PP03 Pancreas: Tumours (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PP03-003 Resected Pancreatic Ductal Adenocarcinoma: Understanding Tumour Tropism to Maximise Benefit from Surgery
Nicola De' Liguori Carino, United Kingdom

M. Frizziero1, A. Malik2, M.G. McNamara1, S. Jamdar2, R. Pihlak1, A. Siriwardena2, D. O’Reilly2, N. De' Liguori Carino2, A. Lamarca1
1Department of Medical Oncology, The Christie NHS Foundation Trust, United Kingdom, 2Hepatobiliary and Pancreatic Surgical Team, Department of Surgery, Manchester Royal Infirmary, United Kingdom

Objectives: Relapse-rate in pancreatic ductal adenocarcinoma (PDAC) remains high. We aimed to describe patterns of disease relapse in PDAC and to identify modifiable factors which could improve patient selection for surgery.
Methods: Consecutive PDAC patients undergoing curative surgery (Jan'05-Sep'17) were retrospectively analysed. Patients without follow-up or relapse information were excluded. Disease relapse patterns were classified as “local-only”, “distant-only” or “combined”. Recurrence Free Survival (RFS) and Overall Survival (OS) were estimated (Kaplan-Meier analysis). Logistic-regression (LR) and Cox-regression (Cox) univariate/multivariable analyses were applied used as appropriate.
Results: One-hundred-eighty-two patients were eligible: microscopically involved resection-margins (R1) 65.7%; adjuvant chemotherapy (adj) 62.1%. Median follow-up 17.9 months. Relapse events 143 (78.6%). Median RFS 11.4 months (95%CI=9.4-13.7) and OS 21.6 months (95%CI=17.9-18.9). Relapse patterns: “local-only” 30.1%, “distant-only” 40.5%, “combined” 29.4%; distant metastases: 69.9% (liver 41.3%; median time-to-liver recurrence 6.64 months (95%CI 4.99-8.56)). Factors impacting on risk of relapse: R1 ((any-pattern) (LR-multivariable: OR=4.02; 95%CI=0.02-0.23)), pre-adj CA19.9>normal limit (NL) (('local-only') (LR-univariate: OR=0.23; 95%CI=0.08-0.62)) and adj (('combined') (LR-univariate: OR=0.46; 95%CI=0.22-0.96)). R1 associated with shorter OS (Cox-multivariable: OR=1.90; 95%CI=1.13-3.19) while pre-adj CA19.9>LN implied shorter RFS (Cox-multivariable: OR=2.28; 95%CI=1.38-3.76) and OS (Cox-multivariable: OR=1.84; 95%CI=1.08-3.14). Preoperative magnetic resonance imaging (MRI) liver reduced the risk of relapse
(any pattern) (LR-multivariable: OR=0.06; 95%CI=0.02-0.23) and was prognostic for longer OS
(LR-multivariable: OR=0.27; 95%CI=0.09-0.74).
Conclusion: Two thirds of patients treated with curative surgery for PDAC will have recurrent disease affecting distant organs, predominantly liver; integrating preoperative imaging with MRI liver to patients pathway may improve patient selection and maximise benefit from surgery. Confirmatory studies are required.
PP03-006 Preoperative Radiotherapy Improves Overall Survival of pT4 Pancreatic Ductal Adenocarcinoma Patients After Surgical Resection
Yaolin Xu, China

Y. Xu, Z. Wu, Y. Zhang, W. Lou
Pancreatic Surgery, Zhongshan Hospital Fudan University, China

Purpose: Aim of delivering radiotherapy for pancreatic ductal adenocarcinoma (PDAC) patients was to sterilize vessel margin, increase R0 resection rate, and delay local progression. Whether preoperative radiotherapy (PR) could prolong overall survival (OS) of surgical candidates remained unknown.
Methods: PDAC patients receiving radical resection from surveillance, epidemiology, and end results (SEER) database were enrolled. Propensity score matching (PSM) was conducted to balance difference in baseline characteristics and survival analyses was performed to compared OS between PR and upfront resection (UR) groups. Cox proportional hazards regression model and subgroup analyses were utilized to identify prognostic factors.
Results: 11,665 and 597 PDAC patients receiving UR and PR followed by resection from 2004 to 2016 were identified respectively, while baseline characteristics were distinct between groups. After PSM, PR was not associated with better OS (UR vs PR, 26 vs 27 months). Subgroup analyses showed that PR was a protective factor in pT4 (hazard ratio (HR) = 0.64, 95% confidence interval (CI): 0.47-0.88) but a negative predictor in pT1 (HR = 1.79, 95% CI: 1.08-2.97) patient populations. Survival analyses showed that PR improved OS of patients with pT4 stage (UR vs PR, 19 vs 25 months) and involvement of celiac axis (CA), superior mesenteric artery (SMA), and aorta (UR vs PR, 20 vs 27 months), while PR was associated with worse OS in patients with pT1 tumor (UR vs PR, 39 vs 24 months).
Conclusion: PR could improve survival of resected PDAC patients with pT4 stage or with CA, SMA, and aorta invasion.
[Survival of Resected PDAC With(out) Preop-radiation]
PP03-007 Proteogenomic Analysis Demonstrates Novel Potential Targets of Pancreatic Ductal Adenocarcinoma in African Patients
Emmanuel Ekene Nweke, South Africa

E.E. Nweke1, P. Naicker2, S. Aaron3, S. Stoychev2, J. Devar1, D. Tabb4, J. Omoshoro-Jones1, M. Smith1, G. Candy1
1Surgery, University of Witwatersrand, South Africa, 2Biosciences, Council for Scientific and Industrial Research, South Africa, 3Sydney Brenner Institute of Molecular Biosciences, University of Witwatersrand, South Africa, 4Biomedical Sciences, Stellenbosch University, South Africa

Pancreatic ductal adenocarcinoma (PDAC) accounts for 2.8% of new cancer cases worldwide and is projected to become the 2nd leading cause of cancer-related deaths by 2030. Patients of African ancestry appear to be at increased risk for PDAC with the worst severity and outcome.This proposed study sought to determine and integrate proteomic and genomic profiles of PDAC patients of African ancestry to identify potential markers and better understand molecular mechanisms of the disease, especially in our population cohort.
Thirty tissues (15 tumours and 15 corresponding normal tissues) were obtained from consenting South African PDAC patients undergoing Whipple procedure at Chris Hani Baragwanath Hospital in Johannesburg, South Africa (HREC-M150778). Protein and DNA were extracted from tissue samples and SWATH Mass Spectrometry and OncoArray anlaysis performed. Network and functional analysis were conducted using STRINGv11.0 and REACTOMEv70. We also used the Variant effect predictor (VEPv98) tool to predict consequences of the SNPs observed.
We found 55 upregulated and 36 downregulated proteins in tumour samples which were mostly involved in key biological processes, including haemostasis, signal transduction, neuronal system and developmental biology. These aberrant processes are known to exacerbate tumour aggressiveness, invasion and metastasis. Furthermore, we observed 219 SNPs covering key gene regions such as those observed to be upregulated by SWATH-MS analysis. They include genes such as PALLD, AVL9, BPGM, SERPINB8 and MYPN.
We have shown the dysregulation and simultaneous mutations of several key genes/proteins highlighting their roles as plausible biomarkers and therapeutic targets. Validation studies are required to confirm these results.
PP03-009 The Satan's Apple: LncRNAs Play the Critical Role of Pancreatic Ductal Adenocarcinoma
Bowen Huang, China

B. Huang1,2, L. Zhou1, J. Lu1, Y. Wang1, B. Jiang1, C. Liu1, Z. Ma2, B. Hou2, J. Guo1
1General Surgery, Peking Union Medical College Hospital, China, 2General Surgery, Guangdong Provincial People's Hospital, China

Introduction: We attempted to build a clinical model to predict the prognosis of PDAC patients by the quantification of the lncRNA and explore the biofunctional mechanism.
Method: We downloaded RNA-Seq profiles from the TCGA and GTEx databases of PDAC patients and normal samples. Moreover, we identified the differential expression lncRNAs, and used the K-M curves, the univariate Cox analysis, the lasso regression model, and the hierarchical clustering to establish a pancreatic cancer risk assessment model. Finally, GO and KEGG analyses were conducted to explore the underlying mechanism of the lncRNAs.
Results: We found that the low expression of LncRNA AC093010.3, LINC01089, AL049840.4, AC005261.1, and high expression of AL513314.2, UNC5B-AS1 are associated with PDAC patients' poor prognosis. Every PDAC patient with lncRNA quantitation produced a risk score and will be divided into different groups. High-risk group two-year OS is 21.28% (vs. low-risk group is 49.32%), and the five-year OS is 9.12% (vs. low-risk group is 28.77%). The AUC of the ROC curve was 0.747. The hierarchical clustering divided patients into two clusters derived for RNA-Seq, and samples in the UNC5B-AS1 enriched cluster had significantly worse OS than patients in the AC093010.3 upregurated cluster (median OS of 15.8 months vs. 20.3 months, p=0.008). The GO and KEGG analyses showed that the most significant biological function is cell adhesion molecule binding, while the cell cycle pathway was the core pathway of the entire prognostic model.
Conclusions: We constructed a reliable prognostic model for pancreatic cancer and identified potential therapeutic targets of lncRNA.
PP03-011 Risk Factors Associated with Recurrence of Pancreatic Solid Pseudopapillary Neoplasms: A Single Institution Experience
Oscar Ricardo Paredes Torres, Peru

O.R. Paredes Torres, K.C. Paredes Galvez, F. Berrospi Espinoza
Abdominal Surgery, Instituto Nacional de Enfermedades Neoplasicas, Peru

Background: Pancreatic solid pseudopapillary neoplasms are rare and low-grade tumors. The milestone of treatment is surgical resection, however, some patients relapse after surgery. The aim of this study is to analyze the clinical and pathological features associated with increased risk of recurrence in SPN.
Methods: Between 2000 and 2019 seventy-four patients with SPN underwent surgical resection and then were followed up periodically. Clinicopathological data were statistically analyzed.
Results: Of the 74 total patients, 70 (94.6%) were women and 4 (5.4%) were men. The median age was 25.1 (range, 7-68 years). The median tumor size was 8.7 (range, 2-20 centimeters) and the tumor localization was: head (n= 35), body (n=16) and tail (n= 23). The surgical treatment was: duodenopancreatectomy (n=32), central pancreatectomy (n=9) and distal pancreatectomy (n= 33). For patients with R0 resection, the Kaplan Meier five years survival was 87%. The five-year rate of locoregional tumor recurrence was 6.7%. The presence of larger tumors size (diameter>5cm), perineural invasion, lymph node metastasis, positive margins, and multi-visceral resection were significant factors for locoregional recurrence and cancer-related survival.
Conclusions: Factors including a larger tumor size (diameter > 5cm), perineural invasion, lymph node metastasis, positive margins, and multi-visceral resection may increase the risk of recurrence of resected SPNs.
Keywords: Pancreatic solid pseudopapillary neoplasms (PSPN), Risk Factors, Recurrence.
PP03-012 Conservative Surgery for Low Grade Head Pancreatic Tumors: A Case Report
Javier Kelly-Garcia, Mexico

J. Kelly-Garcia1, B.B. Cano-Vargas2, G.M. Gazga-Contreras2, J.L. Criales-Cortez3, F. Dominguez-Rangel2, G. Vazquez-Sierra4
1Head of Surgical Oncology, Onco Quality Care, Mexico, 2Onco Quality Care, Mexico, 3CT Scanner del Sur, Mexico, 4Star Medica Centro Patologia, Mexico

Introduction: Conservative pancreatic surgery is a major concern mainly in young patients. Many technics have been described on medical literature, and most of them depend on the type, size, localization and clinical manifestation of the tumor.
Case report: A woman 27 years old, with epigastric pain and palpable abdominal mass as initial symptomatology. The Ct scan reveal a 11.5 x 8.5 cm tumor in head of pancreas (Image 1), clinically no endocrine neither exocrine deficiencies were presented. The clinical evaluation and radiologic expansive patron of the lesion suggests the possibility of conservative surgery and the patient was operated with surgical loupes. A marginal inferior head pancreatectomy was performed, the Wirsung duct was identified and preserved. The patient remained hospitalized without major complication during five days and the closed drainage took out at the third week on a regular postoperative medical visit. No perioperative Morbi- mortality was present. The final histopathology study reported a low-grade pseudopapillary tumor. At two years of follow up the patient remains asymptomatic without pancreatic dysfunction or local recurrence. (Image 2).
Conclusion: Conservative surgery for low grade malignant tumor of pancreatic head should be considered any time it seems feasible with good result at moderate term.
[Image preoperative]
PP03-013 Predictive Nomogram for Early Recurrence after Pancreatectomy in Resectable Pancreatic Cancer: Risk Classification Using Preoperative Clinicopathologic factors
Sang Hyun Shin, Korea, Republic of

S.H. Shin, I.W. Han, J.S. Heo, D.W. Choi
Surgery, Samsung Medical Center, Korea, Republic of

Purpose: The purpose of the present study was to develop a risk prediction model to predict early recurrence after surgery in pancreatic ductal adenocarcinoma (PDAC) using only preoperative factors in classification of patients with resectable disease.
Methods: Between January 2007 and December 2016, data from 631 patients with all considered preoperative factors without omission were classified as training set and used to develop a nomogram.
Results: When a p-value estimated from univariable Cox's proportional hazard regression analysis was less than 0.05, the variables were included in multivariable analysis and used for establishing a nomogram. The established nomogram predicts the probability of early recurrence after surgery in resectable PDAC. A thousand of bootstrap resampling was used to validate the nomogram. A concordance index was 0.665 (95% confidence interval [CI], 0.637 - 0.695), and incremental area under the curve was 0.655 (95% CI, 0.631 - 0.682). We developed a web-based calculator, and the nomogram is freely available at In order to optimize the predictive value of the designed nomogram, we looked for the cutoff value. When cutoff value was set to 0.71, estimated sensitivity and specificity were 54% and 91%, respectively. The likelihood ratios of positive and negative test results were calculated as 5.9 and 0.51, respectively.
Conclusion: This is the first nomogram to predict the early recurrence after surgery for resectable PDAC in the preoperative setting, and is expected to provide a way to advance to customized treatment considering the risk according to individual patient by predicting early recurrence.
PP03-014 The Decrease or Normalization of Carbohydrate Antigen 19-9 Have Comparable Prognostic Performance in Patients with Borderline Resectable and Locally Advanced Pancreatic Cancer after Neoadjuvant Chemotherapy
Woohyung Lee, Korea, Republic of

W. Lee, S.C. Kim, K.B. Song, J.H. Lee, D.W. Hwang
Asan Medical Center, Korea, Republic of

Background: Optimal carbohydrate antigen (CA) 19-9 value after neoadjuvant chemotherapy (NACT) was not confirmed in patients with borderline resectable (BRPC) or locally advanced pancreatic cancer (LAPC).
Methods: BRPC (n = 81) and LAPC (n = 36) patients who underwent surgery after NACT were included from 2012 to 2017 in a tertiary referral center. Prognostic models were established based on carbohydrate antigen (CA) 19-9 regression rate (CRR) and prognostic performance was compared using C-index and Akaike information criterion (AIC).
Results: Prognostic significance was found in patients with 37 U/ml ≤ pre-NACT CA 19-9 ≤ 1000 U/ml, and prognostic model was established in this subgroup. CRR was the independent prognostic factor for better survival (hazard ratio [HR]; 0.112, 95% confidence interval [CI]; 0.035-0.358, p < 0.001) and recurrence (HR; 0.195, 95% CI; 0.067-0.565, p = 0.003) as well as R0 resection (p = 0.002) and non-transfusion during surgery (p = 0.002). Especially, CRR ³ 65 % was related with better survival compared with CRR < 65% (HR; 0.166, 95% CI; 0.067 - 0.410, p < 0.001). Prognostic performance showed no significant difference among CRR (C-index; 0.728, AIC; 164.174), normalization of CA 19-9 after NACT (C-index; 0.688, AIC; 169.569), or surgery (C-index; 0.688, AIC; 162.871) (p = 0.652).
Conclusion: CRR ³ 65 % was the independent prognostic factor for better prognosis after NACT in patients with BRPC or LAPC. Decrease of CA19-9 after NACT was prognostic indicator as well as normalization of CA 19-9 after NACT or surgery.
PP03-015 The Meaning of Post-Operative 5 Years in Patients with Pancreatic Ductal Adenocarcinoma
So Jeong Yoon, Korea, Republic of

S.J. Yoon, I.W. Han, J.S. Heo, D.W. Choi, S.H. Shin
Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea, Republic of

Pancreatic ductal adenocarcinoma(PDAC) is regarded as incurable, since its survival rate is still limited even after curative resection. Factors that predict long-term survival are controversial. Also, it is uncertain that 5 disease-free years means cure of PDAC. The aim of this study is to identify factors associated with long-term survival and determine if 5-year period means confirmation of cure.
Between January 2007 to December 2014, a total of 625 patients underwent resection for PDAC. The clinicopathological data of the patients were retrospectively reviewed. Risk factor analyses were performed to identify the factors associated with actual 5-year overall and disease-free survival. The characteristics of patients who had recurrent disease after postoperative 5 years were reviewed separately.
The actual 5-year overall and disease-free survival rates of total patients were 19.4% and 19.3%, respectively. Long-term survivors (n=89) had a median survival of 84 months. Age and lymph node metastasis were related to long-term survival. In patients with disease-free survival beyond 5 years (n=68), age, tumor size, and lymph node metastasis were associated factors. Among those, recurrent cancer had occurred in 6 patients: 3 loco-regional recurrences, 3 distant metastases. There was no statistically significant factor in these patients comparing to the other 62 patients.
In this study, 89 of total 625 patients have survived longer than 5 years. There still remains risk of recurrence after 5 disease-free years, but no specific factor was identified to be predict the risk. This demonstrates that 5-year period may not guarantee cure of PDAC.
PP03-017 Unusual Presentation of Pancreatic Tumor
Jiunn-Chang Lin, Taiwan, Republic of China

J.-C. Lin, T.-S. Huang
Department of General Surgery, MacKay Memorial Hospital, Taiwan, Republic of China

A 47 year-old female presented with a reducible bulging mass at umbilicus. Physical examination showed no jaundice, no abdominal pain, but the abdomen was distended due to obesity. Under the impression of umbilical hernia, herniorrhaphy was arranged. However, a large cystic mass was observed through the fascia defect during operation. Pancreatic cystic tumor was suspected and CT was arranged after herniorrhaphy. CT demonstrated a giant (28x26cm) lobulated cystic mass was found mainly in central abdomen with internal septa. Distal pancreatectomy with splenectomy was performed and pathology showed mucinous cystic neoplasm (MCN) with low-to intermediate grade dysplasia. The post-operative course was uneventful and her body weight decreased from 90 to 75 kilograms.
Pancreatic tumor usually presented with symptoms such as abdominal pain, back pain, or jaundice. Umbilical hernia is an unusual presentation of pancreatic tumor, and it might be neglected in obese patient. Sophisticated investigation of the etiology of increased intraabdominal pressure and careful inspection during herniorrhaphy may help us not to lose the diagnosis of pancreatic tumor in such an unusual presentation.
PP03-019 Comparison of Conventional Distal Pancreatectomy and Splenectomy with Radical Antegrade Modular Pancreatosplenectomy, Multicenter, Retrospective Study
Hyung Sun Kim, Korea, Republic of

H.S. Kim1, T.H. Hong2, Y.K. You2, D.S. Yoon1, J.S. Park1
1Department of Surgery, Gangnam Severance Hospital, Yonsei University, Korea, Republic of, 2Department of Surgery, Seoul St Mary’s Hospital, the Catholic University, Korea, Republic of

Introduction: Radical antegrade modular pancreatosplenectomy (RAMPS) has been reported to achieve better negative margin and to retrieve more lymph node compared with conventional distal pancreatectomy. Until now, many studies were historical control and the results remain controversial. In this study we evaluated surgical outcomes and long-term prognosis of RAMPS compared with conventional resection through multicenter in recent period.
Methods: A total 106 patients who underwent curative resection for left side Pancreatic cancer in two hospitals (Gangnam Severance Hospital, St Mary's hospital) from 2012 to 2017 were reviewed. Overall survival and recurrence-free survival rates were compared using Kaplan-Meier estimates.
Results: Before propensity scores matching, in RAMPS group had more advanced Tand N stage and larger tumor size than conventional group (T stage, p = 0.04; N stage, p =0.02; tumor size,
p = 0.04) After propensity scores matching based on T stage and N stage, 37 patients (RAMPS) and 37 patients (Conventional DP) were included in the analysis. There was no difference in disease free survival (p = 0.463) and overall survival (p = 0.383) between the two groups in survival analysis. On multivariate analyses, completion of chemotherapy was identified as independent factors for disease-free survival (p < 0.001) and overall survival (p< 0.001).
Conclusions: In advanced tumors, RAMPS procedure may be one option for R0 resection. However, the two procedures compared showed no difference in disease free survival and overall survial. The role of postoperative chemotherapy in pancreatic cancer seems to be more important.
PP03-020 Is Neoadjuvant Chemotherapy Always Justified in Clinical T1 Pancreatic Ductal Adenocarcinoma?
Hyung Sun Kim, Korea, Republic of

H.S. Kim1, K. Nakagawa2, T. Akahori2, K. Nakamura2, T. Takagi2, M. Sho2, J.S. Park1, D.S. Yoon1
1Department of Surgery, Gangnam Severance Hospital, Yonsei University, Korea, Republic of, 2Department of Surgery, Nara Medical University, Japan

Introduction: Recently, several studies using neoadjuvant treatment have been actively conducted in patients with resectable pancreatic cancer. Neoadjuvant treatment usage in Stage I-II pancreatic cancer increased. These cases are needed to determine its effectiveness, especially clinical T1 stage. So we need to compare the survival benefit of preoperative neoadjuvant treatment in early T stage of pancreatic cancer.
Methods: Two institutional data were included in our analysis (Gangnam severance hospital, Nara medical university hospital). Overall survival and disease-free survival was measured as primary outcomes. 36 patients underwent upfront surgery and 10 patients underwent neoadjuvant treatment between January 2010 and December 2017.
Results: Total patients were 46 patients. However, two patients in the neoadjuvant treatment group did not undergo surgery due to distant metastasis after neoadjuvant treatment. Therefore, 44 patients underwent pancreatectomy in clinical T1 stage of pancreatic cancer. Neoadjuvant regimen consisted of gemcitabine and concomitant radiation of 54 Gray. There was no difference in overall survival between the two groups in patients. (Neoadjuvant group: 5 year overall survival rate = 75%, upfront surgery group: 5 year overall survival rate = 42.7%, p = 0.07). However, the neoadjuvant group tended to have a better survival rate than upfront surgery group. On multivariate analyses, age>65, perineural invasion, R1 resection were identified as independent factors for poor overall survival.
Conclusions: Our results showed more better oncological outcomes in neoadjuvant treatment group. Large scale prospective study will be needed to determine the survival benefits of neoadjuvant treatment for early stage pancreatic cancer.
PP03-021 Efficacy and Safety of Nab-Paclitaxel plus Gemcitabine in the Treatment of Advanced Pancreatic Cancer by Transcatheter Arterial Chemotherapy
Yongqiang Hua, China

Y. Hua, Z. Ning, L. Xu, Y. Li, P. Wang, H. Chen, Z. Chen, Z. Meng
Minimally Invasive Treatment Center, Fudan University Shanghai Cancer Center, China

Objective: To evaluate the efficacy and safety of Nab-paclitaxel combined with gemcitabine (AG) regimen in the treatment of advanced pancreatic cancer by transcatheter arterial chemotherapy/chemoembolization (TAC/TACE).
Method: Retrospective analysis of 72 advanced pancreatic cancer patients who were treated at Fudan University Shanghai Cancer Center from 2016 to 2018. The TAC regimen consisted of Nab-paclitaxell 125mg/m2 combined with gemcitabine hydrochloride 1000mg/m2, perfusion 10 minutes, pancreatic head and neck tumor perfused through the gastroduodenal artery. If accompanied by liver metastasis, embolization was implemented.
Result: Among the 72 patients, 8 patients received treatment once, 11 patients received treatment twice, 14 patients received treatment three times, and 39 patients received treatment more than four times with an interval of 21~45 days. The survival rates of 1-year and 2-year were 36.11% and 8.33%. respectively. Median survival time was 8.77 months. The PFS rates of 3-month and 6-month were 72.22% and 45.83% respectively. Multivariate analysis showed that KPS ≥ 80, III stage was associated with longer survival, and that surgery and TAC/TACE treatment suggested a good prognostic factor. The median progression-free survival time was 4.5 months. Treatment-related grade III and above hematologic adverse reactions and non-hematologic adverse reactions were decreased compared with intravenous chemotherapy. All adverse reactions improved after treatment, and there were no treatment-related deaths.
Conclusions: Nab-paclitaxell combined with Gemcitabine has better safety in the treatment of pancreatic cancer by transarterial infusion chemotherapy. Compared with intravenous chemotherapy, Nab-paclitaxell combined with gemcitabine can reduce the adverse reactions, effectively control the disease and prolong patients' survival.
PP03-022 Circulating Cytokine Levels as Biomarkers for Response to FOLFIRINOX Chemotherapy in Pancreatic Cancer Patients
Fleur van der Sijde, Netherlands

F. van der Sijde1, W. Dik2, D. Mustafa3, E. Vietsch1, C. van Eijck1
1Surgery, Erasmus University Medical Center, Netherlands, 2Immunology, Erasmus University Medical Center, Netherlands, 3Pathology, Erasmus University Medical Center, Netherlands

Introduction: FOLFIRINOX chemotherapy is currently standard treatment in patients with advanced pancreatic cancer (PDAC) and is being investigated as neoadjuvant treatment in resectable disease. However, patient stratification is essential, because of the low response to FOLFIRINOX and severe side effects. The balance of tumor-promoting and tumor-suppressing components of the immune system plays a crucial role in cancer progression and treatment response. Cytokines are key players in immune cell signaling. The aim of this study was to identify circulating cytokines as potential biomarkers for FOLFIRINOX response.
Methods: Serum samples of 88 PDAC patients were prospectively collected before and after one cycle of FOLFIRINOX chemotherapy. Patients were categorized as disease control patients (DC) or progressive disease patients (PD), based on the RECIST criteria. Cytokine detection rates and concentrations were measured using a 34-plex Luminex immunoassay (Procarta).
Results: Before start of treatment, the detection rate of IL-2 was higher in DC compared to PD (21.1% vs 0%, p=0.031), but not after chemotherapy. Only after chemotherapy, the detection rate of IL-1RA was higher in DC compared to PD (50.9% vs 21.1%, p=0.032). The IL-1RA detection rate increased during chemotherapy in DC patients only (1.8% before, 50.9% after, p< 0.001). Moreover, absolute IL-1RA concentrations increased in DC patients (0.00 pg/mL before, 16.85 pg/mL after, p< 0.001), but not in PD patients.
Conclusions: IL-2 and IL-1RA are differentially expressed in serum of PDAC patients with DC and patients with PD after FOLFIRINOX chemotherapy. Cytokines are promising biomarkers to aid chemotherapy decision making in PDAC patients.
PP03-023 Mixed Neuroendocrine-Non-Neuroendocrine Neoplasms (MiNEN) of Pancreas: A Rare Entity
Vaibhav Kumar Varshney, India

V.K. Varshney1, J.N. Bharti2, B. Varshney2
1Surgical Gastroenterology, All India Institute of Medical Sciences, India, 2Pathology, All India Institute of Medical Sciences, India

Introduction: Mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN) comprise of both epithelial and neuroendocrine component in which each element has to comprise at least 30% of the tumor. MiNEN usually involve various gastrointestinal organs, however it is very infrequent in pancreas.
Case Presentation: We encountered an 81-year-old male patient who presented with pain in upper abdomen since 3 months. He noticed jaundice with cholestatic features for last 15 days which was associated with anorexia and weight loss. Liver function test revealed: Bilirubin-3.8mg/dl; AST- 76 U/L; ALT- 163 U/L; Alkaline phosphatase- 826 IU/L, while carbohydrate antigen 19-9 was 46.9 U/ml. CECT abdomen reported a mass in the pancreatic head with dilated common bile duct and pancreatic duct. He underwent pancreatoduodenectomy (PD) with uneventful post-operative course. Histopathological examination revealed two different tumours: ductal adenocarcinoma admixed with neuroendocrine tumour of pancreas which was confirmed with immunohistochemistry (CK-7, Chromogranin and Synaptophysin positive). He received adjuvant chemotherapy and at the end of six months follow up, he has no recurrence.
Conclusion: MiNEN is a rare malignancy of pancreas for which pancreatoduodenectomy was performed and diagnosis confirmed on histopathology with immunohistochemistry. It is important to share all individual experience-based information of such anecdotal cases to get knowledge about their clinical and biological behaviour and to standardize optimal therapy.
PP03-024 PD-L1 Induced by Lipopolysaccharide via TLR4/MyD88/NF-κB Pathway Promotes Immune Escape in Pancreatic Cancer
Wenchuan Wu, China

W. Wu
Zhongshan Hospital, Fudan University, Shanghai, China

Background: The programmed death ligand 1(PD-L1) is coinhibitory molecular to induce immunosuppression in pancreatic ductal adenocarcinoma (PDAC). However, the regulatory mechanism of PD-L1 in PDAC is still unclear. Previous study had reported that Toll Liker Receptor4 (TLR4) have co-expression with PD-L1 in lung cancer but the underlying mechanism is unclear. In this study, we used LPS as TLR4 specific agonist to explore the underlying mechanism of how TLR4 inducing PD-L1 expression in PDAC.
Method: TLR4 and PD-L1 expression were analyzed in pancreatic tumor tissue and cell lines. TLR4 and MyD88 sh-plasmid, NF-κB pathway inhibitors were used to explore the potential mechanism. Orthotopic pancreatic cancer animal model were established to further demonstrate regulatory mechanism. The correlation of plasma LPS activation and tumoral PD-L1 level were analyzed in PDAC patient.
Results: TLR4 had higher expression in pancreatic cancer tissues and had positive correlation with PD-L1 expression. LPS activated TLR4/MyD88/ NF-κB pathway and further induced PD-L1 in two pancreatic cancer cell lines. Intervening this pathway could eliminate the effect of LPS. Intraperitoneally injecting LPS could also induce tumoral PD-L1 in orthotopic pancreatic tumor animal model. A positive correlation between circulating LPS activity and tumoral PD-L1 was also observed in PDAC patients.
Conclusions: Our findings demonstrate that LPS can induce PD-L1 expression and promoted immune escape in pancreatic cancer via TLR4/MyD88/ NF-κB pathway. This revealed a potential target for pancreatic PD-1/PD-L1 immunotherapy.
PP03-027 Tissue Biomarker Panel as a Surrogate Marker for Squamous Subtype of Pancreatic Cancer
Sumit Sahni, Australia

S. Sahni, E. Moon, V. Howell, M. Ahadi, A. Gill, J. Samra, A. Mittal
The University of Sydney, Australia

Introduction: Pancreatic ductal adenocarcinoma (PDAC) has been recently classified into four subtypes based on the gene expression levels, with squamous subtype having worst prognostic outcomes. However, gene expression analysis for each individual patient is not clinically feasible due to very high associated cost. We previously reported that levels of three biomarkers (S100A4, Ca-125 and Mesothelin) can be used to classify PDAC patients based on their survival outcomes. This project aimed to determine if this novel biomarker panel can be used as a surrogate to identify squamous PDAC subtype.
Methods: Using the Nanostring gene expression platform, tumor tissue from 24 PDAC patients were analysed for our novel biomarkers and markers associated with four PDAC subtypes.
Results: Gene expression of our biomarker panel (S100A4, Ca-125 and Mesothelin) closely clustered together with markers for squamous PDAC subtype.
Conclusion: These results highlight the potential of our biomarkers to be utilized for identification of squamous PDAC subtype.
PP03-030 Patient-Derived Pancreatic Tumours in a Dish: Implications for Real-Time Precision Medicine
John Kokkinos, Australia

J. Kokkinos1,2, R.M. Ignacio1, K. Haghighi3, C. Kopecky1, G. Sharbeen1, E. Gonzales-Aloy1, J. Youkhana1, L. Butler4,5, D. Goldstein1,3, J. McCarroll2,6,7, P. Phillips1,2
1Pancreatic Cancer Translational Research Group, School of Medical Sciences, Faculty of Medicine, UNSW Sydney, Australia, 2Australian Centre for Nanomedicine, ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, UNSW Sydney, Australia, 3Prince of Wales Hospital, Prince of Wales Clinical School, UNSW Sydney, Australia, 4Adelaide Medical School and Freemasons Foundation Centre for Men's Health, University of Adelaide, Australia, 5South Australian Health and Medical Research Institute, Australia, 6Children's Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Australia, 7School of Women’s and Children’s Health, UNSW Sydney, Australia

Introduction: The poor prognosis of pancreatic cancer (PC) is attributed to the highly fibrotic stroma and complex microenvironment that is difficult to fully recapitulate in preclinical models. Mouse models are often derived using human tumour cells without stromal and immune cells, can take months to establish and are confounded by mouse host with human tumour. To fast-track translation of new drugs and to inform PC personalised medicine, there is an unmet need for preclinical models that closely mimic the biology of human disease.
Aim: To develop a model that maintains viable human PC tissue in culture for testing therapeutics.
Methods: Patient-derived PC tumour tissue was obtained from patients undergoing pancreaticoduodenectomy, cut into 2mm explants, and grown using specialised media on a support scaffold for 12-days ±Abraxane®. Immunohistochemistry was performed for markers of viability, cancer/stromal cell populations and fibrosis.
Results: Explants maintained histological tumour and stromal architecture for 12-days of culture. Immunohistochemistry confirmed viable and proliferating cancer and stromal cells that were dispersed throughout dense fibrosis, consistent with day 0 (Figure 1). As proof-of-principle, patient-x explants responded to a clinical dose of Abraxane® with increased cell death.
Conclusion: Our novel model retains the 3D architecture of human pancreatic tumours. Our technique has several advantages over standard organoids: 1) no manipulation or digestion of tissue, 2) no artificial propagation of organoids, and 3) presence of functional multi-cellular stroma, fibrosis and vascularity. This provides an unprecedented opportunity to study PC biology, rapidly assess therapeutic response, and could drive personalised treatment for PC.
[Figure 1: Pancreatic Tumour Explant Culture]
PP03-031 Pancreatic Metastases Cryosurgery
Dmitry Ionkin, Russian Federation

D. Ionkin, Y. Stepanova, A. Chzhao
Oncology, A.V. Vishnevsky National Medical Research Center of Surgery, Russian Federation

Materials and methods: Since 2016, three unresectable patients with metastatic pancreatic cancer have undergone cryodestruction (CD) of secondary foci.
1. 62 years old man, About metastasis of melanoma in the brain 25 months. complex treatment was performed back. 10 months ago- extended lobectomy on the left + resection of the lower lobe of the left lung. Metastasis up to 2 cm in the body of the pancreas.
2. 62 years old man, 72 months ago underwent nephrectomy on the left for renal cell carcinoma, 32 months back was performed laparoscopic resection of the right kidney. Metastasis in the head of the pancreas- 2x3 cm.
3. 58-year-old patient, 26 months ago was given a combined pneumonectomy on the left with a graduated resection of the pulmonary trunk and plastic surgery with autoderompericardium for squamous cell carcinoma. 6x5 cm metastasis was located in the body tail of the pancreas with the involvement of the celiac trunk and aorta.
Cryodestruction of metastases was performed in all patients.
Results: In all patients, the postoperative period was uneventful. The pain syndrome is stopped. There were no signs of relapse in any case. 2 patients are still alive (1st - 26 months, 2nd -15 months). A patient with lung cancer metastasis died after 10 months.
Conclusions: In patients with metastatic damage to the pancreas, when radical surgery cannot be performed, the use of local cryodestruction is justified. With modern combination treatment, there is an improvement in quality and an increase in life expectancy in these patients.
PP03-032 Efficacy of Liver Metastasectomy in Pancreatic Cancer
Masamichi Mizuma, Japan

M. Mizuma, F. Motoi, H. Hayashi, M. Ishida, H. Ohtsuka, K. Nakagawa, T. Morikawa, T. Kamei, M. Unno
Department of Surgery, Tohoku University, Japan

Background: Standard treatment for metastatic pancreatic cancer is systemnic chemotherapy. Significance of liver metastasectomy in pancreatic cancer remains unknown. This study aims to investigate efficacy of liver metastasectomy in pancreatic cancer.
Methods: Between 2001 and 2019, 14 cases who underwent liver metastasectomy for pancreatic cancer at Tohoku University Hospital, including 7 synchronous metastasis cases and 7 metachronous metastasis cases, were retrospectively investigated.
Results: Synchronous metastasis: Simultaneous resection of primary pancreatic tumor and liver metastases was performed in 5 cases, including 4 cases with neoadjuvant therapy and one cases with upfront surgery. Two-stage resection, which means prior metastasectomy and subsequent resection of primary tumor after chemotherapy, was performed in 2 cases. The number of metastatic tumors was within 3 in 6 cases. Median survival time (MST) after surgery, which was calculated from the primary tumor resection date in two-stage resection, was 12.5 months. One case with two-stage resection has been alive without recurrence for 81 months after surgery.
Metachronous metastasis: The median time between primary tumor resection and liver metastases was 10.7 months. All cases were treated with systemic chemotherapy before liver metastasectomy. Duration of chemotherapy before metastasectomy was 3 months in 1 case, 6-12 months in 4 cases, and 12-24 months in 2 cases. The number of metastatic tumors was within 2 in all cases. MST after metastasectomy was 19.8 months.
Conclusion: There are cases who has benefit of metastasectomy in liver metastasis of pancreatic cancer.
PP03-033 Differential Radiology Diagnostics of Metastasises of Renal Cell Carcinoma in the Pancreas
Yulia Stepanova, Russian Federation

Y. Stepanova, O. Chekhoeva, A. Gritskevich, A. Teplov, A. Krieger
Oncology, A.V. Vishnevsky National Medical Research Center of Surgery, Russian Federation

Metastatic lesion of the pancreas is an extremely rare disease, which occupies 2-5% of all pancreatic tumors, and these figures rise to 11% according to autopsies of patients with malignant tumors. Metastatic lesion of the pancreas from primary renal cancer occurs most often (65-74%).
Materials and Methods: 12 patients with histologically confirmed diagnosis - metastatic renal cell cancer in the pancreas were treated in A.V. Vishnevsky National Medical Research Center of Surgery in 2009-2019 (synchronous metastases were in 1 patient, metachronic - in 11). The lesions of both kidneys with metastases to the pancreas and lungs were revealed at synchronous case. In the period from 2 to 18 years (after an average of 8.3 years) nephrectomy in history was performed in 9 (75,0%) patients (in combination with resection of the contralateral kidney in 1), kidney resection was in 2 patients.
Results: Solitary metastases were detected in 8 (66,7%) patients. Multiple pancreatic lesions were in 4 (33,3%) patients, multifocal - in 2 of them (pancreatectomy was performed). Sizes of metastases ranged from 10 to 56 mm.
The most informative diagnostic method in detecting of pancreas focal lesions is computed tomography with bolus contrast enhancement. Significant difficulties for interpretation are small tumors that are similar in structure to hormonally active neuroendocrine neoplasm.
In case of difficulties with the visualization of metastases, it is intraoperatively advisable to use сontrast-еnhanced ultrasound.
Conclusion: Revealed pancreas solitary or multiple focal lesion in patients after nephrectomy for renal cell carcinoma should be regarded primarily as secondary.
PP03-034 Carcinosarcoma of the Pancreas: Comprehensive Clinicopathological and Molecular Characterization
Jin Li, China

J. Li1,2, T. Wei2,3, T. Liang2,3
1Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University, China, 2Zhejiang Provincial Key Laboratory of Pancreatic Disease, China, 3Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhejiang University, China

CaseAge /SexTumor LocationSize (mm)SymptomsCA19-9 (U/ml)PD dilationOperation typeRFS (mo)OS (mo)
160/MTail75Abdominal painNANoTotal pancreatectomyNA2
266/MHead40Painless jaundice12000YesWhipple2.510.5
369/MHead25Incidental finding30YesWhipple (T3N1M0)1318.5
456/FHead100RUQ pain, jaundice143YesTotal pancreatectomy2.539
551/FHead45Epigastric pain, jaundice358YesWhipple (T3N0M0)1016.5
648/FTail80Epigastric pain44NoTotal pancreatectomyNANA
767/FHead64Epigastric pain9NoWhipple33.5
859/MHead53Abdominal painNAYesWhippleNANA
949/FBody80LUQ pain5000NADistal pancreatectomyNANA
[Clinicopathological characteristics of 9 pancreatic carcinosarcoma cases]

Introduction: Carcinosarcoma of pancreas is a rare subtype of pancreatic cancer. The aim of this study was to comprehensively elaborate the clinicopathological and molecular features of this rare malignancy.
Methods: Patients who were diagnosed with carcinosarcoma of the pancreas were retrospectively identified from an institutional pathology database between 2012 and 2018.
Results: A total of nine patients were identified. Pathological examination of tumor tissues from patients who were included in this study showed coexisting carcinomatous and sarcomatous components. The recurrence rate is 100% and the median OS is 13.5 months. These two components were distinguished by mutually exclusive expression of cytokeratin and vimentin. The sarcomatous tissue exhibited more exuberant proliferation, as revealed by Ki67 staining, and necrosis compared with the carcinomatous counterpart. Genomic analysis of tumor tissues for two individuals demonstrated hotspot mutation at KRAS and TP53. Carcinomatous and sarcomatous components were separately obtained via laser captured microdissection in one patient, and mutations of driving genes were highly concordant between these two components. In line with genomic characterization, immunostaining of frequently-altered tumor suppressor genes suggested consistent outcomes.
Conclusion: Carcinosarcoma of the pancreas represent a rare malignancy with distinct histological characteristics. Genomic analysis suggested monoclonal origin of pancreatic carcinosarcoma.

[Histopathological features of pancreatic carcinosarcoma.]
PP03-036 Solid-Pseulopapillary Tumors: Possibilities of Preoperative Verification
Yulia Stepanova, Russian Federation

Y. Stepanova, S. Berelavichus, D. Gorin, A. Glotov
Oncology, A.V. Vishnevsky National Medical Research Center of Surgery, Russian Federation

Objective: To determine the possibilities of preoperative verification of pancreatic solid-pseudopapillary tumor (SPPT) on the basis of own experience.
Materials and methods: In A.V. Vishnevsky NMRC of Surgery 50 patients with morphologically verified pancreatic SPPT were treated (2005-2019), wemen prevailed (96.0%), average age - 33.6±1.3 years. Preoperatively study: ultrasound, MSCT, MRI. All patients were operated on.
Results: There are three types of SPPT MRI-images (Yu C.-C. et al., 2007): 1st - completely solid neoplasms; 2nd - combination of solid sites with hemorrhages; 3rd - extensive hemorrhages and cystic formations. It's appropriate to apply this classification in the diagnosis of SPPT as a whole.
The greatest difficulties caused by the 1st type lesions diagnostics.
Ultrasound: it's almost impossible to differentiate individual microcavities in solid lesion. SPPT is well-vascularized, however, for the lesion up to 3.0 cm, data of bloodflow at DS cann't obtained.
MSCT: high indicators of HU in the liquid component of the 1st type are possible, because of the cystic cavities are very small and a “trimmed” solid component can get to the measurement point on CT-scans.
MRI makes it possible to identify small liquid lesion gaps and to differentiate their hemorrhagic contents (which is explained by the significant paramagnetic effect of methemoglobin).
Preoperative verification: 56.0%. Misdiagnosis (32.0%): neuroendocrine (5), cystic (5), retroperitoneal (3) tumors, adenocarcinoma (2); pseudocyst with hemorrhage (1). Differential diagnosis was made in 12.0%.
Conclusion: It's advisable to consider MRI as the method of choice for SPPT diagnosis. Immunohistochemistry is of decisive importance in SPPT diagnosis.
PP03-037 Subtype Classification of Pancreatic Ductal Adenocarcinoma Based on Microenvironmental Niche Factors Dependency and Chemotherapy Resistance
Tomohiko Shinkawa, Japan

T. Shinkawa, K. Ohuchida, S. Matsumoto, C. Iwamoto, K. Shindo, K. Nakata, T. Ohtsuka, M. Nakamura
Surgery and Oncology, Kyushu University, Japan

Introduction: Abundant stroma of pancreatic ductal adenocarcinoma (PDAC) produces various microenvironmental < niche> factors. PDAC organoids have different dependencies on niche factors; while there are PDAC subtypes independent of niche factors as represented by conventional pancreatic cancer cell lines, there are also PDAC subtypes that strongly depend on niche factors. We performed the PDAC subtype classification based on niche dependency and their morphological phenotypes and investigated the correlation between niche dependency and drug treatment response.
Methods: PDAC organoids were validated the morphology compared with the primary tissue. The proliferation assay was performed in medium supplemented with fetal bovine serum (serum medium) or with niche factors (niche medium), respectively. Niche dependent organoids and pancreatic stellate cells (PSCs) were cocultured in serum medium to evaluate their organogenesis. Gemcitabine was administered to niche dependent/independent organoids, and the drug sensitivity was compared.
Results: All eight PDAC organoids retained the morphological features in the primary tumors and were classified into poorly, moderately, and well differentiated subtypes. While all the poorly differentiated subtypes showed significantly higher proliferation in serum medium, all the well differentiated subtypes showed significantly higher proliferation in niche medium. When directly cocultured with PSCs, niche dependent organoid strongly formed the organoid structure in serum medium. The viability assay using Gemcitabine showed niche dependent organoids had more resistance to Gemcitabine than the independent organoids.
Conclusion: The niche dependency was correlated with the tumor differentiation. Niche dependent PDAC organoids had more resistance to chemotherapy than the independent organoids.
PP03-038 Clinical Implication of Pin1 Expression in Pancreatic Ductal Adenocarcinoma
Satoshi Kuboki, Japan

S. Kuboki, T. Suzuki, H. Yoshitomi, K. Furukawa, T. Takayashiki, S. Takano, D. Suzuki, N. Sakai, M. Ohtsuka
General Surgery, Chiba University, Graduate School of Medicine, Japan

Purpose: The prognosis of pancreatic ductal adenocarcinoma (PDAC) is poor even after curative surgical resection. Therefore, discovering new important factors controlling PDAC progression is essential. Pin1 overexpression is seen in several malignancies and is reported to promote tumor progression through activation of transcriptional factors such as NF-kappaB, STAT3, and FOXC1. However, no reports have focused on the expression levels of Pin1 in PDAC. Therefore, we thought to evaluate Pin1 expression in PDAC, investigate the correlations with clinicopathological variables, and determine whether Pin1 is a promising therapeutic target in PDAC patients.
Experimental Design: The expression levels of Pin1 and related factors were evaluated by immunohistochemical staining. Moreover, the relationship between Pin1 expression and clinicopathological features or prognosis in 120 PDAC patients were investigated.
Results: Pin1 expression was increased in some cases of PDAC, and was associated with vascular invasion in PDAC. The univariate and multivariate analyses revealed that high Pin1 expression in PDAC was an independent factor for poor prognosis. Pin1 enhanced activation of transcriptional factors such as STAT3 and FOXC1, resulted in aggressive tumor progression. Increased Pin1 expression induced tumor growth by accelerating cell proliferation and inhibiting cell apoptosis. Moreover, Pin1 overexpression promoted tumor invasion by enhancing EMT. As these results, the incidence of hematogenous recurrence was significantly higher in PDAC with high Pin1 expression.
Conclusions: Pin1 overexpression is associated with aggressive tumor progression and poor prognosis in PDAC; therefore, Pin1 is an excellent biomarker for predicting its malignant status and is a promising therapeutic target in patients with PDAC.
PP03-039 Roundabout Homolog 1 Inhibits Proliferation via the YY1-ROBO1-CCNA2-CDK2 Axis in Human Pancreatic Cancer
Qun Chen, China

Q. Chen, J. Zhang, Z. Lu, K. Jiang, Y. Miao
Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, China

Introduction: Pancreatic cancer (PC) is highly malignant and has a high mortality with a 5-year survival rate of less than 8%. As we know, ROBO1 plays an important role in embryogenesis and organogenesis and also inhibits metastasis in PC. Our study was designed to explore whether ROBO1 has effects on the proliferation of PC and its specific mechanism.
Methods: The protein and mRNA levels of ROBO1 in clinical PC specimens were determined by IHC and qRT-PCR. In vivo and in vitro experiments were used to verify the effects of ROBO1 on PC proliferation. ChIP sequencing revealed that YY1 can be used as an upstream target for ROBO1.
Results: The expression of ROBO1 was higher in cancer tissues than in matched adjacent tissues. Overexpression of ROBO1 can inhibit the proliferation of PC cells in vitro, and the S phase fraction can also be induced. Further subcutaneous tumor formation in nude mice showed that ROBO1 overexpression can significantly inhibit tumor growth. YY1 was found to directly bind to the promoter region of ROBO1 to promote transcription by a luciferase reporter gene assay, ChIP and EMSA. Mechanistic studies showed that YY1 can inhibit the development of PC by directly regulating ROBO1 via the CCNA2/CDK2 axis.
Conclusion: Our results suggest that ROBO1 may be involved in the development and progression of PC by regulating cell proliferation and shows that ROBO1 may be a novel and promising therapeutic target for PC.
[Correlation between ROBO1 expression and pancreatic cancer]
PP03-043 Non-Hodgkin Lymphoma Presenting with Obstructive Jaundice - Diagnostic Dilemma
Anshuman Pandey, India

S. Chauhan, S. Jha, A. Pandey, S. Masood, D. Kumar, A. Gautam
Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India

Introduction: Obstructive jaundice is seldom a presenting feature of non-Hodgkin lymphoma (NHL). Indeed, several case reports suggest that only 0.2-2.0% of patients with NHL have biliary tract obstruction. Adenocarcinoma arising from the pancreas, bile duct, duodenum are among the common cause of obstructive jaundice worldwide. Hence NHL is rarely considered among differential diagnosis of obstructive jaundice.
Methods: We present a case series of 4 patients with NHL presenting with obstructive jaundice as an initial manifestation. The aim was to evaluate the clinical and imaging findings, management, and outcome of biliary obstruction caused by lymphoma.
Results: All 4 patients presented with obstructive jaundice with duration ranging from 2 weeks to 4 months. 3 patient had pancreatic mass with lower CBD block and one had hilar block on CECT abdomen. All cases were diagnosed by endoscopic and biopsy. 2 patients presented with cholangitis and stented to relieve sepsis. One patient had poor ECOG status so only stenting was offered but succumbed within a month of diagnosis. 2 patient died of sepsis and multiorgan failure before initiating chemotherapy and only one patient had undergone chemotherapy.
Conclusion: Biliary obstruction is a sign of poor prognosis. The diagnosis of NHL needs to be considered in patients presenting with biliary obstruction. It can be associated with high mortality and poses treatment dilemma. Treatment of biliary obstruction due to lymphoma is controversial regarding chemotherapy alone versus biliary drainage preceded by chemotherapy. Biliary drainage is recommended in patients with infectious complication.
PP03-045 Pancreatic Resections of Metastases from Renal Cell Carcinoma

I.G. Merlo1, J. Grondona1, R. Bracco2, P. Angiolini1, D. Fernández2, F. García2, F. De Francesco3, D. Huerta1, L. Miranda1
1UNACIR HPB, San Isidro, Argentina, 2UNACIR HPB, Mar del Plata, Argentina, 3UNACIR HPB, San Nicolas, Argentina

Introduction: Literature data on pancreatic resections for metastatic renal cell carcinoma (mRCC) are limited to small series. The aim of this study is to report our initial experience in treatment these patients with a combination therapy that consisted of applying peri-operative chemotherapy and radical pancreatic resection.
Methods: Between 2011 and 2019, nine patients bearing pancreatic metastases from left mRCC including 5 males (55.6%) and 4 females (44.4%) were treated in our HPB Oncological Centre. Tumoral locations were: 4 in head (44.4%), 4 in body and tail (44.4%) and 1 (11.2%) in head, body and tail. Number of lesions ranged from 1 to 4 and size average was 47.3 mm (35-60). Two cases were synchronous and the other 7 were metachronous with a median time between resection of the primary and diagnosis of the metastasis of 74 months (6.2 years). All patients received 6 cycles of neoadjuvant chemotherapy, pancreatic resection (4 pancreatoduodenectomy, 4 distal pancreatectomy and 1 total pancreatectomy) and 3 cycles of adjuvant chemotherapy. The 2 synchronous cases also underwent a left nephrectomy simultaneously.
Results: No postoperative mortality occurred and morbidity rate was 33.33%. Histopathological examination confirmed that all specimens were mRCC with free surgical margins. With a median follow-up of 62.5 months. Seven patients are alive, 1 developed bone metastases at 49 months and 2 patients died with 16.4 and 50.1 months of survival respectively.
Conclusions: Combined therapy with an aggressive surgical approach, even in patient with locally advanced tumors may confer a survival benefit for patients with mRCC.
PP03-046 Simultaneous Resection for Synchronous Double Primary Adenocarcinomas of the Head of Pancreas and Rectum. Challenges and Result of an Aggressive Surgical Approach
Ahmad Ramzi Yusoff, Malaysia

A.R. Yusoff1,2, M.F. Ahmad Nazlan1, K.J. Obaid1, N.J. Osman1, M.F. Che Ani1, Y. Mohd Aripin1, S. Khalid1, HPB Selayang
1Department of Surgery, Faculty of Medicine, University Teknologi MARA, Malaysia, 2Department of Hepatobiliary Surgery, Selayang Hospital, Malaysia

Introduction: Pancreatic ductal adenocarcinoma is a malignant disease with poor prognosis and high mortality due to its late presentation. Synchronous double primary tumours of the head of pancreas and rectum is a rare occurrence and scarcely reported in the literature.
Case presentation: A 67-year-old man presented with fever for 10 days associated with anorexia and weight loss for three weeks. He denied abdominal pain, jaundice or altered bowel habit. His co-morbidities included diabetes mellitus and hypertension. Physical examination was unremarkable. His biochemistry showed obstructive jaundice features and non-reactive viral hepatitis infection. Abdominal sonography and contrasted tomography scan meanwhile revealed grossly dilated intra- and extra-hepatic bile ducts. The endoscopic ultrasound demonstrated distal common bile duct mass and fine needle biopsy was performed. A biliary stent was inserted via ERCP to relieve the biliary obstruction. Subsequently, a colonoscopy was performed following his positive fecal occult blood test which unveiled a polypoidal upper rectal mass. Biopsy of both the ductal and rectal lesions revealed adenocarcinoma. He underwent simultaneous pancreaticoduodenectomy and anterior resection but complicated by pancreaticojejunostomy leak postoperatively, which was treated conservatively. The final histology reaffirmed adenocarcinomas of pancreas and rectum. He recovered well and completed adjuvant chemotherapy with no tumour recurrence detected a year later.
Conclusions: Simultaneous resection for synchronous double primary adenocarcinomas of the head of pancreas and rectum is an aggressive approach with considerable perioperative morbidity that necessitates multidisciplinary discussion. We report the surgical management of this rare case, discuss its challenges and present a review of the literature.
PP03-047 Eighty-Six Cases of Total Pancreatectomy for Pancreatic Neoplasms
Minoru Esaki, Japan

M. Esaki, S. Nara, T. Takamoto, T. Mizui, K. Shimada
Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Japan

Background: Although frequency of total pancreatectomy (TP) indicated for pancreatic neoplasm has increased, surgical outcome and nutrition was still unclear.
Objective: To clarify the outcome of TP.
Methods: Patients with pancreatic neoplasms who underwent between 1990 and 2018 were analyzed. Surgical variables and outcome were compared between subjects who underwent simple TP [group A], TP followed by pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) according to intraoperative pathological diagnosis of pancreatic margin [B], TP followed by past PD or DP for another disease [C].
Results: A total 86 patients, 64 [36-80] year-old 44 males and 42 females, underwent TP. Operative time and blood loss were 520 [155-1070] minutes and 1095 [85-8155] ml, respectively. Mortality rate [n=2(2%)] and morbidity rate [>=Clavien-Dindo grade IIIa; n=4(5%)] were acceptable. Sixty-one cases were indicated for ductal adenocarcinoma (PDAC), 7 for neuroendocrine tumor, 7 for metastatic tumor from renal cell carcinoma, 11 for others. Although overall survival of patients with PDAC in group A (n=25), B (n=30), C (n=5) were statistically comparable respectively, the survival (3-5 years survival/ median survival time) of group A (29-29%/15.5 months) tended to be worse than that of group B and C (53-29%/ 46.9 months and 60-30%/ 56.6 months). PDAC patients with CA19-9 level less than 500 U/ml (56-41%/ 48.6 months) survived statistically more than those with CA19-9 level more than 500 U/ml (18-0%/ 16.4 months, P=0.011).
Conclusions: Because of recent advance of surgical technique and management of TP, TP for wide-spread non PDAC or less advanced PDAC provides acceptable prognosis.
PP03-048 Strategy of Therapies in Recurrence Type of Pancreatic Cancer after Surgery
Joji Watanabe, Japan

J. Watanabe, T. Yagyu, E. Uchinaka, M. Morimoto, T. Hanaki, N. Tokuyasu, T. Sakamoto, S. Honjo, Y. Fujiwara
Surgical Oncology, Tottori University Hospital, Japan

Pancreatic cancer is known as a poor prognostic cancer, it has high rate of recurrence even though performed curative surgery. The aim of this study is to evaluate prognosis in each recurrence type of pancreatic cancer after surgery, then consider adequate treatment between recurrence type.
Sixty-eight pancreatic cancer patients who had recurrence after pancreatic resection in our hospital from August 2006 to December 2016 were enrolled. The average age was 70.6, 45 were male, and 23 were female. We compared prognosis between local recurrence group, and any distant recurrence group.
A local recurrence has occurred in 22 patients (32.4%), any distant recurrence is in 46 patients (67.6%). In any distant recurrence group, liver metastasis is in 21 patients (30.9%), and lung metastasis is in 9 patients (13.2%).
When we compared recurrence free survival (RFS) and overall survival (OS) between the groups, there was no difference (RFS: 13.6 vs 12.6 months, p=0.732, OS: 27.3 vs. 27.1 months, p=0.705). Then, we divided distant recurrence into each type of recurrence. The liver recurrence has significant worse RFS and OS than others (RFS: 7.9 vs 15.3 months, p=0.004, OS: 19.6 vs 37.1 months, p=0.014). On the other hand, single lung recurrence has favorable prognosis than multiple lung recurrence (RFS: 31.0 vs 4.5 months, p=0.015, OS: 58.6 vs 11.0 months, p=0.003).
As a conclusion, liver recurrence patients are required a systemic care including palliative care and chemotherapy. On the other hand, single lung recurrence can be considered curative surgery because of their favorable prognosis.
PP03-050 Insulin Upregulates FHOD1 Expression and Promotes the Invasion and Migration of Pancreatic Cancer Cells via Insulin Receptor-dependent EMT Activation
Yong Gao, China

Y. Gao, H. Gao, B. Cai, Z. Lu, Y. Miao
The First Affiliated Hospital of Nanjing Medical University, China

Background: Pancreatic ductal adenocarcinoma (PDAC) is one of the most
deadly cancers in the world and hyperinsulinemia has been considered to be associated with the risk of pancreatic cancer. Our study is to explore the effect of insulin on the migration and invasion of pancreatic cancer cells and possible mechanism.
Results: Insulin could enhance the invasion and migration of pancreatic cancer cells through the transwell assay. Insulin receptor (INSR) is the major membrane receptor in this process. Based on digital gene expression sequencing and cell line confirmation, formin homology 2 domain containing protein 1 (FHOD1) was determined to be positively involved in insulin-induced migration and invasion. In addition, insulin and the downstream molecule FHOD1 could promote epithelial-mesenchymal transition in pancreatic cancer cells, which may subsequently promote malignant biological behaviour.
Conclusion: We reported that INSR is the major receptor involved in insulin-induced pancreatic cell mobility alterations. Epithelial-mesenchymal transition, which was regulated through FHOD1, participated in this INSR-dependent phenotypic modification. This study provided a theoretical explanation for previous epidemiological research and new clues for further exploration of the diagnosis and treatment of T2DM pancreatic cancer patients.
PP03-051 Pancreaticoduodenectomy in a Tertiary Referral Center in Indonesia, Cipto Mangunkusumo Hospital (CMH): A Single Center Experience
Arnetta N L Lalisang, Indonesia

A.N.L. Lalisang, W.S. Jeo, Y. Mazni, T.J.M. Lalisang
Digestive Division, Department of Surgery, Cipto Mangunkusumo Hospital, Universitas Indonesia, Indonesia

Pancreaticoduodenectomy (PD) as a treatment of choice for periampullary tumors is associated with significant risk of morbidity and mortality even in a developed HPB center. Resectable cases are found only in 10% to 20% of cases. Indonesia due to its geographical characteristics make it arduous to treat patients in tertiary referral center only. We are presenting our experience of PD from 1993-2019.
A retrospective review was conducted of patients who underwent PD from 1993-2019.
From 1998 to 2019, 188 patients underwent PD. Of these we were able to provide the medical records of 178 only. The mean age was 55 (range 17-73), 84 (47.1%) males and 94 (52.8%) females. The most common presenting symptom was jaundice 70% and abdominal pain in 18% of patients. Patients required pre-operative bile duct compression was 83.2%. There were 59.5% patients underwent Pyloric preserving PD and 40.5% underwent standard Whipple procedure with mean operative time was 393 min (240-640) and estimated blood loss was 450 cc. Re-laparatomy was experienced by 16% of patients. The commonest post operative morbidity was pancreatic fistula 21.7%. Surgical mortality rate was 19%.
PD provides only chance of cure in periampullary tumors in our set-up. Further improvement is needed to manage complexity of the procedure that may help curtail the postoperative morbidity and mortality rate.
PP03-052 Prognostic Impact of the Ratio of Preoperative CA19-9 to Liver Enzyme Levels in Pancreatic Cancer Patients with Jaundice
Xumin Huang, China

Z. Lu, X. Huang, K. Jiang, Y. Miao
The First Affiliated Hospital of Nanjing Medical University, China

Introduction: CA19-9 has been reported as a significant predictor for poor prognosis of PDAC but the degree of its elevation could be interfered by obstructive jaundice. To evaluate the predictability of CA19-9 for OS of PDAC patients, we adjusted preoperative serum CA19-9 with liver enzyme levels.
Methods: 563 patients undergoing surgery for PDAC in our center were reviewed. Preoperative parameters were recorded as well as OS, which began from the date of operation to that of death or last follow-up. Kaplan-Meier survival curves with log-rank test was applied.
Results: The MST was 17.767 months. We used 39/390/1000 as cutoff values of preoperative CA19-9 and Kaplan-Meier survival analysis illustrated significantly different prognosis among patients with TBIL < 102.6 µmol/L (P < 0.001, MST = NR/19.533/15.067/11.200 months). However, this tendency disappeared (P = 0.086) when TBIL >=102.6 µmol/L. We adjusted the CA19-9 level by dividing it by the value of preoperative serumγ-GGT and AST. The optimal cut off values of CA19-9/γ-GGT and CA19-9/ASTwere 0.4 and 0.5, respectively.Value 0 was assigned to the ratio lower than the cutoff value while value 1 to the higher. Add up the values and we found that patients who got 0 tended to have significantly better survival than those valued 1, and patients scored 2 showed the worst survival (P < 0.001, MST = 33.467/17.867/9.800 months).
Conclusion: Preoperative serum CA19-9 is a defective predictor for survival of PDAC patients with TBIL ≥102.6 µmol/L but this could be adjusted well by the ratio of CA19-9 to γ-GGT and AST.
PP03-053 When Arterial Resection Is Justified in Pancreatic Cancer? Results of 38 Pancreatic Resections with Resection of Truly Involved Celiac and/or Common Hepatic Artery
Viacheslav Egorov, Russian Federation

V. Egorov1, R. Petrov2, J. Zhurina3, K. Petrov4, P. Zelter5, A. Sorokin6, M. Grigorievsky2
1Surgical Oncology, Ilyinskaya Hospital, Russian Federation, 2Surgical Oncology, Bakhrushin Brothers City Hospital, Russian Federation, 3Bakhrushin Brothers City Hospital, Russian Federation, 4Medscan Diagnostic Centers, Russian Federation, 5Samara State Medical University, Russian Federation, 6Plekhanov State University of Economy, Russian Federation

1. It is believed that arterial involvement in pancreatic cancer (PC) is a sign of so far advanced disease that pancreatic resection(PR) is meaningless;
2. Distal pancreatectomy(DP) with celiac artery resection(DPCAR) is justified option for locally advanced PC
Aim: Assessment of the rates of morbidity, mortality, true pathological artery involvement and R0- resections, overall and disease-free survival after PRs with celiac (CA) and/or common hepatic artery (CHA) resections(AR).
Patients and methods: Patients with pancreatic ductal adenocarcinoma (n33) and neuroendocrine cancer(n5) underwent 38 PRs with AR without preoperative occlusion of CHA, 36 without arterial reconstructions(2009-2019). Age 54-76y. ECOG-0-1. Adjuvant chemotherapy,n19, neoadjuvant,n11 with better tendency. IOUS and vascular fluorescence (ICG) were there main methods for assessment of liver and stomach ischemia.
Results: The rate of pathological CA/CHA involvement - 100%. Overall rate of R0-resections 87%, for PDAC 85%, vein resections during DPCAR -12(35%). Morbidity: 18 (47%), pancreatic fistula Grade B/C -14(41%), mortality- 2 (5,3%), median OS- 24 months, median DFS -18 months, overall 5-y survival -41%, actual 5-y survival - 13%. No liver and bowel ischemia, gastric ischemia - 15% (1 perfor ation). All the relapses were distant.
Conclusion: Neoadjuvant treatment and R0-resection with acceptable morbidity and mortality rates justifies arterial resections for PDAC.
PP03-054 In Silico Investigation and Functional Enrichment Analysis of the Human Major Intrinsic Proteins and Voltage-gated Chloride Channel Proteins Reveal Eleven Prognostic Biomarkers for Pancreatic Cancer
Dimitris Zacharoulis, Greece

D. Magouliotis1,2, K. Dimas3, N. Sakellaridis3, M. Fergadi1, D. Symeonidis1, D. Zacharoulis1
1Department of Surgery, University of Thessaly, Greece, 2Division of Surgery and Interventional Sciences, University College London, United Kingdom, 3Department of Pharmacology, University of Thesally, Greece

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is associated with poor prognosis. In this context, the identification of biomarkers regarding the PDAC diagnosis, monitoring, and prognosis is crucial. The purpose of the present study was to investigate the differential gene expression profile of the major intrinsic proteins and chloride channel proteins in patients with PDAC, in order to suggest novel biomarkers.
Methods: In silico techniques were facilitated to construct the interactome of the investigated genes, identify the differentially expressed genes (DEGs) in PDAC as compared to healthy controls, and evaluate their potential prognostic role.
Results: Transcriptomic data of three microarray datasets were included, incorporating 114 tumor and 59 normal pancreatic samples. Fourty DEGs were identified; nine were up-regulated and thirty-one were downregulated. A molecular signature of eleven genes (Chloride Intracellular Channel 1-CLIC1; Chloride Intracellular Channel 3-CLIC3; Chloride Intracellular Channel 4-CLIC4; Ganglioside Induced Differentiation Associated Protein 1 - GDAP1; Ganglioside Induced Differentiation Associated Protein 1 Like 1-GDAP1L1; Glutathione S-Transferase Pi 1 - GSTP1; Prostaglandin E Synthase 2 - PTGES2; Aquaporin 7 - AQP7; Archain 1 - ARCN1; Exocyst Complex Component 3 - EXOC3; Coatomer Protein Complex Subunit Epsilon - COPE) were identified as prognostic markers associated with overall survival. Correlations were reported regarding the expression level of CLIC1-CLIC3, CLIC4-CLIC5, and CLIC5-CLIC6. Finally, gene set enrichment analysis demonstrated the molecular functions and miRNA families (hsa‐miR‐122, hsa‐miR‐618, hsa‐miR‐425, and hsa‐miR‐518) relevant to the seven prognostic markers.
Conclusion: These outcomes demonstrate an eleven-gene molecular panel that predicts the patients' prospective survival following pancreatic resection for PDAC.
PP03-055 Sporadic vs. MEN-associated Pancreatic Neuroendocrine Tumors: Multi-institutional Clinicopathologic Comparison
John Bergquist, United States

J. Bergquist1, A. Li1, N. Chatzizacharias2, Z. Soonawalla3, P. Athanasopoulos4, P. Hansen5, R. Parks6, B. Lawrence7, B. Visser8, International Pancreatic Neuroendocrine Tumor Study Group
1HPB Surgery, Stanford University, United States, 2University of Cambridge and Addenbrooke's Hospital, United Kingdom, 3Oxford University Hospital, United Kingdom, 4University College London, Royal Free Hospitals, United Kingdom, 5Providence Portland, United States, 6University of Edinburgh, United Kingdom, 7University of Auckland, New Zealand, 8Stanford University, United States

Introduction: Clinicopathologic distinctions of Multiple Endocrine Neoplasia (MEN) associated Pancreatic Neuroendocrine Tumor (PNET) are not well established. We sought to improve surgical decision making in MEN-associated PNET.
Method: We reviewed a multi-institutional international PNET database for patients with MEN-associated or sporadic PNET. Clinicopathological characteristics were compared. Overall(OS) and disease-free survival(DFS) were analyzed. Propensity score matching reduced bias based on tumor size, t-stage, and age.
Results: 651 patients were included(45 MEN1, 606 sporadic). Patients with MEN were diagnosed at a younger age (46vs58 years,p< 0.01), and were more often female (60vs49%,p< 0.01), multifocal (71vs19%,p< 0.01) and higher t-stage (76vs55% stage 4,p=0.034). Lymph node involvement and the presence of metastasis were similar between groups. The rate of total pancreatectomy was 5x higher in the MEN cohort (16vs3%,p=0.004). Median follow-up was 46 months. Survival analysis did not show significant differences between groups. DFS was 126 months in the MEN cohort vs.198 months in the sporadic cohort, but these curves were not statistically different (Figure). After matching was performed, survival remained similar between cohorts (OS median was not reached in either cohort, DFS 126 (MEN) vs 198 (Sporadic) months, p>0.5. Matched patients did not demonstrate differences in lymph node positivity (28vs25%,p=0.913) or presence of metastatic disease (22vs13%,p=0.29).
Conclusion: MEN-associated PNET occurs more frequently in younger, female patients, and is associated with multi-focality and high t-stage. Survival for patients with MEN-associated PNET is excellent. Consideration should be given to active surveillance and/or parenchymal-sparing surgical interventions to preserve pancreatic function given the indolence of this disease.
PP03-056 Minimally Invasive versus Open Pancreatectomy for Right-sided and Left-sided Non-functioning Pancreatic Neuroendocrine Tumors; A Multicenter, Matched Analysis with Inverse Probability of Treatment Weighting Method
Ho Kyoung Hwang, Korea, Republic of

H.K. Hwang1, Y.-S. Yoon2, Korean Pancreas Study Club
1Yonsei University College of Medicine, Korea, Republic of, 2Seoul National University Bundang Hospital, Korea, Republic of

Objective: To evaluate the safety and oncologic efficacy of minimally invasive surgery (MIS) in comparison with open surgery (OS) in the treatment of right-sided and left-sided non-functioning pancreatic neuroendocrine tumors (NF-PNETs).
Background: There is no sound evidence for the safety and efficacy of MIS for NF-PNETs according to tumor location.
Methods: Data of patients who underwent curative intended surgery for NF-PNET from August 1991 to July 2017 were collected from 14 institutions.Short-term outcomes and long-term prognosis were analyzed with inverse probability of treatment weightingmethod using the propensity score.
Results: A total of 904 patients were enrolled (OS, n=510; MIS, n=394). After matching analysis in each tumor location, no differences were noted in resection margin, intraoperative blood loss and postoperative complication including pancreatic fistula. However, MIS was associated with longer operation time than OS (318.9 vs. 401.9 min, p< 0.001) in right-sided tumors and shorter postoperative hospital stay (13.0 vs. 8.9 days, p< 0.01) in left-sided tumors. The disease-specific and disease-free survival rates of MIS were equivalent or significantly higher compared with OS in right-sided and left sided tumors. In the multivariate analysis, the surgical approach (OS vs. MIS) did not affect the disease-free survival in both sides.
Conclusion: MIS had comparable short-term outcomes with OS except longer operation time in right-sided NF-PNETs and did not compromise the oncologic outcomes in right-sided and left-sided NF-PNETs. These findings suggest that MIS can be safely applied in selected patients with localized NF-PNETs regardless of tumor location.
PP03-057 Laparoscopic Enucleation and Spleen Saving Distal Pancreatectomy for Synchronous Insulinoma and Nesidioblastosis in an Adult Patient
Xiao Shuang Ling, Singapore

X.S. Ling, Z. Wang, B.K.P. Goh
Singapore General Hospital, Singapore

Introduction: Insulinoma is the most common functional neoplasm of the endocrine pancreas. Patients typically present with features known as Whipple triad. 90% of insulinomas are found to be benign solitary adenomas amenable to surgical resection.
Method: We present a case of a lady who had endogenous hyperinsulinism with two DOTATATE avid nodules in the pancreatic body and tail who subsequently underwent laparoscopic enucleation and spleen saving distal pancreatectomy.
Results: The patient presented initially with features suggestive of Whipple triad. Further workup by the endocrinologist showed results consistent with endogenous hyperinsulinism. Computed Tomography (CT) scan and DOTATATE scan showed that she had one intensely DOTATE-avid exophytic nodule arising from the pancreatic body that is suspicious for a neuroendocrine tumour while the second DOTATATE-avid nodule is close to the pancreatic tail. There is no suspicious nodal or distant DOTATATE-avid metastasis detected. Her case was discussed in the multidisciplinary meeting and the decision was to proceed with laparoscopic enucleation of both lesions. She subsequently underwent laparoscopic enucleation of pancreatic body lesion with spleen saving distal pancreatectomy. She was discharged well on post operative day 3 and remained symptom free during subsequent follow-ups. Final histology came back as grade 1, well differentiated insulinoma of the pancreatic body and incidental pancreatic nesidioblastosis in the pancreatic tail.
Conclusion: Laparoscopic enucleation of pancreatic neuroendocrine tumour is feasible and safe method to resect pancreatic neuroendocrine tumour with less morbidity.
PP03-058 Relationship Between Prognosis of Pancreatic Tail Cancer and Lymphocyte-monocyte Ratio
Shun Sato, Japan

S. Sato, Y. Sakuraoka, T. Shimizu, K.-H. Park, T. Shiraki, S. Mori, Y. Iso, T. Aoki, K. Kubota
Dokkyo Medical University, Japan

Background: It is difficult to illustrate the relationship between inflammation and prognosis in pancreatic cancer. This is due to preoperative cholangitis and pancreatitis caused by the cancer. Recently, it has been reported that the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are useful biomarkers to reflect cancer prognosis and the lymphocyte-monocyte ratio (LMR) is the latest reported marker. In this study, we focused on pancreatic tail cancers which are not affected by inflammation and aimed to explore the relationship between prognosis and LMR.
Methods: Forty patients who were diagnosed invasive ductal carcinoma of the pancreatic tail underwent radical resection of our institute from 2010 to 2018 as having. The cut-off values of preoperative LMR, PLR, and NLR were estimated on the basis of ROC curve. We statistically compared their median overall survival by using the figures.
Results: With regard to ROC curve, area under the curve was 0.54 in LMR (p=0.72), 0.55 in PLR (p=0.65) and 0.59 in NLR (p=0.38). These revealed each parameter did not work as the sufficient predictable markers statistically in terms of prognosis. However, by using 3.64 as the cut-off value in LMR, the median overall survival month in the group having higher figures was 10.4 months compared with 30.8 months in the group being smaller numbers (Log-rank p = 0.04). There were not significant statistical differences in the results of PLR and NLR.
Conclusion: In pancreatic tail cancer, preoperative LMR could possibly be an easily measurable inflammatory marker in order to predict the prognosis.
PP03-060 Solid Pseudopapillary Neoplasm in the Pancreatic Head with Fat Replacement of the Pancreas
Joodong Kim, Korea, Republic of

J. Kim, D. Choi, E. Jwa
Department of Surgery, Catholic University of Daegu College of Medicine, Korea, Republic of

Fat replacement of the pancreas is rare. Obstruction of the main pancreatic duct by a tumor in the head of the pancreas may cause fatty degeneration of the pancreatic parenchyma. We describe the case of a pancreatic solid pseudopapillary neoplasm, associated with fat replacement of the remaining pancreas. A 44-year-old woman presented with epigastric discomfort since one week and was admitted to our hospital. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a 4cm sized tumor in the head of the pancreas with calcification and fatty replacement of the parenchyma in the body and tail. During laparotomy, the tumor was a hard to firm mass and was well capsulated; the pancreatic duct and parenchymal tissue could not be discerned. Therefore, pancreaticoduodenectomy was performed without pancreaticojejunostomy. Also, the fat replacement of the remaining pancreas wasn't resected. Microscopic examination revealed a solid pseudopapillary neoplasm and distal fat tissue; no pancreatic parenchymal tissue was observed in its entirety. The parenchyma was completely replaced by fat tissues, containing scattered viable islets of Langerhans. A routine CT performed on postoperative 7th day revealed no local fluid collection. Although pancreaticojejunostomy was not performed, there was no evidence of a postoperative pancreatic fistula (POPF), and she did not develop diabetes. Serum C-peptide and insulin levels were maintained within the normal range. The case demonstrates that in cases of tumors of the pancreatic head with fat replacement of the remaining pancreas, pancreaticojejunostomy is not essential. In addition, avoiding resection of the pancreatic remnant prevents postoperative diabetes.
PP03-061 Prognostic Impact of Inflammatory Nutritional Factors During Short-term NACRT for Patients with R or BR PDAC
Minoru Oshima, Japan

M. Oshima, K. Okano, H. Suto, H. Matsukawa, Y. Ando, Y. Suzuki
Department of Gastroenterological Surgery, Kagawa University, Japan

We evaluated the prognostic values of inflammatory nutritional scores (NLR, GPS, mGPS, and CRP/Alb) in patients with R or BR PDAC treated with short-term NACRT (sNACRT).
Methods: A total of 49 patients who underwent pancreatectomy after sNACRT from September 2009 to May 2016 were enrolled. The sNACRT consisted of hypofractionated external-beam radiotherapy (30 Gy in 10 fractions) with concurrent S-1 (60 mg/m2) delivered 5 days/week for 2 weeks before pancreatectomy. The inflammatory nutritional scores were determined before and after sNACRT in this series.
Results: The median observation period of patients was 33 months. The 1-, 3-, and 5-year overall survival (OS) rates were 89.6%, 52.5%, and 39.4%, respectively. The median NLR significantly increased after sNACRT (from 2.067 to 3.302 p< 0.001). In multivariate Cox regression analysis, high pre-sNACRT mGPS (2 or 1; p=0.0478) and significant increase in CRP/Alb ratio during sNACRT (≧0.077; p=0.0036) were independent parameters of short OS. The patients were divided into two groups according to the ΔCRP/Alb ratio during sNACRT: the group with high ΔCRP/Alb ratio (≧0.077, Group H, n=13) and the group with low ΔCRP/Alb ratio (< 0.077, Group L, n=36). After sNACRT, the group H had higher CRP (p< 0.001) and lower Alb (p=0.002) compared to the group L. Patients in the group H lost more body weight during sNACRT (p=0.03).
Conclusion: In addition to pre-sNACRT mGPS, ΔCRP/Alb during sNACRT could provide prognostic value in the patients with R and BR PDAC treated by NACRT.
PP03-063 Human Macrophages-derived CAF-like Cells Lead the Invasion of Pancreatic Cancer
Chika Iwamoto, Japan

C. Iwamoto, K. Ohuchida, T. Shinkawa, Y. Otsubo, K. Shindo, T. Moriyama, K. Nakata, T. Ohtsuka, M. Nakamura
Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Japan

Introduction: Pancreatic cancer is characterized by a desmoplastic reaction, which provokes treatment resistance. Recently, it has been reported that CAFs have heterogeneity, tumor-promoting or tumor-suppressive CAFs. The origin of CAFs on tumor progression and its mechanism remains unclear. In the pancreatic tumor, there are macrophages, but its origin is also unclear. Our previous data showed bone marrow-derived macrophages accumulated in the pancreatic tumor. Therefore, we aimed to investigate the involvement of peripheral blood (PB)-derived macrophages with CAF in pancreatic cancer microenvironment.
Methods: Human pancreatic cancer cells (PCCs) were co-injected with PB-derived macrophages into immunodeficient mice to evaluate tumor development. Invaded or migrated PCCs were counted to investigate the involvement of PB-derived macrophages untreated or treated with PCCs-conditioned medium (CM) in the invasive and migratory capability of PCCs. We examined changes in phenotype and function of PB-derived macrophages treated with PCCs-CM.
Results: PCCs co-injected with PB-derived macrophages grew invasively in xenotransplantation models. Invasive and migratory capability of PCCs increased significantly when they were co-cultured with PB-derived macrophages untreated or treated by PCCs-CM. Some PB-derived macrophages treated by PCCs-CM expressed CAF marker. PB macrophages-derived CAF-like cells produced tumor-promoting cytokines, increased their own migratory activity, and led the invasion of PCCs.
Conclusion: These data revealed that PB-derived macrophages were interacted with PCCs and transformed into CAF-like cells and induced the invasion of pancreatic cancer. Therefore, it was indicated that there is a subset of CAFs derived from macrophages although the origins of CAFs is thought to be pancreatic stellate cells or MSCs.
PP03-064 Solid Pseudopapillary Neoplasm of the Pancreas: A Review of the Outcomes of Surgical Resection over a 10-year Period in Tertiary Hospitals in South Australia
Alicia Lim, Australia

A. Lim, G. Asokan, J.-E. Thomson, P. Dolan, J. Chen
Hepatobiliary Department, Royal Adelaide Hospital, Australia

Introduction: Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare tumours of low malignant potential. Owing to their rarity, limited data is available on surgically resected SPNs. Our objective was to identify all cases of SPNs that were surgically resected from 2009 to 2019 in tertiary hospitals in South Australia (SA).
Methods: A comprehensive search was undertaken across SA pathology databases. 10 cases with SPN of the pancreas were found, 9 underwent surgical resection. Information regarding their presentation, surgery, pathology, post-surgical outcomes and overall prognosis were extracted.
Results: Among the 10 patients, 7 were female and 3 were male. At the time of presentation, patients ranged from 13 to 61 years old (median 34.5 years old). The most common location of SPN was the tail of the pancreas (70%). They measured from 2cm to 8cm (mean diameter of 4.5cm). 5 patients presented with abdominal pain and the other 5 had an incidental finding of a pancreatic lesion on imaging. None had metastases. 6 patients with a tail of pancreas lesion underwent distal pancreatectomy and splenectomy, and 3 with a head of pancreas lesion underwent pancreaticoduodenectomy. 1 patient had an endoscopic ultrasound with fine needle biopsy confirming SPN of the pancreas, however, opted for active surveillance over surgical resection. All patients who had surgical resection of their SPN had clear margins (R0) on their pathology reports and no disease recurrence on their follow-up scans.
Conclusion: Complete surgical resection with clear margins is generally curative with patients demonstrating excellent long-term survival.
PP03-068 An analysis of unusual indications for pancreaticoduodenectomy: A single centre experience
Namita Chavan, India

N. Chavan, G. Desai, P. Pande, P. Wagle
Surgical Gastroenterology, Lilavati Hospital and Research Centre, India

Introduction: Pancreaticoduodenectomy(PD) is a highly morbid surgery and has specific indications. For select cases, it is performed due to critical tumor location, involvement of pancreatic duct or as part of other surgery. This study highlights our unusual indications and outcomes for PD.
Methods: This retrospective evaluation of a prospectively maintained data includes 18 consecutive patients who underwent PD alone or as a part of another surgery from January 2004 to December 2018 at our centre.
Results: Of 18 patients, 11 were males and 7 females with median age of 51 years. Indications include duodenal GIST in 6 patients with 4 upfront surgeries and 2 after Imatinib, 3 metastatic colorectal cancer to head of pancreas(HOP), 2 type 1 autoimmune pancreatitis(AIP), two RCC metastasis and one choledochal cyst. Two underwent PD with gastrectomy for carcinoma stomach whereas two underwent whipple with transverse colectomy for carcinoma colon. All pancreaticojejunostomies were performed by a modified Blumgart technique. There were 3 ISGPF Grade B pancreatic fistulas, 2 after PD and one after colo-whipple. One AIP patient had rectus sheath hematoma and incisional hernia which was repaired 2 years after surgery. One AIP patient had postoperative exocrine insufficiency. Patient with metastatic RCC is on sunitinib. The colo-whipple patient expired after 3 years and gastro-whipple expired at 1 ½ years of surgery.
Conclusion: Careful selected indications for PD can give good outcomes in unusual cases when performed at high volume centres.
PP03-069 Adjuvant Chemotherapy Is Beneficial in Biologically Favorable Pancreatic Adenocarcinoma: A Propensity Score Weighted Study
Elizabeth Olecki, United States

E. Olecki1, J. Peng2, M. Dixon2, C. Shen1, N. Gusani2
1General Surgery, Penn State Medical Center, United States, 2Program for Liver, Pancreas, and Foregut Tumors, Penn State Medical Center, United States

Despite low representation of biologically favorable pancreatic adenocarcinomas in randomized control trials (RTCs), guidelines recommend all early pancreatic cancers undergo resection and chemotherapy. With inherently longer overall survival (OS) and unclear evidence from RCTs, risk-benefit ratio of chemotherapy in favorable cancers remains unclear. We used propensity score weighting (PSW) to examine association of adjuvant chemotherapy on OS in patients with negative nodes, low-grade histology, and tumors < 2cm.
Data from National Cancer Database was used to identify stage I/II pancreatic adenocarcinoma that underwent surgery. PSW was implemented from logistic regression for adjuvant chemotherapy while controlling for demographic and biological variables. The survival benefit of chemotherapy in negative lymph nodes, low-grade histology, and tumor size < 2cm was examined using Cox proportional hazard ratio (HR) model with PSW.
Within the cohort undergoing resection (22,131), subgroups with favorable pathology included 7,082 with negative nodes, 13,880 with low-grade histology, and 2,420 with tumors < 2 cm. PSW were well balanced (absolute standardized differences less than 10%). All subgroups had a significant benefit in OS with receipt of adjuvant chemotherapy, including those with negative lymph nodes (HR 0.802, p< 0.0001),low-grade histology (HR 0.727, p< 0.0001), and tumors < 2cm (HR 0.773, p=0.0004).
This study demonstrates improved OS with adjuvant chemotherapy in patients with negative lymph nodes, low-grade, and tumors < 2 cm. Results serve as evidence that all early pancreatic cancers, including biologically favorable tumors, benefit from guideline concordant care and that omission of chemotherapy in these subgroups results in decreased OS.
PP03-070 Incidence and Impact of Textbook Outcome among Patients Undergoing Resection of Pancreatic Neuroendocrine Tumors: Results of the US Neuroendocrine Tumor Study Group
Charlotte Heidsma, United States

C. Heidsma1, F. Rocha2, S. Weber3, R. Fields4, K. Idrees5, G. Poultsides6, C. Cho7, S. Maithel8, T. Pawlik9, The United States Neuroendocrine Tumor Study Group
1The Ohio State University Wexner Medical Center, Columbus, United States, 2Virginia Mason Medical Center, Seattle, United States, 3University of Wisconsin, Wisconsin, United States, 4Washington University School of Medicine, St Louis, United States, 5Vanderbilt University, Nashville, United States, 6Stanford University, California, United States, 7University of Michigan, Ann Arbor, United States, 8Emory University, Atlanta, United States, 9Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, United States

Introduction: Textbook outcome (TO) is an increasingly recognized composite measure of quality. We sought to define the incidence and impact of TO on conditional disease-free survival (cDFS) among patients undergoing resection of pancreatic neuroendocrine tumors (PNET).
Methods: Patients undergoing resection of PNET between 2000-2018 were identified using an international multi-institutional database. TO was defined as no postoperative >3 grade complication, no 90-day mortality, no prolonged length-of-hospital stay(LOS)(ie. LOS > 75thpercentile), no 90-day readmission after discharge, and R0 resection. 3-year cDFS was calculated and the association of TO with cDFS was examined.
Results: Among 821 patients with PNET, median tumor size was 2.1 cm (IQR:1.4-14.6) with a median Ki-67 index of 2.4 (IQR:1.4-5.0). Resection consisted of pancreatoduodenectomy (PD)(n=231, 28.1%), distal pancreatectomy (DP)(n=492, 59.9%) and enucleation (EN)(n=98, 11.9%). Incidence of TO varied by procedure type (PD, 32.5% vs. DP, 56.7% vs. EN, 52.0%; p< 0.001). While certain TO factors such asno 90-day mortality (PD: 99.1% vs. DP: 99.0% vs EN: 99.0%) was comparable among surgery subtypes, other factors such as avoidance ofprolonged LOS (PD: 59.7% vs. DP: 85.4% vs. EN: 73.5%), no complications (PD: 70.1% vs. DP: 78.9% vs. EN: 82.7%), and readmission (PD: 74.0% vs. DP: 81.7% vs EN: 84.7%) were all achieved more often following DP and EN versusPD(all p< 0.05)(Figure).TO was independently associated with improved cDFS (HR:0.54, 95%CI 0.35-0.81; p=0.003).
Conclusions: Many patients undergoing resection of PNET did not experience a TO, which varied markedly based on procedure type. Achieving TO was associated, however, with improved cDFS.
PP03-071 The Elucidation of Interaction Between Autonomic Nervous System, Immune System and Pancreatic Cancer
Takahiro Ikeda, Japan

T. Ikeda, T. Adachi, S. Ono, T. Tanaka, N. Matsumura, T. Hara, M. Hidaka, K. Kanetaka, S. Eguchi
Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Japan

Background and aim: Catecholamine is secreted by stress and was reported that would effect to pancreatic cancer progresses (Renz et al. Cancer Cell, 2018). However interaction between autonomic nervous system, immune system and pancreatic cancer is not well elucidated. In this study, we examined the relationship on pancreatic cancer progression and immune system under the stress load in mice.
Methods: LTPA(3×10³cells), a mouse-derived pancreatic cancer cell line, was cultured in media containing various concentrations of noradrenaline for 4 days, and the number of viable cells was measured using WST-8. Mice (C57BL / 6J) were divided into a stress group (N = 17) restrained for 6 hours and a nonstress group (N = 7), and blood catecholamine was measured. In addition, blood immune cells in the long-term stress group (8 weeks, N = 14) and the nonstress group (N = 10) were measured using flow cytometry.
Results: LTPA proliferated significantly in culture media containing 0.01 µM to 1 µM noradrenaline compared to media alone (p < 0.01). In mice, blood noradrenaline increased significantly in the stress group compared to the nonstress group (5102.3 vs 1980.1pg/mL p < 0.05). In the long-term stress group, B cells decreased (29.0 vs 9.6%, p < 0.01) and myeloid derived suppressor cells increased significantly compared to the nonstress group (13.9 vs 43.4%, p < 0.01).
Conclusion: Stress may promote the growth of pancreatic cancer and have an immunosuppressive effect in pancreatic cancer development. Examination in mice with pancreatic cancer as in vivo study would be needed.
PP03-075 The Dynamic Immune Landscape Reveals Substantial Differences During PDAC Development
Qi Zhang, China

Q. Zhang, J. Yang, X. Bai, T. Liang
Zhejiang University, School of Medicine, the First Affiliated Hospital, China

Pancreatic ductal adenocarcinoma (PDAC) has been recognized as a immunologic-cold tumor. That partly explains why PDAC is not reactive to the currently available immunotherapies. Taking an insight into the characteristics of the PDAC immune microenvironment is fundamental to generate more effective strategies. Here, using mass cytometry (CyTOF), we identified the dynamic changes of tumor-infiltrating immune cells from healthy pancreas to spontaneous PDAC in the KPC mouse model. We observed two significant immunosuppressive stages with few T/B cell infiltrate. One is the acinar-ductal metaplasia (ADM) stage with transiently increased Tregs, the other is metastatic tumor stage with a large amount of myeloid suppressive cells. Surprisingly, tumors in an early stage still have a prominent presence of T/B cells. Trajectory analysis of monocyte/macrophage showed that the differentiation/activation branch of Ly-6C+ monocyte changes from a BST2+/MHC-II+ M1-like phenotype to an Arg-1+ M2-like phenotype over time during PDAC carcinogenesis and progression. The temporal immune characteristics were also confirmed in patient specimens. Our study demonstrates the coevolution of histopathology and immunology of developing PDAC and highlights that immunotherapy strategy exploitation should base on specific tumor stage.
PP03-077 Malignant Hypercalcemia Caused by Pthrp-Secreting Pancreatic Neuroendocrine Tumor (Pnet) - Diagnosis and Treatment of a Very Rare Tumor Entity
Konstantin Schuerheck, Germany

K. Schuerheck, Z. Madarasz, W. Hiller
Department of General and Visceral Surgery, Klinikum Lippe, Germany

Introduction: Hypersecretion of parathyroid hormone-related peptide (PTHrP) by gastroenteropancreatic NETs is very rare. We present the case of a 41-year-old female suffering from a hepatic metastatic pancreatic NET with consecutive malignant hypercalcemia undergoing surgical treatment combining extensive local resection and staged right hepatectomy.
Case report: A 41-year-old female was admitted with persisting nausea and vomiting. Clinical chemistry assays revealed severe hypercalcemia of 4.9mM and acute renal failure with elevated serum creatinine of 2.75mg/dL. Dialysis and administration of calcitonin/pamidronate led to temporary normalization of serum calcium levels. Further investigations showed severe elevation of PTHrP accompanied by normal levels of PTH and vitamin D. Imaging studies confirmed the presence of a distal pancreatic tumor and a large mass in the right hepatic lobe. An octreotide scan and liver biopsy led to the final diagnosis of a hepatic metastatic pNET. The initial surgical treatment included distal pancreatectomy, en-bloc splenectomy, partial gastrectomy, segmental colonic resection (R0 locally) and right portal vein ligation. During the postoperative phase the hypercalcemia persisted and showed resistance to all drug treatment including somatostatin. After three weeks, a CT scan confirmed sufficient growth of the future liver remnant, and the right hepatectomy was performed (R0). Within days, the serum calcium levels finally declined and the patient was discharged. 3- and 12-month follow-up were unremarkable.
Discussion: Controlling malignant hypercalcemia is challenging. In the few similar cases reported, agents like somatostatin analogue were administered with palliative intent. In face of the nature of well-differentiated GEP-NET however, surgery is the preferred therapy.
PP03-078 Long Term Oncological Outcomes of Laparoscopic Pancreatoduodenectomy
Roman Izrailov, Russian Federation

I. Khatkov, R. Izrailov, M. Baychorov, J. Normedova
High-Tech Surgery, Moscow Clinical Scientific Center, Russian Federation

Background: Two hundred and fifty laparoscopic pancreatoduodenectomies (LPDE) were performed in single center in patients with periampullary area diseases.
Objective is to assess the long-term oncological outcomes of LPDE performed in patients with pancreatic head and ampullary carcinoma
Methods: 250 patients underwent LPDE during 2007-2018 years. 216 patients had malignancies (125 had pancreatic cancer, 44 patients had ampullary carcinoma) and 34 had benign diseases. Patients were followed up by control examination and phone calls every year. Kaplan-Maier survival analysis was performed in order to analyze long term results of treatment.
Results: 119 patients with PDAC and 44 patients with ampullary carcinoma were followed up. 114 patients with PDAC were referred to adjuvant. Only 63 patients received chemotherapy, 26 patients had no chemotherapy and data about 25 patients was not available. Median overall survival rate (OSR) of patients with PDAC was 21 months. 5-years OSR was 24%. Patient who did not receive adjuvant had significantly worse results with median OSR of 16 months vs 24 months. 5-years OSR of patients received chemo was significantly higher (27% vs 17%, p< 0.05). Another predictor of better survival was lymph nodes negativity, N+ patients had lower median OSR (26 months vs 18 months, p< 0.05) and 5-years OSR (27% vs 15%, p< 0.05). Patients with ampullary carcinoma had better oncological outcomes. Median OSR was 44 months and 5-years OSR was 52%.
Conclusion: Lymph nodes positivity and non-receiving of adjuvant chemotherapy are predictors of lower survival rates in patients with pancreatic adenocarcinoma.
PP03-079 Zip Codes Drive Overall Survival for Patients Diagnosed with Pancreatic Cancer
Cataldo Doria, United States

C. Doria, S. Ranieri Dolan, P. De Deyne, K. Yatcilla, J. Chung, E. Schwartz
Capital Health, Cancer Center, United States

Introduction: The purpose of this study was to determine if a patient's zip code is affecting patient overall survival (OS) when diagnosed with pancreatic cancer. Our hypothesis was that socio-economic status (SES) is associated with this outcome.
Methods: We interrogated a convenience sample from our cancer center registry and obtained 479 subjects diagnosed with pancreatic cancer between 2010-2018. We selected subjects (328) by zip code, representing the plurality of the cases in our catchment area. Outcome variables were overall survival and socio-economic status; predictor variables were recurrence, insurance, type of treatment, gender, cancer stage, age, and gender. We converted zip code to municipality and culled data using Adjusted Gross Income (AGI, FY 2017) We then created groups using a cutoff at filings of >$100,000 of AGI; Low SES = municipalities where ≤5% of the filings were over $100,000, Mid SES = municipalities where between 5%-40% of the filings were over $100,000, High SES = municipalities where ≥40% of returns were over $100,000. Comparative statistical analysis was performed using Chi-square for nominal and ordinal variables, a two-way ANOVA test was used for continuous variables, p- value was set at 0.05.
Results: We found a statistical significant difference in OS in patients with low SES, Table 1.
Conclusion: We believe that our findings are multifactorial. Access to care, optimal nutritional status, overall fitness, co-morbidities could play a major role and confound the results. Our study suggests low SES has a negative impact on overall pancreatic cancer survival and deserves additional study.
[Table 1]
PP03-080 The Nutrition Status During Preoperative Chemoradiotherapy Affects the Postoperative Prognosis for the Patient with Unresectable Pancreas Cancer
Takashi Kokumai, Japan

T. Kokumai, S. Aoki, K. Nakagawa, H. Hayashi, T. Morikawa, F. Motoi, T. Kamei, M. Unno
Tohoku University, Japan

Background: Conversion surgery (CS) is promising option to improve the prognosis for unresectable pancreatic cancers (UR-PC). However, it remains unclear whether the nutrition status in preoperative chemoradiotherapy affects the postoperative prognosis.
Purpose: To evaluate the relation of the nutrition during preoperative therapy with post-operative prognosis.
Methods: Between 2007 and 2017, 40 patients with UR-PC were underwent conversion surgery. 42.5/52.5/5.0/0.0% of the patients before preoperative therapy and 10.0/55.0/27.5/7.0% after preoperative therapy were defined as Normal/Light/Moderate/Severe levels by the CONUT score. Nutrition group (N: n=25) is the patient who maintained Normal/Light and Malnutrition group (M: n=13) is people whose nutrition was getting worse (Normal/Light→Moderate/Severe) during preoperative therapy. The clinical factors and the prognosis were analyzed between these two groups.
Results: The serum nutrition biomarkers, such as transferrin (226vs204 mg/dl: p=0.045), prealbumin (21.3vs15.4 mg/dl: p=0.019), retinol binding protein (2.8vs1.7mg/dl: p=0.019) and PNI (42.63vs36.71: p< 0.0001) were significantly lower in M group, compared to N group. Intraoperative blood loss was significantly higher and R1 resection was highly occurred in group M (1105vs2432ml, p=0.0002 and 8.7vs46.2%, p=0.002, respectively). No significant differences were detected in TNM classification, the post-operative nutrition status and the time to the postoperative chemotherapy. In survival analysis, M group showed the worse prognosis than N group (median overall survival: 30.6vs11.5 months, p=0.062: median disease free survival: 16.3vs6.1 months: p=0.027).
Conclusion: Decreased preoperative nutrition status is significantly correlated with increased intraoperative blood lost and R1 resection, resulting in poor prognosis.
PP03-081 Adjuvant Chemotherapy Is Not Guided by Pathologic Treatment Effect after Neoadjuvant Chemotherapy in Pancreatic Cancer
Elizabeth Gleeson, United States

E. Gleeson1, N. Leigh1, B. Golas1, D. Magge1, U. Sarpel1, S. Hiotis1, D. Labow1, S. Pintova2, N. Cohen1
1Surgical Oncology, Icahn School of Medicine at Mount Sinai, United States, 2Medical Oncology, Icahn School of Medicine at Mount Sinai, United States

Introduction: Neoadjuvant chemotherapy for pancreatic cancer is increasingly utilized. However, no guidelines exist for optimal adjuvant therapy after pancreatectomy with a partial or poor response to neoadjuvant therapy. This qualitative study seeks to describe our institution's patterns of adjuvant chemotherapy regimen selection after neoadjuvant therapy.
Methods: All patients at a single institution from January 2013 through June 2019 receiving neoadjuvant chemotherapy followed by pancreatectomy for pancreatic cancer were reviewed. Patients enrolled in trials limiting chemotherapy or with missing medical oncology notes were excluded. Chemotherapy regimen, the College of American Pathologists pathologic tumor response, and medical oncology plans were recorded.
Results: Fifty-three patients were reviewed and 41 patients met inclusion criteria. Neoadjuvant chemotherapy regimen are shown. Twenty-nine (70.7%) underwent pancreatoduodenectomy, 10 (24.3%) distal pancreatectomy, and 2 (4.8%) total pancreatectomy. Pathologic review of treatment effect demonstrated that 3 (7.3%) patients had complete pathologic response (cPR), 3 (7.3%) had near cPR, 16 (39%) had partial response, and 14 (34.1%) had poor/no response to neoadjuvant chemotherapy. Treatment effect was missing in 5 (12.2%) patients. Thirty-three (80.5%) patients received adjuvant chemotherapy, with 15 (45.5%) switching regimen adjuvantly. Pathology results guided therapy in 53.6% of patients and tumor response specifically guided therapy in 11 (30.5%) patients.
Chemotherapy RegimenN (%)
gemcitabine/nab-paclitaxel13 (31.7)
FOLFIRINOX, gemcitabine/nab-paclitaxel3 (7.3)
FOLFIRINOX, gemcitabine1 (2.4)
FOLFIRINOX, gemcitabine, bevacizumab1 (2.4)
[Table 1. Neoadjuvant Chemotherapy]

Conclusions: Despite 73.1% of patients having partial or poor response to neoadjuvant chemotherapy, only 45.5% switched chemotherapy adjuvantly. Medical oncologists rarely considered treatment effect when choosing adjuvant therapy. Future trials should be designed to determine the optimal adjuvant regimen guided by pathologic treatment effect of neoadjuvant therapy.
PP03-083 Obstructive Jaundice in Pancreatic Malignancy - Primary Biliary Drainage with Stenting or Upfront Surgery?
Alexander Beath, Australia

A. Beath, C. Choi, S. Chan, J. Choi
UGIG, Western Health, Australia

Introduction: There is currently no clear consensus whether to proceed for pre-operative biliary drainage for malignant obstructive jaundice versus upfront pancreaticoduodenectomy (PD). This study seeks to compare pre-operative biliary drainage with stenting vs upfront PD for jaundiced patients with a resectable pancreatic malignancy. The primary outcome measure was overall postoperative complications.
Method: A prospectively maintained database was used to identify jaundiced patients with a resectable pancreatic malignancy from January 2014 to July 2019 at a single centre. Categorical data were analysed by difference in binomial proportions using exact tests. Overall complication rates between stenting and upfront surgery groups were analysed using the Cochran-Mantel-Haenszel test to adjust for potential confounders. A summary odds ratio was generated and presented graphically as a Forest plot. Two-sided P values of < 0.05 was accepted as statistically significant.
Results: Overall post-operative complications occurred in 37% (10/27) of the stented group and in 72% (13/18) of the upfront PD group (P = 0.02). Univariate analysis for age > 65 years, gender, ASA ≥ 3 and histopathology were not associated with overall complications. Despite a bilirubin < 50 on the day-of-surgery showing a significant reduction in post-operative complications (26% vs 69%, P = 0.005), the summary odds ratio revealed stented patients were associated with 77% lower odds of overall complications relative to those receiving upfront PD (odds ratio: 0.23; 95% confidence interval: 0.12 - 0.47).
Conclusion: Pre-operative biliary drainage with stents in obstructive jaundiced patients with resectable pancreatic cancers did not have increased overall complications.
PP03-084 Surgery of Pancreas Tumors in Children and Adolescents: A Single Institution Experience
Francisco Berrospi Espinoza, Peru

O.R. Paredes Torres, E. Ruiz Figueroa, E. Payet Meza, F. Berrospi Espinoza
Abdominal Surgery, Instituto Nacional de Enfermedades Neoplasicas, Peru

Purpose: The aim of this study is the surgical management and the clinical and pathological features of patients who underwent pancreatic resection for benign and malignant pancreatic tumors in childhood and adolescence and described the morbidity and mortality of this group of patients.
Methods: This is a retrospective review of medical reports of patients ≤19 years with pancreatic tumors who underwent surgery in National Cancer Center, Lima, Peru from January 2000 to January 2019.
Results: Thirty-two patients underwent surgery, the mean age was 13.65 years (3-18), 26 patients were women and 6 men. The tumor location was in the head (n = 18), tail (n = 9) and body (n = 5), the mean tumor size 7.34cm (2-13.5cm). The histological types were: solid pseudopapillary tumor (SSP) (n = 27), pancreatoblastoma (n = 3) and neuroendocrine tumor (n = 2) of which one was neuroendocrine carcinoma and another insulinoma. All tumors had R0 in bloc resection, surgical treatment was: pancreaticoduodenectomy (n = 18), distal pancreatectomy (n = 9), central pancreatectomy (n = 4) and tumor enucleation (n = 1). The survival rate according to 5-year Kaplan Meier analysis was 74%. The median duration of follow-up was 33 months. The postoperative mortality was 0%.
Conclusions: Radical surgery is a safe treatment in patients with primary tumors of the pancreas with a low mortality rate and postoperative complications. The SSP is the most frequent pathology with a good prognosis.
Key Words: Pancreatic tumors, children, adolescents, surgery
PP03-085 Blood Based Molecular Profiling: The Future of Pancreatic Adenocarcinoma Detection
Christine Chung, United States

C. Chung1, R. Galvin2, E. Achenbach3, S. Sen3
1General Surgery, Swedish Medical Center, United States, 2General Surgery, Swedish Medical Center, United States, 3Sarah Cannon Research Institute at HealthONE, United States

Introduction: Molecular profiling is currently being explored as a tool for selecting patients in targeted therapy clinical trials and to determine prognosis for patients with pancreatic adenocarcinoma (PDAC). Noninvasive molecular profiling strategies are critical given the invasiveness of obtaining tissue biopsies. Here we characterize the landscape and therapeutic implications of blood-based circulating tumor DNA (ctDNA) in PDAC.
Methods: We retrospectively analyzed blood samples from eighty-two patients with PDAC using comprehensive genomic testing of ctDNA.
Results: A total of 42/82 (51%) were men, median age being 66 years (range 40-85). A total of 42/82 patients had one or more alteration. The total number of alterations was 140 (non-unique), and median number of alterations/patient was 3. Median mutant allele frequency (% ctDNA), was 0.5% (range 0.09-75.2). KRAS was the most common altered gene (>25 alterations), followed by TP53, SMAD4, and BRCA2 (23, 7, 6 alterations). Of the patients with alterations, 24% (20/83) had one or more potentially actionable alterations, most commonly KRAS. In these genes, mutations occurred most frequently.
Conclusion: This study analyzes blood-derived ctDNA in PDAC in Denver, Colorado. Genomic distinction based on PDAC risk factors and the high percentage of potentially actionable genomic alterations suggests potential clinical utility for patient selection onto clinical trials. Further research is required to determine if this data is being utilized for trial enrollment, whether drugs are available to target these markers, and whether these markers are associated with response to therapy on trials.
PP03-086 Patterns and Quality of Care for Patients Diagnosed with Pancreatic Cancer in Victoria, Australia from 2016 - 2018
Charles Henry Caldow Pilgrim, Australia

A.D. Maharaj1, S.M. Evans1, L.J. Ioannou1, D. Croagh1, J.F. Holland1, A. Earnest1, C.H. Pilgrim2, M. Quinn1, J.R. Zalcberg1
1Monash University, Australia, 2Alfred Health, Australia

Introduction: A core set of quality indicators (QIs) was developed in 2017 using a modified Delphi approach to monitor quality of care, and optimise quality of life and survival in patients diagnosed with pancreatic cancer (PC). This study (1) describes the patterns of care based on disease stage at diagnosis and (2) assesses the association between meeting the QI and survival.
Methods: Data were collected from hospitals and consulting rooms for patients recruited to the Upper Gastrointestinal Cancer Registry (UGICR). Associations between 23 QIs and patient and health service characteristics were tested using linear regression and survival analysed using Kaplan-Meier and Cox proportional hazards models.
Results: A total of 871 patients were eligible for this study with 52% male, 74% over the age of 65 27% potentially resectable and 47% with metastatic disease at diagnosis. A third of patients had no known treatment, and 56% received treatment according to their operability at diagnosis (Figure 1). Half the patients were deceased within 6 months from diagnosis. Meeting the following QIs was associated with improved patient survival at 6 months (1) imaging using a pancreatic protocol CT or MRI (OR=3.1, 95% CI=2.2 - 4.4); (2) documentation of performance status (ECOG or ASA) at presentation (OR=2.1, 95% CI=1.5 - 2.9); (3) disease management discussion at a multidisciplinary team meeting (OR=6.4, 95% CI=4.3 - 9.6) and (4) being included in a clinical trial (OR=5.0, 95% CI=2.7 - 9.1).
Conclusion: Adherence to QIs can optimise care and may improve survival in PC.
[Figure 1: Patterns of treatment for patients diagnosed with pancreatic cancer (UGICR dataset)]
PP03-087 Choline Metabolism Is Associated with Pathological Response and Recurrence of Patients with Pancreatic Cancer after Neoadjuvant Chemoradiation Therapy
Yukiko Wada, Japan

Y. Wada, K. Okano, H. Matsukawa, Y. Ando, H. Suto, M. Oshima, Y. Suzuki
Gastroenterological Surgery, Kagawa University, Japan

Introduction: Pancreatic ductal adenocarcinoma (PDAC) has poor prognosis even if it is resectable. Although the efficacy of neoadjuvant therapies for PDAC are reported in recent years, it is still unclear the optimal target of neoadjuvant therapy. We investigated the metabolic changes in PDAC to identify mechanisms of treatment effect of neoadjuvant chemoradiation therapy (NACRT).
Methods: Frozen tissue of tumor and normal pancreas were obtained from 49 patients with PDAC who underwent surgery. There were 30 patients who received NACRT (NACRT group) and 19 patients who did not receive any neoadjuvant therapy (control group). Metabolites levels of tumor and normal pancreatic tissue were measured by capillary electrophoresis-mass spectrometry (CE-MS). In NACRT group, pathological responses were classified according to Evans grade (evans grade Ⅰ~ⅡA; resistant group (n=19), ⅡB~Ⅳ; response group (n=10) ). RNA microarray was also performed for NACRT group (10 patients) and control group (5 patients).
Results: In comparison of metabolite levels of tumor, there were significant differences in 22 metabolites between NACRT group and control group. There were significant differences in 9 metabolites between response group and resistant group. Among these 9 metabolites, only phosphocholine was associated with recurrence in NACRT group. RNA microarray showed marked gene suppression of choline transporter in PDAC tissue of NACRT group.
Conclusion: Present study, identify new metabolic consequences of PDAC and potential target of NACRT. Choline metabolism is associated with pathological responses and prognosis in patients with PDAC who received NACRT.
PP03-089 Preoperative Evaluation of Systemic Inflammatory and Immune Response Indexes in Potentially Resectable Pancreatic Cancer: Prognostic Role and Correlation with Histopathological Features
Daniele Nicolini, Italy

D. Nicolini, R. Rossi, G. Borrelli, G. Conte, M. Coletta, E. Dalla Bona, A. Vecchi, F. Mocchegiani, M. Vivarelli
Department of Experimental and Clinical Medicine, Division of HPB and Transplant Surgery, Polytechnic University of Marche, Italy

Introduction: The systemic inflammation and immune response indexes seems to be associated to tumor aggressiveness and poor prognosis in patients affected by pancreatic ductal adenocarcinoma (PDAC); however, their ability in discriminating the best candidates for surgery is still unclear.
Methods: From 2015 to 2019, 57 (median age: 69.5; M/F: 29/28) patients underwent pancreatic resection for pathologically confirmed PDAC. Baseline clinical and radiological characteristics, CA19-9 levels and preoperative blood cell count were collected in order to calculate the lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), systemic inflammation response (SIRI) and systemic immune-inflammation (SII) index. The cut-offs for continuous variables were established from the analysis of the receiver operating characteristics curves (ROC), setting the specificity value at 80%. The prognostic impact of each preoperative variable on recurrence-free (RFS) and cancer-specific survival (CSS) was explored using multivariate Cox-regression analysis. The diagnostic performance of each index in identifying the unfavorable histopathological characteristics was evaluated by ROC curves analysis.
Results: Preoperative LMR≤1.96 [Exp(b):2.90; 95% C.I.:1.28-6.58; p=0.0112] and CA 19-9 >521 U/mL [Exp(b):3.20; 95% C.I.:1.35-7.57; p=0.0086] were independent prognostic factors for RFS. The Resectability Status according to NCCN guidelines [Exp(b):2.80; 95% C.I.:1.10-7.13; p=0.0315] and CA 19-9>521 U/mL [Exp(b):2.80; 95% C.I.:1.11-7.05; p=0.0301] were predictors of cancer-related death. LMR was the best preoperative index in identifying lymph node involvement (AUC=0.72; C.I.:0.59-0.83; p=0.0125).
Conclusions: Given its prognostic value and ability in predicting pathological tumor stage, preoperative LMR is useful to identify high-risk patients and individualize treatment strategy for potentially resectable PDAC.
[ROC-curve comparison of best six preoperative predictors of lymph-node pathological status]
PP03-090 Solid Pseudopapillary Tumor of the Pancreas: Our Experiences of 36 Cases at Bangabandhu Sheikh Mujib Medical University, Bangladesh & Review of Literature
Zulfiqur Rahman Khan, Bangladesh

Z. Rahman Khan, A. Rahman
Hepatobiliary & Pancreatic Surgery, Bangabandhu Sheikh Mujib Medical University, Bangladesh

Solid pseudopapillary tumor (SPT) of the pancreas is rare, accounting for 0.13-2.7% of all pancreatic tumors. Another name is Frantz tumour.It was first described in 1959. It is unique, has low malignant potential and predominantly affects young women. Radiological and pathological studies have revealed that the tumor is quite different from other pancreatic tumors. But the cell origin of SPT and tumorigenesis are still enigmatic. Abdominal mass is the most common presenting symptom. Our study was undertaken to examine the clinico-pathological characteristics of the disease and to evaluate the outcome of surgical intervention in dept. hepatobiliary and pancreatic surgery unit in Bangabandhu Sheikh Mujib Medical University, Bangladesh.
In our hospital we reported 36 cases.About 30 patients were female and 6 patients are male. Age ranges about 18-45 year.Most common clinical feature is abdominal lump having abdominal pain and discomfort.Among them 26 patients had undergone whipple's procedure and 10 patients had undergone distal pancreatectomy.All are alive and postoperative recovery was uneventful.Postoperatively all patients histopathology confirmed SPT.
Thus our experience is SPT is rare, but treatable pancreatic tumor. While clinical signs and symptoms are relatively nonspecific, characteristic findings on imaging and histology separate these tumors from the more malignant pancreatic tumors. The prognosis is favorable even in the presence of distant metastasis. Although surgical resection is generally curative, a close follow-up is advised in order to diagnose a local recurrence or distant metastasis.
[solid pseudopapillary tumour]
PP03-091 Standard Uptake Value of the Primary Tumour on FDG-PET Correlates with the Presence of Metastasis in Pancreatic and Peri-ampullary Malignancies
William McGahan, Australia

W. McGahan, N. O'Rourke, D. Cavallucci, M. Burge
Royal Brisbane and Women's Hospital, Australia

Introduction: Our aim was to determine if an association exists between the standard uptake value (SUV) of the primary lesion on FDG-PET and resectability in patients with pancreatic and peri-ampullary cancer.
Methods: This was a prospective clinical study in which patients from a single institution thought to have resectable pancreatic or peri-ampullary cancer underwent compulsory pre-operative FDG-PET. Uptake at the site of the primary tumour was distinguished from uptake around the biliary stent if present, and SUV of the discrete tumour was determined where possible. The presence of metastasis or local invasion, as well as the outcome of attempted resection were audited for each patient.
Results: SUV of the primary tumour was not able to be determined in 4 of 53 enrolled patients. Distant metastasis discovered either on FDG-PET or at operation was associated with higher measurable SUV (6.0 vs 4.2, p=0.03). There was no association between SUV and presence of local invasion (4.6 vs 5.2, p=0.31). In the group who underwent surgery SUV was not associated with the discovery of unresectable features intra-operatively (5.1 vs 4.1, p=0.17). No difference in SUV was found between R0, R1 and R2 margin status (p=0.52). Multi-variate analysis of patient and tumour factors did not identify any likely confounders.
Conclusion: SUV of the primary tumour as measured on FDG-PET appears to be associated with distant metastasis in pancreatic and peri-ampullary cancers. A higher powered study may determine if this association extends to surgical outcome in those proceeding to attempted resection.
[SUV of the primary tumour according to margin status and the presence of unresectable features.]
PP03-092 Factors Associated with Access to Treatment for Pancreatic Cancer in New Zealand
June Oo, Australia

J. Oo1, I. Nielsen2,3, B. Van der Werf2, S. Pandanaboyana2,4, B. Loveday1,2,5
1Peter MacCallum Cancer Centre, Australia, 2University of Auckland, New Zealand, 3University of Gothenburg, Sweden, 4Department of HPB and Transplant Surgery, Freeman Hospital, United Kingdom, 5Royal Melbourne Hospital, Australia

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is a large contributor towards cancer mortality, and there is limited literature on access to care for PDAC in New Zealand. The aim of this study was to identify factors associated with access to treatment for PDAC in New Zealand.
Methods: De-identified data were obtained from linked New Zealand Ministry of Health datasets. All patients diagnosed with PDAC from 2011-2014 were included in the study, with follow-up until December 2016. Socio-economic deprivation was defined using the NZDep2013. Orthodromic distances were calculated to each patient's treatment facilities. Treatment was categorised as meeting current standard (TMS), below standard (TBS) or no treatment (NT).
Results: 1282 patients were included, with a median age of 71.2 years. Age standardised PDAC incidence and mortality rates were higher in Māori than non-Maori (11.9 vs. 7.0/100,000; 9.4 vs. 5.3/100,000). For potentially resectable disease, age and deprivation index were associated with lower likelihood of receiving treatment. Survival was shorter in those with TBS or NT (HR 0.30, p = 0.0001) compared to TMS. For metastatic disease, deprivation index (p = 0.002) and distance from treatment facility (p = 0.006) were associated with lower likelihood of receiving treatment. Survival was shorter for those with NT (HR 0.64, p=0.0001) compared with TMS.
Conclusion: Access to PDAC treatment in New Zealand are affected by age and socioeconomic deprivation. Age, stage of disease, treatment received and distance to nearest oncology center affect overall survival. Understanding this may inform strategies to increase treatment uptake and improve survival.
PP03-093 Long Term Survival and Outcomes from Surgery in Patients who Have Undergone Pre-operative FDG-PET for Pancreatic or Peri-ampullary Cancer
William McGahan, Australia

W. McGahan, N. O'Rourke, D. Cavallucci, M. Burge
Royal Brisbane and Women's Hospital, Australia

Introduction: Our aim was to determine if compulsory pre-operative FDG-PET resulted in different long-term outcomes in patients who proceeded to attempted resection for pancreatic or peri-ampullary cancer.
Methods: This was a prospective clinical study that enrolled patients from a single institution with apparently resectable pancreatic or peri-ampullary cancer. All patients underwent compulsory FDG-PET prior to surgery. Survival statistics, completion of surgery, margin status, lymph node status and uptake of post-operative chemotherapy were determined for the cohort who proceeded to attempted resection.
Results: 35 of 53 enrolled patients undergoing FDG-PET proceeded to an operation. Median overall survival and disease-free survival were similar at 15.9 months. 1 and 5-year survival were 55% and 8.6% respectively. 8 patients (23%) had resection abandoned intraoperatively. Of the remaining cohort 16 patients (59%) had R0 margin status, while 7 patients (26%) had R1 and 4 patients (15%) had R2 margin status. 21 patients (75%) had positive resected lymph nodes. 26 (75%) proceeded to post-operative chemotherapy. Comparison with similar cohorts reported in the literature is displayed in table 1. Patient and tumour characteristics were similar to other large cohorts of potentially resectable pancreatic cancer.
Conclusion: Compulsory pre-surgical screening with FDG-PET for apparently resectable pancreatic or peri-ampullary cancer does not appear to improve survival or surgical outcome within the group who proceed to an operation.
PP03-094 Primary Pancreatic Ewing's Sarcoma: Dreadful Yet Treatable Alien
M Srinivasan, India

M. Srinivasan1, S. Srivatsan Gurumurthy1, V. Nalankilli2, N. Anand Vijai2, P. Senthilnathan1, C. Palanivelu1
1Division of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, India, 2Gem Hospital, India

Background: Ewing's sarcoma is a highly aggressive malignant tumour most commonly affecting long bones in children and adolescents. Approximately 30% of Ewing's sarcoma are extraosseous and Pancreas is considered to be an extremely uncommon site. We report the case of a 26-year-old man with immunohistochemically confirmed primary pancreatic Ewing's sarcoma.
Case details: A 26-year-old man was evaluated for upper abdominal pain. CECT abdomen revealed 3.7 x 3.1cm heterogenous cystic mass lesion in pancreatic head, with a probable diagnosis of neuroendocrine tumour or Solid pseudopapillary neoplasm of pancreas. Serum tumour markers were within normal limits. DOTONAC whole body PET CT and Endoscopic ultrasound could not rule out high grade neuroendocrine tumour. Hence, he underwent laparoscopic pancreaticoduodenectomy. He was re-explored on 2nd POD for intra-peritoneal bleed and haemostasis secured and patient was managed in ICU for 4 days and subsequently his general condition improved and discharged on 15th Postoperative day. Histopathology and Immunohistochemistry confirmed the diagnosis of Ewing's sarcoma of pancreas. Currently, the patient is receiving regular follow-up care and received 3 cycles of adjuvant chemotherapy till now and has no evidence of cancer at six months post-surgery.
Conclusion: Primary pancreatic Ewing sarcoma is a very rare highly aggressive malignant tumour that should be considered in differential diagnosis of an unusual pancreatic tumour especially in young adults. There are only 32 cases reported in literature. Complete surgical excision with adjuvant chemotherapy and with or without radiation therapy is the standard of care.
PP03-095 Laparoscopic Distal Pancreatectomy of Solitary Metastatic Colon Adenocarcinoma to the Pancreas
Daniel Kilburn, Australia

D. Kilburn, N. O'Rourke
Royal Brisbane Hospital, Australia

Introduction: Laparoscopic liver resection for metastatic colorectal cancer has demonstrated good long term survival outcomes. In order to achieve this, case selection is paramount. Blood borne metastasis to the pancreas are uncommon and rarely reported. We report 2 cases of laparoscopic distal pancreatectomy for metachronous solitary metastatic colon adenocarcinoma to the pancreas.
Method: A retrospective analysis of consecutive patients undergoing laparoscopic distal pancreatectomy for solitary metastatic colon adenocarcinoma to the pancreas was performed. Operative characteristics, perioperative morbidity, and pathological data were described.
Results: 2 patients underwent laparoscopic distal pancreatectomy for this indication. One was a 58 year old women, the other was a 59 year old man. Both had minimal other comorbidities. Mean LOS was 3.5 days. 1 patient developed a pancreatic fistula, which was treated successfully with an intra-abdominal drain. Both are alive and disease free at 22 and 23 months follow-up.
Conclusion: We have demonstrated that laparoscopic surgery for isolated intrapancreatic metastasis is warranted and feasible in selected cases.
PP03-096 Local Recurrence Following Curative Surgery for Periampullary Cancers - Incidence, Factors Associated and Outcomes
Arindam Mondal, India

A. Mondal, M. Bhandare, V. Chaudhari, S. Shrikhande
Tata Memorial Hospital, India

Introduction: The study was aimed to examine the incidence, factors associated and long-term outcomes following local recurrences (LR) after curative resections for periampullary cancers.
Methods: A retrospective analysis of a prospectively maintained database was undertaken comprising of all patients of periampullary cancers who underwent curative resections from January 2012 to January 2018, at Tata Memorial Hospital, Mumbai. The incidence, patterns of recurrences and factors associated with LR were studied.
Results: A total of 424 patients underwent resections for periampullary cancers. With a median follow up of 42 months, 23 patients (5.4%) developed isolated LR, 50 patients (11.8%) developed LR with distant metastases (DM) and 103 patients (24.3%) developed isolated DM. The median OS for patients with LR was 47.9 months, and 24.8 months for patients with DM (p=0.000).
On multivariate analysis of all patients with LR, tumour subsite (distal CBD), and nodal positivity (p=0.000) were independently associated with higher rates of LR, and advanced T stage (p=0.060) reached near statistical significance.
The most common site for LR was SMA nodal region (52.2%).
Conclusions: Incidence of LR after resection for periampullary cancers is 5.4%; however, they have significantly better OS compared to systemic recurrences. Nodal involvement and higher tumour stage, especially in distal CBD tumours are associated with increased risk of LR. Strategy to prevent LR should involve radical surgery with complete lymphadenectomy along the SMA, celiac and periportal region, especially in advanced T and N stage disease. Also, management of LRs should involve aggressive approach in the form of radiotherapy or ablation and possibly re-surgery.
PP03-097 Sustained Elevation of CA19-9 after Resection Is a Strong Prognostic Factor for Resectable Pancreatic Cancer
Kazuya Yasui, Japan

K. Yasui, R. Yoshida, Y. Umeda, T. Kuise, K. Yoshida, K. Takagi, T. Yagi, T. Fujiwara
Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Japan

Introduction: Although standard therapy for resectable pancreatic ductal adenocarcinoma (R-PDAC) is discussed to perform upfront surgery, surgical outcomes still remain poor and predictors of recurrence are not to be determined. The aim of this study is to investigate the prognostic significance of pre-/post-operative CA19-9 status.
Methods: A total of consecutive 176 patients with R-PDAC underwent upfront pancreatectomy between April 2007 and June 2019 were analyzed retrospectively. Among the 151 patients enrolled, we divided into 3 groups by CA19-9 status, group A (without elevation of preCA19-9; n=54), group B (with normalized postCA19-9; n=60) and group C (with elevation of postCA19-9; n=37). The relationship between CA19-9 status, survival and other clinicopathological features were analyzed.
Results: PostCA19-9 were measured within 3 months after surgery (20-88 days, median; 43 days). Group C patients showed significantly poorer survival (group A/B/C; 3-year OS 61.9% /53.4% /12.4%; median survival time 44.2m /37.3m/ 13.6m; p< 0.001). The early recurrence rate within 6 month (p< 0.001) and the frequency of liver metastasis (p=0.009) were significantly higher in Group C. Multivariate analysis revealed that without adjuvant chemotherapy (HR=3.29; p< 0.001), preoperative-CT tumor size>20mm (HR=2.76; p< 0.001) and sustained elevation of postCA19-9 (HR=2.49; p=0.0017) were the independent significant prognostic factors for poor survival. The ROC curve analysis revealed that the optimal cut-off value of preCA19-9 which predict postCA19-9 normalization was 116 U/ml.
Conclusion: Sustained elevation of postCA19-9 is a strong prognostic factor for R-PDAC. Patients with preCA19-9>120 could be considered the existence of potential distant metastasis (especially liver metastasis).
PP03-098 Pre-treatment Neutrophil to Lymphocyte Ratio as a Predictive Marker for Pathological Response to Preoperative Intensity-modulated Chemoradiotherapy in Pancreatic Head Cancer
Hideo An, Japan

H. An, R. Nishitai, N. Sasaki, T. Ota, R. Kudo, K. Kawaguchi, S. Konishi, S. Hamasu, D. Manaka
Digestive Center, Department of Surgery, Kyoto Katura Hospital, Japan

Introduction: The pre‑treatment neutrophil to lymphocyte ratio (NLR) was reported to be a predictive indicator of pathological response of pancreatic cancer to neoadjuvant chemoradiotherapy (NAC-RT). The reported cut-off value of NLR is 2.2. Intensity modulated radiotherapy (IMRT) has shown to be able to improve pathological response by escalating radiological dose intensity.
The aim of this study is to clarify the association between pre-treatment NLR and the pathological response to NAC-IMRT in pancreatic cancer patients.
Methods: The consecutive 17 borderline resectable pancreatic cancer patients who underwent pancreatico-duodenectomy after NAC-IMRT between December 2017 and December 2019 were studied. Predictive factors, including NLR, platelet to lymphocyte ratio (PLR), and prognostic nutrition index (PNI), and CRP/albumin ratio (CAR) were measured prior to treatment. A comparison was made between those with a good response (Evans classification IIb/III) and those with a poor response (Evans I/IIa).
Result: The 17 patients comprised 7males and 10 females, and the median age was 66 (range,57-86). The mean NLR value was significantly higher in the poor response group than in the good response group (3.39 vs 1.92; p=0.02), whereas the other examined factors demonstrated no significant differences between the two groups.From the ROC curve, the optimal cut-off level of the pretreatment NLR for predicting pathological non‑responders (Evans I/IIa) was determined to be 3.06 (AUC=0.929).
Conclusion: NLR was a best predictive indicator among various nutritional indexes. The cut-off level of the pretreatment NLR between might be different between NAC-IMRT and NAC-RT because of the difference of effective radiation dose.
PP03-099 Pancreatic Solid Pseudopapillary Neoplasm: Not So Benign Pathology. A Latin American Center Experience
Oscar A. Guevara, Colombia

H. Facundo1, O.A. Guevara2, R. Oliveros1, J. Mesa3, B. Escobar4, R. Pinilla5
1Gastroenterology, Instituto Nacional de Cancerologia, Colombia, 2Surgery, Universidad Nacional de Colombia / Instituto Nacional de Cancerologia, Colombia, 3Pathology, Instituto Nacional de Cancerologia, Colombia, 4Anestesiology, Universidad Nacional de Colombia / Instituto Nacional de Cancerologia, Colombia, 5Gastroenterology, Universidad Nacional de Colombia / Instituto Nacional de Cancerologia, Colombia

Introduction: Pancreatic Solid Pseudopapillary Neoplas (SPN) is a unfrequent tumor, malignant by definition but considered with very god prognosis. We evaluate the metastatic burden in a Cancer Center in Colombia.
Methods: a retrospective cohort of adult patients treated at Instituto Nacional de Cancerologia in Bogota, Colombia, a reference center. We include patients surgically treated form January 2009 to December 2019, including demographic and clinical variables, stage, treatment and follow up. Dissemination time and organ were registered.
Results: in this period 17 patients were included, all were women, age median 30 years (range 19-61y), median tumor size was 8cm (Range 2-25cm). Two patients presented with synchronous liver metastasis and a third patient arrives 21 years after a distal pancreatectomy relapsing in pancreas, peritoneum and liver. Surgical resection was a Pancreaticoduodenctomy in 42% of patients, 46% distal pancreatectomy and 12% central pancreatectomy. 29% were operated by laparoscopic approach. In 2 cases resection includes other organs (liver, stomach, colon) because of metastasis. All but 1 patient were R0 resection. In the follow up a patient required 2 liver resection of metastasis and resection of peritoneal perisplenic relapse and is living without disease. Another patient required 1 resection of liver metastasis.
Conclusion: SPN is considered with good prognosis, however in our center 4 of 17 patient had metastasis. Even with the reference center bias, metastasis are not so unfrequent. Then, we recommend a long follow up in the patients resected for SPN.
PP03-100 Total Pancreatectomy for NET Pancreas: Early Experience with the 'Artery-First' Approach at a Tertiary Care Centre in India
Manpreet Uppal, India

M. Uppal1, S. Pal1, S. Dangi1, T. Dutta1, N. Tandon2, K.S. Madhusudan3, R. Kumar4, P. Garg5, P. Sahni1
1Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, India, 2Department of Endocrinology, Metabolism and Diabetes, All India Institute of Medical Sciences, India, 3Department of Radiology, All India Institute of Medical Sciences, India, 4Department of Nuclear Medicine, All India Institute of Medical Sciences, India, 5Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, India

Introduction: Total pancreatectomy (TP) is indicated for multi focal PNETs. The complexity of this surgery, and morbidity related to brittle diabetes and exocrine insufficiency have prevented TP from gaining popularity in India. This report highlights the use of the 'artery first' approach to TP and subsequent outcomes in patients with multifocal PNETs at a tertiary care centre in India.
Methods: A retrospective analysis of all records was done for the patients who underwent TP and they were followed up to assess the present status.
Results: TP was performed in 3 patients (2 males; 22, 42, 46 years) with MEN 1 who presented with hypercalcemia and episodes of hypoglycemia for a duration between 8 - 192 months. Following multidisciplinary assessment, parathyroidectomy and thymectomy was done to achieve normocalcemia before undertaking TP. Intraoperative ultrasound was used to confirm multifocality (2-6 tumors). Pancreatic resection was approached by identifying the SMA as the first step and the pancreata were removed en bloc with the spleens. The mean duration of surgery was 430 minutes with blood loss ranging between 750 - 1800 ml. A prolonged postoperative stay (23, 35 and 40 days) was required to establish glycemic control. All 3 patients are asymptomatic on follow up (at 2, 4 and 21 months). They are on pancreatic enzyme supplements, and are euglycemic with an insulin requirement of 15, 33 and 49 units respectively.
Conclusions: The 'artery first' approach is a safe and effective technique to achieve en bloc total pancreatetctomy in patients with multifocal NETs.
PP03-101 Primary Signet Ring Cell Carcinoma of the Pancreas in the Elderly with Indistinct Imaging Characteristics: A Case Report
Ryan Joseph de Gracia, Philippines

R.J. de Gracia, C. Alfonso
Surgery, Section of HPB, The Medical City, Philippines

Signet ring cell carcinoma occur in < 1% of pancreatic cancers with few reported cases worldwide. Commonly, it arises in the stomach (96%). Early diagnosis is vital due to its poor prognosis. Further studies are needed to understand this type of malignancy.
A 69/F, with 4 wks epigastric discomfort w/ jaundice & weight loss, came for 2nd opinion. No cause of obstruction on previous Ct scan. On MRCP, biliary tree dilatation & a vague mass at pancreatic head was seen. Normal tumor markers, no evidence of metastasis. Underwent Whipples procedure. Histopathology: SIGNET RING CELL ADENOCARCINOMA, R0 resection. Chemotherapy was planned, but patient opted alternative treatment. 5 months later, recurrence documented by CT scan.
Etiology of SRCC is still unknown, most researchers consider a genetic mutation in the pancreatic parenchyma secondary inflammation. EUS-FNA only provides cytologic sample with inadequate cellularity that is needed for proper identification. Reliability of tumor markers such as Ca 19-9 and CEA can still be in question since clinicopathologic behavior of SRCC especially in pancreas.
High index of suspicion should prompt the search of cause for biliary obstructive diseases especially in the elderly where malignancy is common. Risk factors should always be considered in profiling a patient. Utilization of a high yield imaging is vital in decision making process whether to proceed with surgical treatment that has a high morbidity percentage. Further studies are needed to understand the clinicopathologic character of this rare subtype.
PP03-105 ZIP Codes Are Associated with Disease Recurrence in Patients Diagnosed with Pancreatic Cancer
Cataldo Doria, United States

C. Doria, P. De Deyne, S. Ranieri Dolan, K. Yatcilla, J. Chung, E. Schwartz
Capital Health, Cancer Center, United States

Introduction: The purpose of this study was to determine if patient's zip codes are associated with disease recurrence in patients diagnosed with pancreatic cancer. Our hypothesis was that low socio economic status (SES) is associated with worse outcome.
Methods: We interrogated a convenience sample from our cancer center registry and obtained 479 subjects diagnosed with pancreatic cancer between 2010-2018. We selected subjects (328) by zip code, representing the plurality of the cases in our catchment area. Outcome variables were overall survival and socio-economic status; predictor variables were recurrence, insurance, type of treatment, gender, cancer stage, age, and gender. We converted zip code to municipality and culled data using Adjusted Gross Income (AGI, FY 2017) We then created groups using a cutoff at filings of >$100,000 of AGI; Low SES = municipalities where ≤5% of the filings were over $100,000, Mid SES = municipalities where between 5%-40% of the filings were over $100,000, High SES = municipalities where ≥40% of returns were over $100,000. Comparative statistical analysis was performed using Chi-square for nominal and ordinal variables, a two-way ANOVA test was used for continuous variables, p- value was set at 0.05.
Results: Recurrence was associated with gender and overall survival (Table 1, in months). However, the association between SES and recurrence was not strong.
Conclusion: Access to care, tumor's grading and staging, all play a major role in determining the length of the disease free survival. Our study shows that the poor are at disadvantage when diagnosed with pancreatic cancer.
[Tab. 1]
PP03-106 The Importance of Sarcopenia as a Predictor of Postoperative Complications and it Impact on Surgical Outcomes after Pancreaticoduodenectomy in Patients with Pancreatic Adenocarcinoma
Liudmyla Pererva, Ukraine

L. Pererva, V. Kopchak, O. Duvalko, S. Andronic, V. Trachuk, H. Shevkolenko, V. Khanenko
Pancreatic and Bile Duct Surgery, State Institution «A.A. Shalimov National Institute of Surgery and Transplantology», Ukraine

Introduction: To evaluate the impact of sarcopenia on postoperative complications, pancreatic fistula, mortality and survival after pancreatic resection in patients with pancreatic adenocarcinoma.
Methods: Retrospective study of treatment of 127 patients with pancreatic adenocarcinoma, who underwent pancreaticoduodenectomy in the period from 2016 till 2018, was performed. Sarcopenia was quantified using Total Psoas Index (TPI) after preoperative computed tomography (CT). The measurements were conducted at the level of the third lumbar vertebral body (L3).
Results: Sarcopenia was diagnosed in 55 (43.3%) patients. Postoperative complications occurred in 30 (54.5%) patients, in patients without sarcopenia postoperative complications occurred in 18 (25%) patients (c2=11.5, p=0.0007). Mortality was 3 (5.4%) and 2 (2.8%) respectively (c2=0.6, p=0.44).
In patients with sarcopenia infections complications occurred in 6 patients, pancreatic fistula Grade B or C in - 16 patients, haemorrhage - in 8. In patients without sarcopenia infections complications occurred in 8 patients, pancreatic fistula Grade B or C in - 4 patients, haemorrhage - in 6. We didn't find any significant difference in the number of infections complications (c2 = 3.2, p=0.07) and haemorrhage (c2 = 0.2, p=0.6), but the level of pancreatic fistula Grade B or C was significant higher (c2 = 4.5, p=0.03) in patients with sarcopenia. The overall survival in patients with sarcopenia was significantly lower than those without sarcopenia (23 and 35 month respectively, c2 = 4.1, p=0.04).
Conclusions: Using of TPI may enhance prediction of postoperative complications, pancreatic fistula and surgical outcome and may help surgeons guide preoperative and intraoperative clinical tactics.
PP03-107 Metaanalysis of Recurrence and Survival after Resection for Pancreatic Neuroendocrine Tumours (PNETs)
Khlud Asanai, United Kingdom

K. Asanai1, C.B.B. Ratnayake2, S. Robinson1, J. French1, C. Wilson1, S. Pandanaboyana1
1HPB, Freeman Hospital, United Kingdom, 2University of Auckland, New Zealand

Introduction: There is paucity of data regarding recurrence patterns after resection of PNETs. This systematic review aimed to appraise the literature regarding the recurrence rates and survival outcomes for various grades of resected PNETs.
Method: A systematic search was performed in PUBMED, MEDLINE, and EMBASE databases using the PRISMA frame work. The data analysis included weighted disease free survival (DFS); overall survival (OS) and weighted median recurrence rates for various grades of PNETs.
Results: Following the literature search, 18 studies with a total of 3588 patients met the inclusion criteria. The number of patients with Grade 1, 2, 3 PNETs respectively was 57, 97 and 27. The DFS and OS at 10 years for the entire cohort was 88.6% (CI 76.6-94.9) and 65.7% (CI 52.7-76.6) respectively. The mean time to recurrence was 41 months and overall recurrence rate was 18 %. 14 studies reported site of recurrence with liver being the most common site with recurrence rate of 11%. The weighted mean estimate for loco-regional recurrence was 2.7%. 9/17 studies reported grade specific recurrence. The overall recurrence rate for G1, G2 and G3 tumours was 6 %, 33 % and 85% respectively.
Conclusion: Liver recurrence is more frequent than loco regional recurrence after surgery for PNETs. In spite of good survival outcomes, the risk of recurrence persists even after 10 years warranting ongoing surveillance.
PP03-108 Retrospective Investigation of Optimal Duration of Neoadjuvant Treatment in Locally Advanced Pancreatic Cancer Prior to Resection
Monica Polcz, United States

M. Polcz1, C. Bailey2, M. Tan2, K. Idrees2
1General Surgery, Vanderbilt University Medical Center, United States, 2General Surgery, Division of Surgical Oncology, Vanderbilt University Medical Center, United States

Introduction: Patients with locally advanced pancreatic cancer (LAPC) often undergo neoadjuvant treatment with the goal of eventual resection. Though recent advances in chemotherapeutic regimens have demonstrated improved efficacy, optimal duration of neoadjuvant therapy is undefined. The aim of this study was to determine whether duration of neoadjuvant therapy prior to definitive resection influenced survival.
Method: The National Cancer Database (2011-2014) was queried for Stage III pancreatic ductal cancer with definitive surgery after neoadjuvant chemotherapy (NAC) or neoadjuvant chemotherapy followed by radiation therapy (NAC-CRT). Duration of chemotherapy was defined as time of chemotherapy initiation to time of resection or initiation of radiation, and characterized as < 3, 3-5, 6-8 or >9 months. Survival analyses were conducted with Kaplan-Meier curves and multivariate Cox proportional hazards models.
Results: 383 patients met inclusion criteria; median overall survival (OS) of the entire cohort was 29.9 months. 189 patients received NAC with median OS of 26.1 months; 194 received NAC-CRT with median OS of 30.8 months (p=0.21). Compared to NAC duration of < 3 months, duration of 3-5 months (Hazard Ration [HR] 0.31, p< 0.05) and 6-8 months (HR 0.19, p< 0.05) were associated with decreased risk of death, while NAC-CRT duration of 6-8 months (HR 0.26, p< 0.05) and > 9 months (HR 0.28, p< 0.05) were associated with decreased risk of death.
Conclusions: Our results suggest that in patients with LAPC who proceed to resection, duration of chemotherapy between 6-8 months prior to resection or radiation conferred the most survival benefit.
[Figure 1. Kaplan-Meier curves for NAC or NAC-CRT by duration of neoadjuvant chemotherapy]
PP03-109 Pylorus Preserving Versus Classic Pancreaticoduodenectomy: A Single Center Retrospective Review of Total Lymph Node Yield
Yasmin Essaji, Canada

Y. Essaji
Department of Surgery, McMaster University, Hamilton, Canada

Objective: Pylorus preserving pancreaticoduodenectomy (PPPD) has been promoted for its ability to preserve the entire gastric reservoir and pyloric sphincter, however, some surgeons favor classic pancreaticoduodenectomy (PD) with distal gastrectomy as it encompasses pyloric and peri-gastric lymphadenectomy. We evaluated patients undergoing PD for pancreatic cancer and total lymph node yield (LNY) to determine if this reflects any difference in lymphadenectomy yield.
Methods: This is a retrospective review of 216 patients undergoing PD for pancreatic ductal adenocarcinoma (PDAC) between 2009 to 2015 at a high volume institution. LNY and pathology specimen outcomes associated with poor prognosis were evaluated by univariable and multivariable analysis between patients undergoing classic PD versus PPPD.
Results: There were 18 patients who underwent PPPD with mean LNY 18.3 (SD 6.70). This was found to be significantly lower than for classic PD (mean 25.7; SD 13.6) (p< 0.001). Mean survival was 18.9 months with no difference in overall survival between patients who underwent PPPD or classic PD (p = 0.120). Adequate LNY which is defined by AJCC as ≥12 total lymph nodes and is associated with higher survival was achieved in 88.9% (16/18) of patients undergoing PPPD in comparison to 90.4% (179/198) of patients undergoing classic PD.
Conclusions: Preservation of the pylorus in pancreaticoduodenectomy specimens does result in significantly lower LNY, however, this has no impact on other pathological outcomes (lymph node involvement, margin status) or overall survival. This suggests that PPPD is valid for adequate lymph node sampling in PD specimens and does not affect overall survival.
PP03-110 A Comparison of Lymph Node Ratio with AJCC Lymph Node Status for Survival after Resection for Pancreatic Adenocarcinoma
Yasmin Essaji, Canada

Y. Essaji
Department of Surgery, McMaster University, Hamilton, Canada

Background: Pancreaticoduodenectomy (PD) is a complex surgical procedure used to resect pancreas adenocarcinoma (PDAC). Metastatic lymph node involvement is a strong predictor of survival after resection for PDAC. Lymph node ratio (LNR) has been suggested as a marker of poor outcome. We compared LNR with the current stratification of lymph node (LN) status by AJCC criteria (7th edition and 8th edition) for predicting prognosis.
Methods: We identified 216 patients from a retrospective surgical database who underwent pancreatic resection for PDAC from January 2009 to December 2015. The predictive value of LNR for 2-year survival using a Cox proportional hazards model was calculated. Clinicopathological risk factors for survival were evaluated by univariable and multivariable analyses. Receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to determine accuracy of the test to estimate survival according to LNR greater than 25% and nodal status as defined by the AJCC 7th and 8th editions.
Results: Mean LNR was 0.183 (range 0-0.883) with mean overall survival of 568 days (range 10 - 2262). Comparative analysis using receiver operating characteristic (ROC) curves established that patients with 4 or more positive LN had the highest accuracy for overall survival (AUC 0.6015). LNR >25% and any LN positive had similar accuracy (AUC 0.556 and 0.553 respectively).
Conclusions: The presence of 4 or more positive LN has the highest accuracy in predicting overall survival in node positive patients with resected PDAC. The recent changes in nodal staging in AJCC 8th edition have improved prognostication.
PP03-111 Characteristics of Patients with Pancreatic Acinar Cell Carcinoma in Comparison with Pancreatic Ductal Adenocarcinoma
Filipe Kunzler Maia, United States

F. Kunzler Maia1, N. Lad2, N.D. Machado3, R.E. Jimenez2, H. J Asbun2
1Miami Cancer Institute, United States, 2Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, United States, 3Centro Hospitalar do Tâmega e Sousa, Portugal

Introduction: Acinar cell carcinoma is a rare subtype of pancreatic cancer, accounting for 1% to 2% of exocrine adenocarcinomas of the pancreas.
Methods: The NCDB was analyzed from 2004 to 2016.
Results: Between 2004 and 2016, 1,060 patients were diagnosed with acinar cell carcinoma (ACC) while 330,578 were diagnosed with pancreatic ductal adenocarcinoma (PDAC). ACC patients were younger than PDAC patients (66; 56-75 vs. 70; 61-78 yo, p< 0.001) and predominantly males (70% vs 50%, p< 0.001). ACC were less common in the head (41% and 52%, p< 0.001), and more common in the tail (23% and 12%, p< 0.001) with similar rates in the body (10% and 12%, p=0.055). ACC presented more frequently with stage I disease than PDAC (17 vs 11%), with stage II comprising 20% and 17%, stage III 7% and 11%, and stage IV 39% and 43% (p< 0.001). A total of 41% of the ACC patients had surgery, in comparison with 19% in the PDAC group (p< 0.001). Mortality within 30 days of the primary site surgery was 2.79% and 3.46% (p=0.41) and within 90 days 5.58% and 7.36% (p=0.16). Long term survival differs significantly with 5 years survival rates of 22.4% vs 5.25% (p< 0.001).
Conclusion: Patients with ACC were typically younger, more commonly male, presented at an earlier stage, and were more often submitted to surgical treatment.
PP03-112 An Innocent Bystander or a Harbinger of Doom? - Impact of Diabetes Mellitus on Perioperative Outcomes and Survival in Pancreatic and Periampullary Adenocarcinoma
Rajesh Gupta, India

R. Gupta, K.B. Deo, G. Krishnamurthy, A. Kulkarni, R. Nada, S.S. Rana
Surgical Gastroenterology Division, Postgraduate Institute of Medical Education and Research, India

Background: Though diabetes mellitus (DM) is a known risk factor for pancreatic adenocarcinoma, its impact on long-term survival after surgical resection is controversial.
Methods: This is a retrospective analysis of prospectively maintained database of 141 patients with periampullary and pancreatic head adenocarcinoma. Clinical records, histopathological reports and survival data were retrieved. Patients were compared taking Diabetes mellitus as grouping variable.
Results: Location of tumor was in pancreatic head in 25.0%, ampulla in 33.3%, lower-third bile duct in 24.3%, and duodenum in 17.4%. DM was present in 31 (21.9%) patients with 16 (11.3%) being new onset DM. There was no significant difference in morbidity between diabetics and non diabetics. there was no difference in tumor size, differentiation, lymphovascular invasion, perineural invasion, lymph node positivity, R0 resection rate and TNM stage among patients with and without DM. ON univariate analysis patients with DM and New onset DM (NODM) had worse survival compared to non-diabetic patients at 3 years and 5 years (OS: HR, 3.32 (1.46 - 7.53) p=0.004, DFS: HR, 2.87 (1.29 - 6.41) p=0.009).
Conclusions: Preoperative diabetes mellitus (new-onset or long-standing) has a negative impact on 3-year and 5-year overall survival and disease-free survival among surgically resected patients of pancreatic and periampullary adenocarcinoma. This difference is not attributable to worse tumor stage, as tumor characteristics and adequacy of resection were similar to those of non-diabetics. Further investigation of this phenomenon is warranted.
PP03-113 Surgical Management and Outcomes for Acinar Cell Carcinoma of the Pancreas
Bishoy Mekaeil, Australia

B. Mekaeil1, J. Lewin2, P. Waters2, M. Singh2, D. Cavallucci2, R. Bryant2, N. O'Rourke2
1General Surgery, Royal Brisbane Hospital, Australia, 2Royal Brisbane Hospital, Australia

Introduction: Pancreatic acinar cell carcinomas (pACC) are rare, solid, exocrine neoplasms. Surgical resection with clear margins offers improved long-term outcomes compared with pancreatic ductal adenocarcinoma(pDAC). Diagnosis of pACC is difficult due to similar imaging characteristics to other solid pancreatic lesions.
Methods: A surgical and pathological review of a prospectively maintained pathology database across the Royal Brisbane, St. Vincent Northside and Wesley Hospital from 2008 to 2019 was carried out for patients who underwent operative management of pACC.
Results: Twelve patients underwent surgical resection for pACC. Six patients underwent a Whipple's procedures (1 requiring portal vein resection) and six had distal pancreatectomy with splenectomy (1 requiring gastrectomy, 1 with partial left nephrectomy). Mean tumour size was 44mm (22-190mm). 83.3% of patients had R0 resections, and 25% had lymph node involvement. Seven patients were disease free at last follow up. The two patients who had R1 resections had 7/15 and 7/23 lymph nodes involved with survival of 0.65 and 2.56 years respectively. Of the overall cohort, mean follow-up was 4.27 years (0.82 - 18.2). Mean overall survival was 5.32 years (1.1 - 18.2 years) with a mean disease-free survival of 3.65 years (0.37 - 12.72).
Conclusion: This series adds tot the limited literature regarding aggressive surgical resection of pACC. Overall survival is significantly better than that seen with pDAC, despite the need for multi-organ resection to obtain clear margins. Clinicians should consider the role for aggressive surgery.
PP03-117 Pancreatic Groove Cancer
Yi-Ming Shyr, Taiwan, Republic of China

Y.-M. Shyr
Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China

Background: Pancreatic groove cancer is very rare and could be masqueraded as groove pancreatitis. This study is to clarify the characteristics, clinical features, managements and survival outcomes of this rare tumor.
Methods: Brief descriptions were made for each case of pancreatic groove cancer encountered at our institute. Individualized data of pancreatic groove cancer cases described in the literature were extracted and added to our database to expand the study sample size for a more complete analysis.
Results: A total of 33 patients with pancreatic groove cancer were included for analysis, including 4 cases from our institute. The median tumor size was 2.7 cm. The most common symptom was nausea or vomiting (89%), followed by jaundice (67%). Duodenal stenosis was noted by endoscopy in 96% of patients. The histopathological examination revealed well differentiated tumor in 43%. Perineural invasion was noted in 90%, and lymphovascular invasion and lymph node involvement in 83%. Overall 1-year survival rate was 93.3%, and 3-year or 5-year survival rate was 62.2%, with a median survival of 11.0 months. Survival outcome for the well-differentiated tumor was better than that for moderate/poorly differentiated ones.
Conclusions: Early involvement of duodenum with vomiting is often the initial presentation, and obstructive jaundice is not always inevitable until the disease progresses. The possibility of pancreatic groove cancer should be carefully excluded before making the diagnosis of groove pancreatitis for any questionable case.
PP03-118 Hepatoid Carcinoma of the Pancreas
Yi-Ming Shyr, Taiwan, Republic of China

Y.-M. Shyr
Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China

Background: Hepatoid carcinoma of the pancreas is extremely rare. This article tries to summarize the clinical features and outcomes of pancreatic hepatoid carcinoma.
Methods: Data pool for analysis includes the case we encountered with hepatoid carcinoma of the pancreas and reported cases in the literature.
Results: Twenty-three cases of hepatoid carcinoma of the pancreas were recruited. The most common symptom was epigastric pain (36.4%). When the tumor locates at pancreatic head, nausea/vomiting (62.5%) is more common, followed by jaundice and epigastric pain (50.0%). For those at pancreatic body-tail, 42.9% of the patients presented no symptom. Alpha-fetoprotein (AFP) was abnormally elevated in 60% cases. Hepatoid carcinoma in the pancreas could be either pure form or mixed form with other malignancy (40.9%). Metastasis occurred in 36.4% cases at the diagnosis of this tumor, including liver metastasis in 31.8% and lymph node metastasis in 21.1%. The overall 1-year survival rate was 71.1% and 5-year 40.4%. Irresectability, hepatic and lymph node metastasis are associated with poor survival outcome.
Conclusions: Elevation of serum AFP may be a clue leading to the diagnosis of pancreatic hepatoid carcinoma. This tumor could be mixed form with other malignancy. Surgical resection should be the treatment of choice whenever possible.
PP03-119 Prognosis after Surgical Resection in Patients with Small NF-PNET: International Retrospective Study
Jangho Park, Korea, Republic of

J. Park1, W. Lou2, S.J. Park1, S.-S. Han1, H.M. Park1, E.Y. Park1, S.-W. Kim1
1National Cancer Center, Korea, Republic of, 2Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, China

Background: Incidence of non-functioning pancreatic neuroendocrine tumor has increased recently. Treatment of pancreatic neuroendocrine tumor is surgical removal. However, indications of surgery are still debating. The purpose of this study was to investigate prognostic factors of non-functioning pancreatic neuroendocrine tumor.
Methods: We retrospectively analyzed prognostic factors of patients who underwent surgical resection for non-functioning pancreatic neuroendocrine tumor between November 2000 and December 2017 in Korea and China. Three hundred thirty-one Korean patients and 157 Chinese patients were analyzed separately and integrally.
Results: Age more than 65 years (HR: 2.871, 95% CI: 0.999-8.251, p=0.05), Ki-67 index more than 3% (HR: 21.64, 95% CI: 5.863-79.871, p< 0.0001), and vascular invasion (HR: 5.571, 95% CI: 1.91-16.247, p=0.002) were negatively affecting overall survival in Korean and Chinese patients.
Conclusion: Age, Ki-67 index, and vascular invasion were significant risk factors for non-functioning pancreatic neuroendocrine tumor.
PP03-120 Current Situation in Postoperative Adjuvant Chemotherapy and Perioperative Nutritional Management for the Treatment of Pancreatic Cancer
Yoichiro Uchida, Japan

Y. Uchida1,2, R. Kamimura1, T. Okamoto1, T. Kawai1, K. Iguchi1, H. Terajima1
1Department of Gastroenterological Surgery and Oncology, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Japan, 2Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan

Introduction: We have standardized the operative procedures and perioperative managements for pancreaticoduodenectomy(PD) and performed “Step-by-step” renovations to improve surgery-associated outcomes. In case of invasive pancreatic ductal carcinoma(IPDC), postoperative adjuvant chemotherapy with S-1 has been applied together with strengthened nutritional management. In this study, we examine the efficacy of our treatment and compare it with the results of JASPAC 01 trial (the induction within 70days after operation, completion rate:72%, no dose-reduction rate:59%).
Methods: Forty-eight patients underwent PD from November 2015 to November 2018. Nineteen patients with IPDC, excluding IPMN and stage0 were selected.
Results: The patients who had been treated with S-1 within 70days after operation were 16 patients(84%) and median postoperative day was 42(22-89). The regimen was “2 weeks on/1 week off” in 17 and “4 weeks on/2 week off” in 2 patients. The completion rate was 79%, and no dose-reduction rate was 80%. Four patients were incomplete due to liver metastasis, patient's desire, undernutrition and adverse event. Elemental diet was used in all cases, and 84% were concurrently used with S-1. Adverse events(≧grade2) were leucopenia in 6, appetite loss in 4, oral inflammation in 1, liver dysfunction in 1, eye symptom in 1. There was no patient with Grade 4. The 1-year overall survival was 94%, and it in patients who completed S-1 was 100%.
Conclusion: Perioperative nutritional management appears to contribute to early induction and increase of completion rate of adjuvant chemotherapy. Combining nutritional management with adjuvant chemotherapy may enable to improve the treatment outcome in pancreatic cancer.
PP03-121 Investigation of Neoadjuvant Therapy for Borderline Resectable Pancreatic Cancer
Gaku Shimane, Japan

G. Shimane, M. Kitago, M. Shinoda, H. Yagi, Y. Abe, G. Oshima, S. Hori, Y. Endo, Y. Kitagawa
Department of Surgery, Keio University, School of Medicine, Japan

Aim: Although there are a few reports on the efficacy of neoadjuvant therapy (NAT) as a treatment for borderline resectable pancreatic carcinoma (BRPC), the topic remains controversial. Therefore, we conducted a retrospective study to analyze the long-term outcome.
Method: Fifty-one patients who underwent neoadjuvant chemotherapy (NAC) or neoadjuvant chemoradiotherapy (NACRT) for BRPC at our hospital, between April 2003 and September 2019 were recruited in this study.
Result: Altogether, 51 patients were diagnosed with BRPC based on the General Rules for the Study of Pancreatic Cancer (7th edition), of which, 15 had NAC, and 36 underwent NACRT. In total, 33 patients underwent resection of the pancreas (10 from NAC group (66.7%) and 23 from NACRT group (63.9%)), and 32 had radical surgery (9 from NAC group (60.0%) and 23 from NACRT group (63.9%)). R0 resection rate was 50% (16/32), and there was no significant difference between the NAC and NACRT groups (44.4% vs. 52.2%, P = 0.16). OS (21.0 months vs. 36.1 months, P = 0.974) and RFS (20.0 months vs. 24.0 months, P = 0.266) showed no significant differences between the NAC and NACRT groups. As revealed by the pathological findings, the percentage of patients with positive dissected peripancreatic tissue margin was significantly lower for the NACRT group than that of the NAC group (66.7% vs. 26.1%, P = 0.033).
Conclusion: Although no significant difference was observed regarding long-term prognosis between the NAC and the NACRT groups, the results indicate the effectiveness of radiotherapy in local tumor control of BRPC.
PP03-122 Initial Experience of Lap Assisted Whipple's Procedure from a Tertiary Care Institute
Sanjeet Kumar Rai, India

V. Bansal1, O. Prakash1, A. Krishna1, M. Jain1, A. Baksi1, W. Khan1, S. Kumar1, P. Garg2, S.K. Rai3
1Department of Surgical Disciplines, AIIMS, New Delhi, India, 2Department of Gastroenterology, AIIMS, New Delhi, India, 3AIIMS, New Delhi, India

Introduction: Pancreatico-duodenectomy is one of the most complex and challenging abdominal surgical procedures performed till date. Since Gagner performed first laparoscopic whipple's procedure in 1994, only few series have been published for the same mostly because of challenging resection as well as complex reconstruction involved in the procedure. We hereby present our initial experience with laparoscopic assisted Whipple's procedure in peri-ampullary tumours.
Materials: This was a retrospective analysis of prospectively collected database of all laparoscopic assisted pancreatico-duodenectomy done in a single surgical unit at a tertiary care centre from January 2017 - October 2019. All the procedures were performed for malignancy.
Result: Eight patients were operated for periampullary tumour. All were male except one, and the mean age was 53.1 years. Mean operating time was 298 ± 37 minutes. Mean hospital stay was 6.1 ± 2.7 days. SSI and delayed gastric emptying was noted in 2 patients each. One patient had grade A pancreatic fistula. There was no mortality. All patients had R0 resection.
Conclusion: Laparoscopic assisted pancreatico-duodenectomy is a safe and feasible treatment option for periampullary carcinoma with out any increase in mortality and morbidity with equivalent oncological outcome
PP03-123 Solid Pseudo Papillary Tumor of Pancreas: Diagnosis and Management Approaches of 39 Patients
Mohammad Ali, Bangladesh

M. Ali, M. Rashid, H. Rabbi, A.T. Ahmed
Hepato-Biliary-Pancreatic Surgery, BIRDEM General Hospital, Bangladesh

Introduction: Solid Pseudopapillary tumour of pancreas (Frantz tumour), a rare tumour. Affecting mostly young females, benign with low malignant potential. Represent 1-2% of pancreatic neoplasms.
Methods: A retrospective study of treatment results in 39 patients with Solid pseudopapillary neoplasms (SPN) was performed in the institute from Nov 2009 to Dec 2019. The mainstay of assessment was clinical, its mode of onset & physical findings. Abdominal ultrasound, contrast-enhanced computed tomography (CECT) and Magnetic Resonance Imaging (MRI). Asymptomatic, septated or multilocular cysts with a solid component, thick walls, mucoid material or hemorrhagic cyst fluid are predictors of malignancy. An elevated tumour marker (CA 19-9), a contributory factor for malignancy.
Result: Patients were female 37 & male 2, between 3rd to 4th decade (average 35 yr.). 15 (38.46%) were pancreatic head tumour, 10 (25.64%) body tumour and 14 (35.9%) in the tail of the pancreas. Distal Pancreatectomy with splenectomy done in 12 (30.77%), Spleen preserving distal Pancreatectomy 7 (17.95%), Whipple's procedure 14 (35.9%) and middle pancreatectomy in 6 (15.38%). Post-operative pancreatic leakage noted in 4 (10.25%), Pseudocyst in 2 (5.12%) & pancreatic fistula in 1 (2.56%). Followed-up 8 to 106 months, recurrence after 6 yr. in 1 (2.56%), without any postoperative deaths.
Conclusion: SPN is a relatively indolent tumour. initial diagnosis is suggested by radiologic imaging, which should be considered in the context of clinical and histopathologic characteristics. SPN is often misdiagnosed as Pseudocysts of Pancreas and leads to therapeutic indecisiveness. We advocate for complete surgical resection once it is diagnosed.
PP03-124 Pediatric Pancreatic Cancer in the United States: A 45 Year Experience
Krishnaraj Mahendraraj, United States

K. Mahendraraj, I. Kim, K. Kosari, T. Brennan, G. Voidonikolas, A. Klein, T. Todo, N. Nissen
Surgery, Cedars-Sinai Medical Center, United States

Introduction: Primary pancreatic cancer is rare in children, with an incidence rate of 0.018 cases per 100,000. There are no large patient series of pancreatic cancer in the pediatric population.
Method: Clinical data on 103 pediatric pancreatic cancer patients (age≤19) from the Surveillance Epidemiology and End Result (SEER) database (1973 - 2017) was analyzed.
Results: 103 cases were identified. There were 8 ductal adenocarcinomas (7.8%), 5 acinar cell carcinomas (4.8%), 18 pancreatoblastomas (17.5%), 32 solid-cystic tumors (31.1%), 31 endocrine tumors (30.1%), 3 sarcomas (2.9%), and 6 undetermined (5.8%). 50.5% patients were Caucasian and 61.2% female with mean age 13. Most cancers were well differentiated (46.7%), size >4 cm (75.4%) and in the head of the pancreas (41.7%). 44.4% cancers had metastasis, except for solid-cystic tumors (52.2% localized disease). Longest survival seen among endocrine tumors (18.9 years) and shortest in acinar cell carcinoma (5.1 years). Highest mortality was seen in ductal cell carcinoma (75.0%) and lowest amongst solid-cystic (6.3%). Surgical resection with chemotherapy conferred the longest survival (33.7 years), compared to no treatment (8.8 years), or combination surgery and radiation (5.1 years), p< 0.005. Multivariate analysis identified a survival advantage for females (OR 0.18) and resection (OR 0.06), p< 0.001.
Conclusions: Pediatric pancreatic cancer is rare, and presents more often in female Caucasian children age >10 as well-differentiated tumors >4 cm in size at the head of the pancreas. Surgery is the most common and effective treatment. Enrollment into clinical trial registries will allow for more defined multimodality management.
[Demographic and Clinical Data on 103 Pediatric Pancreatic Cancer Patients (1973-2017)]
PP03-125 A preoperative prognostic score based on a nomogram to predict survival in patients with locally advanced pancreatic ductal adenocarcinoma undergoing pancreatectomy with arterial resection
Niccolò Napoli, Italy

N. Napoli, E.F. Kauffmann, C. Cacace, F. Menonna, S. Iacopi, A. Tudisco, V.G. Perrone, F. Vistoli, U. Boggi
Division of General and Transplant Surgery, University of Pisa, Italy

Introduction. Our aim was to define a pre-operative score able to predict survival in patients with locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) in order to improve the selection process for pancreatectomy with arterial resection (P-Ar).
Methods. A retrospective study was conduct on P-Ar performed for LA-PDAC between 2000 and 2017. Cancer specific survival (CSS) was calculated using Kaplan-Meier curves. Univariate and multivariate proportional hazards model were used to identify the preoperative prognostic factors. A nomogram was developed and a score reflecting the individual probability of survival was calculated for each patient in order to classify them into different categories of risk. Performance was assessed by Harrell's C-index.
Results. In a cohort of sixty patients the CSS was 20.9 (14-39) months. The prognostic model was composed by male gender (OR=1.81, p< 0.01), insulin-dependent diabetes (OR=0.49, p< 0.01), Ca15.3 (OR=1.04, p< 0.01), Ca125 (OR=1.02, p< 0.01) and tumor size (OR=1.02, p< 0.01). The median value of the prognostic score was 54 (43.5-68.5). Twenty-five percent of the patients were at high-risk, 50% at intermediate-risk, and 25% at low-risk. Corresponding median CSS was 12.7 (10.4-21.9), 24.3 (15.7-33.4), and 44.9 (18.5-NA) months (p=0.0062). Harrell's C-Index was 0.75. The probability of cancer recurrence at 3 years in the three risk groups was 100%, 84.2%, and 50.5%, respectively.
Conclusions. Based on this model the risk of recurrence following P-Ar for LA-PDAC can be predicted. The score could be used to select patients for P-Ar. An online calculator is available at
PP03-126 Neuroendocrine Cystic Carcinoma in the Pancreas Tail. Asymptomatic
Vicente Carrillo-Maciel, Mexico

V. Carrillo-Maciel1, V.A. Carrillo-Acosta2, A.L. Acosta-Saludado1, S. Ramos Linaje1, J. Garza Sanchez1, L.Y. Rodriguez Valenzuela3, F.G. Estada Alonso1, Y. Jaramillo Rodriguez4
1Cirugia, Universidad Autonoma de Coahuila, Mexico, 2Student, Universidad Autonoma de Coahuila, Mexico, 3Anestesiologia, Universidad Autonoma de Coahuila, Mexico, 4Patology, Universidad Autonoma de Coahuila, Mexico

Introduction: Pancreatic neuroendocrine neoplasms are second most common neoplasm. Incidence are fewer than 1 per 100 000 individuals per year. 2017 World Health Organisation (WHO) classification: As well-differentiated pancreatic neuroendocrine tumours (PanNETs), poorly differentiated pancreatic neuroendocrine carcinomas (PanNECs) and mixed neuroendocrine-non-neuroendocrine neoplasms (MiNENs) of the pancreas. PanNETs are much more common than PanNECs and present typically in adults between the fifth and sixth decades and may be asyntomatic or syntomatic due to inappropriate hormone secretion.
A 60-year-old male patient presented with spondylolisthesis and underwent thoracoabdominal magnetic resonance, incidentally finding lumps in the pancreas tail measuring 10X12 centimeters. Laboratory tests and tumor markers were performed in normal range, he was sent to our service.
Results: Was performed tail resection of pancreas of 10X12 centimeters, in the postoperative period it presented an acid base imbalance so it is handled in Intensive Care, it evolves favorably and it is discharged from the hospital 4 weeks after the surgery.
Pathology report: Tumor in pancreas tail, cystic, well differentiated neuroendocrine, with focal invasion to the capsule and free edges of lesion of low malignant potential.
1.- Pancreatic neuroendocrine tumors are usually asymptomatic and are diagnosed by incidental findings.
2.- The success in the postoperative evolution is that they are treated by surgeons who are experts in liver, pancreas and biliary tract surgery.
PP03-127 High Circulating Tumour DNA is a Strong Negative Prognostic Factor in Operable Pancreatic Cancer
Ravindu Sellahewa, Australia

R. Sellahewa1, J. Lundy1, D. Croagh1,2, B. Jenkins1,3
1Monash University, Australia, 2Monash Health, Australia, 3Hudson Institute of Medical Research, Australia

Introduction: Pancreatic cancer has a poor five-year survival rate of 9%. In order to improve this overall survival, we need better investigations that can enable early diagnosis, better prognostication and monitoring of disseminated and residual disease. Further, these tests would have to be accurate, minimally invasive and cost-effective to decease the burden of cancer. This study aims to establish the utility of circulating tumour DNA as a test to help in the diagnosis and prognostication of patients with pancreatic cancer.
Methods: Patients who underwent an EUS-FNA for the investigation of solid pancreatic masses or underwent resections for pancreatic cancer at Monash Health between January 2015 and January 2019 had their plasma stored in the Victorian Pancreatic Cancer Biobank (VPCB). These plasma samples were then removed from the biobank and the cell-free DNA component was extracted. The cell-free DNA was then analysed using droplet digital PCR looking for KRAS G12/13 mutations commonly found in pancreatic cancer. In the validation cohort 25 plasma samples from patients with pancreatic cancer were analysed. In the final cohort 59 patients with pancreatic cancer and 14 patients with benign pancreatic disease were analysed. These results were then compared against the patient's diagnosis, stage of disease, tumour size, tumour location, CA19-9, Tissue KRAS results and survival.
Results: Circulating tumour DNA (ctDNA) G12/13 plasma mutations were detected in 66% of patients and 76% of patients with G12/13 mutations in their tissue. Specificity was 100%. Concordance with tissue was 100%. Circulating tumour DNA corresponded with stage and tumour size. High ctDNA was associated with a significantly worse prognosis. Patients with a high ctDNA, MAF>0.10%, had a median overall survival of 155 days compared to 560 days for patients with a MAF< 0.10% (p< 0.001). Patients with operable disease and a high ctDNA, MAF >0.10%, had a median survival of 193.5 days compared to 762 days for patients with a MAF< 0.10% (p=0.015).
Conclusion: Circulating tumour DNA is a useful test to aid in the diagnosis and prognostication of patients with pancreatic cancer. Through continuing to investigate the utility of circulating tumour DNA there is the potential to apply it in clinical practice to optimize the care and survival outcomes of patients with pancreatic cancer.
[Table 1: Kaplan-Meier curve of ctDNA as a prognostic marker of overall survival in patients who have]