Cyst Removal Recommendations

Cyst removal is recommended when cysts are symptomatic, show concerning features for malignancy, or demonstrate significant growth over time. 1

Pancreatic Cysts

Surgical removal is recommended for pancreatic cysts with high-risk features including:
- Presence of both a solid component and a dilated pancreatic duct 1
- Concerning features on EUS-FNA (endoscopic ultrasound with fine needle aspiration) 1
- Significant changes in cyst characteristics over time 1
All solid-pseudopapillary neoplasms (SPN) should undergo radical resection 1

For pancreatic cysts without concerning features, MRI surveillance is recommended after 1 year and then every 2 years 1
Surveillance may be discontinued if there has been no significant change in cyst characteristics after 5 years 1
Patients with invasive cancer or dysplasia in a surgically resected cyst should undergo MRI surveillance of any remaining pancreas every 2 years 1

Serous cystadenomas (SCN):
- Surgery is only recommended for symptomatic patients with compression of adjacent organs (bile duct, stomach, duodenum, portal vein) 1
- Asymptomatic patients with radiological evidence of SCN should be followed up for 1 year, then symptom-based follow-up 1
Mucinous cystic neoplasms (MCN):
- Standard oncologic resection with lymph node dissection is indicated for MCN with imaging features suggesting high-grade dysplasia or cancer 1
- MCN without suspicious features can be treated with non-oncological resection 1

Simple cysts up to 5cm in premenopausal women require no intervention 2
For hemorrhagic cysts >5cm, follow-up ultrasound in 8-12 weeks is recommended 2
If a cyst persists or enlarges on follow-up, referral to a gynecologist is suggested 2
Complicated cysts that increase in size on follow-up should undergo tissue biopsy 1

Transvaginal and transabdominal ultrasound are first-line imaging modalities for evaluation of pelvic cysts 2
Color Doppler should be included to assess cyst vascularity 2
MRI is preferred over CT for follow-up of benign adnexal masses 1

Minimal excision technique is recommended for removal, which is less invasive than complete surgical excision 3
Inflamed cysts are difficult to excise; postpone excision until inflammation has subsided 3

Management of simple renal cysts is indicated only for symptoms or complications (hemorrhage, infection, hydronephrosis, hypertension) 4
Percutaneous aspiration alone or with sclerotherapy is often first-line treatment 4
Surgical decortication is reserved for recurrent or very large symptomatic cysts 4

Presence of symptoms predicts higher likelihood of premalignant or malignant pathology in pancreatic cysts (60% vs. 23%) 5
Age over 70 years is associated with higher malignancy risk in pancreatic cysts (60% vs. 21%) 5
Incidental pancreatic cysts are common in older patients but more than half are either malignant or premalignant 6

Patients requiring pancreatic surgery should be referred to centers with demonstrated expertise in pancreatic surgery 1
This recommendation is based on data showing lower immediate postoperative mortality and long-term mortality for patients who undergo surgery in high-volume pancreatic centers 1

Dismissing incidental pancreatic cysts, as they have significant malignant potential 6
Failing to characterize ovarian cysts properly, especially in perimenopausal women 2
Delaying intervention for cysts with concerning features or significant growth 1, 5