Pancreatic cystic lesions are being increasingly identified with the widespread use of state-of-the-art imaging. These lesions are categorized into a broad range of neoplastic cysts and inflammatory pseudocysts. Identification of a pancreatic cyst requires the clinician to focus on the main clinical challenge of the benign or malignant nature of the cyst. Neoplastic cysts range the spectrum from benign, to premalignant, to frank malignancy. The management of these lesions is difficult, and the decision to resect or observe a lesion is hampered by limitations in current imaging and tissue sampling techniques that prevent the accurate characterization of all lesions. This article reviews current guidelines for the evaluation of pancreatic cystic lesions, underscores the challenges posed by these lesions, and discusses current and future studies that will aid in patient management.