Abstract
BACKGROUND: As a heterogeneous group of lesions, pancreatic cystic lesions (PCLs) vary enormously in malignant potential, mandating different treatment strategies. Despite significant advances in diagnostic imaging and laboratory tests, the accurate diagnosis of PCLs remains challenging, leading to overtreatment or delayed/missed surgical timing in patients with PCLs. CASE SUMMARY: We present a case of a 64-year-old female patient in whom an asymptomatic, incidental cystic mass was found in the pancreatic tail on a routine abdominal ultrasound. After a comprehensive work-up with laboratory examinations, contrast-enhanced computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography, a pancreatic pseudocyst was suspected. Subsequent endoscopic ultrasound with fine-needle aspiration and needle-based confocal laser endomicroscopy supported a benign diagnosis. Follow-up computed tomography and magnetic resonance imaging examinations five months later showed significant cyst shrinkage without any abnormalities. However, three years after being lost to follow-up, the patient was readmitted and diagnosed with pancreatic adenocarcinoma with multiple metastases, suggesting that the initial lesion was a mucinous cystic neoplasm misdiagnosed as a pancreatic pseudocyst. CONCLUSION: Comprehensive integration of all available information (e.g., cyst features, abnormal imaging findings, cyst biochemistry, clinical history, and patient demographics) rather than over-reliance on imaging or endoscopic findings is pivotal to diagnosing PCLs, and patients with concerning features should undergo strict surveillance.