G a s t r o i n t e s t i n a l I m a g i n g • B e s t P r a c t i c e s / R ev i ew

Sahani et al.
Cystic Pancreatic Lesions

Gastrointestinal Imaging
Best Practices/Review
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Diagnosis and Management

of Cystic Pancreatic Lesions
Dushyant V. Sahani1 OBJECTIVE. The purpose of this review is to outline the management guidelines for the
Avinash Kambadakone1 care of patients with cystic pancreatic lesions.
Michael Macari2 CONCLUSION. The guidelines are as follows: Annual imaging surveillance is gener-
Noaki Takahashi 3 ally sufficient for benign serous cystadenomas smaller than 4 cm and for asymptomatic le-
Suresh Chari 4 sions. Asymptomatic thin-walled unilocular cystic lesions smaller than 3 cm or side-branch
intraductal papillary mucinous neoplasms should be followed up with CT or MRI at 6 and
Carlos Fernandez-del Castillo 5
12 months interval after detection. Cystic lesions with more complex features or with growth
Sahani DV, Kambadakone A, Macari M, Takahashi rates greater than 1 cm/year should be followed more closely or recommended for resection if
N, Chari S, Fernandez–del Castillo C the patient’s condition allows surgery. Symptomatic cystic lesions, neoplasms with high ma-
lignant potential, and lesions larger than 3 cm should be referred for surgical evaluation. En-
doscopic ultrasound with fine-needle aspiration (FNA) biopsy can be used preoperatively to
assess the risk of malignancy.

Clinical Vignettes and Images ing inflammatory (pseudocysts), benign (serous

Keywords: cystic pancreatic lesion, MDCT, MRI
DOI:10.2214/AJR.12.8862
Received February 25, 2012; accepted after revision
July 18, 2012.
1
Department of Radiology, Division of Abdominal
Imaging and Intervention, Massachusetts General
Hospital, Harvard Medical School, 55 Fruit St, White 270,
Boston, MA 02114. Address correspondence to
D. V. Sahani (dsahani@partners.org).
2
Department of Radiology, Division of Abdominal
Imaging, New York University Langone Medical Center,
New York, NY.
3
Department of Radiology, Division of Abdominal
Imaging, Mayo Clinic, Rochester, MN.
4
Department of Medicine, Division of Gastroenterology,
Mayo Clinic, Rochester, MN.
5 The Imaging Question
Department of Surgery, Division of Pancreatic Surgery,
Massachusetts General Hospital, Harvard Medical
School, Boston, MA.
AJR 2013; 200:343–354
0361–803X/13/2002–343
© American Roentgen Ray Society
The increasing use and improved spatial
and contrast resolution of advanced cross-
sectional imaging techniques such as MDCT
and MRI have resulted in a marked increase
in the incidental detection of cystic pancreat-
ic lesions. They are encountered in as many
as 2.6% of abdominal MDCT examinations
and 20% of MRI studies [1–3]. Larger cystic
pancreatic lesions are typically symptomat-
ic, and incidentally detected cystic pancreat-
ic lesions are often small. Increased identifi-
cation of cystic pancreatic lesions at MDCT
and MRI presents a clinical conundrum for
appropriate further management [4–7]. Ac-
curate characterization of these cystic le-
sions is essential for further management,
either surgical or conservative. In a select
group of patients, endoscopic ultrasound and
cyst aspiration can be performed for further
characterization. Clinical vignettes are pre-
sented in Figures 1–4.
How do we characterize, diagnose, and ap-
propriately manage incidentally found cystic
pancreatic lesions?
Background and Importance
Cystic pancreatic lesions encompass a var-
ied group of pancreatic abnormalities, includ-
cystadenomas), precancerous (intraductal pap-
illary mucinous neoplasms [IPMNs] and mu-
cinous cystic neoplasms [MCNs]), and frank-
ly malignant (cystadenocarcinomas) [8–12].
Cystic pancreatic lesions not only have di-
verse histologic and imaging appearances but
also differ in clinical presentation, biologic be-
havior, growth pattern, and risk of malignan-
cy (Table 1). Accurate risk stratification and
decisions on treatment and follow-up strate-
gy necessitate precise lesion characterization
and diagnosis [2, 13–16]. The current manage-
ment of common cystic pancreatic lesions is
summarized in Table 2.
Synopsis and Synthesis of Evidence
The most common nonneoplastic cystic pan-
creatic lesions are pseudocysts, which usually
arise as a sequela of pancreatitis or trauma. The
most common cystic pancreatic neoplasms
are IPMNs, MCNs, and serous cystaden­omas
(SCAs) [12, 17–20]. Although SCAs and
pseudocysts are considered benign, IPMNs and
MCNs have malignant potential [19, 21–23].
Other cystic pancreatic lesions account for few-
er than 10% of cases and include uncommon
pathologic findings such as solid pseudopap-
illary neoplasms, cystic pancreatic neuroen-
docrine neoplasms, cystic degeneration in other
solid pancreatic neoplasms, lymphoepithelial

AJR:200, February 2013 343


cysts, and cystic adenocarcinoma of the pan-
creas [5, 24, 25].
Diagnosis
Imaging plays a crucial role in the man-
agement of cystic lesions of the pancreas,
including lesion detection and character-
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ization. Technologic innovations in MDCT
and MRI have led to improvement in anal-
ysis and morphologic differentiation of cys-
tic pancreatic lesions and are widely consid-
ered the primary imaging modalities in the
care of patients with cystic lesions of the
pancreas. In addition, advances in postpro-
cessing have enabled enhanced definition of
the extent of a lesion and its relation to ad-
jacent structures. These techniques are par-
ticularly valuable in delineating the relation
between the cystic lesion and the pancreat-
ic duct, a key feature in differentiating side-
branch IPMNs from other cystic lesions [24,
26, 27]. The following imaging modalities
can be used either independently or in com-
bination to help in the diagnosis and manage-
ment of cystic pancreatic lesions.
A B
C D
344
Sahani et al.
MDCT
MDCT is the primary modality for imaging
of cystic pancreatic lesions, including IPMNs,
owing to its high spatial and temporal resolu-
tion, speed of acquisition, wide availability,
and ease of interpretation [2, 15, 16, 28]. The
superior quality of 2D and 3D image displays
generated from isotropic MDCT datasets has
facilitated excellent depiction of the detailed
regional pancreatic anatomy and precise def-
inition of the morphologic characteristics of
cysts [26, 29, 30]. Image postprocessing in a
desired plane also allows determination of the
communication between the cystic lesion and
the main pancreatic duct, a key feature in the
diagnosis of side-branch IPMNs [26]. Howev-
er, the presence of a small duct or a collapsed
duct can impede visualization of ductal com-
munications [26].
MDCT has a reported accuracy of 56–
85% for characterization of cystic pancreatic
lesions, which is comparable to that of MRI
[2, 15, 16, 28, 31]. Visser et al. [30] found
that MDCT had an accuracy of 76–82% in
establishing the diagnosis of malignancy in
58 histopathologically proven cystic pancre-
atic masses. In a study of 100 cystic pancre-
atic lesions, Chaudhari and colleagues [32,
33] reported an accuracy of 71–79% for
MDCT for discriminating premalignant or
malignant lesions from benign lesions. Lee
et al. [2] reported a comparable accuracy
(63.9–73.5%) of MDCT for differentiating
benign from malignant cystic pancreatic le-
sions. However, subclassification of cystic
lesions into histopathologic types is often
difficult because of overlapping imaging fea-
tures. Increasingly, the morphologic pattern
depicted on MDCT images is being used to
categorize cystic pancreatic lesions broadly
into mucinous and nonmucinous types and
then subdivide them on the basis of complex
features into aggressive and nonaggressive
lesions [2, 15, 22]. In a study of 114 patients
with 130 cystic pancreatic lesions, Sahani
and colleagues [15] stratified the lesions into
mucinous and nonmucinous subtypes with
an accuracy of 82–85% and reported an ac-
curacy of 85–86% for recognizing aggres-
sive biologic features. Similar accuracy has
Fig. 1—MDCT images in four patients with incidental
finding of pancreatic cystic lesion.
A, 62-year-old-man with 1.2-cm cystic lesion (arrow)
in pancreatic body without main pancreatic ductal
dilatation or enhancing solid components. Coronal
MDCT image shows main pancreatic duct intimately
associated with cystic lesion, and communication
between cystic lesion and main duct is evident.
Lesion is typical of nonaggressive side branch
intraductal papillary mucinous neoplasm that does
not warrant surgical resection.
B, 69-year-old woman with cystic lesion in pancreatic
tail. Axial MDCT image shows cystic lesion in
pancreatic tail (white arrows) with enhancing
solid components (black arrow) and peripheral rim
calcification. Findings are indicative of aggressive
mucinous cystic lesion. Patient underwent distal
pancreatectomy, and histopathologic examination
revealed mucinous cystadenocarcinoma.
C, 65-year-old woman with recurrent dull, aching
epigastric pain. Axial MDCT image shows 3.5-cm
microcystic lesion (arrow) in pancreatic body and tail
with multiple small loculations. Patient underwent
distal pancreatectomy because of considerable
symptoms. Histopathologic finding was serous
cystadenoma.
D, 67-year-old man with pancreatic ductal dilatation.
Curved multiplanar reformatted MDCT image shows
main pancreatic ductal dilatation (arrows) in region of
head and proximal body of pancreas with prominence
of pancreatic tail indicative of main duct intraductal
papillary mucinous neoplasm. Patient underwent
Whipple procedure. Histopathologic finding was main
duct intraductal papillary mucinous neoplasm with
ductal carcinoma in situ.
AJR:200, February 2013
 Cystic Pancreatic Lesions

Fig. 2—54-year-old man with incidentally detected

lesion in pancreatic tail.
A, Axial MDCT image shows 8-mm low-attenuation
lesion (arrow) in pancreatic tail. MRI was considered
for evaluation of internal morphologic features of
lesion and for assessing any communication with
main pancreatic duct.
B, Axial T2-weighted MR image shows T2
hyperintense lesion in tail of pancreas with mild
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nodular wall thickening (arrow) along lateral wall.

C, Coronal T2-weighted MR image shows septate
cyst (arrow).
D, Axial T2-weighted gadolinium-enhanced MR
image shows enhancing nodular thickening (arrow)
of lateral wall. Distal pancreatectomy was performed
because of complex morphologic features of cyst,
especially enhancing solid component, and young
age. Histopathologic finding was side-branch
intraductal papillary mucinous neoplasm with low-
grade dysplasia.
A B

been reported for small cystic pancreatic le-

sions (≤ 3 cm). Sainani et al. [16] found that
MDCT had 71–84.2% accuracy for differen-
tiating mucinous and nonmucinous subtypes
of small cystic pancreatic lesions.
The presence of solid nodules, thick sep-
tations, and cyst wall thickening on MDCT
images favors the diagnosis of an aggressive
cystic lesion [2, 15, 16, 22, 30, 31]. Sahani
and colleagues [15] reported that pancreatic
protocol MDCT had sensitivities of 93.6%,
71.4%, and 86.4% for detecting morpholog-
ic features such as septa, mural nodules, and
main pancreatic duct communication. Kim
et al. [34] found that shape and wall thick-
ness (> 1 mm) were two independent pre-
dictors of malignancy of a macrocystic pan-
creatic lesion. Tomimaru et al. [35] reported
that the presence or absence of mural nod-
ules on CT images had a sensitivity, specific-
ity, and accuracy of 93%, 80%, and 86% in
the diagnosis of malignant IPMNs. Sainani
and colleagues [16] found that in the detec-
tion of small cystic pancreatic lesions (≤ 3
cm), MDCT had 73.9% sensitivity for the as-
sessment of septa and 86% sensitivity for de-
piction of ductal communication.
MDCT has the additional advantage of de-
picting calcifications, which can be difficult
to recognize on MR images. Despite its im-
proved performance in the assessment of the
biologic characteristics of pancreatic cysts,
false-negative results can occur because the
dysplastic changes in the cystic lesions do not
have distinct MDCT features [15]. In addi-
tion, MDCT has limited utility for differenti-
ating minimally invasive carcinoma from car-
cinoma in situ. Similarly, the recognition of
internal details and pancreatic duct communi-
cation in a small cystic lesion can be challeng-
C D
ing with MDCT. Sainani et al. [16] reported
that MRI had higher sensitivity than MDCT in
showing ductal communication of small cys-
tic pancreatic lesions (100% vs 85.7%). In ad-
dition, inflammatory changes from concurrent
pancreatitis can obscure the morphologic de-
tails of cystic pancreatic lesions.
MRI and MRCP
MRI of the pancreas with MRCP has
emerged as a reliable tool for detecting and
characterizing cystic pancreatic lesions. The
superior soft-tissue and contrast resolution
makes MRI a sensitive study for assessing
the morphologic features of cystic lesions,
including their communication with the main
pancreatic duct [3, 16, 30, 36, 37]. Visser and
colleagues [30] found that MRI had an accu-
racy of 85–91% in establishing the diagno-
sis of malignancy in cystic pancreatic lesions.
Lee et al. [2] found that MRI had an accuracy
of 73.2–79.2% in determining the malignan-
cy of cystic pancreatic lesions. In particular,
in small cystic lesions (≤ 3 cm), MRI facili-
tates confident assessment of the morpholog-
ic features of the cyst and reliably displays
small cystic lesions not obvious on MDCT
images [16]. Sainani et al. [16] reported that
MRI had an accuracy of 78.9–81.6% for dif-
ferentiating mucinous and nonmucinous sub-
types of small pancreatic cystic lesions (≤ 3
cm). They also reported that MRI had a sen-
sitivities of 91% and 100% in the assessment
of septa and main pancreatic duct communi-
cation in small cystic pancreatic lesions.
The transition from 2D software to higher-
quality 3D acquisition has resulted in more ef-
fective detection of connections with the main
pancreatic duct compared with the 2D single-
slab technique [37, 38]. Yoon et al. [38] found
that compared with 2D MRCP, 3D MRCP fa-
cilitated superior evaluation of the pancreatic
duct and the morphologic details of IPMNs.
The 2D MRCP sequence is usually performed
as a breath-hold coronal single-shot fast spin-
echo sequence or HASTE sequence [37, 38].
The 3D imaging technique is a high-spatial-
resolution MRCP sequence that entails either
a breath-hold turbo spin-echo sequence or a
respiratory-triggered fast spin-echo approach

AJR:200, February 2013 345

 Sahani et al.

[37, 38]. An additional advantage of MRI with
or without MRCP is in the follow-up of young
patients with cystic pancreatic lesions because
MRI eliminates exposure to ionizing radiation.
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Although MRCP is more sensitive in dis-
playing the details of cystic lesions, in most
cases appropriately performed thin-section
MDCT in combination with image process-
ing (multiplanar reconstructions and curved
reformations) can provide sufficient detail
on cystic lesions to allow decision making
[15, 16]. Variants in anatomy of the pancre-
atic ductal system can be confidently defined
with both MDCT and MRCP. This capability
is important in cases of ductal anatomic vari-

ants such as pancreas divisum. The presence

of such an anomaly can influence the surgical
approach. A main duct IPMN affecting the
dorsal duct can be treated with newer surgical
techniques involving dorsal pancreatectomy
and sparing the ventral pancreas, thus avoid-
ing biliary and pancreatic anastomoses [39].
Secretin-enhanced MRCP is a modified
MRCP technique in which MRI is performed
after stimulation of pancreatic exocrine func-
tion by IV injection of secretin [36, 37, 40].
Through stimulation of pancreatic secretion,
secretin administration can improve the utility
A B

Fig. 3—69-year-old woman with incidentally

detected cyst in pancreatic head.
A, Axial T2-weighted MR image shows 17-mm
hyperintense lesion (arrow) in pancreatic head.
B, Gadolinium-enhanced T1-weighted fat-saturated
MR image shows suspicious nodular enhancement
(arrow) along cyst wall. Close imaging follow-up was
performed.
C and D, Follow-up MR images 1 year after B show
nodule (arrow) within lesion on T2-weighted image
(C) that was enhancing on gadolinium-enhanced
T1-weighted fat-saturated image (D). Middle
pancreatectomy was performed because of enlarging
enhancing component in cyst. Histopathologic finding
was side-branch intraductal papillary mucinous
neoplasm with low- to moderate-grade dysplasia.
Operative decision was based on development of
suspicious features on follow-up images. Case falls
into category of cyst with solid component.
C D

A B C
Fig. 4—61-year-old woman undergoing follow-up of side-branch intraductal papillary mucinous neoplasm in pancreas.
A, Axial T2-weighted MR image shows 12-mm T2 hyperintense lesion (arrow) in pancreatic neck that had communication with pancreatic duct on MRCP images (not
shown). No enhancing solid components or main ductal dilatation was seen. Yearly surveillance with MRI was prescribed.
B, Axial T2-weighted MR image 1 year after A shows stability of lesion size (arrow) and no development of suspicious features.
C, Axial T2-weighted MR image 2 years after A shows stability of side-branch intraductal papillary mucinous neoplasm (arrow). T2 hyperintense simple cyst in left kidney
is incidental finding.

346 AJR:200, February 2013

 Cystic Pancreatic Lesions

of MRCP in evaluating ductal anatomy and

the communication of small cystic pancreat-
Cystic Pancreatic

No specific imaging
Neuroendocrine

ic lesions [36, 37, 40]. However, the clinical

Neoplasm

Head, body, tail

Present (thick)
benefit of secretin MRCP in the care of pa-
tients with IPMN and other cystic lesions is

features
Present
5th–6th

Absent

Absent
Absent
currently unknown.
F=M

Oval

NA
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PET and PET/CT

As in a number of other malignancies, PET
Solid Pseudopapillary

invasion or enlarged
nodes (all have very
has a potential advantage in detection of meta-
Neoplasmc

static spread of invasive pancreatic neoplasms

Large size, local

low malignant
[41]. Hybrid PET/CT with 18F-FDG allows

Uncommon

potential)
Unilocular
Body, tail

assessment of tumor extent and microinva-

2nd–4th

Present

Absent

Absent
Absent
sion in minimally invasive disease, which can
Oval

be missed with other imaging techniques [42,

Fb

43]. The sensitivity of PET/CT for detecting

Mucinous Neoplasm
Intraductal Papillary

Main pancreatic duct

carcinoma in situ and borderline lesions re-
Diffuse pancreatic

> 10 mm; nodules

TABLE 1: General Features and Imaging Appearances of Commonly Encountered Pancreatic Cystic Lesions

mains unsatisfactory [44, 45]. A few studies

M > F (60%/40%)
Main Duct

duct dilatation
Head, body, tail

have shown that PET/CT performs marginally

Uncommon

better than MDCT alone in the detection and

present
Present
6th–7th

Absent
Absent

characterization of malignant cystic pancre-

NA
NA

atic neoplasms [35, 46]. In a study of 72 pa-

tients, Tomimaru et al. [35] found that with a
cutoff maximum standardized uptake value of
Mucinous Neoplasm
Intraductal Papillary

mucinous neoplasms

septa; mural nodules

Size > 3 cm; main duct
intraductal papillary

thick irregular wall,

dilatation (> 6 mm);

2.5, FDG PET had sensitivity, specificity, and

Usually present as a
Uncommon (septal)
Side Branch

and large lesions

accuracy of 93%, 100%, and 96% in the di-

M > F (60%/40%)

Present in mixed
Bunch of grapes
Head, body, tail

agnosis of malignant IPMN. Likewise, Sperti

Macrocystic

and colleagues [42] found that FDG PET was

channel
Present
6th–7th

Absent

useful in the differentiation of benign and ma-

lignant IPMNs with a specificity, sensitivity,
and accuracy of 92%, 97%, and 95%. Man-
Solid areas and irregular

sour et al. [45] found that PET had sensitivity

Macrocystic (< 6, each
Present (usually thick)
Mucinous Cystic

Present (peripheral)

and specificity of 57% and 85% in determina-

Neoplasm

wall; peripheral

tion of the malignancy of pancreatic cystic tu-

calcification

mors. The major limitations of PET/CT in the

evaluation of pancreatic cystic lesions include
Body, tail

> 2 cm)
4th–5th

Absent

Absent
Absent

higher cost, false-negative results for border-

Oval

bMore than 90% of patients with solid pseudopapillary neoplasm are women [25].

line and in situ tumors, and false-positive up-

Fa

take in areas of lesion-associated pancreatitis

and postbiopsy changes [35, 46]. Therefore,
Present (20–30%)

cAll solid pseudopapillary neoplasms have very low malignant potential.

Cystadenoma

Present (central)
F > M (75%/25%)

Microcystic (> 6,

Note—Data from [14, 18–20, 24, 25, 27, 60, 69, 70]. NA = not applicable.
Typically benign

there are not enough data to justify a role of

aMucinous cystic neoplasms occur almost exclusively in women [19].
Head, body, tail

each < 2 cm)

Serous

Present (thin)

PET/CT in the characterization of cystic pan-

Lobulated

creatic lesions [47].

6th–7th

Absent

Absent

Endoscopic Ultrasound
Endoscopic ultrasound is an excellent im-
Present (usually thin,

aging technique for detecting signs predictive

Involved in chronic
thick if infected)
Pseudocyst

Uncommon (rim)

of malignancy or aggressiveness in cystic

Head, body, tail

pancreatitis
multilocular

pancreatic lesions. Such signs include inter-

Uncommon
Unilocular/

nal septations, mural nodules, solid masses,

Variable
3rd–7th

Absent

vascular invasion, and lymphatic metastasis

None
M>F

[48, 49]. An additional benefit is its capability

for sampling fluid and solid components and
Main pancreatic duct

Main pancreatic duct

Imaging predictors of

depicting debris and wall thickness [50]. En-

Characteristic

communication

doscopic ultrasound also shows the details of

involvement
Calcifications
Age (decade)

malignancy

the pancreatic parenchyma and the pancreat-

Central scar
Loculation

ic duct. In a study involving 50 patients, Kim

Location
Shape

et al. [51] found that endoscopic ultrasound

Wall
Sex

had sensitivity, specificity, and accuracy of

AJR:200, February 2013 347


TABLE 2: Management of Commonly Encountered Cystic Lesions of the Pancreas
Lesion
Pseudocyst
Serous cystadenoma
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Mucinous cystic neoplasm
Side-branch intraductal papillary mucinous
neoplasm
Main-duct intraductal papillary mucinous
neoplasm
Solid pseudopapillary neoplasm
Cystic pancreatic neuroendocrine neoplasm
aFollow-up guidelines are based on Sendai criteria [22].
90.5%, 86.2%, and 88% for differentiating
cystic from solid pancreatic lesions. Kim and
colleagues also found that the sensitivity of
endoscopic ultrasound for characterization of
septa (77.8%), mural nodules (58.3%), main
pancreatic duct dilatation (85.7%), and main
pancreatic duct communication (88.9%) was
comparable to that of MRI. However, endo-
scopic ultrasound is invasive and operator
dependent, and these limitations have led to
considerable variability in determining accu-
racy in differentiating benign and malignant
lesions [48, 52–54]. Ahmad et al. [55] found
only fair agreement (κ = 0.24) between expe-
rienced endosonographers in the diagnosis of
neoplastic versus nonneoplastic cystic pan-
creatic lesions. In addition, several investiga-
tors have noted difficulty in sampling lesions
smaller than 3 cm [48, 52–54]. Currently, en-
doscopic ultrasound with or without aspira-
tion is used in the following instances: in-
determinate MDCT or MRCP findings; care
of patients at high surgical risk owing to co-
morbid conditions or advanced age, which
precludes them from undergoing extensive
surgery; and confirmation of the malignant
status of a cystic lesion before it is resected
[48, 52–54].
Endoscopic ultrasound–guided cyst fluid
aspiration is often performed in conjunction
348
Sahani et al.
Malignant Potential
None
Very low (malignant lesion is termed serous
cystadenocarcinoma)
6–36% prevalence of invasive carcinoma [19]
(malignant lesion is termed mucinous
cystadenocarcinoma)
6–46% risk of development of high-grade dysplasia
or malignancy [18]
57–92% risk of development of high-grade
dysplasia or malignancy within 5 y; follow-up
typically not conducted because the prevalence
of carcinoma and carcinoma in situ at diagnosis
is high [18]
Low malignant potential [25]
Variable malignant potential [25]
with endoscopic ultrasound for definitive di-
agnosis (Table 3). In a multicenter trial that
included 341 patients with cystic pancreatic
lesions [56], endoscopic ultrasound had low
sensitivity (56%) and specificity (45%) for
differentiation of mucinous and nonmuci-
nous cystic lesions on the basis of endoscop-
ic ultrasound morphologic features. Howev-
er, based on results of cytologic (fine needle
aspiration [FNA]) evaluation, sensitivity,
specificity, and accuracy were 34.5%, 83%,
and 51%. Biochemical analysis of the cyst
fluid aspirate for estimation of carcinoem-
bryonic antigen (CEA), mucin, and amylase
concentrations can facilitate reliable differ-
entiation of mucinous and nonmucinous cys-
tic neoplasms [18–20, 25, 56]. A cutoff CEA
concentration of 192 ng/mL has been found
to have 84% specificity in differentiation of
mucinous from nonmucinous lesions [54,
56–59]. Cyst fluid amylase concentration
also is helpful in differentiating pseudocysts
from lesions that are not pseudocysts [56, 58,
59]. Although amylase concentrations less
than 250 U/L are helpful for excluding pseu-
docysts, concentrations greater than 250 U/L
are nonspecific because they occur not only
in pseudocysts but also in benign IPMNs and
MCNs [58]. FNA cytologic evaluation of the
cyst fluid is also performed for cyst charac-
Recommendation
Referral to gastroenterologist or pancreatic
surgeon if lesion is symptomatic
Serial imaging annually for 3 y; referral to surgeon
if lesions is symptomatic or larger than 4 cm; for
patients at poor surgical risk, endoscopic
ultrasound (fine-needle aspiration to confirm
diagnosis and rule out malignancy)
Resection if patient’s condition allows surgery
Resection—if lesion is symptomatic, larger than
30 mm, or mural nodules or main duct dilatation
larger than 6 mm is present; if lesion is not
resectable, imaging follow-upa is recommended;
yearly follow-up imaging if lesion is smaller than
10 mm, 6- to 12-mo follow-up imaging if 10–20
mm, 6-mo follow-up if > 20 mm
Resection if patient’s condition allows surgery
Resection if patient’s condition allows surgery
Resection if patient’s condition allows surgery
terization, but the yield of cytologic evalua-
tion is often limited by low cellularity of the
fluid aspirate [18–20].
Evidence-Based Management
Guidelines
Imaging Appearance
Optimal management of cystic pancreat-
ic lesions begins with morphologic classifi-
cation into one of four types: unilocular, mi-
crocystic, macrocystic, and cysts with solid
components [27]. Unilocular cysts are thin-
walled simple cystic lesions without internal
septa, solid components, or calcifications [24,
27]. Pseudocysts are the most common lesion
in this category, and usually, features of pan-
creatitis, such as inflammation, atrophy, and
pancreatic parenchymal calcifications, are
also seen [24, 27]. In rare instances, IPMNs,
SCAs (< 10%), MCNs, and lymphoepitheli-
al cysts present as unilocular cysts [27, 60].
Microcystic lesions typically present with
multiple tiny cysts (more than six, each mea-
suring < 2 cm) with lobulated outlines and
thick or fleshy stroma [20, 27, 60, 61]. The
microcystic appearance is typically seen in
SCAs, and the pathognomic fibrous central
scar is present in only 30% of cases [20, 27,
60, 61]. Microcystic lesions can have avid
enhancement on arterial phase images after
AJR:200, February 2013

TABLE 3: Fluid Characteristics of Pancreatic Cystic Lesions
Characteristic Pseudocyst
Nature Turbid, hemorrhagic
Viscosity Low
Mucin content Low
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Carcinoembryonic antigen < 5 ng/mL
concentration
Amylase concentration High (> 250 U/L)
Glycogen content None
Note—Data from [20, 24, 58]. NA = not applicable.
aHigh concentration of amylase (> 250 U/L) can be seen in benign intraductal papillary mucinous neoplasms and benign mucinous cystic neoplasms.
IV contrast injection owing to the presence
of a vascular epithelial lining. This effect is
especially pronounced in lesions with a very
small cyst size, causing them to masquerade
as solid pancreatic neoplasms such as neu-
roendocrine tumors and metastatic lesions
from a primary cancer such as renal cell car-
cinoma or melanoma [60]. Delayed phase
contrast-enhanced images can show the mi-
crocysts and the enhancing stroma. Similar-
ly, T2-weighted MR images can confirm the
presence of high-signal-intensity microcysts
[20, 60]. Most SCAs have a microcystic ap-
pearance on images. Oligocystic and macro-
cystic patterns of SCA have been described
in fewer than 10% of patients, and they can
be difficult to differentiate from mucinous
neoplasms on imaging [20, 61, 62].
Macrocystic lesions are composed of few-
er cysts than are microcystic lesions, and the
cysts are often larger than 2 cm in diameter
[18, 19, 27]. MCNs and side-branch IPMNs
are included in this category. Patient demo-
graphics (age, sex) and presence or absence of
cyst communication can be used to differen-
tiate MCNs and side-branch IPMNs [18, 19,
27]. MCNs are common among middle-aged
women, are usually well defined, and are often
located in the pancreatic tail [18, 19, 24, 27].
Side-branch IPMNs are commonly detected in
older men and are more frequently located in
the proximal pancreas (head and uncinate pro-
cess) [18, 19, 24, 27]. An important differenti-
ating feature between MCN and IPMN is visu-
alization of pancreatic ductal communication.
If a clear channel of communication with the
pancreatic duct is visualized, the diagnosis of
side-branch IPMN is almost certain because
SCAs and MCNs do not communicate with
the pancreatic ductal system [16, 26].
Cysts with solid components include true
cystic tumors (MCNs, IPMNs) and solid pan-
creatic neoplasms associated with a cystic
AJR:200, February 2013
Cystic Pancreatic Lesions
Mucinous Cystic
Serous Cystadenoma Neoplasm
Thin and clear, possibly bloody Thick and viscous
Low High
Low High
< 5 ng/mL High (> 192 ng/mL)
Low (< 250 U/L) Variablea
Abundant None
component, which includes tumors such as
pancreatic neuroendocrine neoplasm, solid
pseudopapillary neoplasm, adenocarcinoma
of the pancreas, and metastatic lesions [27].
Both MDCT and MRI can depict the presence
of enhancing solid components in a cystic le-
sion, which is diagnostic for this category of
lesions. The lesions encountered in this cate-
gory are either frankly malignant or have high
malignant potential. Therefore, surgical re-
section is the preferred management [27, 63].
Management Guidelines
With MDCT and MRI, a selective man-
agement approach can be considered for each
patient after factors such as clinical presenta-
tion, age, sex, and surgical risk are accounted
for [12, 22, 63, 64] (Figs. 5 and 6). The even-
tual management paradigm should weigh the
risk of aggressiveness and the benefit of pan-
creatic resection. It should also include risk
of development of advanced dysplastic or in-
vasive changes in presumed mucinous lesions
[12, 22, 63]. Surgery is often recommended
for symptomatic cystic lesions, cystic lesions
having complex morphologic features (e.g.,
solid components), and cystic lesions detect-
ed in patients younger than 50 years [12, 22,
63]. Asymptomatic SCAs larger than 4 cm of-
ten are resected because of a high likelihood of
rapid growth and a propensity to development
of symptoms [65, 66]. Because mucinous le-
sions have a higher propensity toward aggres-
sive biologic behavior at detection and toward
later transformation, knowledge of the muci-
nous nature of cystic lesions influences man-
agement [22, 31, 67, 68]. In selected patients,
endoscopic ultrasound–guided cyst aspiration
and FNA can be considered if the imaging
findings are indeterminate or the risk of sur-
gery outweighs the benefits.
Because MCNs are encountered in young
patients and are premalignant or malignant,
Intraductal Papillary Solid Pseudopapillary
Mucinous Neoplasm Neoplasm
Thick and viscous Possibly bloody
High NA
High NA
High (> 192 ng/mL) NA
Variablea Low
None None
they are usually surgically treated at diagno-
sis [22]. The imaging predictors of malig-
nancy in MCNs include large size (> 4 cm)
and the presence of mural nodules and egg-
shell calcification [22]. Because the natural
history of MCNs can follow a stepwise pro-
gression to malignancy, these lesions typi-
cally require a more aggressive approach,
even when obvious imaging evidence of ma-
lignant behavior is lacking at the initial pre-
sentation [15, 22].
The prevalence of biologic aggressiveness
of cystic lesions varies from 44.6% to 60%
[6, 15, 30]. Biologically aggressive cystic le-
sions include those with overtly malignant
features and lesions with higher likelihood of
becoming malignant (histopathologic finding
of moderate- to high-grade dysplasia) [10, 68,
69]. The prevalence of potential malignancy is
higher in mucinous than in nonmucinous le-
sions [15, 31, 67, 68]. Mucinous cystic lesions
with low-grade dysplastic changes (adeno-
mas) are generally considered benign, and the
risk of malignant transformation is unknown.
Therefore, aggressive monitoring after surgi-
cal resection is not necessary [70–73].
On the basis of involvement of the pancre-
atic duct, IPMNs are classified as either main
duct IPMN, side-branch IPMN, or mixed vari-
ant IPMN involving both the main pancreatic
duct and side branches [14, 18, 22, 27]. IPMNs
have distinct histologic subtypes: gastric, in-
testinal, pancreatobiliary, and oncocytic [74].
Main duct IPMNs often have intestinal-type
epithelium, and side-branch IPMNs usually
have gastric-type epithelium [74]. Although all
morphologic variants of IPMN can progress to
cancer, invasive adenocarcinoma originat-
ing in gastric-type IPMNs is associated with
a significantly worse survival rate than that
originating from other types of IPMNs [74].
However, the imaging features are not spe-
cific for differentiating the various histologic
349

variants of IPMNs. IPMNs can be managed ei-
ther surgically or conservatively, depending on
their characteristics, the clinical presentation,
and the patient’s age. Because of the higher
risk of invasive cancer associated with main
duct lesions, resection is recommended for
all main duct and mixed variant IPMNs [14,
Downloaded from www.ajronline.org by 80.82.77.83 on 10/08/17 from IP address 80.82.77.83. Copyright ARRS. For personal use only; all rights reserved
22, 75]. In patients whose condition is consid-
ered acceptable for surgery, the type of sur-
gical resection is influenced by lesion loca-
tion and the extent of tumor foci in the duct
epithelium. For side-branch IPMNs, a surgi-
cal approach is undertaken if the patient has
symptoms (pain, nausea, diarrhea, weight loss,
jaundice), if there is main duct involvement or
dilatation (> 6-mm), if the cyst is larger than
3 cm, or complex features such as a thick ir-
regular wall, thick septa, and solid nodules are
identified on imaging [22].
Because side-branch IPMNs without com-
plex morphologic features usually have low
malignant potential, surgical management is
not always warranted [4, 22]. Although the
incidence of potential malignancy is low-
er for smaller lesions (< 3 cm), the presence
of suspicious features on images, even in a
small cystic lesion, should be approached
more aggressively [8, 16]. Therefore, despite
the low incidence of aggressiveness of mu-
cinous cystic lesions 3 cm and smaller, the
incidence is not low enough to dismiss the
lesions entirely, and careful review of the im-
aging features is mandated. In addition, pa-
tients whose condition is found not suitable
for surgical management often need frequent
assessments for growth and change in imag-
ing features [14, 15, 22].
A panel of experts have proposed the Sen-
dai criteria as guidelines for the management
of side-branch IPMNs [22]. The follow-up
guideline varies in accordance with the size
of side-branch IPMN [22]. Lesions small-
er than 1 cm are evaluated annually; those
measuring 1–2 cm are evaluated every 6–12
months; and those measuring 2–3 cm are im-
aged at intervals of 3–6 months [22]. How-
ever, authors of more recent studies have rec-
ommended considering a longer surveillance
interval of 2 years for cystic lesions small-
er than 3 cm after baseline detection in the
absence of mural nodules [63, 76]. Accord-
ingly, it would be prudent to perform follow-
up evaluations every 2 years for side-branch
IPMNs smaller than 2 cm and to perform an-
nual evaluations for IPMNs measuring 2–3
cm [63, 76].
The choice of imaging modality for moni-
toring IPMNs depends on institutional prefer-
350
Sahani et al.
Pancreatic cystic mass detected with MDCT or MRI
Macrocystic or cyst with Cyst with solid components
Unilocular Microcystic
septa (indeterminate) or with suspicious features
Symptomatic ≥ 4 cm < 4 cm
Possible Possible
Indeterminate
MCN IPMN
EUS with or
Consider surgical See Figure 6
resection depending
without aspiration
on comorbidities
and risk
Benign Indeterminate Suspicious features
< 3 cm
≥ 3 cm
Follow-up imaging
Consider surgical resection depending
on comorbidities and risk
Fig. 5—Flowchart shows management guidelines for pancreatic cystic lesions seen on imaging. Suspicious
features include presence of mural nodules, main duct dilatation, solid component, symptoms, and thick wall
or septations. Differentiation of possible intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic
neoplasm (MCN) is based on classic imaging features. EUS = endoscopic ultrasound.
ence and the patient’s age. Although MDCT ture (Fig. 6). In patients in whom endoscop-
and MRI are both accepted methods for fol- ic ultrasound findings indicate a cystic lesion
low-up of these lesions, for adults younger is benign, follow-up is performed in accor-
than 50 years, MRI can be considered ow- dance with the size of the cystic lesion.
ing to concerns about radiation exposure from
MDCT. Regardless of the type of imaging Surgical Management
modality used, contrast-enhanced examina- A variety of open and laparoscopic surgi-
tions are crucial for improving detection of cal options are available for patients whose
enhancing solid components, the cyst wall, condition allows surgery. For lesions in the
and septa. Contrast injection is desirable, but head of the pancreas, such as an IPMN with
for patients with compromised renal function one or more of the aforementioned suspicious
and those with lower cancer risk (small lesion, features, either a standard Whipple procedure
advanced age), follow-up CT or MRI can be or pylorus-sparing pancreaticoduodenectomy
performed without contrast injection. Howev- can be performed [5, 39, 78]. Medial segmen-
er, if suspicious features are observed during tal pancreatectomy is performed for a lesion
follow-up examinations, IV contrast medium in the neck or the body of the pancreas. For
should be used [77]. lesions involving the tail of the pancreas, the
A vexing issue in the follow-up of pancre- spleen is assessed for involvement because it
atic cystic lesions is the total duration of fol- does not necessarily have to be removed with
low-up. It would be reasonable to increase the distal pancreas [5, 39, 78].
the follow-up intervals to 2 years for lesions
2 cm and larger that are stable for 2 years. For Postsurgical Follow-Up
lesions smaller than 2 cm, imaging follow-up The postsurgical follow-up of patients who
can stop after stability has been found for 2 have undergone resection of cystic pancreat-
years. However, due consideration needs to ic neoplasms depends on the histologic fea-
be given to the patient’s age, symptoms, and tures. Benign MCNs do not recur and there-
capability of undergoing surgical resection. fore require no postoperative follow-up [22].
At follow-up imaging, lesions that are in- Because the risk of local recurrence and dis-
determinate or have a growth spurt of more tant metastasis is higher for malignant MCNs,
than 1 cm/year, endoscopic ultrasound can postsurgical follow-up evaluations are needed
be performed to confirm the malignant na- every 6 months [22]. The postsurgical surviv-
AJR:200, February 2013

al rate for invasive IPMN varies between 35%
and 60%, mortality being associated with can-
cer recurrence, most commonly local or ex-
trapancreatic metastasis [79–81]. The risk of
recurrence ranges from 3% to 11% [75, 79].
In cases of local recurrence, completion pan-
createctomy may be necessary. It is important
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to emphasize that invasive IPMN has a bet-
ter survival rate than pancreatic ductal adeno-
carcinoma [74]. Follow-up of a side-branch
IPMN should be pursued carefully, and the
time frame of follow-up should be based on
the patient’s risk and the lesion size. Guide-
lines laid down by the International Associa-
tion of Pancreatology call for yearly follow-up
evaluations of benign IPMNs and for imaging
follow-up in conjunction with measurement
of serum markers (CEA and CA19-9) after re-
section of invasive IPMN [7, 22]. The follow-
up imaging protocol used in these scenarios
should consider the aggressiveness of the re-
sected lesion and the surgical margins. Most
recurrences take place within 3 years. There
have been reports [69, 82], however, of recur-
rence after 5 years. If the surgical margins are
negative, benign lesions can be evaluated at
intervals of 1 year. Patients with borderline le-
sions or carcinoma in situ, a positive margin,
or indeterminate cystic lesions in the pancreat-
ic remnant need more frequent evaluations for
the first 2–3 years [83]. An added objective of
follow-up imaging is to detect invasive cancer,
IPMN detected with MDCT or MRI
Main duct IPMN
Combined IPMN
Symptomatic side-branch IPMN
> 3 cm
High risk
Risk and benefits of surgery
Positive cytologic result
Low risk
Resection
Growth > 1 cm/y, increase in size to > 3 cm, suspicious features
Fig. 6—Flowchart shows management guidelines for intraductal papillary mucinous neoplasm (IPMN). High-
risk factors for surgery are old age and presence of comorbid conditions. Low-risk factors for surgery are
young age and no comorbid conditions. Suspicious features are mural nodules, main duct dilatation, solid
component, symptoms, and thick wall or septations. Follow-up guidelines are based on Sendai criteria [22].
EUS = endoscopic ultrasound.
AJR:200, February 2013
Cystic Pancreatic Lesions
because patients with IPMN are at increased
risk of development of synchronous or meta-
synchronous invasive ductal adenocarcinoma
[14] (Fig. 3).
The Gastroenterologist’s Perspective
The detection of a potentially malignant
lesion in the pancreas causes considerable
anxiety to both patient and physician. The
prevalence of incidentally identified cystic
lesions of the pancreas is high, but it is in-
creasingly becoming apparent that only a
small minority of such lesions progress to
cancer. Imaging, especially MRI, MDCT,
and endoscopic ultrasound, plays an impor-
tant role in risk stratification, avoiding un-
necessary surgery, and safe follow-up of le-
sions that are not resected. Most incidentally
identified cystic lesions can be safely fol-
lowed up. Current international guidelines
help in this regard. They are highly sensitive
to identification of high-risk lesions (in situ
and invasive cancer) but need further refine-
ment to improve their positive predictive val-
ue for high-grade pathologic findings.
The Pancreatic Surgeon’s Perspective
Cystic neoplasms of the pancreas are one
of the most common indications for pancre-
atic surgery. Because most of the cystic le-
sions that we remove do not contain invasive
cancer and are asymptomatic, we can state
Asymptomatic side-branch
IPMN
2−3 cm
< 2 cm
EUS
Negative cytologic result
Follow-up with imaging
Size < 1 cm Size 1−2 cm Size 2−3 cm
follow-up
yearly
follow-up
every
follow-up
every
6−12 months 3−6 months
that many of these operations are preventive.
Most of these lesions are IPMNs that contain
only low-, moderate-, or high-grade dyspla-
sia (what we used to refer to as in situ carci-
noma), and we remove them either because
we cannot reliably exclude invasive cancer
or because we believe that progression will
inevitably occur and the lesion will become
invasive, akin to the process that occurs in a
colonic polyp. The decision to operate, how-
ever, is not straightforward. Although pan-
creatic surgery has become safer and the risk
of dying after a Whipple procedure or dis-
tal pancreatectomy is less than 2% at most
major medical centers, the frequency of
complications is still high (> 40%), and the
consequences of endocrine and exocrine in-
sufficiency with loss of pancreatic tissue are
not trivial. These risks have to be carefully
weighed against the potential benefit. Strik-
ing the right balance can be difficult because
most of these lesions occur in elderly per-
sons, and our knowledge of the natural his-
tory of IPMNs is incomplete.
Practice Recommendations
Annual imaging surveillance is gener-
ally sufficient for benign serous cystadeno-
mas smaller than 4 cm and for asymptomatic
lesions. Asymptomatic thin-walled unilocular
cystic lesions smaller than 3 cm or side-branch
IPMNs should be followed up with CT or MRI
at 6 and 12 months interval after detection and
then annually for 3 years. Cystic lesions with
more complex features or with growth rates
greater than 1 cm/year should be followed more
closely or recommended for resection if the pa-
tient’s condition allows surgery. Symptomatic
cystic lesions, neoplasms with high malignant
potential, and lesions larger than 3 cm should
be referred for surgical evaluation. Endoscopic
ultrasound with FNA biopsy can be used preop-
eratively to assess the risk of malignancy.
Recommendations for Further
Research
Despite great strides in noninvasive imag-
ing and endoscopic ultrasound in the charac-
terization of pancreatic cystic lesions, current
imaging techniques are not accurate in the dif-
ferentiation of cystic lesions associated with
carcinoma in situ or high-grade dysplasia
from benign lesions. Though MDCT and MRI
can reliably depict cystic lesions with obvious
aggressive biologic features, their value for
prediction of the biologic behavior of all the
cysts is limited. Advanced techniques such as
PET/MRI with targeted radioisotopes have
351

potential for characterization of changes at
the molecular level. Endoscopic ultrasound–
guided FNA and fluid analysis already have a
specific role in surgical decision making [84].
However, though the commonly used cyst
fluid CEA levels are useful in differentiating
mucinous from nonmucinous cystic lesions
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of the pancreas, they have no value for as-
sessing the degree of dysplasia in mucinous
lesions [59, 84]. Pancreatic cyst fluid DNA
analysis that includes identification of KRAS2
gene mutations is being explored for predict-
ing the aggressiveness of pancreatic cysts
[84]. Few initial studies have shown promise
with this technique over FNA and other types
of cyst fluid analysis in predicting the biolog-
ic features of cysts [84]. Further studies are
necessary to validate reliable molecular and
imaging markers for accurate prediction of
the biologic behavior of cysts and to guide
the management of pancreatic cystic lesions.
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