The Eastern Canadian Gastrointestinal Cancer Consensus Conference convened annually and was held in Fredericton, New Brunswick, from 18 to 20 September 2025. Attendees included experts in medical oncology, radiation oncology, nuclear medicine, and general practitioners in oncology (GPO) from across the eastern Canadian provinces who are engaged in the care and management of patients with gastrointestinal malignancies. The consensus statement resulting from this meeting addresses several key topics, including the management of early-stage gastroesophageal junction cancer, recent developments in molecular biomarkers and colorectal cancer treatments, secondary prevention strategies for colorectal cancer, and treatment of hepatocellular carcinoma.

The Eastern Canadian Gastrointestinal Cancer Consensus Conference was an annual meeting that was held in St. John’s, Newfoundland and Labrador, from 26 to 28 September 2024. This included experts in medical oncology, radiation oncology, surgical oncology, nuclear medicine, and general practitioners in oncology (GPO) from across the eastern Canadian provinces who are involved in the management of patients with gastrointestinal malignancies. This consensus statement generated by the conference addresses multiple topics, including the management of localized rectal cancer, liver-limited colorectal cancer, systemic therapy for advanced biliary tract cancers, radioligand therapy for gastroenteropancreatic neuroendocrine tumors (GEP-NETs), systemic therapy for pancreatic and midgut well-differentiated NETs, and systemic therapy for HER2-positive gastroesophageal cancers.

Introduction: Thymic epithelial tumors are rare and are classified as thymoma, thymic carcinoma, and thymic neuroendocrine tumors. The objective of this systematic review was to evaluate the treatment options for patients with thymic epithelial tumors. Methods: This systematic review was developed by Ontario Health (Cancer Care Ontario)'s Program in Evidence-Based Care and by the Lung Cancer Disease Site Group. MED-LINE, EMBASE, and the Cochrane Library were searched for studies comparing surgical, radiotherapy, or systemic treatments against any combination of these treatments in patients with thymic epithelial tumors. Meta-analyses were conducted with clinically homogenous studies. Results: A total of 106 studies were included, mainly from observational studies. There was an overall survival benefit with postoperative radiotherapy for patients with thymic carcinoma (hazard ratio = 0.65, 95% confidence interval: 0.47-0.89) and for patients with thymoma (hazard ratio = 0.70, 95% confidence interval: 0.59-0.82), especially for those with a high risk for mortality. Patients with thymic carcinoma or thymoma had a response to chemotherapy. Selection bias affected the results for studies that evaluated neoadjuvant chemotherapy or minimally invasive surgical techniques. Furthermore, the overall survival benefit found for adjuvant chemotherapy may have been confounded by the administration of postoperative radiotherapy. Conclusions: For patients with thymoma or thymic carci-noma, the literature is of low quality and subject to bias. There were overall survival benefits with postoperative radiotherapy. The results of this systematic review were used to inform treatment recommendations in a clinical practice guideline. Future large-scale prospective studies that control for confounders are needed. (c) 2022 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

PURPOSE: To evaluate clinical outcomes of endobronchial malignancy treated using high-doserate endobronchial brachytherapy (HDREB).METHODS AND MATERIALS: A retrospective chart review was conducted for all patients treated with HDREB for malignant airway disease between 2010 and 2019 at a single institution. Most patients had a prescription of 14 Gy in two fractions given a week apart. The Wilcoxon signed rank test and paired samples t test were used to compare changes in mMRC dyspnea scale prior to and after brachytherapy at first followup appointment. Toxicity data were collected for dyspnea, hemoptysis, dysphagia, and cough.RESULTS: A total of 58 patients were identified. Most (84.5%) had primary lung cancer with advanced cancers, stage III or IV (86%). Eight were treated while admitted in the ICU. Previous external beam radiotherapy (EBRT) was received by 52%. An improvement in dyspnea was seen in 72%, with an mMRC dyspnoea scale score improvement of 1.13 points ( p < 0.001). Most (22, 88%) had an improvement in hemoptysis and 18 out of 37 (48.6%) had an improvement in cough. Grade four to five events occurred in 8 (13%) at the median time of 2.5 months from brachytherapy. Twenty-two patients (38%) had complete obstruction of the airway treated. Median progression free survival was 6.5 months and median survival was 10 months.CONCLUSIONS: We report a significant symptomatic benefit among patients receiving brachytherapy with endobronchial malignancy, with rates of treatment related toxicities similar to prior studies. Our study identified new subgroups of patients, ICU patients & those with complete obstruction, who benefited from HDREB. & COPY; 2023 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

INTRODUCTION:Stage classification is an important underpinning of management in patients with cancer and rests on a combination of three components-T for tumor extent, N for nodal involvement, and M for distant metastases. This article details the revision of the N and the M components of thymic epithelial tumors for the ninth edition of the TNM classification of malignant tumors proposed by the Thymic Domain of the International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee.METHODS:The N and M components of the eighth edition staging system were verified by a large international collaborative data source through a data-driven analysis. A total of 9147 cases were included for analysis, including 7662 thymomas, 1345 thymic carcinomas, and 140 neuroendocrine thymic tumors.RESULTS:Lymph node involvement rates were 1.5% in thymomas and 17.6% and 27.7% in thymic carcinomas and neuroendocrine thymic tumors, respectively. Rates of lymph node metastasis were increasingly higher in tumors with higher T stage and higher-grade histologic type. Survival analysis validated the differences in the N and M categories proposed in the eighth edition staging system. Good discrimination in overall survival was detected among pathologic (p)N and pM categories in patients with thymoma and thymic carcinoma.CONCLUSIONS:No changes are proposed from the eighth edition for the N and M components. The proposed stage classification will provide a useful tool for management of the disease among the global thymic community.

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference 2023 was held in Quebec City, Quebec 2–4 February 2023. The purpose of the conference was to develop consensus statements on emerging and evolving treatment paradigms. Participants included Canadian medical oncologists, radiation oncologists, pathologists and surgical oncologists from across Ontario, Quebec, and the Atlantic provinces. Consensus statements were developed following rapid review presentations and discussion of available literature. The recommendations proposed here represent the consensus opinions of physicians involved in the care of patients with gastrointestinal malignancies who participated in this meeting.

Introduction: In 2014, a TNM-based system for thymic epithelial tumors was proposed. The TNM stage classification system was published as a result of a joint project from the International Association for the Study of Lung Cancer and the International Thymic Malignancy Interest Group for the eighth edition of the American Joint Commission on Cancer and the Union for International Cancer Control stage classification system. The Thymic Domain of the Staging and Prognostic Factors Committee of the International Association for the Study of Lung Cancer received the mandate to make proposals for the ninth edition of the TNM stage classification. Methods: A central thymic database was collected by the Cancer Research And Biostatistics with the contribution of the major thymic associations in the world. Results: A total of 11,347 patients were collected. Submitting organizations were the following: Japanese Association for Research in the Thymus, European Society of Thoracic Surgeons, Chinese Alliance for Research in Thymoma, Korean Association for Research in the Thymus, International Thymic Malignancy Interest Group, and Reseau tumeurs THYMiques et Cancer. Additional contributions came from centers in the United States, United Kingdom, Turkey, Australia, Spain, and Italy. A total of 9147 cases were eligible for analysis. Eligible cases for analysis came from Asia and Australia (5628 cases, 61.5%), Europe (3113 cases, 34.0%), and North America (406 cases, 4.4%). Conclusions: This report provides an overview of the database that has informed the proposals for the updated T, N, and M components and the stage groups for the ninth TNM of malignant tumors. (c) 2023 Published by Elsevier Inc. on behalf of International Association for the Study of Lung Cancer.

Purpose: Uncontrolled studies suggest that the addition of high-dose-rate intraluminal brachytherapy (HDRIB) to external beam radiation therapy (EBRT) may improve palliation for patients with advanced non-small cell lung cancer (NSCLC). The purpose of this study was to evaluate the potential clinical benefit of adding HDRIB to EBRT in a multicenter randomized trial. Methods and Materials: Patients with symptomatic stage III or IV NSCLC with endobronchial disease were randomized to EBRT (20 Gy in 5 daily fractions over 1 week or 30 Gy in 10 daily fractions over 2 weeks) or the same EBRT plus HDRIB (14 Gy in 2 fractions separated by 1 week). The primary outcome was the proportion of patients who achieved symptomatic improvement in patient-reported overall lung cancer symptoms on the Lung Cancer Symptom Scale (LCSS) at 6 weeks after randomization. Secondary outcomes included improvement in individual symptoms, symptom-progression-free survival, overall survival, and toxicity. The planned sample size was 250 patients based on detection of symptomatic improvement from 40% to 60% with a 2-sided a of .05 and 80% power.Results: A total of 134 patients were randomized over 4.5 years: 67 to each arm. The study closed early owing to slow accrual. The mean age was 69.8 years, and 67% of patients had metastatic disease. At 6 weeks, 19 patients (28.4%) in the EBRT arm and 20 patients (29.9%) in the EBRT plus HDRIB arm experienced an improvement in lung cancer symptoms (P = .84). When limited to patients who completed the LCSS, percentages were 40.4% versus 47.6%, respectively (P = .49). Between group dif-ferences in mean change scores (0.3-0.5 standard deviations) in favor of EBRT plus HDRIB were observed for overall symp-toms, but only hemoptysis was significantly improved (P = .03). No significant differences were observed in progression-free or overall survival. Grade 3/4 toxicities were similar between groups. Conclusions: Small to moderate improvements were seen in symptom relief with the combined therapy, but they did not reach statistical significance. Further research is necessary before recommending HDRIB in addition to EBRT for palliation of lung cancer symptoms. & COPY; 2023 Elsevier Inc. All rights reserved.

Purpose: To examine circulating tumor DNA (ctDNA) and its association with residual cancer burden (RCB) using an ultrasensitive assay in patients with triple-negative breast cancer (TNBC) receiving neoadjuvant chemotherapy (NAT). Patients and Methods: We identified responders (RCB-0/1) and matched non-responders (RCB-2/3) from the phase II TBCRC 030 prospective study of neoadjuvant paclitaxel vs. cisplatin in TNBC. We collected plasma samples at baseline, three weeks, and twelve weeks (end of therapy). We created personalized ctDNA assays utilizing MAESTRO mutation enrichment sequencing. We explored associations between ctDNA and RCB status and disease recurrence. Results: Of 139 patients, 68 had complete samples and no additional NAT. Twenty-two were responders and 19 of those had sufficient tissue for whole-genome sequencing. We identified an additional 19 non-responders for a matched case-control analysis of 38 patients using a MAESTRO ctDNA assay tracking 319-1000 variants (median 1000) to 114 plasma samples from 3 timepoints. Overall, ctDNA positivity was 100% at baseline, 79% at week 3, and 55% at week 12. Median tumor fraction (TFx) was 3.7 x 10-4 (range: 7.9 x 10-7 to 4.9 x 10-1). TFx decreased 285-fold from baseline to week 3 in responders and 24-fold in non-responders. Week 12 ctDNA clearance correlated with RCB: clearance was observed in 10/11 patients with RCB-0, 3/8 with RCB-1, 4/15 with RCB-2, and 0/4 with RCB-3. Among 6 patients with known recurrence five had persistent ctDNA at week 12. Conclusion: NAT for TNBC reduced ctDNA TFx by 285-fold in responders and 24-fold in non-responders. In 58% (22/38) of patients, ctDNA TFx dropped below the detection level of a commercially available test, emphasizing the need for sensitive tests. Additional studies will determine if ctDNA-guided approaches can improve outcomes.

Introduction: The aim of this guideline was to provide recommendations for the most effective therapy for pa-tients with thymic epithelial tumors, including thymoma, thymic carcinoma, and thymic neuroendocrine tumors (NETs). This guideline is intended to be used by all health care professionals managing patients with thymic epithe-lial tumors.Methods: The guideline was developed by Ontario Health (Cancer Care Ontario)'s Program in Evidence-Based Care and by the Lung Cancer Disease Site Group through a sys-tematic review of the evidence, expert consensus, and formal internal and external reviews.Results: Evidence-based recommendations were devel-oped to improve the management of patients with thymic epithelial tumors. The guideline includes recommenda-tions for surgical, radiation, and systemic treatments for patients with thymoma, thymic carcinoma, and thymic NETs separated by stage of disease using the TNM staging system. Recommendations for patients with thymic NETs were endorsed from the 2021 National Comprehensive Cancer Network Neuroendocrine and Adrenal Tumors Guideline.Conclusions: This guideline reflects the new staging sys-tem for patients with thymoma and thymic carcinoma and includes supporting evidence from the best available studies.(c) 2022 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

Background Thymomas are characterized by a low tumor mutation burden and a paucity of actionable mutations. Clinical behavior can vary from relatively indolent to very aggressive and impact survival. Platinum-based chemotherapy is the primary treatment modality for inoperable disease and is palliative in intent. Patients with advanced thymoma frequently experience disease recurrence after frontline therapy. Treatment options for relapsed thymoma are relatively limited. A case of recurrent thymoma harboring a breast cancer gene 2 (BRCA2) mutation was presented for multidisciplinary discussion at the International Thymic Malignancy Interest Group (ITMIG) Tumor Board meeting. Case Description A 63-year-old female presented with Tumor Node Metastasis (TNM) stage I, World Health Organization (WHO) subtype B1 thymoma at diagnosis and underwent surgical resection. First recurrence occurred in the left costophrenic recess and was treated with preoperative external beam radiotherapy (EBRT), surgical excision, and post-operative chemotherapy. Histology was consistent with WHO subtype B2 thymoma and genomic analysis of the resected tumor detected a BRCA2 mutation. Second recurrence occurred in the mediastinum and bilateral pleurae. Mediastinal disease was treated with EBRT, and the pleural deposits were observed initially. However, upon further progression, the case was discussed at the ITMIG tumor board meeting to determine optimal second line therapy for this patient. Conclusions A potential role of poly (ADP-ribose) polymerase (PARP) inhibitors versus cytotoxic chemotherapy for treatment of BRCA2-mutated recurrent thymoma merits discussion. However, due to the absence of data to support the functional and therapeutic significance of BRCA2 mutations in patients with thymoma, the potential for severe toxicity associated with PARP inhibitors, and availability of other safe and effective alternatives, other treatment options should be considered. PARP inhibitors can be considered for treatment of BRCA2-mutated thymomas as part of a clinical trial or when other treatment options have been exhausted.

Thymic epithelial tumors are presently staged using a consistent TNM classification developed by the International Association for the Study of Lung Cancer (IASLC) and approved by the Union for International Cancer Control and the American Joint Committee on Cancer. The stage classification is incorporated in the eight edition of the TNM classification of thoracic malignancies. The IASLC Staging and Prognostic Factors Committee (SPFC)-Thymic Domain (TD) is in charge for the next (ninth) edition expected in 2024. The present article represents the midterm report of the SPFC-TD: in particular, it describes the unresolved issues identified by the group in the current stage classification which are worth being addressed and discussed for the ninth edition of the TNM classification on the basis of the available data collected in the central thymic database which will be managed and analyzed by Cancer Research And Biostatistics. These issues are grouped into issues of general importance and those specifically related to T, N, and M categories. Each issue is described in reference to the most recent reports on the subject, and the priority assigned by the IASLC SPFC-TD for the discussion of the ninth edition is provided.

Breast conservation therapy with a partial mastectomy followed by adjuvant radiotherapy has become the standard approach for women diagnosed with an early stage breast cancer. Accelerated partial breast irradiation using multi-catheter interstitial brachytherapy can be used to deliver RT. Electromagnetic reconstruction (EMR) is a new technology that has been recently developed to determine the catheter placement post implantation. In this technique, a position sensor is pulled through a catheter. The path of the sensor is then reconstructed to delineate the path of the catheter. EMR is a promising technology that can potentially be used to validate the position of the catheters post implantation. We have previously shown that our EMR technology can accurately reconstruct catheter paths in breast phantoms. We performed a clinical feasibility study in patients to assess the accuracy of EMR in reconstructing the catheter paths in patients. Eligible patients for breast brachytherapy were enrolled in a prospective, single-center pilot study. All patients underwent breast brachytherapy as per the standard of care. A spatial tracking machine is positioned next to the patient's bed, which creates an external electromagnetic field around the patient's breast. A reference electromagnetic sensor is clamped on the patient's sternum. An electromagnetic sensor was guided through each of the implanted catheters, and the positions in real time were recorded. Using 3D slicer (an open source platform, we reconstructed the paths of the catheters. The paths generated manually on the planning CT scan were registered over the reconstructed paths. The accuracy of the EMR workflow was determined by measuring the mean + standard deviation between the EM generated reconstruction to the path segmented on the planning CT scan. A total of 38 catheters were implanted in 3 patients between July 2019-September 2019. We found that the mean distance between the CT generated catheter paths and the paths created by EMR was 1.7 + 0.3 mm. Reconstruction of the catheter paths in a patient typically took less than 5 minutes. Our results are promising and suggest that EM reconstruction can be accurate in identifying the catheter paths for interstitial breast brachytherapy. We will expand the patient cohort to confirm this data.

Accelerated partial breast irradiation (APBI) using multi-catheter interstitial brachytherapy can be used as adjuvant local therapy post-lumpectomy in early stage breast cancer. In a recent survey, over 50% of residents reported being dissatisfied with the training they received in high-dose rate (HDR) breast brachytherapy. Furthermore, only 15% of residents felt they were competent to perform the procedure. The purpose of this study is to demonstrate that participation in a simulation program for HDR breast brachytherapy will improve resident confidence, competence and efficiency in implanting catheter needles. From July 2019-August 2019, 10 radiation oncology residents from first year to fourth year were recruited. They all attended a didactic lecture in HDR breast brachytherapy, followed by a demonstration on an anthropomorphic phantom performed by a radiation oncologist experienced in breast brachytherapy. Participants then completed a pre-simulation survey prior to starting the simulation procedure. Using an opaque anthropomorphic plastic breast phantom with an internal target, each resident placed a total of 5 needles, in two parallel planes, 1 cm apart. The first row consisted of 3 needles and the second row was made up of 2 needles. Each resident repeated this procedure three times over a period of one month and there was no time limit to complete the implantation. A CT scan of the phantom was acquired after the first and the last session. A researcher assessed participant performance by evaluating the number of needles within the target and the correct geometry. A further survey was then done evaluating participant satisfaction and confidence with the procedure by using a 10-point Likert scale from low (1) to high (10). Of the 10 participants in this study, only one resident had implanted a needle under direct supervision. The number of catheters placed within the target ranged from 2-5 needles in their first attempt. In the final attempt, all participants were able to place the needles within the target. The mean deviation of the needles from the ideal distance of 1 cm in their first attempt was 3.4 mm +0.11 mm compared to 2.9 +0.11 mm in their final attempt. Residents reported in the surveys that their confidence to implant a needle in a supervised setting on a patient and their confidence to explain brachytherapy in an oral exam increased by a magnitude of 1.5 (Wilcoxon Signed Rank Test, p<0.05). We believe this is the first simulation program for teaching HDR breast brachytherapy implant skills. We have shown that simulation can help residents improve their skills and confidence in inserting needles. This model has the potential to be developed into a module for teaching residents breast brachytherapy in a competency-based curriculum.

Management options are limited for a primary or secondary malignant airway disease. This study evaluates symptomatic response, toxicities and local control of endobronchial malignancy treated with HDR. A retrospective chart review was conducted and data collected on all patients treated between 2010 and 2019 who received brachytherapy for endobronchial obstructive airway disease at one center. AJCC 8th edition was used for staging. All patients were treated using an iridium-192 isotope source to deliver a dose of 14 Gy in 2 fractions a week apart. Treatment length of the endobronchial disease was defined by imaging and endoscopic findings. Computed-tomography was used to define the volume. A total of 58 patients were identified; 34 (58.6%) were male and 24 (41.4%) female. Most (49, 84%) had a primary lung cancer and 9 (15.5%) had metastatic endobronchial disease from a primary elsewhere. Most lung cancer patients had stage III and IV (40, 69%). Eight (13.8%) were treated while admitted in the ICU. About half (52%) had prior external beam radiotherapy and 14 (24.1%) were treated with a curative intent. Most (47, 81%) reported a symptomatic improvement in dyspnea, cough, or hemoptysis. An improvement in dyspnea was seen in 72% of presenting with this symptom. The MRC dyspnea scale score improved by a mean of 1.13 (P<0.001, Wilcoxon paired samples test). Most (22, 88%) had an improvement in hemoptysis and 18 out of 37 (48.6%) had an improvement in cough. Grade I to III adverse events including dyspnea, small volume hemoptysis, or cough were noted in 25 (43.1%). Grade 4-5 hemoptysis occurred in 7(12%) at the median time of 2.5 months. Grade 4-5 dyspnea was seen in 3 patients. Median progression free survival was 6.5 months and median survival was 10 months. Median survival for patients treated with curative intent was 43 months. We report a significant symptomatic benefit after brachytherapy among patients with endobronchial malignant disease including among patients admitted to ICU for their dyspnea, hemoptysis and cough. Most had previous treatment. Toxicities such as significant hemoptysis were consistent with the prior reports. Limitations include retrospective data collection. We suggest an increase in awareness of endobronchial brachytherapy and provision of opportunities for trainees to learn this modality.

To evaluate a novel navigation system for breast brachytherapy, based on ultrasound (US)-guided catheter needle implantations followed by electromagnetic (EM) tracking of catheter paths. Breast phantoms were produced, containing US–visible tumors. Ultrasound was used to localize the tumor pose and volume within the phantom, followed by planning an optimal catheter pattern through the tumor using navigation software. An electromagnetic (EM)-tracked catheter needle was used to insert the catheters in the desired pattern. The inserted catheters were visualized on a post-implant CT, serving as ground truth. Electromagnetic (EM) tracking and reconstruction of the inserted catheter paths were performed by pulling a flexible EM guidewire through each catheter, performed in two clinical brachytherapy suites. The accuracy of EM catheter tracking was evaluated by calculating the Hausdorff distance between the EM-tracked and CT-based catheter paths. The accuracy and clinical feasibility of EM catheter tracking were also evaluated in three breast cancer patients, performed in a separate experiment room. A total of 71 catheter needles were implanted into 12 phantoms using US guidance and EM navigation, in an average ± SD time of 8.1 ± 2.9 min. The accuracy of EM catheter tracking was dependent on the brachytherapy suite: 2.0 ± 1.2 mm in suite 1 and 0.6 ± 0.2 mm in suite 2. EM catheter tracking was successfully performed in three breast brachytherapy patients. Catheter tracking typically took less than 5 min and had an average accuracy of 1.7 ± 0.3 mm. Our preliminary results show a potential role for US guidance and EM needle navigation for implantation of catheters for breast brachytherapy. EM catheter tracking can accurately assess the implant geometry in breast brachytherapy patients. This methodology has the potential to evaluate catheter positions directly after the implantation and during the several fractions of the treatment.

The 9th International Thymic Malignancy Interest Group's (ITMIG) Annual Meeting was held in Seoul, South Korea in October 2018, and in this article, we discuss three of the cases presented and review the radiology imaging and pathology slides. The first two cases involve thymic carcinoma: the first reviews systemic therapy recommendations for non-resectable recurrence and the second case the optimal treatment recommendations after incomplete resection. The third case discusses treatment recommendations for recurrent thymoma after complete resection.