Case Description/Methods: A 64-year-old female with Gardner syndrome requiring colectomy and classic pancreaticoduodenectomy for an ampullary adenoma 10 years prior presented for surveillance endoscopy. She previously underwent endoscopic mucosal resection and intraductal radiofrequency ablation (RFA) of adenomatous tissue at the hepaticojejunal (HJ) anastomosis. She subsequently developed a stricture at the HJ anastomosis needing sequential dilations. A 1T scope was used and advanced to the HJ anastomosis. After balloon dilation of the HJ anastomotic stricture, cholangioscopy was performed and revealed abnormal biliary mucosa (Figure) approximately 2 cm below the hilum raising concern for intraductal extension of adenomatous tissue. Cholangioscopy directed biopsies were obtained and pathology revealed tubular adenoma without high-grade dysplasia. Intraductal RFA is planned in the future. Discussion: ERCP in patients with pancreaticoduodenectomy can be challenging. Different endoscopes have been used to overcome some challenges of ERCP in altered anatomy, each offering certain advantages and limitations. Commonly used endoscopes for ERCP in patients with pancreaticoduodenectomy include the adult and pediatric colonoscopes and single balloon enteroscope. These endoscopes do not allow for performing single operator cholangioscopy due to the length of the scope or the width of the accessory channel. Our report highlights that the 1T endoscope allows for performing single operator cholangioscopy in patients with prior pancreaticoduodenectomy when the HJ anastomosis can be reached.[1833] Figure 1. Intraductal extension of adenomatous tissue seen on cholangioscopy.

Introduction: Gastrointestinal (GI) sites of metastatic breast cancer (BC) are rare, compared to more frequent sites of bone, lung and brain. Incidence of stomach metastasis from primary tumors is , 1-2%, and according to literature as low as 0.3% from primary BC. The hormone receptor profile of metastatic sites is discordant in up to 15% of cases with triple negative metastatic sites from primary hormone receptor positive tumors. We present a case of metastatic BC to the stomach with tumor discordance. Case Description/Methods: A 49-year-old African American female was admitted after undergoing an esophagogastroduodenoscopy (EGD) for complaints of progressive dysphagia, 50 lb. weight loss, and reflux for 6-months. 10-years ago, patient was diagnosed with Stage II estrogen receptor (ER) and progesterone receptor (PR) positive, human epidermal growth factor receptor 2 (Her-2/neu) negative, invasive ductal carcinoma with lobular features. She underwent right breast lumpectomy and was treated with tamoxifen successfully. 4-years ago, inflammatory breast changes and flank pain revealed cancer recurrence with osseous metastasis. She was treated with several hormonal chemotherapies and radiation, and her disease was stable on a positron emission tomography scan 6-months ago. Bone marrow biopsy 1-month ago revealed ER/PR1 disease with PIK3CA gene mutation, with a treatment regimen of alpelisib and fulvestrant. EGD revealed nodular, erythematous, friable mucosa at the distal esophagus, causing inability to transverse EGD scope further (A). EGD scope was changed to ultraslim endoscope and advanced to show gastric mucosa that was nodular, friable, with ulcerations that bled upon contact with endoscope (B). Immunohistochemistry stain (IHC) of gastric biopsies revealed ER/PR/Her-2/neu negative (triple negative), cytokeratin 7 (CK7) and GATA binding protein 3 (GATA3) positive, metastatic breast carcinoma (C,D). Surgery was consulted for jejunostomy tube placement to provide nutrition and confirmed severe malignancy encasing the entire stomach. Discussion: Triple negative BC can rarely metastasize to the stomach, often mimicking primary gastric malignancy on initial presentation. Clinicians should have a higher index of suspicion for metastases in the setting of previous diagnosis of BC, to not delay potential therapies. Timely EGD biopsies, with useful BC specific markers on IHC staining (CK7 and GATA3), assisted in a rare diagnosis of a metastatic discordant triple negative BC in the stomach. [3565] Figure 1. (A) EGD view of distal esophagus. (B) Ultrathin endoscope view of abnormal stomach mucosa. (C) Ultrathin endoscope view of abnormal stomach mucosa. (D) Rare, poorly differentiated malignant cells -consistent with breast primary -that on IHC stain are positive for CK7 and GATA3. Tumor cells are negative for ER, PR, CDX2, CK20.