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Welcome to the CIST Center

The Cyst Imaging Surveillance and Treatment (CIST) Center at MGH provides imaging services as well as treatment and monitoring of patients with pancreatic cystic lesions. Clinicians in the CIST Center offer a comprehensive and personalized history and physical examination of patients. The evaluation includes a review of previous imaging results, cyst fluid analysis, and risk factors for malignancy. CT and MRI scans are submitted for interpretation by specialists in the MGH Department of Radiology.

Clinicians in the Department of Surgery and Division of Gastroenterology are available for patient consultations:

Keith Lillemoe, MD
Kumar Krishnan, MD
Motaz Qadan, MD, PhD
Carlos Fernandez-del Castillo, MD
Brenna W. Casey, MD
Cristina Ferrone, MD

At the MGH CIST Center, patients with pancreatic cystic lesions are monitored with advanced pancreas imaging at regular intervals. Magnetic resonance cholangiopancreatography (MRCP) imaging provides detailed images of the cystic lesions and associated findings of nodules, masses, dilated ducts and thickened septations.

Learn More About Imaging

The Cyst Imaging Surveillance and Treatment (CIST) Center provides state-of-the-art imaging services for diagnosis and surveillance of pancreatic cystic lesions. 

Magnetic resonance cholangiopancreatography

At MGH, the preferred imaging test for pancreatic cystic lesions is magnetic resonance cholangiopancreatography (MRCP). Advanced MRI techniques are used to obtained high resolution, 3-dimensional images of the pancreas and cystic lesions. The images are used to calculate the precise diameters and volume of cystic lesions. Growth of the cystic lesions is calculated over time. The presence of abnormal growths in the wall of cysts (mural nodules) is noted, along with other findings such as dilated pancreatic ducts.

Endoscopic ultrasound

Endoscopic ultrasound (EUS) provides high-resolution images of pancreatic cystic lesions and guides fine needle aspiration. At MGH, EUS has proven to be a strong tool for the evaluation of mural nodules and masses, and collection of cyst fluid. One of the most accurate markers for mucinous cysts, carcinoembryonic antigen (CEA), was developed at MGH in a large multi-center trial. Other markers of mucinous cysts and malignancy based on DNA mutations are being pioneered in the MGH Molecular Pathology Laboratory.

In selected patients, endoscopic ultrasound is used to aspirate pancreatic cysts. The aspirated fluid is analyzed for cytology (imaging of cells), tumor markers (CEA), and DNA markers of malignancy. KRAS is the most commonly used DNA marker and helps define the presence of a mucinous cyst. Advanced DNA analysis is performed in the MGH Molecular Pathology Laboratory, which has established itself as an important new resource for diagnostic studies in genetic mutations.

Surgical Options

The Cyst Imaging Surveillance and Treatment (CIST) Center includes expert surgeons who specialize in the excision of pancreatic cysts.

The surgical management of pancreatic cysts was pioneered by Dr. Andrew Warshaw at MGH nearly 40 years ago. Surgical excision of cysts requires that an entire segment of the pancreas be resected and not just the cyst alone. The type of resection is dependent upon the location of the cyst. A resection of a cyst in the head of the pancreas involves a Whipple resection.

MGH performs more Whipple resections than any other hospital in New England. Cysts located in the body and tail of the pancreas require a distal pancreatectomy, which is often done laparoscopically. For cysts located in the neck or proximal body of the pancreas, a middle pancreatectomy, an operation that was pioneered at MGH, can be done. Compared to the alternative of a distal pancreatectomy, a middle pancreatectomy is much less likely to lead to diabetes or pancreatic exocrine insufficiency. 

Surgical resection margins are evaluated by an expert pancreatic pathologist at the time of the operation to ensure that no concerning disease is left behind. Resected lesions are carefully analyzed by pathologists to determine the type of cyst, the presence of malignancy and the stage of malignancy. One of the major developments in the classification of IPMN has been lead by a MGH pathologist, Dr. Mari Mino-Kenudson. There are four tissue types of IPMN and the type of IPMN has a major impact on the behavior and aggressiveness of malignant IPMNs.

Featured Publications

The physicians at the Cyst Imaging Surveillance and Treatment (CIST) Center at Massachusetts General Hospital are active researchers. Members of the CIST team actively publish clinical and translational papers describing their advancements in diagnosis and treatment of pancreatic cysts.

Brenna W. Casey, MD

  • Lee LS, Saltzman JR, Bounds BC, Poneros JM, Brugge WR, Thompson CC. EUS-guided fine needle aspiration of pancreatic cysts: a retrospective analysis of complications and their predictors. Clin Gastroenterol Hepatol. 2005;3(3):231-6. PMID: 15765442. PubMed
  • Gan SI, Thompson CC, Lauwers GY, Bounds BC, Brugge WR. Ethanol lavage of pancreatic cystic lesions: initial pilot study. Gastrointest Endosc. 2005;61(6):746-52. PMID: 15855986. PubMed
  • Pitman MB, Michaels PJ, Deshpande V, Brugge WR, Bounds BC. Cytological and cyst fluid analysis of small (< or =3 cm) branch duct intraductal papillary mucinous neoplasms adds value to patient management decisions. Pancreatology. 2008;8(3):277-84. PMID: 18497541. PubMed

Carlos Fernandez-del Castillo, MD

  • Alexander BM, Fernandez-Del Castillo C, Ryan DP, Kachnic LA, Hezel AF, Niemierko A, Willett CG, Kozak KR, Blaszkowsky LS, Clark JW, Warshaw AL, Hong TS. Intraductal papillary mucinous adenocarcinoma of the pancreas: clinical outcomes, prognostic factors, and the role of adjuvant therapy. Gastrointest Cancer Res. 2011;4(4):116-21. PMID: 22368734. PubMed
  • Arvold ND, Ryan DP, Niemierko A, Blaszkowsky LS, Kwak EL, Wo JY, Allen JN, Clark JW, Wadlow RC, Zhu AX, Fernandez-Del Castillo C, Hong TS. Long-term outcomes of neoadjuvant chemotherapy before chemoradiation for locally advanced pancreatic cancer. Cancer. 2012;118(12):3026-35. PMID: 22020923. PubMed
  • Conrad C, Fernandez-Del Castillo C. Preoperative evaluation and management of the pancreatic head mass. J Surg Oncol. 2012. PMID: 22674403. PubMed

Cristina Ferrone, MD

  • Haynes AB, Deshpande V, Ingkakul T, Vagefi PA, Szymonifka J, Thayer SP, Ferrone CR, Wargo JA, Warshaw AL, Fernandez-del Castillo C. Implications of incidentally discovered, nonfunctioning pancreatic endocrine tumors: short-term and long-term patient outcomes. Arch Surg. 2011;146(5):534-8. PMID: 21576607. PubMed
  • Cecchini S, Correa-Gallego C, Desphande V, Ligorio M, Dursun A, Wargo J, Fernandez-del Castillo C, Warshaw AL, Ferrone CR. Superior prognostic importance of perineural invasion vs. lymph node involvement after curative resection of duodenal adenocarcinoma. J Gastrointest Surg. 2012;16(1):113-20; discussion 120. PMID: 22005894. PubMed
  • Kelly PJ, Shinagare S, Sainani N, Hong X, Ferrone C, Yilmaz O, Fernandez-del Castillo C, Lauwers GY, Deshpande V. Cystic papillary pattern in pancreatic ductal adenocarcinoma: a heretofore undescribed morphologic pattern that mimics intraductal papillary mucinous carcinoma. Am J Surg Pathol. 2012;36(5):696-701. PMID: 22367300. PubMed
Keith Lillemoe, MD
  • Waters JA, Schnelldorfer T, Aguilar-Saavedra JR, Chen JH, Yiannoutsos CT, Lillemoe KD, Farnell MB, Sarr MG, Schmidt CM. Survival after resection for invasive intraductal papillary mucinous neoplasm and for pancreatic adenocarcinoma: a multi-institutional comparison according to American Joint Committee on Cancer Stage. J Am Coll Surg. 2011;213(2):275-83. PMID: 21601488. PubMed
  • Beane JD, House MG, Cote GA, DeWitt JM, Al-Haddad M, LeBlanc JK, McHenry L, Sherman S, Schmidt CM, Zyromski NJ, Nakeeb A, Pitt HA, Lillemoe KD. Outcomes after preoperative endoscopic ultrasonography and biopsy in patients undergoing distal pancreatectomy. Surgery. 2011;150(4):844-53. PMID: 22000199. PubMed
  • Cauley CE, Waters JA, Dumas RP, Meyer JE, Al-Haddad MA, DeWitt JM, Lillemoe KD, Schmidt CM. Outcomes of primary surveillance for intraductal papillary mucinous neoplasm. J Gastrointest Surg. 2012;16(2):258-67; discussion 266. PMID: 22089952. PubMed

Vikram Deshpande, MD

  • Ferrone CR, Pieretti-Vanmarcke R, Bloom JP, Zheng H, Szymonifka J, Wargo J, Thayer SP, Lauwers GY, Deshpande V, Mino-Kenudson M, Castillo CF, Lillemoe KD, Warshaw AL. Pancreatic ductal adenocarcinoma: Long-term survival does not equal cure. Surgery. 2012. PMID: 22763261. PubMed
  • Arvold ND, Willett CG, Fernandez-Del Castillo C, Ryan DP, Ferrone CR, Clark JW, Blaszkowsky LS, Deshpande V, Niemierko A, Allen JN, Kwak EL, Wadlow RC, Zhu AX, Warshaw AL, Hong TS. Pancreatic neuroendocrine tumors with involved surgical margins: prognostic factors and the role of adjuvant radiotherapy. Int J Radiat Oncol Biol Phys. 2012;83(3):e337-43. PMID: 22414286. PubMed
  • Kelly PJ, Shinagare S, Sainani N, Hong X, Ferrone C, Yilmaz O, Fernandez-del Castillo C, Lauwers GY, Deshpande V. Cystic papillary pattern in pancreatic ductal adenocarcinoma: a heretofore undescribed morphologic pattern that mimics intraductal papillary mucinous carcinoma. Am J Surg Pathol. 2012;36(5):696-701. PMID: 22367300. PubMed

Mari Mino-Kenudson, MD

  • Ono J, Yaeger KA, Genevay M, Mino-Kenudson M, Brugge WR, Pitman MB. Cytological analysis of small branch-duct intraductal papillary mucinous neoplasms provides a more accurate risk assessment of malignancy than symptoms. Cytojournal. 2011;8:21. PMID: 22145009. PubMed
  • Genevay M, Mino-Kenudson M, Yaeger K, Konstantinidis IT, Ferrone CR, Thayer S, Castillo CF, Sahani D, Bounds B, Forcione D, Brugge WR, Pitman MB. Cytology adds value to imaging studies for risk assessment of malignancy in pancreatic mucinous cysts. Ann Surg. 2011;254(6):977-83. PMID: 22041510. PubMed
  • Mino-Kenudson M, Fernandez-del Castillo C, Baba Y, Valsangkar NP, Liss AS, Hsu M, Correa-Gallego C, Ingkakul T, Perez Johnston R, Turner BG, Androutsopoulos V, Deshpande V, McGrath D, Sahani DV, Brugge WR, Ogino S, Pitman MB, Warshaw AL, Thayer SP. Prognosis of invasive intraductal papillary mucinous neoplasm depends on histological and precursor epithelial subtypes. Gut. 2011;60(12):1712-20. PMID: 21508421. PubMed

Martha Pitman, MD

  • Ono J, Yaeger KA, Genevay M, Mino-Kenudson M, Brugge WR, Pitman MB. Cytological analysis of small branch-duct intraductal papillary mucinous neoplasms provides a more accurate risk assessment of malignancy than symptoms. Cytojournal. 2011;8:21. PMID: 22145009. PubMed
  • Genevay M, Mino-Kenudson M, Yaeger K, Konstantinidis IT, Ferrone CR, Thayer S, Castillo CF, Sahani D, Bounds B, Forcione D, Brugge WR, Pitman MB. Cytology adds value to imaging studies for risk assessment of malignancy in pancreatic mucinous cysts. Ann Surg. 2011;254(6):977-83. PMID: 22041510. PubMed
  • Tanaka M, Fernandez-Del Castillo C, Adsay V, Chari S, Falconi M, Jang JY, Kimura W, Levy P, Pitman MB, Schmidt CM, Shimizu M, Wolfgang CL, Yamaguchi K, Yamao K. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology. 2012;12(3):183-97. PMID: 22687371. PubMed

Dushyant Sahani, MD

  • Sahani DV, Sainani NI, Blake MA, Crippa S, Mino-Kenudson M, del-Castillo CF. Prospective evaluation of reader performance on MDCT in characterization of cystic pancreatic lesions and prediction of cyst biologic aggressiveness. AJR Am J Roentgenol. 2011;197(1):W53-61. PMID: 21700995. PubMed
  • Genevay M, Mino-Kenudson M, Yaeger K, Konstantinidis IT, Ferrone CR, Thayer S, Castillo CF, Sahani D, Bounds B, Forcione D, Brugge WR, Pitman MB. Cytology adds value to imaging studies for risk assessment of malignancy in pancreatic mucinous cysts. Ann Surg. 2011;254(6):977-83. PMID: 22041510. PubMed
  • Perez-Johnston R, Sainani NI, Sahani DV. Imaging of chronic pancreatitis (including groove and autoimmune pancreatitis). Radiol Clin North Am. 2012;50(3):447-66. PMID: 22560691. PubMed

Sarah Thayer, MD, PhD

  • Mino-Kenudson M, Fernandez-del Castillo C, Baba Y, Valsangkar NP, Liss AS, Hsu M, Correa-Gallego C, Ingkakul T, Perez Johnston R, Turner BG, Androutsopoulos V, Deshpande V, McGrath D, Sahani DV, Brugge WR, Ogino S, Pitman MB, Warshaw AL, Thayer SP. Prognosis of invasive intraductal papillary mucinous neoplasm depends on histological and precursor epithelial subtypes. Gut. 2011;60(12):1712-20. PMID: 21508421. PubMed
  • Haynes AB, Deshpande V, Ingkakul T, Vagefi PA, Szymonifka J, Thayer SP, Ferrone CR, Wargo JA, Warshaw AL, Fernandez-del Castillo C. Implications of incidentally discovered, nonfunctioning pancreatic endocrine tumors: short-term and long-term patient outcomes. Arch Surg. 2011;146(5):534-8. PMID: 21576607. PubMed
  • Valsangkar NP, Morales-Oyarvide V, Thayer SP, Ferrone CR, Wargo JA, Warshaw AL, Castillo CF. 851 resected cystic tumors of the pancreas: A 33-year experience at the Massachusetts General Hospital. Surgery. 2012. PMID: 22770958. PubMed