Objective The role of circulating tumor DNA (ctDNA) in management of patients with colorectal cancer is evolving, however, there are no data on ctDNA monitoring in patients with resected colorectal liver metastases (CRLM) who receive adjuvant hepatic artery (HAI) chemotherapy. We report our center’s initial experience with postoperative ctDNA monitoring in patients receiving adjuvant HAI chemotherapy. Summary Background Data Adjuvant HAI chemotherapy improves survival after CRLM resection. ctDNA has been shown to predict recurrence in patients with resected CRLM, however no ctDNA data are available in patients who receive adjuvant HAI chemotherapy. Methods All patients with CRLM who underwent surgical resection and HAI pump placement at our center were included in this study. Demographic, clinicopathologic, radiographic, and ctDNA data are reported. Results From 2019-2024, 13 patients with CRLM underwent surgical resection and HAI pump placement and had ctDNA testing. With median follow-up of 2.6 years (1.14-4.15), 11 (85%) patients experienced recurrence at a median of 7.9 months (2.3-22.5). In total, 10 (77%) patients were ctDNA-positive all of whom had radiographic evidence of recurrence. Three patients have died at the time of last follow-up. Conclusions After surgical resection and HAI chemotherapy, ctDNA was detectable in most patients, and was associated with radiographic recurrence in all ctDNA-positive patients. We report a high recurrence rate in this series of heavily-pretreated patients with known risk factors for recurrence.

OBJECTIVE:Pancreatic cancer (PC) has a high mortality rate due to the lack of early-stage detection strategies and lethality of advanced stage presentations. New-onset diabetes (NOD) in individuals ≥50 years old increases the risk 6- to 8-fold, making this group a target of early detection studies. There is also evidence that deteriorating diabetes (DD) may be a risk factor. RESEARCH DESIGN AND METHODS:The study prospectively enrolled individuals ≥50 years with NOD or DD. Participants underwent magnetic resonance imaging/cholangiopancreatography, blood biobanking and anxiety/depression monitoring. Magnetic resonance imaging scans were scored as normal, benign-abnormal, suspicious, or incidental finding. Glycemic indices and physician referral patterns were captured. RESULTS:Over a 6-year period, 625 individuals were screened and 109 enrolled, 97 (89%) had NOD, and 12 (11%) had DD. Compared to the NOD cohort, the DD cohort was older, had higher hemoglobin A1c levels (P = .02), greater weight loss (P = .0038), and insulin requirements (P < .0001). Four pancreas biopsies were performed for suspicious findings (3.6%), with a stage 1 pancreatic ductal adenocarcinoma identified in the DD group, corresponding to an overall detection rate of 0.9% (1/109). The detection rates of benign pancreatic abnormalities and incidental findings revealed no safety signals. Endocrinologists were the main referral source for the DD cohort (P < .001). CONCLUSION:Results from the PANDOME study thus far include the first reported screen-detected early-stage PC in a sporadic cohort. Our findings support the inclusion of a DD cohort in prospective PC screening studies in high-risk diabetes. Endocrinologists play an especially important role in the referral of individuals with DD.

698 Background: Patient communication barriers are associated with worse quality of care and clinical outcomes. However there are limited data exploring their impact on shared decision-making (SDM) in the preoperative setting, especially for pancreatic ductal adenocarcinoma (PDAC). This study investigates the impact of patient communication barriers on patient-physician communication surrounding the decision to pursue pancreatectomy. Methods: This cross-sectional study investigates the impact of communication barriers on the degree of decisional regret (DR) in patients with PDAC who have undergone curative-intent resection at least 6 months prior to study recruitment. Patients completed validated surveys assessing communication preferences, SDM participation, and DR. Health literacy was assessed by the BRIEF Health Literacy survey. Groups were stratified by presence or absence of DR, assessed by the Decisional Regret Scale (DRS). Characteristics and survey scores were compared by chi-square and independent t-test. Given significant findings, results of this interim analysis are reported below. Results: 45 patients met inclusion criteria and completed all questionnaires. 19 (42.2%) patients expressed regret about their decision to pursue surgery with 5 patients expressing moderate to severe regret (DRS ≥25). Baseline characteristics were similar between groups. There were no significant differences in neoadjuvant or adjuvant treatments, or operative characteristics. Both groups reported high participation in preoperative SDM (average score 34.47 ± 9.67 in DR group vs 36.08 ± 8.88, P=0.567). Despite similar levels of education between groups, those expressing regret had a lower level of health literacy (14.68 ± 4.10 vs 17.35 ± 2.07, P=0.016). Fewer patients also identified English as their primary language in the DR group (78.9% vs 100%, P=0.026). While most patients preferred an active role in the final decision making process, fewer patients in the DR group reported this happening in actuality (ƙ= 0.635 vs ƙ=0.934). Conclusions: Almost half of patients expressed some regret pursuing surgery for PDAC. Despite similar educational backgrounds, a higher proportion of those expressing regret did not identify English as their primary language and had lower health literacy. While there was high participation in SDM, there was greater discordance between preferred and actual roles in the final decision making process. This identifies an important disparity to address in future preoperative discussions.

699 Background: Surgery is potentially curative for patients with localized pancreatic ductal adenocarcinoma (PDAC). Given the high rate of complications, decline in quality of life (QoL) postoperatively, and high rates of recurrence, clear preoperative communication and expectation setting is critical. This study investigates clinical outcomes that affect postoperative decisional regret (DR) in patients with PDAC. Methods: This mixed-methods study investigates the impact of clinical outcomes and QoL on the degree of DR in patients with PDAC who have undergone curative-intent resection at least 6 months prior to study recruitment. Patients completed validated surveys assessing DR and QoL by the European Organization for Research and Treatment of Cancer (EORTC). Groups are stratified by presence or absence of DR, assessed by the Decisional Regret Scale (DRS). Characteristics and survey scores were compared by chi-square, independent t-test, and median test. Narrative responses were thematically analyzed. Given significant findings, results of this interim analysis are reported below. Results: 45 patients met inclusion criteria and completed all questionnaires. 19 (42.2%) patients expressed regret about their decision to pursue curative-intent surgery, with 5 patients expressing moderate to severe regret (DRS ≥ 25). There was no significant difference in median postoperative timing of survey completion between groups (56 months in DR group vs 34 months, P=0.465). Baseline characteristics, medical treatments, and operative approaches were similar. Both groups had similar recurrence rates at time of survey completion. While 30 and 90 day readmission rates were similar, a greater proportion of the DR group had 30 day complications (42.1% vs 15.4%, P=0.045). Those expressing regret reported poorer physical functional status (mean score 79.30 ± 18.84 vs 92.31 ± 10.27, P=0.011) and greater impact on social activities (mean score 67.54 ± 33.55 vs 84.67 ± 19.19, P=0.038). Thematic analysis of narrative responses revealed that a majority of patients expressed a strong desire to have a greater focus on potential QoL changes during preoperative discussions. Conclusions: Patients expressing postoperative DR experienced more 30 day complications, and still report lasting effects on their current physical status and social activities. This emphasizes the importance of thorough preoperative counseling on surgical risks and potential changes in postoperative QoL so that patients may make the best informed decision.

The prognostic impact of genetic mutations for patients who undergo cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) of colorectal origin (CRC) is not well defined. We aimed to describe the genetic classifications in an unsupervised fashion, and the outcomes of this patient population. A retrospective, bi-institutional study was performed on patients who underwent CRS-HIPEC with targeted mutation data with a median follow-up time of 61 months. Functional link analysis was performed using STRING v11.5. Genes with similar functional significance were clustered using unsupervised k-means clustering. Chi-square, Kaplan–Meier, and the log-rank test were used for comparative statistics. Sixty-four patients with peritoneal carcinomatosis from CRC origin underwent CRS-HIPEC between 2007 and 2022 and genetic mutation data were extracted. We identified 19 unique altered genes, with KRAS (56

The PRECINCT (Pattern of peritoneal dissemination and REsponse to systemic Chemotherapy IN Common and uncommon peritoneal Tumors) is a prospective, multicenter, observational study. This report from phase I of PRECINCT outlines variations in recording the surgical peritoneal cancer index (sPCI) at experienced peritoneal malignancy centers and the incidence of pathologically confirmed disease in morphologically different peritoneal lesions (PL). The sPCI was recorded in a prespecified format that included the morphological appearance of PL. Six prespecified morphological terms were provided. The surgical and pathological findings were compared. From September 2020 to December 2021, 707 patients were enrolled at 10 centers. The morphological details are routinely recorded at two centers, structure bearing the largest nodule, and exact size of the largest tumor deposit in each region at four centers each. The most common morphological terms used were normal peritoneum in 3091 (45.3

BACKGROUND:While cholecystectomy is one of the most common operations performed in the United States, there is a continued debate regarding its prophylactic role in elective surgery. Particularly among patients with peritoneal carcinomatosis who undergo cytoreduction surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), further abdominal operations may pose increasing morbidity due to intraabdominal adhesions and potential recurrence. This bi-institutional retrospective study aims to assess postoperative morbidity associated with prophylactic cholecystectomy at the time of CRS-HIPEC.METHODS:We performed a bi-institutional retrospective analysis of 578 patients who underwent CRS-HIPEC from 2011 to 2021. Postoperative outcomes among patients who underwent prophylactic cholecystectomy at the time of CRS-HIPEC were compared to patients who did not, particularly rate of bile leak, hospital length of stay, rate of Clavien-Dindo classification morbidity grade III or greater, and number of hospital re-admissions within 30 days.RESULTS:Of the 535 patients available for analysis, 206 patients (38.3%) underwent a prophylactic cholecystectomy. Of the 3 bile leaks (1.5%) that occurred among patients who underwent prophylactic cholecystectomy, all 3 occurred in patients who underwent a concomitant liver resection. There were no significant differences in hospital length of stay, postoperative morbidity, and number of hospital re-admissions among patients who underwent prophylactic cholecystectomy compared to those who did not.CONCLUSION:Prophylactic cholecystectomy in patients undergoing CRS-HIPEC is not associated with increased morbidity or increased bile leak risk compared to historical data. While the benefits of prophylactic cholecystectomy are not yet elucidated, it may be considered to avoid potential future morbid operations for biliary disease.

ABSTRACT Background and Aim In this report from Phase 1 of the prospective, observational, PRECINCT ( P attern of peritoneal dissemination and RE sponse to systemic C hemotherapy IN C ommon and uncommon peritoneal Tumours) study, a correlation was performed between the radiological PCI (peritoneal cancer index; rPCI) and surgical PCI (sPCI). The impact of timing of peritoneal malignancy (PM) and previous abdominal surgery was also studied. Methods The rPCI and sPCI were considered the ‘same’ if they differed by ≤ 3 points. The agreement was assessed using Bland–Altman analysis and the strength of the agreement was assessed using the concordance correlation coefficient (CCC). The extent of prior surgery was classified according to prior surgical score (PSS). Results In 707 (79.4%) patients, rPCI and sPCI concurred in 280 (39.6%). In the Bland–Altman analysis, < 40% patients were in the ±3 PCI points limit of acceptable difference. The average difference between the two scores was 4.5 points (95% CI‐ −5.16 to −3.92). The CCC‐ was 0.59 for the whole cohort (‘moderate’ concordance) and was not influenced by imaging modality, timing of PM or PSS. Conclusions The rPCI underestimated sPCI by an average of 4.5 points. The role of peritoneal MRI in patients undergoing iterative procedures and the performance of imaging according to sites of recurrence need further evaluation.

BACKGROUND AND OBJECTIVES:There are no guidelines for intravenous fluid (IVF) administration after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). This study assessed rates of post-CRS/HIPEC morbidity according to perioperative IVF administration. METHODS:All patients undergoing CRS/HIPEC March 2007 to June 2018 were reviewed, recording clinicopathologic, operative, and postoperative variables. Patients were divided by peritoneal cancer index (PCI), comparing IVF volumes and types administered intraoperatively and during the first 72 h postoperatively. Optimal IVF rate cutoffs calculated using area under the receiver operating characteristic curves and Youden's index determined associations with complications. RESULTS:Overall, 185 patients underwent CRS/HIPEC, and 81 (51%) had low PCI (<10) and 77 (49%) had high PCI (≥10). In low-PCI patients, high IVF rates on postoperative days (POD) #0-2 were associated with higher overall complications: POD#0 (46% vs. 89%, p = 0.001), POD#1 (40% vs. 86%, p < 0.05), and POD#2 (42% vs. 72%, p < 0.05). High IVF rates were associated with respiratory distress (7% vs. 26%, p = 0.02) on POD#0, ileus (14% vs. 47%, p = 0.007) and intensive care unit stay (11% vs. 33%, p = 0.022) on POD#1, and ICU stay (8% vs. 33%, p = 0.003) on POD#2. CONCLUSIONS:For low PCI patients undergoing CRS/HIPEC, higher IVF rates were associated with postoperative complications. Post-CRS/HIPEC, IVF rates should be limited to prevent morbidity.

Guidelines for perioperative systemic therapy administration in patients undergoing pancreatoduodenectomy for pancreatic adenocarcinoma (PDAC) and distal cholangiocarcinoma (dCCA) are evolving. Decisions regarding adjuvant therapy are influenced by postoperative morbidity, which is common after pancreatoduodenectomy. We evaluated whether postoperative complications are associated with receipt of adjuvant therapy after pancreatoduodenectomy. A retrospective analysis of patients undergoing pancreatoduodenectomy for PDAC or dCCA from 2015 to 2020 was conducted. Demographic, clinicopathologic, and postoperative variables were analyzed. Overall, 186 patients were included—145 with PDAC and 41 with dCCA. Postoperative complication rates were similar for both pathologies (61 Patients who underwent pancreatoduodenectomy for either PDAC or dCCA and who experienced an MPC had lower rates of adjuvant therapy and worse RFS, suggesting that clinicians adopt a standard neoadjuvant systemic therapy strategy in patients with PDAC. Our results propose a paradigm shift towards preoperative systemic therapy in patients with dCCA.

Background. Frailty, a multidimensional state leading to reduced physiologic reserve, is associated with worse postoperative outcomes. Despite the availability of various frailty tools, surgeons often make subjective assessments of patients' ability to tolerate surgery. The Risk Analysis Index (RAI) is a validated preoperative frailty assessment tool that has not been studied in cancer patients with plans for curative-intent surgery. Methods. In this prospective, surgeon-blinded study, patients who had abdominal malignancy with plans for resection underwent preoperative frailty assessment with the RAI and nutrition assessment by measurement of albumin, prealbumin, and C-reactive protein (CRP). Postoperative outcomes and survival were assessed. Results. The study included 220 patients, 158 (72%) of whom were considered frail (RAI >= 21). Frail patients were more likely to be readmitted within 30 and 90 days, (16% vs. 3% [P = 0.006] and 16% vs. 5% [P = 0.025], respectively). Patients with abnormal CRP, prealbumin, and albumin experienced higher rates of unplanned intensive care unit admission (CRP [27% vs. 8%; P < 0.001], albumin [30% vs. 10%; P < 0.001], prealbumin [29% vs. 9%; P < 0.001]) and increased postoperative mortality at 90 and 180 days. Survival was similar for frail and non-frail patients. In the multivariate analysis, frailty remained an independent risk factor for readmission (hazard ratio, 5.58; 95% confidence interval, 1.39-22.15; P = 0.015). In the post hoc analysis using the pre-cancer RAI score, the postoperative outcomes did not differ between the frail and non-frail patients. Conclusion. In conjunction with preoperative markers of nutrition, the RAI may be used to identify patients who may benefit from additional preoperative risk stratification and increased postoperative follow-up evaluation.

BackgroundCurrently, patients with T1 gastric cancers undergo upfront resection while those with loco-regional disease often are recommended for systemic therapy. Over-staging by endoscopic ultrasound (EUS), specifically in T2 disease, introduces the risk of overtreatment with chemotherapy without the benefit of a confirmed pathological stage. This risk of overtreatment compared to the risk of recurrence after upfront surgery must be weighed in this group.MethodsWe retrospectively reviewed patients with gastric cancer who underwent upfront resection between 2010-2020 at our institution. Patients were excluded if they received preoperative systemic therapy or radiation. EUS clinical staging and pathological staging were reconciled for accuracy. Recurrence-free survival and overall survival was calculated for the T2 intramural group. Survival was confirmed by chart review and utilization of the Social Security Death Index.Results134 patients were included. EUS over-staged 20/37 (54%) of patients defined as having clinical T2 (cT2). Lymph node involvement (cN+) as determined by EUS without biopsy was accurate in 1/9 (11%) when compared to final pathology. In total, 22 cases were confirmed as intramural disease (T2) on final pathology. Six patients with T2 disease (18%) experienced recurrence. With a median follow-up of 32 months, no patients experienced mortality at five years.ConclusionsClinical staging by EUS introduces the risk of over-staging for patients with T2 gastric cancer. Upfront surgery for these individuals demonstrated encouraging recurrence-free and overall survival. Patients with cT2 gastric cancers should be selectively evaluated for benefits of upfront resection, given risk of over-treated without a survival benefit.SynopsisClinical over-staging with endoscopic ultrasound introduces the risk of overtreatment with systemic chemotherapy especially in patients with T2 disease. In this retrospective review, we report the accuracy of EUS in patients with pT2 gastric cancer who underwent upfront resection as well as the recurrence and survival outcomes.

Cytoreductive surgery and heated intraperitoneal chemotherapy (CRS/HIPEC) improves survival compared with chemotherapy alone in patients with peritoneal carcinomatosis (PC) of colorectal (CRC) origin, however, long-term survival data are lacking. We report the actual survival of patients who underwent CRS/HIPEC for PC of CRC origin with a minimum potential 5-year follow-up period to identify factors that preclude long-term survival. We performed a retrospective analysis of a prospective database, analyzing patients undergoing CRS/HIPEC for PC of CRC origin from 2007 to 2017. Patients with aborted CRS/HIPEC, postoperative follow-up <90 days, or non-CRC histology were excluded. Overall survival (OS) and disease-free survival (DFS) were measured from date of surgery. Surviving patients with <60 months of follow-up were censored at date of last follow-up. A total of 103 patients met inclusion criteria and were analyzed. CC score 0–1 was achieved in 89.3