Pancreatic cysts: significance and management

Detection of pancreatic cystic lesions has significantly increased, often incidentally, due to the greater use and improved sensitivity of cross-sectional imaging. They may be benign, potentially malignant or malignant lesions, therefore accurate characterization is needed to decide on management. Ultrasound can be very useful in assessing cyst morphology but visibility may be poor. CT and MRI/ MRCP are the main diagnostic tools for evaluating pancreatic cysts. Endoscopic ultrasound gives detailed morphological assessment and its main use is in allowing aspiration for cytology and tumour marker measurement. Larger cysts with specific features on imaging are managed according to the most likely diagnosis. The management of smaller (<3 cm) cysts is more difficult and should be based on their imaging appearance and associated patient morbidity. Although pseudocysts are a very common cause for cystic pancreatic lesions, more recent data suggest more than 60% of small pancreatic cysts may be mucinous. The precise management algorithm is controversial and still evolving. In general, unilocular cysts <3 cm can be followed up with imaging, EUS aspiration and fluid analysis should be considered for complex cysts, especially if <2 cm, depending on patient age and morbidity. The length of follow-up is controversial, but should probably be for at least four years.