Interdisciplinary Management of Cystic Neoplasms of the Pancreas

Table 2

Interdisciplinary management of pancreatic cystic tumors.

	IMPACT Clinic	Action points
Step 1; Collect outside data for IMPACT MD to review before office visit	Initial review of outside medical records: symptoms, laboratory, imaging review with staff radiologist	Consider repeat pancreas protocol CT and MRI/MRCP to better visualize pancreatic parenchyma and ductal anatomy
		Proceed to Step 2: arrange office visit and imaging based on symptoms and imaging
Step 2; Initial triage based on symptoms or ominous features on imaging:	Symptomatic or high risk lesion	Surgical referral (age, ASA grade, resectability) may request EUS based on findings
recurrent pancreatitis, dilated main duct, mural nodule, solid component, obstructive jaundice, abrupt caliber change of duct	Asymptomatic	Triage based on size
		Proceed to Step 3
Step 3; Secondary triage based on cyst size; (i) IAP Guidelines, 2012; (ii) Am College of Radiology Guidelines, 2010; (iii) Markov model, 2010; (iv) Cost-effective analysis, 2009	Cyst <1 cm; Cyst 1–3 cm; Cyst > 3 cm	Medical pancreatology; Therapeutic endoscopy for EUS; Surgical referral (age, ASA grade, resectability) may request EUS based on findings
		Proceed to Step 4 or 5 based on results of evaluation
Step 4; Clinical challenges	Indeterminate results: equivocal imaging and/or cyst fluid analysis	Present case in weekly Multidisciplinary Pancreas Study Group for consensus recommendations
		Proceed to Step 5
Step 5; IMPACT recommendations	Schedule follow-up appointment: surgical resection, EUS –FNA, or; observation	Letter to referring MD and patient
		Proceed to Step 6
Step 6; Followup	Surveillance recommendations based on imaging, fluid analysis, and/or surgical pathology findings	IMPACT Clinical Database entry; Letter to referring MD and patient; Automated follow-up letter: 3 mo, 6 mo etc…

Modified from Tanaka et al. [30], Berland [33], Khalid and Brugge [32], Das et al. [28], and Weinberg et al. [31].