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Objective Evaluate the value of cytology relative to imaging features in risk assessment for malignancy as defined in the Sendai Guidelines. Background The Sendai Guidelines list symptoms, cyst size > 30mm, dilated main pancreatic duct (MPD) > 6mm, mural nodule (MN) and “positive” cytology as high risk stigmata for malignancy warranting surgical triage. Methods We reviewed clinical, radiological and cytological data of 112 patients with histologically confirmed mucinous cysts of the pancreas evaluated in a single tertiary medical center. Cytology slides were blindly re-reviewed and epithelial cells grouped as either benign or high grade atypia (HGA) [≥ high grade dysplasia]. Histologically, neoplasms were grouped as benign (low-grade and moderate dysplasia) and malignant (in-situ and invasive carcinoma). Performance characteristics of cytology relative to other risk factors were evaluated. Results Dilated MPD, MN and HGA were independent predictors of malignancy (p<0.0001), but not symptoms (p=.29) or cyst size > 30 mm (p=.51). HGA was the most sensitive predictor of malignancy in all cysts (72%) and in small (≤ 30 mm) branch-duct IPMN (67%) while also being specific (85 and 88% respectively). MN and dilated MPD were highly specific (>90%), but insensitive (39–44%). Cytology detected 30% more cancers in small cysts than dilated MPD or MN and half of the cancers without either of these high risk imaging features. Conclusions Cytology adds value to the radiological assessment of predicting malignancy in mucinous cysts, particularly in small branch-duct IPMN.

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