Pancreatic cysts are common. Some harbor malignant potential but are not always distinguishable from benign lesions. Premalignant cysts offer an opportunity for preventive surgery. Pancreatic surgery is associated with morbidity and mortality; hence appropriate patient selection is mandated. The most common pancreatic cystic neoplasms are intraductal papillary mucinous neoplasm and mucinous cystic neoplasm, both of which have a malignant potential, while serous cystic neoplasm is benign. Clinical, biochemical and radiological signs of increased risk for malignancy may constitute an absolute or relative indication for surgery. All patients fit for surgery with newly discovered cysts should be evaluated at a tertiary center. Follow up MRI (or EUS) and S-CA19-9 is recommended 6 months from diagnosis for premalignant cysts, and - if there is no progress - annually, for as long as the patient is fit for surgery.