Table 2: Interdisciplinary management of pancreatic cystic tumors.

IMPACT ClinicAction 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 radiologistConsider 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 lesionSurgical 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 ductAsymptomaticTriage 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 findingsIMPACT 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].