Patient description: A 54-year-old obese woman admitted to the emergency department with abdominal pain that started 4 days ago with nausea and vomiting. The epigastric pain radiates to the right upper quadrant, getting worse after eating fatty food. The patient experienced similar pain twice in the past year. Her past medical history is remarkable for hypercholesterolemia and 2 NVDs. She has 2 children, and she is menopausal. She does not smoke, drink alcohol, or use illicit drugs. She is mildly febrile. Her BP is 150/85, HR 115, RR 15, T 38.2, SpO2 98% on RA. She is an obese woman with no acute distress. On palpation, she experiences epigastric tenderness and tenderness in the right upper quadrant without rebound. Bowel sounds are normal. Laboratory analysis is remarkable for elevated ESR and leukocytosis with a left shift. The ultrasound revealed several gallstones, biliary sludge and CBD stones. The smallest stone is 14mm.

Clinical trial eligibility criteria: eligible ages (years): 18.0-999.0,  Adenocarcinoma Pancreatic Neoplasms Patient must have a histologically confirmed malignancy that is metastatic or unresectable and for which standard curative or palliative measures to not exist or are no longer effective (dose-escalation cohorts only) Patient must have a histologically or cytologically confirmed diagnosis of pancreatic cancer or poorly differentiated neuroendocrine tumor and must have been treated with a regimen with known benefit for pancreatic cancer or poorly differentiated neuroendocrine tumor (MTD expansion cohort only) Patient must have measurable disease defined as lesions that can be accurately measured in at least one dimension (longest diameter to be recorded) as ≥ 10 mm with CT scan, ≥ 20 mm by chest x-ray, or ≥ 10 mm with calipers by clinical exam Patient must have disease that is easily accessible for a core biopsy as determined by the treating physician or study PI. Patient must agree to the mandatory biopsies at baseline and end of Cycle 2 (MTD expansion cohort only, and at the discretion of the PI/PI optional) Patient must be ≥ 18 years of age Patient must have an ECOG performance status of 0 or 1 Patient must have normal bone marrow and organ function as defined below Leukocytes ≥ 3,000/mcL Absolute neutrophil count ≥ 1,500/mcL Platelets ≥ 100,000/mcL  Patient must not have received chemotherapy or radiotherapy ≤ 4 weeks or 5 half-lives prior to study entry Patient must not have had radiation therapy to more than 25% of the bone marrow. Whole pelvic radiation is considered to be over 25% Patient must not have a history of other malignancy ≤ 2 years previous with the exception of basal cell or squamous cell carcinoma of the skin which was treated with local resection only, an in situ malignancy, or low-risk prostate cancer after curative therapy Patient must not have had a prior allogeneic bone marrow or organ transplantation Patient must not have previously received nab-paclitaxel Patient must not have received any other investigational agents within 14 days prior to study enrollment Patient must not have known brain metastases. Patients with known brain metastases must be excluded from this clinical trial because of their poor prognosis and because they often develop progressive neurologic dysfunction that would confound the evaluation of neurologic and other adverse events Patient must not have a history of allergic reactions attributed to compounds of similar chemical or biologic composition to either MLN8237 or nab-paclitaxel, or other agents used in the study Patient must not have been treated with clinically significant enzyme inducers, such as the enzyme-inducing antiepileptic drugs phenytoin, carbamazepine, or Phenobarbital, or rifampin, rifabutin, rifapentine, or St. John's wort within 14 days prior to the first dose of MLN8237 Patient must not have received any previous treatment with any Aurora-kinase inhibitors (MTD expansion cohort only)