Pancreatic cysts are common findings on MRI. The approach to decision making and interpretation involves a combination of clinical assessment, classification of imaging findings to establish the most likely pathological diagnosis. The establishment of a definitive pathological diagnosis with imaging is often not possible and there is a high frequency of insignificant benign or indolent pancreatic cysts. As a results there is danger of over utilization of imaging followup.

The pancreatic "ditzel" meaning a very tine cyst seen on MRI (i.e <=3mm) without a clear connection to a pancreatic duct is an extremely common finding and not directly addressed in these guidelines as a separate entity. There is no clear consensus on what to do with these however there is a feeling that continued imaging followup of these incidentals is likely unnecessary.

Although there are multiple guidelines and consensus statements on cystic pancreatic lesions we will focus on three: The American College of Radiology Guidelines (ACR 2010); the International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas (Tanaka or Fukuoka 2012); and the American Gastroenterologist Association Institute Guideline on the Diagnosis and Management of Asymptomatic Neoplastic Pancreatic Cysts (AGA 2015). See Figures 1 and 2 for flow diagram proposed in the ACR and Tanaka guidelines.

The presence of pancreatic cysts is associated with a 3 fold increased risk of pancreatic ductal adenocarcinoma (PDAC) and in patients under 65 there is an increased mortality risk however this is not much different than the risk of PDAC related to smoking and we do not screen for pancreatic cancer in smokers. Additional features must be present. Three key risk factors are noted: main duct dilation >5mm, a size >3cm particularly in younger patients and solid components. Pancreatic cysts fluid analysis is a promising area of research however standard criteria for risk stratification have not been developed

For incidental cysts <3cm the general approach is imaging followup and intervals of 1 year or longer with the AGA2015 guidelines recommending 1yr then q 2years for a maximum of 2 years. Cysts with significant change undergo EUS and FNA as do cysts with at least two high risk features according to the AGA 2015 guidelines.

A multidisciplinary approach and a case by case discussion is advocated for best decision making for these cases as imaging based diagnostic criteria alone are of modest accuracy