The Differential Diagnosis and Management of Pancreatic Cystic Neoplasms

The prevalence of pancreatic cyst lesions in the general population worldwide is 16%. The majority of these cysts are intraductal papillary mucinous neoplasms (IPMN), which are associated with a risk of developing pancreatic cancer. In this article, we summarize the current knowledge of the differential diagnosis and management of cystic pancreatic neoplasms.

This narrative review is based on a selective search for pertinent literature (1 January 2014 to 9 January 2025).

Most cysts are less than 10 mm in diameter and have practically no potential for malignant transformation. If a small cyst remains unchanged in the absence of risk factors, monitoring can be ended five years after initial detection. Magnetic resonance imaging (MRI) is the best method of characterizing and following up such lesions. If the diagnosis is unclear, endosonography should be performed. For IPMN, the most common type of pancreatic cystic neoplasm, the international Kyoto guideline 2024 contains a revised management algorithm based on risk factors. IPMN with high-grade dysplasia is an ideal indication for surgical resection. Serous cystic adenomas should generally not be operated on, and mucinous cystic neoplasia or a cystic neuroendocrine tumor of the pancreas should be operated on only if it has reached a certain size. Minimally inva - sive and parenchyma-sparing techniques are now being increasingly used in pancreatic surgery.

Oncological criteria as well as potential surgical risks and long-term sequelae must enter into the decision whether a pancreatic lesion should be resected. Exocrine and endocrine insufficiency are relevant and sometimes irreversible complications.