Pancreatic Head Adenocarcinoma Research Articles

Cerebellopontine angle metastasis from pancreatic cancer: a case report

Introduction: Pancreatic cancer metastasis to the cerebellopontine angle (CPA) is extremely rare and often misdiagnosed preoperatively. The clinical characteristics and prognosis of this uncommon condition remain largely unknown. Case presentation: We report the case of a 68-year-old male who presented with recurrent headaches, dizziness, and gait disturbances. The patient had undergone pancreaticoduodenectomy for pancreatic head adenocarcinoma two years prior. Preoperative imaging suggested a right CPA meningioma. The patient underwent resection of the CPA tumor under general anesthesia. Postoperative pathology revealed a metastatic pancreatic adenocarcinoma. Despite treatment with adjuvant chemotherapy, the patient developed widespread metastatic disease and succumbed 2 months after the CPA tumor resection. Discussion: The rarity of pancreatic cancer metastasizing to the CPA presents diagnostic challenges, as evidenced by the initial misdiagnosis of meningioma in this case. The clinical presentation can mimic benign conditions, leading to delays in appropriate management. This case underscores the importance of considering metastatic disease in patients with a history of cancer, even when presenting with symptoms typical of more common CPA lesions. Conclusion: Vigilant monitoring is crucial in pancreatic cancer patients, as neurological symptoms may herald metastatic spread to uncommon sites like the CPA. Despite surgical intervention, widespread metastasis can lead to poor outcomes. Early diagnosis and a high index of suspicion are essential for optimal management of these rare cases.

Impact of hepatic artery variation on surgical and oncological outcomes in robotic pancreaticoduodenectomy.

In patients with hepatic artery variation (HAV), feasibility and justification of robotic pancreatoduodenectomy (RPD) for periampullary lesions have been not been well established. A total of 600 patients with periampullary lesions receiving RPD or open pancreaticoduodenectomy (OPD) were identified from our prospectively collected computer database. Surgical outcomes, oncological radicality, and survival outcomes after RPD in HAV ( +) and (-) patients were compared. The incidence of HAV was 16%, including 12.7% in patients with RPD and 23.0% in those with OPD. In the HAV ( +) group, vascular injury rate had no statistical difference between the RPD (3.7%) and OPD (9.1%) patients, P = 0.404. Among the RPD patients, those with HAV ( +) had longer operation time (8.5 ± 2.5 vs. 7.7 ± 2.0h, P = 0.013) and higher vascular injury (3.8% vs. 0.6%, P = 0.024) when compared with the HAV (-) patients. There was no significant difference between the HAV ( +) and (-) patients with RPD regarding blood loss, open conversion, vascular resection, and surgical mortality and morbidity. There was no survival difference between the HAV ( +) and (-) patients with pancreatic head adenocarcinoma after RPD. There was no survival difference between RPD and OPD in the HAV ( +) group. When compared with OPD, RPD is feasible and justifiable without increasing vascular injury rate for patients with HAV ( +). Hepatic artery variation has no negative impact on surgical, oncological, and survival outcomes following an RPD, if it is accurately identified pre-operatively and appropriately managed intraoperatively.

Stepwise Analysis of Resection Margin Impact on Survival and Distant Metastasis in Pancreatic Head Ductal Adenocarcinoma.

The prognostic role of tumor cells in pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head with direct microscopic infiltration (DMI) or in close proximity (≤1 mm) to the resection margin (RM) remains unclear. This single-center, retrospective study included specimens from 75 patients who underwent oncological resection of pancreatic head PDAC between February 2013 and July 2020. Two pathologists independently re-measured the distance between tumors and the multiple RMs. The impact of RM involvement for DMI, tumor cells within ≤1 mm, in general, and for individual RMs on overall survival (OS) and development of distant pulmonary (PM) and hepatic (HM) metastasis was analyzed. DMI of RMs was significantly associated with a shorter OS (median 5 vs 19 months, P = .02). The presence of tumor cells within ≤1 mm of RMs yielded a negative impact on OS with a trend toward significance (median 9 vs 21 months, P = .09). DMI and tumor cells within ≤1 mm of the pancreatic transection margin (PRM), individually, had a significant negative impact on OS (median 4 vs 19 months and 6 vs 19 months, P < .05), but not for any other individual RM. RM involvement of ≤1 mm of only the vascular circumferential resection margin (VCRM) resulted in a shorter time to HM development (P = 0.05). DMI of the posterior circumferential resection margin (PCRM) and VCRM, individually, showed shorter time to PM (P < .05). Potential clinical considerations include extended intraoperative evaluation of the PRM (1 mm) and intensified preoperative prediction of R1 resection as a basis for neoadjuvant therapy.

The Diagnostic Yield of Endoscopic Ultrasound in Asymptomatic Patients with Unexplained Dilated Common Bile Duct, or Double Duct Sign with Normal Transaminase a Retrospective Study from a Single Urban-based University Endoscopy Center.

Common bile duct dilatation alone or double duct sign (both CBD and dilated pancreatic duct dilatation) and abnormal liver enzymes are highly predictive of biliary disease. This can be identified on ultrasound (US), CT scan, and/or magnetic resonance cholangiopancreatography (MRCP). Unexplained dilatation on imaging might warrant endoscopic ultrasound (EUS) to identify any occult causes. Supporting literature about the importance of using EUS in these conditions is evolving with no clear evidence-based approach to evaluate asymptomatic dilated ducts.We aim to investigate the diagnostic yield of EUS in unexplained CBD dilatation or double duct sign with normal liver enzymes. A retrospective data analysis was conducted from January 2015 to October 2021 on asymptomatic patients with a dilatated CBD of 7 mm or more and 9 mm if the patient had a cholecystectomy history or double duct sign with normal liver enzymes. 32 EUS procedures were indicated for unexplained dilated CBD or double duct sign on imaging with normal liver enzymes. 23 had CBD dilatation alone (72 %), and 9 had a double duct sign (28 %). 20 of the included patients were females (63 %), and 12 were males (37 %), with a mean age of 63.8 ± 17 and 68.2 ± 14 years old, respectively (p = 0.424). The diagnosis after EUS in CBD dilatation alone showed a yield of 56 % as follow; no pathology in 10 (44 %), sludge in 9 patients (39 %), CBD stone in 3 (13 %), malignant stricture in 1 (4 %) (Fig. 1). On the other hand, EUS in those with double duct signs showed a diagnostic yield of 55 %; no pathology in 4 (45 %), pancreatic head adenocarcinoma in 3 patients (33 %), Biliary stone in one patient, and malignant CBD stricture in one patient (11 % each) (Fig. 2). Unexplained CBD dilatation or Double duct sign on imagining in patients with normal liver enzymes should warrant further investigation with EUS to avoid missing serious pathological conditions such as stones, sludge, stricture, or a mass.

Correlation of maintenance chemotherapy and improved survival in patients with locally advanced unresectable pancreatic head adenocarcinoma receiving neoadjuvant chemotherapy and concurrent chemoradiotherapy.

To assess the efficacy of maintenance chemotherapy in the management of unresectable locally advanced pancreatic head adenocarcinoma (PHA) cancer after neoadjuvant chemotherapy and concurrent chemoradiation therapy (CCRT). This study, a large-scale head-to-head propensity score matching (PSM) cohort study, employed real-world data. PSM was used to evaluate the impact of maintenance chemotherapy on overall survival and cancer-specific survival in patients with unresectable locally advanced PHA who underwent neoadjuvant chemotherapy and CCRT. A total of 148 patients with locally advanced pancreatic head adenocarcinoma were included in the study after PSM. These patients were equally divided into two groups, those receiving maintenance chemotherapy and those who did not. Confounding factors were balanced between the groups. The adjusted hazard ratios for all-cause mortality and cancer-specific mortality were 0.56 (95% CI: 0.40-0.77; P = 0.0005) and 0.56 (95% CI: 0.40-0.78; P = 0.0007), respectively, in patients receiving maintenance chemotherapy compared to those who did not. Our large-scale, real-world study demonstrates that maintenance chemotherapy may enhance survival outcomes for patients with unresectable locally advanced pancreatic head adenocarcinoma who underwent neoadjuvant chemotherapy and concurrent chemoradiation therapy.

Are positive celiac lymph nodes a contraindication to surgical resection in patients with pancreatic ductal adenocarcinoma of the pancreatic head?

Are positive celiac lymph nodes a contraindication to surgical resection in patients with pancreatic ductal adenocarcinoma of the pancreatic head?

Initial Experience of Pancreaticoduodenectomy in a Newly Developed Hepato-Pancreato-Biliary Unit Serving in a Lower-Middle-Income Country.

Pancreaticoduodenectomy (PD) is the only potentially curative treatment for pancreatic head adenocarcinoma. This study aimed to determine the short-term outcomes of PD performed over 1 year at a newly established hepato-pancreatico-biliary unit in Khyber Pakhtunkhwa province of Pakistan. A retrospective analysis of a prospectively maintained hospital information system (HIS) was undertaken of all patients referred to the unit between May 2021 and August 2022. Data were collected from the medical records of patients in the HIS. Data were analyzed for primary location, age, complications, and operative parameters. The primary sites of disease were ampulla (n = 18, 52.9%), pancreas (n = 11, 32.4%), and duodenum (n = 5, 14.7%). The median duration of surgery was 7 h. 16 (47.1%) patients required blood transfusion either intraoperatively or in the perioperative period. Patients with pre-operative biliary drainage (PBD) were more likely to have multidrug-resistant positive bile cultures with a P-value of 0.2 (n = 12 [35.3%] vs. n = 5 [14.7%]). Overall morbidity was 38.2%. The most common complications were wound infection (n = 12, 35.3%), delayed gastric emptying (n = 6, 17.6%), and type B pancreatic fistula (n = 3, 8.8%). The complication rate was higher in patients with biliary stenting (n = 11 [32.4%] vs. n = 2 [5.9%]; P = 0.06). The median length of hospital stay for patients without complications was less (6 vs. 12 days; P < 0.001). The complication rate was lower in total laparoscopic PD (TLPD) with P = 0.4 (TLPD: 2.9%, open: 23.5%, laparoscopic assisted: 11.8%). 90-day mortality was zero. Short-term outcomes for PD in our facility are comparable to high-volume centers. PBD can significantly increase operative time, hospital stay, and morbidity.

Combination of CA19.9 with albumin and total bilirubin predicts lymph node positivity in patients with upfront r resectable pancreatic head adenocarcinoma: the ALBICA-N model

Combination of CA19.9 with albumin and total bilirubin predicts lymph node positivity in patients with upfront r resectable pancreatic head adenocarcinoma: the ALBICA-N model

Reappraisal of surgical and survival outcomes of 500 consecutive cases of robotic pancreaticoduodenectomy.

The role of the robotic approach for pancreaticoduodenectomy has not been well established with robust data. This study aimed to reappraise feasibility and justification of robotic pancreaticoduodenectomy (RPD) over time. A total of 500 patients undergoing RPD were enrolled and divided into early (first 250 patients) and late (last 250 patients) groups for a comparative study. The conversion rate was 8.8% overall and was significantly lower in the late group (5.6% vs. 12.0%; p = .012). The overall median intraoperative blood loss was 130 mL. Radicality of resection was similar between early and late groups. The overall surgical mortality after RPD was 1.3%. The overall surgical morbidity and major complication was 44.1% and 13.2%, respectively, and similar between early and late groups. Chyle leakage was the most common complication after RPD (25.0%), followed by postoperative pancreatic fistula (POPF). The POPF rate was 8.6% overall, with 5.9% in the early group and 11.0% in the late group, p = .051. The overall delayed gastric emptying rate was 3.5%. The late group had better survival outcomes than those of the early group after RPD for ampullary adenocarcinoma (p = .027) but not for pancreatic head adenocarcinoma. Reappraisal of this study has confirmed that RPD is not only technically feasible without increasing surgical risks but also oncologically justified without compromising survival outcomes for both pancreatic head and other periampullary cancers over time. Moreover, RPD is associated with the benefits of low surgical mortality, blood loss, and delayed gastric emptying.

398 Histological Lymph Node Ratio and Long-Term Survival After Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma

Abstract Background Pancreatoduodenectomy (PD) is recommended in fit patients with a resectable pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head. Early rates of recurrence are high and long-term survival is uncommon. This study aimed to investigate the association between histological lymph node ratio (LNR) and long-term survival. Method Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres in 8 countries, n = 1484). Patients with histologically confirmed PDAC were identified, and five-year and overall survival rates were compared by LNR (number of positive resected nodes/total number of resected nodes). Analyses were performed using Fisher’s exact test, the Kaplan-Meier method, and the log-rank test. Results In total, 885 patients (59.6%) were found to have PDAC. Concerning LNR, 412 patients (48.3%) had a LNR &amp;lt;0.2 and 437 (51.5%) had a LNR ≥0.2 (unknown: 36 cases). Five-year survival was significantly higher in the former (34.0% vs 10.5%, p&amp;lt;0.0001). LNR was 0, &amp;gt;0.0-0.2 and &amp;gt;0.2 in 116 (17.5%), 261 (39.5%) and 284 (43.0%) patients, respectively (patients with missing data were excluded). Median survival was 646 (95% confidence interval: 526-766), 532 (483-581) and 438 (395-481) days, respectively (p&amp;lt;0.00001). Conclusions In our multicentre study of PD patients with confirmed PDAC, a histological LNR ≥0.2 was associated with reduced five-year survival. Patients with a LNR of &amp;gt;0.0-0.2 and &amp;gt;0.2 lived a median of 114 and 208 days less than those with a LNR of 0.0.

SP2.6 Histological TNM stage and five-year survival after pancreatoduodenectomy for pancreatic ductal adenocarcinoma

Abstract Aims Patients with a pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head may be offered pancreatoduodenectomy (PD) providing they are suitable candidates. Unfortunately, recurrence rates are high following this operation and few patients achieve long-term survival. This study aimed to investigate and quantify the relationship between histological tumour, node and metastasis stage, and five-year survival. Methods Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for malignancy (29 centres from 8 countries, n=1484). PDAC patients were grouped by their T stage, N stage and M stage, and five-year survival rates were compared using Fisher’s exact test. Results A total of 885 patients (59.6%) had PDAC confirmed histologically. Five-year survival was 57.4%, 46.0%, 17.0% and 32.0% in patients with T1, T2, T3 and T4 disease, respectively (unavailable: 7 patients). T1-2 patients (vs T3-4) had significantly higher rates of five-year survival (OR: 4.8, 95% CI: 3.3-7.0). N0 patients (vs N1-2) had significantly higher rates of five-year survival (OR: 4.5, 95% CI: 3.2-6.3). M0 patients (vs M1) also had higher five-year survival rates but this was not quite significant due to the small sample size of the M1 group (OR: 3.8, 25.7% vs 8.3%, p=0.06). Conclusion In our multicentre study of patients who underwent PD for PDAC, increasing T and N histological stages were found to correlate with reduced five-year survival. The figures provided can be used to guide the consenting process and predict outcomes in individual patients.

Analysis of Radiation Therapy Quality Assurance in NRG Oncology RTOG 0848

NRG/Radiation Therapy Oncology Group 0848 is a 2-step randomized trial to evaluate the benefit of the addition of concurrent fluoropyrimidine and radiation therapy (RT) after adjuvant chemotherapy (second step) for patients with resected pancreatic head adenocarcinoma. Real-time quality assurance (QA) was performed on each patient who underwent RT. This analysis aims to evaluate adherence to protocol-specified contouring and treatment planning and to report the types and frequencies of deviations requiring revisions. In addition to a web-based contouring atlas, the protocol outlined step-by-step instructions for generating the clinical treatment volume through the creation of specific regions of interest. The planning target volume was a uniform 0.5 cm clinical treatment volume expansion. One of 2 radiation oncology study chairs independently reviewed each plan. Plans with unacceptable deviations were returned for revision and resubmitted until approved. Treatment started after final approval of the RT plan. From 2014 to 2018, 354 patients were enrolled in the second randomization. Of these, 160 patients received RT and were included in the QA analysis. Resubmissions were more common for patients planned with 3-dimensional conformal RT (43%) than with intensity modulated RT (31%). In total, at least 1 resubmission of the treatment plan was required for 33% of patients. Among patients requiring resubmission, most only needed 1 resubmission (87%). The most common reasons for resubmission were unacceptable deviations with respect to the preoperative gross target volume (60.7%) and the pancreaticojejunostomy (47.5%). One-third of patients required resubmission to meet protocol compliance criteria, demonstrating the continued need for expending resources on real-time, pretreatment QA in trials evaluating the use of RT, particularly for pancreas cancer. Rigorous QA is critically important for clinical trials involving RT to ensure that the true effect of RT is assessed. Moreover, RT QA serves as an educational process through providing feedback from specialists to practicing radiation oncologists on best practices.

Surgical Risks and Survival Outcomes in Robotic Pancreaticoduodenectomy for the Aged Over 80: A Retrospective Cohort Study.

Whether to execute pancreaticoduodenectomy or not for older people could pose a dilemma. This study clarifies the safety and justification of robotic pancreaticoduodenectomy (RPD) for older individuals over 80. A total of 500 patients undergoing RPD were divided into group O (≥ 80 y/o) and group Y (< 80 y/o) for comparison. There were 62 (12.4%) patients in group O. Surgical mortality was 1.6% for overall patients and higher in group O, 6.5% vs 0.9%; p = 0.001. The surgical complication was comparable between groups O and Y. Delayed gastric emptying and bile leakage were higher in group O, 9.7% vs 2.5%; p = 0.004, and 6.5% vs 0.9%; p = 0.001, respectively. Length of stay was also longer in group O, with a median of 26 vs 19 days; p = 0.001. Survival outcome after RPD was poorer in group O for overall periampullary adenocarcinomas, with a 5-year survival of 48.1% vs 51.2%; p = 0.025 and also for the subgroup of pancreatic head adenocarcinoma, with a 3-year survival of 27.4% vs 42.5%; p = 0.030. RPD is safe and justified for the selected octogenarians and even nonagenarians, whoever is fit for a major operation. Nevertheless, pancreatic head cancer and higher mortality risk for the aged over 80 with advanced ASA score ≥ 3 should be informed as part of counselling in offering RPD.

Can combined use of tumor markers in pancreatic cancer be a solution to short- and long-term consequences?: A retrospective study.

As in other types of cancer, tumor markers are used in pancreatic ductal adenocarcinoma (PDAC) for disease follow-up, especially after surgery. There has been shown to be a significant correlation between the tumor marker levels and poor prognosis in locally or systemic advanced stage PDAC patients. However, there is no significant correlation between prognosis and marker levels in patients with early stage PDAC patients. This study aimed to examine the effect of the carbohydrate antigen 19-9 (Ca19-9)/carcinoembryogenic antigen (CEA) ratio in ductal adenocarcinoma of the pancreatic head on disease prognosis and mean survival. This retrospective study was conducted with 129 pancreatic head adenocarcinoma patients who were treated with whipple procedure at the Ankara University Surgical Oncology Clinic between 2010 and 2020. All patients' demographics, stage of the disease, CEA, CA 19-9 levels, and CEA/Ca 19-9 ratio were enrolled and compared statistically. A new cutoff value was calculated for the Ca19-9/CEA ratio. A Ca19-9/CEA ratio >29.77 showed 69.9% sensitivity and 70.9% specificity for the probability of the T3 and T4 stages. The cutoff value for the Ca19-9/CEA ratio was 27.18. This cutoff value had a sensitivity of 79.4% and a specificity of 80.3% for lymph node metastasis. Patients with a Ca19-9/CEA ratio below the cutoff value of 28.475 had a mean survival of 93.161 months and those with a value higher than the cutoff value had a mean survival of 28.541 months (P < .001). A simple combination of tumor markers was determined to have higher accuracy rates in predicting tumor prognosis and in determining mean survival, which are particularly needed in early stage cancers.

Pancreatic head adenocarcinoma – long term survival

Background: Pancreatic cancer is one of most aggressive tumours. Its incidence is rising. Radical surgery is the only chance for long term survival. But most of the patients die shortly (months) after diagnosis. The unsatisfactory results are unfortunately influenced by late diagnosis

Surgical Eligibility Does Not Imply Surgical Equity: Recommendations for Curative Treatment in Patients With Stage I/II Pancreatic Head Adenocarcinoma Differ by Age and Race.

We sought to characterize differences in pancreatectomy recommendation rates to surgically eligible patients with pancreatic ductal adenocarcinoma of the pancreatic head across age and racial groups. Pancreatectomy is not recommended in almost half of otherwise healthy patients with stage I/II pancreatic ductal adenocarcinoma lacking a surgical contraindication. We characterized differences in pancreatectomy recommendation among surgically eligible patients across age and racial groups. Non-Hispanic White (NHW) and Non-Hispanic Black (NHB) patients were identified in the National Cancer Database with clinical stage I/II pancreatic head adenocarcinoma, Charlson Comorbidity Index of 0 to 1, and age 40 to 89 years. Rates of surgery recommendation and overall survival (OS) by age and race were compared. A Pancreatectomy Recommendation Equivalence Point (PREP) was defined as the age at which the rate of not recommending surgery matched the rate of recommending and completing surgery. Marginal standardization was used to identify association of age and race with recommendation. OS was compared using Kaplan-Meier and Cox regression models. Among 40,866 patients, 36,133 (88%) were NHW and 4733 (12%) were NHB. For the entire cohort, PREP was 79 years. PREP was 5 years younger in NHB patients than in NHW patients (75 vs 80 years). Adjusted rates of not recommending surgery were significantly higher for NHB than for NHW patients in each age group. After adjusting for surgery recommendation, we found no difference in OS between NHW and NHB patients (hazard ratio 0.98 [95% CI 0.94-1.02]). PREP of NHB patients was 5 years younger than NHW patients, and in every age group, the rate of not recommending pancreatectomy was higher in NHB patients. Age and race disparities in treatment recommendations may contribute to shorter longevity of NHB patients.

Sensitivity, Specificity of Vessel Involvement in Pancreatic Head Adenocarcinoma by Imaging Modality per Treatment Effect

Background: In patients with pancreatic adenocarcinoma, the accuracy of identifying vascular involvement via EUS and MDCT remains unclear, especially in the setting of neoadjuvant therapy. Methods: We conducted a retrospective analysis of patients who underwent a pancreaticoduodenectomy between 2012 and 2016 at Advent Health Orland Hospital. Sensitivity, specificity, positive predictive value and negative predictive value of MDCT and EUS with respect to vessel involvement (SMV, PV, SMA) in a given treatment setting (no treatment, neoadjuvant chemotherapy, neoadjuvant chemotherapy/radiation) were analyzed. Results: In the setting of no treatment, MDCT has the highest sensitivity, specificity, PPV, NPV in the evaluation of the SMA: 22%, 94%, 50%, and 83% respectively. In the setting of no treatment, EUS has the highest sensitivity, specificity, PPV, NPV in the evaluation of the SMV: 33%, 95%, 33% and 95% respectively. The modality with the highest specificity in the assessment of PV involvement is intra-operative evaluation regardless of treatment setting. In the setting of neoadjuvant therapy, either EUS or intra-operative evaluation is preferred over MDCT for the evaluation of the SMA, SMV and PV. Discussion: In the setting of no treatment, the SMA is best evaluated via MDCT, the SMV via EUS, and the PV is best evaluated intra-operatively.

Preoperative CA19.9 Level Predicts Lymph-Nodal Involvement in Resectable Pancreatic Head Adenocarcinoma: A Further Plea for Neoadjuvant Treatment

Preoperative CA19.9 Level Predicts Lymph-Nodal Involvement in Resectable Pancreatic Head Adenocarcinoma: A Further Plea for Neoadjuvant Treatment

S1790 Portal Biliopathy in a Patient Who Underwent a Whipple Procedure With Portal Vein Reconstruction

Introduction: Portal biliopathy is a condition that is defined as abnormalities in the biliary tract due to portal hypertension. Some patients may present with abdominal pain, fever, jaundice, or pruritis. Rarely, portal hypertension secondary to portal vein abnormalities cause peri-biliary varices. We report a case of a patient with a peri-biliary variceal bleed due to portal hypertension from acquired portal vein stenosis. Case Description/Methods: A 59-year-old female with a past medical history of pancreatic ductal adenocarcinoma presented to the hospital with 5 days of Black tarry stools. Two years prior, she was diagnosed with pancreatic head adenocarcinoma and underwent a pancreaticoduodenectomy with portal vein reconstruction. Subsequent CT scans demonstrated post surgical portal vein stenosis. On admission, she denied fevers, abdominal pain, or hematemesis. Labs were notable for a hemoglobin of 5.7 g/dl, INR of 1.6, and bilirubin of 1.0 mg/dl. Physical exam demonstrated an abdominal fluid wave and melena on digital rectal exam. CT abdomen showed post Whipple anatomy, severe portal vein stenosis, large volume ascites, and extensive upper abdominal collaterals including peri-portal and peri-biliary varices. Upper endoscopy revealed blood in the afferent jejunal limb. Bleeding was found to be originating from the choledochojejunostomy. Multiple large visible vessels with stigmata of recent bleeding were visualized within the common bile duct. A single hemostatic clip was placed on one of the vessels, resulting in increased bleeding. Hemostasis was achieved with cyanoacrylate injection. The patient was transferred to the interventional radiology suite, where she underwent portal venography confirming severe stenosis of the porto-mesenteric confluence. Interventional radiology performed portal vein balloon dilation and stent placement. The patient had no further bleeding following the procedure (Figure). Discussion: Bleeding from peri-biliary varices is a rare cause of upper GI bleeding. In this case, non cirrhotic portal hypertension from acquired portal vein stenosis after pancreaticoduodenectomy led to clinically significant gastrointestinal bleeding. Portal biliopathy is an uncommon and late presentation in patients with extrahepatic portal vein obstruction. In many cases, patients present with signs and symptoms of biliary obstruction. Treatment of PB should involve a multidisciplinary discussion among various subspecialties including gastroenterology, interventional radiology, and hepatobiliary surgery.Figure 1.: A. Choledochojejunostomy with visible varices. B. Hemostatic clip placement with subsequent bleeding. C. Injection of cyanoacrylate glue with hemostasis. D. Portal venography demonstrating portal vein stenosis at the porto-mesenteric confluence.

S1731 Fibrosing Pancreatitis Initially Diagnosed as Ductal Adenocarcinoma by Endoscopic Ultrasound of a Pancreatic Mass in a Pediatric Patient

Introduction: Pancreatic cancer is very rare in the pediatric population. Incidence data is scarce, and few case reports have been published. Pancreatic ductal adenocarcinoma (PDA) is the most common subtype in adults, but is rare in children. We report a case of a benign pancreatic head mass in a pediatric patient initially diagnosed as PDA on endoscopic ultrasound (EUS) guided biopsy. Case Description/Methods: A 13-year-old male with past medical history of treated Helicobacter pylori infection 6 months prior was admitted for severe acute intermittent epigastric pain. Labs showed elevated transaminases and gamma-glutamyl transferase. Abdominal ultrasound demonstrated an indeterminate solid mass-like lesion of 3 cm at the pancreatic head, and the common bile duct (CBD) was dilated to 0.9 cm. Magnetic resonance cholangiopancreatography showed a 2.2 cm indeterminate lesion along the pancreatic head region with dilated CBD of 1.4 cm, tapering at the level of the lesion. On hospital day 3, the patient underwent esophagogastroduodenoscopy and EUS. A parenchymal mass of 2.2 cm was visualized in the head of pancreas, and fine needle biopsy was performed. Cytology diagnosis was well differentiated ductal adenocarcinoma. Serum carcinoembryonic antigen, carbohydrate antigen 19-9, and alpha-fetoprotein were all normal. The patient underwent elective Whipple procedure. Surprisingly, no malignancy was identified on the surgical specimen. Instead the findings supported a diagnosis of localized fibrosing pancreatitis with high background of immunoglobulin G4 with interlobular pattern. Patient was discharged home on post-operation day 13. EUS cytology was reviewed at a tertiary cancer center and later reported as acute on chronic inflammation without malignancy (Figure). Discussion: Despite increased use of EUS for diagnosis of pancreatic masses, 5-10% of patients who undergo Whipple procedure for presumed malignancy will have benign pathology: most commonly chronic fibrosing pancreatitis, chronic pancreatitis, or focal active pancreatitis. The false positive rate for diagnosing malignancy using EUS-fine needle aspiration (FNA) of solid pancreatic lesions is less than 1%. However, it may be higher in pediatrics as the prevalence of PDA is much lower in adults. For suspected cases of PDA in pediatric patients, additional review of EUS cytology at an experienced and dedicated cancer institution is advisable before further intervention to prevent the medical and psychosocial ramifications of a false positive cancer diagnosis.Figure 1.: (Left) A parenchymal mass (2.2 x 1.8 cm) in the head of the pancreas by endoscopic ultrasound (EUS) adjacent to the portal confluence, with the common bile duct dilated to 12.8 mm (marked by yellow cross signs). Initial cytopathology from EUS-FNA of pancreatic head mass A. Diff-Quik staining at low magnification, 4x. B. Smear is cellular and well preserved with sheets, clusters and single malignant cells, 10x. C. Cells have crowded nuclei, 20x. D. Malignant cells exhibit loss of polarity, irregular nuclear contours, finely granular chromatin and some with prominent nucleoli, 40x . Based on cytomorphological features, the mass is a well differentiated ductal adenocarcinoma of pancreatic head. Note: The review of this cytopathology by a tertiary cancer institution was inconsistent with malignancy. The glandular cells had mild cytologic atypia, and the acinar cells remained lobular in configuration. Although there was some higher nuclear to cytoplasmic ratio, no absolute nuclear enlargement was noticed.