Imaging plays an essential and expanding role in managing pancreatic cystic lesions (PCLs) [1], enhancing detection and understanding of their biology and morphology to better differentiate benign from malignant lesions [2]. The main clinical challenge is identifying high-risk cysts warrant intervention while avoiding unnecessary operations for benign lesions, which carry risks and costs [3,4]. Combining imaging with clinical and demographic data allows cyst-specific diagnosis with 70–80 % accuracy [5,6]. This review provides a comprehensive radiological overview of PCLs and discuss current imaging protocols and emerging imaging advances as potential tools to enhance diagnostic precision.

Evaluating malignancy risk in PCLs relies heavily on imaging, with Magnetic Resonance Imaging (MRI), especially with Magnetic Resonance Cholangiopancreatography (MRCP), preferred over Computed Tomography (CT) for its superior contrast resolution and ability to visualize internal features like mural nodules, septations, and ductal communication [[7], [8], [9], [10]]. MRI also avoids radiation, making it ideal for long-term surveillance. Nonetheless, MRI has limitations including lower spatial resolution, motion sensitivity, poor calcification detection, longer scan times, and higher cost [11]. Although MRI offers greater sensitivity for detecting cysts and their features, accuracy between MRI and CT in malignancy detection is similar [[12], [13], [14]].

Despite the proliferation of multiple guidelines, no universally accepted imaging protocol exists for PCL assessment due to inconsistent data and limited high-quality studies [[15], [16], [17], [18]]. While the European Study Group have failed to reccomend minimum technical requirements, the American College of Radiology (ACR) suggest to perform at least a late arterial and a portal venous phases for CT studies and fat-suppressed T2-weighted sequences, multiphase gadolinium-enhanced T1-weighted imaging with arterial, early portal and late portal phases, and MRCP with 3D reconstruction to assess ductal communication for MRI studies [19].

Given the rising PCL detection and imaging demand, recent studies have explored the feasability and accuracy of abbreviated MRI protocols for follow-up that omit contrast-enhanced sequences. These approaches have demonstrated to significantly reduce both scan times (by 10–27 min) and costs (by 61–75 %) while maintaining comparable diagnostic accuracy and interobserver agreement. Moreover, eliminating gadolinium administration offers additional advantages, including reduced patient discomfort, elimination of the risk of nephrogenic systemic fibrosis, and fewer logistical challenges related to intravenous contrast delivery. Although some concern persists about regarding the potential misinterpretation of a true neoplastic mural nodule for a false nodule and vice-versa, data suggest that such cases are sporadic and typically represent false positives [1]. Additionally, diffusion-weighted imaging (DWI) has emerged as a valuable adjunctive tool that enhances the accuracy of unenhanced MRI in detecting malignancy, particularly for mural nodules >5 mm, thereby improving diagnostic consistency among radiologists. DWI can be assessed both qualitatively, through signal intensity, and quantitatively, via apparent diffusion coefficient (ADC) measurements, with malignant lesions typically showing high signal on DWI and reduced ADC values due to increased cellularity and tissue disorganization. The use of high b-values (e.g., b = 1000 s/mm²) has been shown to improve malignancy detection in PCLs by reducing the T2 shine-through effect, which is accentuated by the long T2 relaxation time of their inhereint cystic nature and might be mistaken for restricted diffusion [[20], [21], [22]]. Despite these encouraging results, most guidelines still favor full contrast-enhanced MRI [[15], [16], [17], [18], [19]]. An exception is represented by the Korean Society of Abdominal Radiology, which explicity endorses abbreviated protocols, particularly for patients with renal impairment as it can provide “sufficient information equivalent to the standard MR protocol”, suggesting performing at least axial and coronal heavily T2-weighted and axial T1-weighted sequences [23]. While abbreviated MRI shows promise for follow-up or screening, it is not yet recommended to replace full protocols for initial diagnosis due to unpredictability. Nevertheless, exploring their use in long-term follow-up or screening represent a compelling avenue for investigation since it could help optimize resource allocation and improve patient experience in real-world clinical practice.