new england journal
n engl j med
Cystic Neoplasms of the Pancreas
William R. Brugge, M.D., Gregory Y. Lauwers, M.D., Dushyant Sahani, M.D.,
Carlos Fernandez-del Castillo, M.D., and Andrew L. Warshaw, M.D.
From the Gastrointestinal Unit (W.R.B.) and
the Departments of Pathology (G.Y.L.), Ra-
diology (D.S.), and Surgery (C.F.C., A.L.W.),
Massachusetts General Hospital, Boston.
Address reprint requests to Dr. Brugge at
the Gastrointestinal Unit, Blake 452c,
Massachusetts General Hospital, 55 Fruit
St., Boston, MA 02114, or at wbrugge@
N Engl J Med 2004;351:1218-26.
Copyright © 2004 Massachusetts Medical Society.
hysicians from a wide range of disciplines are being confront-
ed with questions regarding the management of cystic lesions of the pancreas.
Owing to recent improvements in pancreatic imaging, an increasing number of
cystic lesions have been identified in asymptomatic patients as well as in patients pre-
senting with jaundice, pancreatitis, or abdominal pain. Here we review recent develop-
ments in the understanding and management of cystic lesions of the pancreas.
Because inflammatory pseudocysts constitute a majority of cystic lesions of the pancre-
as, the clinical challenge is the differential diagnosis and management of cystic neo-
plasms, which represent less than 10 percent of pancreatic neoplasms. In the 1990s, at
our institution, the proportion of pancreatic resections that were performed for cystic
neoplasms doubled, from 16 percent to 30 percent.
With increasing experience with these lesions has come a refinement of our under-
standing of the pathology of pancreatic cystic neoplasms (Fig. 1) and of their natural
history. These tumors encompass a spectrum of benign, malignant, and borderline
neoplasms that either are primarily cystic or result from the cystic degeneration of solid
tumors (Table 1). Among these neoplasms, serous cystadenomas (32 to 3