Because of the inability to determine benign from malignant, many have recommended that all cystic lesions of the pancreas be resected. Patients evaluated between January 1995 and December 2000 for the ICD-9 diagnosis of pancreatic cyst (577.2) or benign neoplasm of the pancreas (211.6) were reviewed. Patient, cyst, and treatment characteristics were recorded. Comparisons were made between patients who underwent operative and nonoperative management. Over the 5-year period, 209 patients were evaluated. Nonoperative treatment was initially chosen for 144 patients (69%). In this group the average cyst diameter was 2.5 cm (range 0.5 cm to 13.0 cm), and the median change in diameter during follow-up was zero cm (range 1.5 cm to 4.0 cm). In six patients (4%) changes occurred within the cyst that resulted in resection. None of these patients had a malignant diagnosis. Operative treatment was initially chosen for 65 (31%) of the 209 patients. Malignancy was found in six of the operative patients (6 [9%] of 65). Differences in patient and cyst characteristics between groups included the cyst size, septations, a solid component, and the presence of symptoms. Selected patients with cystic lesions of the pancreas may be safely followed radiographically. Selection criteria identified in this study (symptoms, cyst size, solid component, and septations) and the utilization of new imaging techniques allow the creation of treatment plans for these patients that can be prospectively tested.