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Pancreatic cystic lesions
A pancreatic cyst is a common incidental finding; identify the type (IPMN, MCN, serous cyst or pseudocyst) and look for "high-risk stigmata" and "worrisome features" — these, not size alone, decide between surgery, EUS and surveillance.
Why it matters in the exam
Questions usually present an incidental finding on CT or MRI and test whether you can classify it. A serous cyst ("honeycomb" with a central scar, older woman) is almost always benign; an MCN occurs almost only in women, in the body and tail of the pancreas, and is resected because of malignant potential; an IPMN is connected to the pancreatic duct — main-duct (high risk) or branch-duct (lower risk). A pseudocyst follows pancreatitis and has no epithelium.
The treatment decision rests on the international criteria: high-risk stigmata — a cyst of the pancreatic head causing obstructive jaundice, an enhancing solid component of 5 mm or more, or a main duct dilated to 10 mm or more — call for surgery in a fit patient. Worrisome features — a cyst of 3 cm or more, a solid component smaller than 5 mm, a thickened wall, a main duct of 5–9 mm, a raised CA 19-9 or rapid growth — call for EUS. A pseudocyst is drained only for symptoms or complications, preferably once the wall has matured, at about 4 weeks or more, by an endoscopic route into the stomach.
Key points
- Four types: serous, MCN, IPMN, pseudocyst.
- High-risk stigmata — jaundice, enhancing component of 5 mm or more, main duct of 10 mm or more: surgery.
- Worrisome features — cyst of 3 cm or more, duct of 5–9 mm, rapid growth: EUS.
- MCN — resect; serous — almost always benign.
- Pseudocyst — drain only for symptoms, after 4 weeks or more.
Summary table
| Type | Features | Treatment |
|---|---|---|
| Serous cyst | Older woman, "honeycomb" with a central scar | Almost always benign; surgery only for symptoms |
| MCN | Almost only in women, body and tail, no duct connection | Resection (usually distal pancreatectomy) in a fit patient |
| Main-duct IPMN | Dilated main duct | High malignant risk; surgery when the duct is 10 mm or more |
| Branch-duct IPMN | Cyst communicating with a side branch of the duct | Surveillance; EUS for worrisome features; surgery for high-risk stigmata |
| Pseudocyst | After pancreatitis, no epithelium | Drain only for symptoms or complications, usually after 4 weeks or more, endoscopically |
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Sources
- International consensus guidelines for the management of IPMN (Kyoto guidelines), 2024 — High-risk stigmata, worrisome features and surveillance
- European evidence-based guidelines on pancreatic cystic neoplasms, 2018 — Diagnosis and indications for surgery
- Sabiston Textbook of Surgery, 21st edition (2022) — Exocrine Pancreas
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.