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Pancreatic Neoplasms: HELP
Articles by Martin D. McCarter
Based on 10 articles published since 2010
(Why 10 articles?)
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Between 2010 and 2020, Martin McCarter wrote the following 10 articles about Pancreatic Neoplasms.
 
+ Citations + Abstracts
1 Article Quality of Life Following Major Laparoscopic or Open Pancreatic Resection. 2019

Torphy, Robert J / Chapman, Brandon C / Friedman, Chloe / Nguyen, Christina / Bartsch, Christan G / Meguid, Cheryl / Ahrendt, Steven A / McCarter, Martin D / Del Chiaro, Marco / Schulick, Richard D / Edil, Barish H / Gleisner, Ana. ·Department of Surgery, University of Colorado, Aurora, CO, USA. · Department of Surgery, University of Oklahoma, Oklahoma City, OK, USA. · Department of Surgery, University of Colorado, Aurora, CO, USA. ana.gleisner@ucdenver.edu. ·Ann Surg Oncol · Pubmed #31228131.

ABSTRACT: PURPOSE: This study was designed to compare quality of life (QoL) among patients who underwent open versus laparoscopic pancreatic resection, including distal pancreatectomy and pancreaticoduodenectomy, and to identify clinical characteristics that are associated with changes in QoL. METHODS: Quality of life (QoL) was assessed in patients undergoing pancreatic resection with the Functional Assessment of Cancer Therapy-Hepatobiliary questionnaire preoperatively and 2 weeks, 1, 3, and 6 months postoperatively. Multilevel regression modeling was used to determine the variability in each QoL domain within the first 2 weeks (postoperative period) and thereafter (recovery period). RESULTS: Among 159 patients, 60.4% underwent open and 39.6% underwent laparoscopic surgery. Physical, functional, hepatobiliary, and total QoL scores decreased in the postoperative period but returned to baseline levels by 6 months postoperatively. Emotional QoL improved from baseline by 2 weeks after surgery (p < 0.001) and social QoL improved from baseline by 3 months after surgery (p < 0.001). Emotional QoL was the only domain where significant differences were observed in QoL in the postoperative and recovery periods between patients who underwent open and laparoscopic pancreatic resection. Controlling for surgical approach, patients who experienced a grade III or IV complication experienced greater declines in physical, functional, hepatobiliary, and total QoL in the postoperative period. The negative impact of complications on QoL resolved by 6 months postoperatively. CONCLUSIONS: The impact of pancreatic resection on QoL was comparable between patients who underwent laparoscopic versus open pancreatic resection. Complications were strongly associated with changes in postoperative QoL, suggesting that performing a safe operation is the best approach for optimizing patient reported QoL.

2 Article Perioperative and Survival Outcomes Following Neoadjuvant FOLFIRINOX versus Gemcitabine Abraxane in Patients with Pancreatic Adenocarcinoma. 2018

Chapman, Brandon C / Gleisner, Ana / Rigg, Devin / Messersmith, Wells / Paniccia, Alessandro / Meguid, Cheryl / Gajdos, Csaba / McCarter, Martin D / Schulick, Richard D / Edil, Barish H. ·Department of Surgery, University of Colorado School of Medicine, Aurora, CO. · Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO. · Division of Medical Oncology, University of Colorado School of Medicine, Aurora, CO. · Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104. ·JOP · Pubmed #29950957.

ABSTRACT: Context: Neoadjuvant chemotherapy is increasingly used in borderline resectable and locally advanced pancreatic cancer to facilitate surgical resection. Objective: To compare progression free survival and overall survival in patients receiving neoadjuvant FOLFIRINOX with those receiving gemcitabine/abraxane. Design: Retrospective cohort study. Setting: University of Colorado Hospital from 2012-2016. Participants: Patients with pancreatic adenocarcinoma. Interventions: Neoadjuvant FOLFIRINOX or gemcitabine/abraxane. Outcome Measures: Perioperative outcomes, progression free survival, and overall survival were compared between groups. A multivariate Cox proportional hazard model was applied to evaluate survival outcomes. Results: We identified 120 patients: 83 (69.2%) FOLFIRINOX and 37 (30.8%) gemcitabine/abraxane. The FOLIFRINOX group was younger and had a lower ECOG performance status (p<0.05). Patients in the FOLFIRINOX group were more likely to undergo surgical resection compared to gemcitabine/abraxane (66.3% Conclusion: Neoadjuvant FOLFIRINOX may improve progression free survival by increasing the proportion of patients undergoing surgical resection. Improved understanding of the role for selection bias and longer follow up are needed to better define the impact of neoadjuvant FOLFIRINOX on overall survival.

3 Article Utility of Viscoelastic Assays Beyond Coagulation: Can Preoperative Thrombelastography Indices Predict Tumor Histology, Nodal Disease, and Resectability in Patients Undergoing Pancreatectomy? 2018

Moore, Hunter B / Paniccia, Alessandro / Lawson, Peter J / Torphy, Robert J / Nydam, Trevor L / Moore, Ernest E / McCarter, Martin D / Schulick, Richard D / Edil, Barish H. ·Department of Surgery, University of Colorado School of Medicine, Denver, CO. Electronic address: hunter.moore@ucdenver.edu. · Department of Surgery, University of Colorado School of Medicine, Denver, CO. ·J Am Coll Surg · Pubmed #29605725.

ABSTRACT: BACKGROUND: Hypercoagulability and malignancy have been linked since the 1860s. However, the impact of different neoplasms on multiple components of the coagulation system remains poorly understood. Thrombelastography (TEG) enables measurement of coagulation incorporating clotting through fibrinolysis. We hypothesize that specific TEG indices that are associated with hypercoagulability can be appreciated in patients with adenocarcinoma undergoing pancreatic resection. STUDY DESIGN: Blood samples were obtained from patients undergoing pancreatic resection before surgical incision and assayed with TEG. The 4 indices of coagulation measured by TEG included in the analysis were R time, angle, maximum amplitude, and lysis at 30 minutes. Patient tumor type, nodal disease, and mass resectability were contrasted with TEG indices. RESULTS: One hundred patients were enrolled over 18 months. The majority (63%) of patients had adenocarcinoma. Patients with adenocarcinoma had increased angle compared with other lesions (49 degrees [interquartile range {IQR} 37 to 59 degrees] vs 43 degrees [IQR 32 to 49 degrees]; p = 0.011). When excluding patients that underwent neoadjuvant therapy, patients with adenocarcinoma had shorter R times (13 minutes [IQR 9 to 16 minutes] vs 14 minutes [IQR 12 to 18 minutes]; p = 0.051), steeper angles (49 degrees [IQR 40 to 59 degrees] vs 43 degrees [IQR 32 to 49 degrees]; p = 0.010), and higher maximum amplitude (67 mm [IQR 61 to 69 mm] vs 62 mm [IQR 57 to 67 mm]; p = 0.017). Nodal disease was associated with a significantly increased angle (49 degrees [IQR 42 to 59 degrees] vs 40 degrees [IQR 32 to 50 degrees]; p = 0.002) and maximum amplitude (64 mm [IQR 61 to 69 mm] vs 62 mm [IQR 56 to 67 mm]; p = 0.017). Patients who underwent successful mass resection had longer R times (14 minutes [IQR 11 to 17 minutes] vs 10 minutes [IQR 9 to 15]; p = 0.033) and shorter angles (44 degrees [IQR 35 to 55 degrees] vs 58 degrees [IQR 45 to 66 degrees]; p = 0.025). CONCLUSIONS: Patients with adenocarcinoma undergoing pancreatic resection have multiple TEG abnormalities consistent with hypercoagulability. These TEG outputs are associated with tumor type, nodal disease, and probability of a successful resection. The use of preoperative TEG has the potential to aid surgeon and patient discussions on anticipated disease burden and prognosis before resection.

4 Article Perioperative outcomes and survival following neoadjuvant stereotactic body radiation therapy (SBRT) versus intensity-modulated radiation therapy (IMRT) in pancreatic adenocarcinoma. 2018

Chapman, Brandon C / Gleisner, Ana / Rigg, Devin / Meguid, Cheryl / Goodman, Karyn / Brauer, Brian / Gajdos, Csaba / Schulick, Richard D / Edil, Barish H / McCarter, Martin D. ·Department of Surgery, University of Colorado School of Medicine, Aurora, CO. · University of Colorado School of Medicine, Aurora, CO. · Division of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO. · Division of Gasteroenterology, University of Colorado School of Medicine, Aurora, CO. ·J Surg Oncol · Pubmed #29448308.

ABSTRACT: BACKGROUND AND OBJECTIVES: To compare outcomes in patients receiving neoadjuvant stereotactic body radiation therapy (SBRT) with those receiving intensity-modulated radiation therapy (IMRT) for pancreatic adenocarcinoma. METHODS: We analyzed patients receiving neoadjuvant SBRT for borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC) (2012-2016). Differences in baseline characteristics, perioperative outcomes, progression-free survival (PFS), and overall survival (OS) were compared. RESULTS: Seventy-five (82.4%) patients received SBRT and 16 (17.6%) received IMRT. There were no differences in surgical resection rates in the SBRT (n = 38, 50.7%) and IMRT (n = 11, 68.8%) groups (P = 0.188). Among resected patients, there was no difference in postoperative outcomes or pathologic outcomes including lymph node status, margin status, lymphovascular and perineural invasion, or pathologic response to neoadjuvant treatment (P > 0.05). Among all patients, median PFS and OS were 9.9 and 23.5 months in the SBRT group, respectively, and 15.3 and 21.8 months in the IMRT group, respectively (P > 0.05). Similarly, there was no difference in PFS or OS between groups when stratified by BRPC, LAPC, and surgically resected patients (P > 0.05). CONCLUSIONS: In the neoadjuvant setting, SBRT and IMRT appear to have similar rates of resection, perioperative outcomes, and survival outcomes, but additional studies with increased sample size and longer follow up are needed.

5 Article Comparison of laparoscopic to open pancreaticoduodenectomy in elderly patients with pancreatic adenocarcinoma. 2018

Chapman, Brandon C / Gajdos, Csaba / Hosokawa, Patrick / Henderson, William / Paniccia, Alessandro / Overbey, Douglas M / Gleisner, Ana / Schulick, Richard D / McCarter, Martin D / Edil, Barish H. ·Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA. · Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, CO, USA. · Division of Surgical Oncology, University of Colorado School of Medicine, 1665 Aurora Court Room 3337, MS-F-703, Aurora, CO, 80045, USA. barish.edil@ucdenver.edu. ·Surg Endosc · Pubmed #29067580.

ABSTRACT: INTRODUCTION: The purpose of the study is to compare perioperative and survival outcomes in elderly patients undergoing laparoscopic pancreaticoduodenectomy (LPD) to those undergoing open pancreaticoduodenectomy (OPD). METHODS: Patients aged ≥ 75 years with pancreatic adenocarcinoma undergoing LPD or OPD were identified from the NCDB (2010-2013). Baseline characteristics and perioperative outcomes were compared using a χ RESULTS: We identified 1768 patients aged ≥ 75 years who underwent LPD (n = 248, 14.0%) or OPD (n = 1520, 86.0%). The majority of patients in the LPD group had their surgery at facilities performing less than 5 LPDs per year (n = 165, 66.5%). 90-day mortality was significantly lower in the LPD compared to the OPD (7.2 vs. 12.2%, p = 0.049). The laparoscopic conversion rate was 30% (n = 74) and was associated with higher readmission rates (13.5 vs. 8.1%), 30-day mortality (8.0 vs. 3.8%), and 90-day mortality (10.4 vs. 6.0%), but these did not reach statistical significance. Median OS was significantly longer in the LPD group (19.8 vs. 15.6 months, p = 0.022). After adjusting for patient and tumor-related characteristics, there was a trend towards improved survival in the LPD group (HR 0.85, 95% CI 0.69-1.03). CONCLUSION: The vast majority of the NCDB participating facilities perform less than 5 LPD cases per year, which was associated with an increased risk of perioperative mortality. Overall 90-day mortality was significantly lower in the LPD group and there was a trend towards improved OS in the LPD group compared to the OPD group after adjusting for patient and tumor-related characteristics. Studies with increased sample size and longer follow-up are needed before definitive conclusions can be made.

6 Article Predictors for Surgical Referral in Patients With Pancreatic Cystic Lesions Undergoing Endoscopic Ultrasound: Results From a Large Multicenter Cohort Study. 2016

Ge, Phillip S / Gaddam, Srinivas / Keach, Joseph W / Mullady, Daniel / Fukami, Norio / Edmundowicz, Steven A / Azar, Riad R / Shah, Raj J / Murad, Faris M / Kushnir, Vladimir M / Ghassemi, Kourosh F / Sedarat, Alireza / Watson, Rabindra R / Amateau, Stuart K / Brauer, Brian C / Yen, Roy D / Hosford, Lindsay / Hollander, Thomas / Donahue, Timothy R / Schulick, Richard D / Edil, Barish H / McCarter, Martin D / Gajdos, Csaba / Attwell, Augustin R / Muthusamy, V Raman / Early, Dayna S / Wani, Sachin. ·From the *Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, †Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, MO; ‡Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO; §Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; ∥Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora; and ¶Division of Gastroenterology, Veterans Affairs Medical Center, Denver, CO. ·Pancreas · Pubmed #26262589.

ABSTRACT: OBJECTIVE: Endoscopic ultrasound (EUS) plays an integral role in the evaluation of pancreatic cysts lesions (PCLs). The aim of the study was to determine predictors of surgical referral in patients with PCLs undergoing EUS. METHODS: We performed a multicenter retrospective study of patients undergoing EUS for evaluation of PCLs. Demographics, EUS characteristics, and fine-needle aspiration results were recorded. Patients were categorized into surgery or surveillance groups on the basis of post-EUS recommendations. Univariate and multivariate analyses were performed to identify predictors of surgical referral. RESULTS: 1804 patients were included. 1301 patients were recommended to undergo surveillance and 503 patients were referred for surgical evaluation, of which 360 patients underwent surgery. Multivariate analysis revealed the following 5 independent predictors of surgical referral: symptoms of weight loss on presentation (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.44-5.03), EUS findings of associated solid mass (OR, 7.34; 95% CI, 3.81-14.16), main duct communication (OR, 4.13; 95% CI, 1.71-9.98), multilocular macrocystic morphology (OR, 2.79; 95% CI, 1.78-4.38), and fine-needle aspiration findings of mucin on cytology (OR, 3.06; 95% CI, 1.94-4.82). CONCLUSIONS: This study identifies factors associated with surgical referral in patients with PCLs undergoing EUS. Future studies should focus on creation of risk stratification models to determine the need for surgery or enrollment in surveillance programs.

7 Article Suboptimal accuracy of carcinoembryonic antigen in differentiation of mucinous and nonmucinous pancreatic cysts: results of a large multicenter study. 2015

Gaddam, Srinivas / Ge, Phillip S / Keach, Joseph W / Mullady, Daniel / Fukami, Norio / Edmundowicz, Steven A / Azar, Riad R / Shah, Raj J / Murad, Faris M / Kushnir, Vladimir M / Watson, Rabindra R / Ghassemi, Kourosh F / Sedarat, Alireza / Komanduri, Srinadh / Jaiyeola, Diana-Marie / Brauer, Brian C / Yen, Roy D / Amateau, Stuart K / Hosford, Lindsay / Hollander, Thomas / Donahue, Timothy R / Schulick, Richard D / Edil, Barish H / McCarter, Martin / Gajdos, Csaba / Attwell, Augustin / Muthusamy, V Raman / Early, Dayna S / Wani, Sachin. ·Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA. · Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. · Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA. · Division of Gastroenterology, Feinberg School of Medicine Northwestern University, Chicago, Illinois, USA. · Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. · Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA; Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Denver, Colorado, USA. ·Gastrointest Endosc · Pubmed #26077458.

ABSTRACT: BACKGROUND AND AIMS: The exact cutoff value at which pancreatic cyst fluid carcinoembryonic antigen (CEA) level distinguishes pancreatic mucinous cystic neoplasms (MCNs) from pancreatic nonmucinous cystic neoplasms (NMCNs) is unclear. The aim of this multicenter retrospective study was to evaluate the diagnostic accuracy of cyst fluid CEA levels in differentiating between MCNs and NMCNs. METHODS: Consecutive patients who underwent EUS with FNA at 3 tertiary care centers were identified. Patients with histologic confirmation of cyst type based on surgical specimens served as the criterion standard for this analysis. Demographic characteristics, EUS morphology, FNA fluid, and cytology results were recorded. Multivariate logistic regression analysis to identify predictors of MCNs was performed. Receiver-operating characteristic (ROC) curves were generated for CEA levels. RESULTS: A total of 226 patients underwent surgery (mean age, 61 years, 96% white patients, 39% female patients) of whom 88% underwent Whipple's procedure or distal pancreatectomy. Based on surgical histopathology, there were 150 MCNs and 76 NMCNs cases. The median CEA level was 165 ng/mL. The area under the ROC curve for CEA levels in differentiating between MCNs and NMCNs was 0.77 (95% confidence interval, 0.71-0.84, P < .01) with a cutoff of 105 ng/mL, demonstrating a sensitivity and specificity of 70% and 63%, respectively. The cutoff value of 192 ng/mL yielded a sensitivity of 61% and a specificity of 77% and would misdiagnose 39% of MCN cases. CONCLUSIONS: Cyst fluid CEA levels have a clinically suboptimal accuracy level in differentiating MCNs from NMCNs. Future studies should focus on novel cyst fluid markers to improve risk stratification of pancreatic cystic neoplasms.

8 Article Characteristics of 10-Year Survivors of Pancreatic Ductal Adenocarcinoma. 2015

Paniccia, Alessandro / Hosokawa, Patrick / Henderson, William / Schulick, Richard D / Edil, Barish H / McCarter, Martin D / Gajdos, Csaba. ·Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora. · Health Outcomes Program, University of Colorado, Aurora. ·JAMA Surg · Pubmed #26062046.

ABSTRACT: IMPORTANCE: To our knowledge, this study reports on the largest cohort of long-term survivors (LTSs) (≥10 years) following a diagnosis of pancreatic ductal adenocarcinoma (PADC) and identifies the characteristics associated with LTS. OBJECTIVE: To determine patient, tumor, surgical, and sociodemographic characteristics associated with LTS. DESIGN, SETTING, AND PARTICIPANTS: A nationwide retrospective cohort study of patients with invasive PADC (International Classification of Diseases for Oncology, Third Edition codes 8140/3, 8500/3, 8021/3, and 8035/3) was conducted using data collected in the National Cancer Database (NCDB). A multivariable logistic regression model of factors significantly associated with LTS was developed and used to generate a nomogram predicting the likelihood of surviving at least 10 years from initial diagnosis. Data collected from more than 1500 academic centers and community hospitals in the United States and Puerto Rico were assessed. Patients included were those with histologically proven PADC who underwent pancreatic surgical resection aimed at removal of the primary tumor between January 1, 1998, and December 31, 2002 (n = 11,917). The initial cohort (n = 70,915) excluded noninvasive tumors or tumors with unknown histology (n = 11,696) and was limited to patients who underwent surgical resection (n = 47,302 excluded). Analysis was conducted from January 1, 1998, to December 31, 2011. EXPOSURES: Pancreatic ductal adenocarcinoma. MAIN OUTCOMES AND MEASURES: Long-term survival, defined as surviving at least 10 years from initial diagnosis. RESULTS: Of the 11,081 patients with complete survival information, 431 individuals (3.9%) were LTSs. Significant predictors of LTS included (determined using odds ratio [OR]; 95% CI), in order of importance, lymph node positivity ratio (0%: 4.6; 3.4-6.4), adjuvant chemotherapy (2.4; 2.0-3.0), pathologic T stage (T1: 3.1; 1.8-5.6), patient age (50-60 years: 3.4; 1.8-6.7), tumor grade (well differentiated: 2.2; 1.5-3.0), surgical margin (negative: 1.9; 1.4-2.6), pathologic M stage (M = X: 5.6; 2.1-22.8), tumor size (<2 cm: 1.7; 1.2-2.5), educational level (>86% high school graduates: 1.7; 1.2-2.4), and insurance status according to the patient's zip code (private: 2.0; 95% CI, 0.9-5.1). The model C index was 0.768. Based on our nomogram, patients with the most favorable characteristics had an 18.1% chance of LTS. Furthermore, survival curves demonstrated that the probability of dying following initial diagnosis of PADC reached a plateau of approximately 10% per year after 7 years of survival. CONCLUSIONS AND RELEVANCE: Although PADC remains a deadly disease, long-term survival is possible, even beyond the 10-year mark. Our adjusted analysis identified lymph node ratio, administration of adjuvant chemotherapy, and pathologic T stage as being the top 3 variables associated with LTS of PADC. In addition, our easy-to-use nomogram may be able to identify potential LTS among patients with resected PADC.

9 Article Neoadjuvant FOLFIRINOX application in borderline resectable pancreatic adenocarcinoma: a retrospective cohort study. 2014

Paniccia, Alessandro / Edil, Barish H / Schulick, Richard D / Byers, Joshua T / Meguid, Cheryl / Gajdos, Csaba / McCarter, Martin D. ·From the Division of Gastrointestinal, Tumor, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO. ·Medicine (Baltimore) · Pubmed #25501072.

ABSTRACT: 5-Fluorouracile, oxaliplatin, irinotecan, and leucovorin (FOLFIRINOX) has not been extensively used in the neoadjuvant setting because of concerns with safety and toxicity. We evaluated our institutional experience with neoadjuvant FOLFIRINOX in borderline resectable pancreatic adenocarcinoma (BRPAC). The primary endpoints were completion of therapy to surgery and negative resection margin (R0) rate. Patients with BRPAC treated with neoadjuvant FOLFIRINOX were retrospectively analyzed. Between August 2011 and September 2013, 20 patients with BRPAC treated with neoadjuvant FOLFIRINOX were identified. Most patients (88.8%) completed FOLFIRINOX therapy and underwent resection. Abutment of venous structures was identified in 13 cases (72.2%), while short segment portal vein encasement in 3 cases (16.6%) with concomitant arterial involvement in 3 cases (16.6%). Isolated superior mesenteric artery abutment was identified in 2 cases (11.2%). Patients received a median of 4 cycles of FOLFIRINOX. There was 1 case of progression. Vascular resection was performed in 9 cases (52.9%). Preoperative radiation therapy was used in 8 patients (44%). All patients underwent margin negative resection (R0). Histopathologic treatment response was evident in 10 cases (58.8%). Neoadjuvant FOLFIRINOX was generally safe and the expected toxicity did not prevent surgery allowing for a high rate of R0 resection.

10 Article Recurrent pancreatic adenocarcinoma after pancreatic resection. 2010

Dasari, Arvind / McCarter, Martin / McManus, Martine C / Russ, Paul / Messersmith, Wells A. ·Department of Medical Oncology, University of Colorado, Aurora, Colorado, USA. arvind.dasari@ucdenver.edu ·Oncology (Williston Park) · Pubmed #21294478.

ABSTRACT: The patient is a 57-year old Caucasian female who presented with right upper quadrant pain and obstructive jaundice and was diagnosed with resectable pancreatic cancer. She underwent pancreaticoduodenectomy (PD) after preoperative biliary stenting. She subsequently presented to the clinic, where it was noticed that she had an elevated CA 19-9. CT C/A/P revealed multiple new liver lesions.