Cystic neoplasms of the pancreas are interesting, but rare. We reviewed the Indiana University experience with these tumors over a 15-year period to study preoperative evaluation and long-term outcome. Twenty-one patients (18 females and three males, mean age 59 years) were treated between 1977 and 1992. The lesions included mucinous cystic neoplasm-benign (6), mucinous cystic neoplasm-malignant (6), serous cystadenoma (5), ductal adenocarcinoma with cystic degeneration (2), papillary cystic neoplasm (1), and intra-ductal mucin hypersecreting neoplasm (1). The most common symptoms were abdominal pain, back pain, and weight loss. All eight patients with malignant tumors had symptoms; however, only seven of 13 patients with benign lesions had symptoms (P = 0.046, Fisher exact test). Patients were evaluated with computed tomography of the abdomen (20), endoscopic retrograde cholangiopancreatography (12), ultrasound (5), fine needle aspiration (4), and other studies (6). Six lesions were found incidentally. A correct preoperative diagnosis was made in only two cases. Operations performed included 14 distal pancreatectomies, five pancreaticoduodenectomies, and one total pancreatectomy. Fifteen of 21 patients are alive and well, with follow-up ranging from 4 months to 16 years. Five deaths occurred in patients with malignant mucinous cystic neoplasms, while only one death occurred in the patients with benign cystic neoplasms. Although computed tomography and other diagnostic modalities can identify cystic neoplasms of the pancreas, it is often difficult to make a definitive diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)