either dual-phase or noncontrast MRI
surveillance. abdomen with MRCP are complementary (ie, more
than one procedure is ordered as a set or simulta-
US Abdomen Endoscopic. The risk of malignant trans- neously where each procedure provides unique clinical
formation of a pancreatic cyst is approximately 0.24% per information to effectively manage the patient’s care).
year [9]. Although detection of new or evolving dysplasia
may prompt evaluation with EUS-FNA, EUS-FNA is not
recommended for routine follow-up of pancreatic cysts
because of its invasive approach [7-10]. Patients who SUPPORTING DOCUMENTS
undergo EUS-FNA without concerning results may The evidence table, literature search, and appendix for this
resume surveillance with CT or MRI according to the rec- topic are available at https://acsearch.acr.org/list. The ap-
ommendations for cysts without high-risk stigmata or pendix includes the strength of evidence assessment and the
worrisome features [7-9]. final rating round tabulations for each recommendation.
For additional information on the Appropriateness
Criteria methodology and other supporting documents go to
SUMMARY OF RECOMMENDATIONS
www.acr.org/ac.
n Variant 1: MRI abdomen without and with IV
contrast with MRCP is usually appropriate for the
RELATIVE RADIATION LEVEL INFORMATION
initial evaluation of an incidentally detected
Potential adverse health effects associated with radiation
pancreatic cyst 2.5 cm in size.
exposure are an important factor to consider when selecting
n Variant 2: MRI abdomen without and with IV the appropriate imaging procedure. Because there is a wide
contrast with MRCP is usually appropriate for the range of radiation exposures associated with different diag-
initial evaluation of an incidentally detected nostic procedures, a relative radiation level (RRL) indication
pancreatic cyst >2.5 cm in size with no high-risk has been included for each imaging examination. The RRLs
stigmata or worrisome features. are based on effective dose, which is a radiation dose
n Variant 3: US abdomen endoscopic and MRI quantity that is used to estimate population total radiation
abdomen without and with IV contrast with MRCP risk associated with an imaging procedure. Patients in the
are usually appropriate for the initial evaluation of an pediatric age group are at inherently higher risk from
incidentally detected pancreatic cyst >2.5 cm in size exposure, because of both organ sensitivity and longer life
with high-risk stigmata and worrisome features. expectancy (relevant to the long latency that appears to
These procedures are complementary (ie, more than accompany radiation exposure). For these reasons, the RRL
one procedure is ordered as a set or simultaneously dose estimate ranges for pediatric examinations are lower as
where each procedure provides unique clinical infor- compared with those specified for adults (see Table 2).
mation to effectively manage the patient’s care). Additional information regarding radiation dose
assessment for imaging examinations can be found in the
n Variant 4: US abdomen endoscopic, MRI abdomen
ACR Appropriateness Criteria Radiation Dose
without and with IV contrast with MRCP, and MRI
Assessment Introduction document [35].

Journal of the American College of Radiology S205

Fábrega-Foster et al n Pancreatic Cyst
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