Cystic neoplasms of pancreas

Pancreatic cystic neoplasms (PCNs) are increasingly recognized with the widespread use of cross-sectional imaging. They comprise a diverse group including intra-ductal papillary mucinous neoplasms (IPMNs), mucinous cystic neoplasms (MCNs), serous cystic neoplasms (SCNs), solid pseudopapillary neoplasms (SPNs) and cystic neuroendocrine tumors (cNETs), each differing in their clinico-pathological features, malignant potential and management. Accurate characterization, using a stepwise approach including high-quality cross-sectional imaging and endoscopic ultrasound with cyst fluid analysis when indicated, is crucial to distinguish high-risk lesions requiring surgery from benign cysts suitable for surveillance. Advances such as molecular testing, micro-forceps biopsy and confocal endomicroscopy have enhanced diagnostic precision. Current international guidelines recommend a risk-stratified approach-resection for main-duct IPMNs, all SPNs and MCNs ≥ 4 cm or with high-risk features, while SCNs and small, stable branch-duct IPMNs may be observed. Indian surgical series demonstrate a younger age at presentation and a higher prevalence of MCN and SPN compared with western cohorts, but a lower rate of malignancy. Surgical resection, preferably in high-volume centres, remains the mainstay for high-risk cysts, whereas endoscopic ablation is emerging for select non-surgical candidates. Guidelines are many in this area with constant evolution, increasing focus on newer diagnostic modalities and post-operative endocrine and exocrine insufficiency.