Background Routine provider-performed physical examinations remain a standard element of breast cancer survivorship despite increasing evidence that diagnostic yield is limited. With growing survivorship populations and mounting demands on oncology services, reassessment of the value of this practice is warranted. This study sought to evaluate the diagnostic yield and prognostic relevance of surveillance physical exams. Methods A retrospective review was conducted of women with breast cancer treated between January 2019 and December 2023 at a single tertiary center. Surgical oncology survivorship visits >90 days postoperatively were analyzed. Recurrence events were categorized by initial detection modality: provider-performed physical examination, patient-reported, screening imaging, or symptom-prompted non-breast imaging. Results Among 3337 patients, 131 recurrences (3.9%) occurred after a median of 20 months. Patients collectively attended 12,840 survivorship visits; only eight recurrences (6.1% of all recurrences; 0.06% of examinations) were first detected by physical examination. By comparison, 32 (24.4%) were patient-reported, 38 (29.0%) were detected on screening imaging, and 53 (40.5%) were identified by non-breast diagnostic imaging. When stratified by detection method, exam-detected recurrences were evenly divided between locoregional and combined locoregional/distant disease, whereas patient-reported and screening-detected recurrences were predominantly locoregional, at 72% and 92%, respectively. Conclusions Breast and chest wall examinations accounted for a small proportion of recurrence detections despite thousands of survivorship visits annually. Most clinically meaningful recurrences were identified by imaging or patient self-report. These findings support survivorship strategies that prioritize imaging adherence and structured symptom assessment, with less emphasis on routine physical examination as a primary detection modality.

BACKGROUND:Bedside exploratory laparotomy is a heroic intervention for unstable patients who cannot be transported to the operating room. Given a previously documented high mortality rate, some argue against the procedure on assumption of non-beneficence. This study aims to evaluate procedural mortality rate and identify physiologic factors associated with death after bedside exploration. METHODS:A single-center, retrospective review of consecutive patients who underwent bedside exploratory laparotomy between 2019 and 2024 was conducted. Patients were stratified into cohorts based on a composite outcome of in-hospital or 30-day survival, and an analysis was conducted to identify factors associated with mortality. RESULTS:A total of 51 patients underwent bedside exploratory laparotomy, with a mortality rate of 82.4% (42/51) within 30 days or during index hospitalization. The median postoperative time to death was 18.1 hours. Mortality rates were 73.9% in SICU, 90.0% in MICU, and 88.2% in CTICU. Survivors were younger than non-survivors (46.5 vs. 60.8 years; p = 0.025) and had lower Charlson Comorbidity Index scores (2 vs. 4; p = 0.0011). Preoperative lactate was lower (4.12 vs. 10.16 mmol/L; p = 0.0012) and pH higher (7.30 vs. 7.20; p = 0.042) in survivors. Significant intraoperative findings were more frequent in non-survivors (95% vs. 33%; p < 0.001). CONCLUSION:Bedside exploratory laparotomy is a last-resort intervention with exceedingly high mortality. We observed older patients with significant acidosis or identifiable intraoperative findings have worse prognoses. Preoperative goals-of-care discussions should be prioritized in elderly patients before proceeding with bedside exploration to ensure ethical delivery of surgical care.

TPS790 Background: Postoperative pancreatic fistula (POPF) remains the defining complication of pancreatectomy, leading to significant morbidity, mortality, and increased healthcare costs. Multiple trialed interventions have failed to meaningfully reduce the incidence of POPF. Since the early 1990s, studies have explored the role of perioperative somatostatin analogs (SSAs) for POPF prophylaxis. Earlier trials focused on octreotide and reported mixed results. A randomized trial of perioperative pasireotide reported a reduced incidence of POPF, but faced criticism due to its single-center design, inconvenient dosing regimen, and pasireotide’s high rate of dose-limiting side effects. Lanreotide is a more recently developed SSA with a simpler dosing regimen due to its depot formulation and a favorable side-effects profile that has been proposed for POPF prophylaxis. In a single-arm phase II trial, a single dose of preoperative lanreotide was associated with low POPF rates of 11% and 3% in patients undergoing pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), respectively. Methods: SWOG 2408 is a multicenter, phase III randomized controlled trial sponsored by the National Cancer Institute Division of Cancer Prevention comparing the incidence of POPF in participants receiving a single dose of preoperative lanreotide (120 mg subcutaneous) versus saline placebo immediately prior to DP for suspected or biopsy-proven pancreatic malignancy. Planned enrollment of 274 participants will take place at academic and community hospitals in North America. The primary objective is to compare the incidence of POPF between treatment groups within 60 days after surgery. Secondary objectives include comparing the incidences of other postoperative sequelae (biochemical leak, delayed gastric emptying, post-pancreatectomy hemorrhage) within 60 days of surgery, postoperative length of hospital stay, and changes from baseline in cancer-specific quality of life between treatment groups. Blood, pancreas fluid, and tissue specimens will be banked for future correlative studies. Clinical trial information: NCT06807437 .

LBA9505 Background: Advances in the neoadjuvant (neo) setting of locoregionally advanced melanoma have recently transformed practice. However, there continues to be a need to enhance efficacy while minimizing systemic toxicity. Preliminary data support an important role for vidutolimod (V), a CpG-A TLR9 agonist packaged within a virus-like particle given intratumorally (IT) in combination with IV anti-PD1. Methods: A U.S. intergroup randomized phase II trial of pembrolizumab (P) vs P + V in patients (pts) with resectable clinical AJCC8 stages IIIB-D. It planned to randomize ~60 pts (for 54 evaluable) 1:1 to Arm A (neo P 200 mg IV Q3W x3) or Arm B (neo P 200 mg IV Q3W x3 + V 5 mg SC x1 then 10 mg IT QW x6) followed by definitive surgery then adjuvant P 400 mg IV Q6W x8, stratified by stage (IIIB/C vs IIID). Primary endpoint was pathologic (path) complete response (pCR) on each arm. Secondary endpoints included path responses, recurrence, overall survival, event-free survival [EFS: disease progression (PD), recurrence or death] and safety. Results: EA6194 enrolled 57 pts March 2021-March 2024, 19 female, 38 male, all cutaneous primary (1 acral on Arm B), median age 64 (26-88), 29 on Arm A [10 IIIB (8N1b, 1N1c, 1N2b), 19 IIIC (3N1b, 1N1c, 3N2b, 3N2c, 7N3b, 2N3c)] and 28 on Arm B [13 IIIB (11 N1b, 2 N2b), 13 IIIC (5 N1b, 2N2b, 2N2c, 3N3b, 1N3c), 2 IIID (N3b)]. The median numbers of neo P/adjuvant P doses were similar for both arms at 2/7. Median number/total dose of V were 7/60 mg. Among pts who initiated treatment, highest grade related AEs (Gr 3/4) were 25% in Arm A (N=28) and 29% in Arm B (N=28) including in Arm B diarrhea (1), injection site reaction (1), cytokine release (1), wound dehiscence (1), lymphocytopenia (1), pain (1), headache (1), hypertension (1), hypotension (1), all Gr 3 and one Gr 4 hyperglycemia. Median time to surgery from randomization 2.5 months. Median follow up time from enrollment 19 months. There were 3 deaths on Arm A and 1 on Arm B. On Arm A 25 pts had surgery, 6 path non-response (pNR), 2 partial (pPR), 3 near-pCR, 14 pCR (56%; 95% CI, 35 - 76). MPR (pCR + near-pCR) was 17/25 (68%; 95% CI, 46 - 85). Among these, 3 had recurrence after surgery (1 pNR, 1 near-pCR, 1 pCR). On Arm B 27 pts had surgery, 3 pNR, 2 pPR, 2 near-pCR, 20 pCR (74%, 95%, CI 54 - 89). MPR 22/27 (79%; 95% CI 62 - 94). Among these, 2 had recurrence after surgery (1 pNR, 1 pPR). Table 1 summarizes efficacy data including all enrolled pts. Conclusions: Neoadjuvant P + Vdemonstrated acceptable safety and encouraging clinical activity in pts with resectable clinical stages IIIB/IIIC/IIID melanoma when considering Arm A and historical controls, warranting further investigation. Clinical trial information: NCT04708418 . Arm A:P (N=29*) Arm B:P + V (N=28*) pCR (%; 95% CI) 14 (48; 29 - 67) 20 (71; 51 - 87) MPR (%; 95% CI) 17 (59; 39 - 76) 22 (79; 59 - 92) 1-year EFS (95% CI) 75% (59 – 91) 89% (78 - 100) *4 on Arm A and 1 on Arm B did not have surgery due to PD.

BACKGROUND:Approximately 20% of women diagnosed with ductal carcinoma in situ on core biopsy will be upstaged to invasive disease on final pathology. Sentinel lymph node biopsy at the time of mastectomy for ductal carcinoma in situ is the current standard of care. However, the underlying invasive cancer is frequently of low grade with favorable biology, bringing into question the necessity of sentinel lymph node biopsy to help guide clinical treatment recommendations. The primary study objective was to determine how often sentinel lymph node biopsy at the time of mastectomy for ductal carcinoma in situ alters adjuvant therapy recommendations. METHODS:A single-institution cancer registry retrospectively identified women treated with mastectomy for a preoperative diagnosis of ductal carcinoma in situ between November 2017 and November 2023, excluding those with a previous history of ipsilateral breast cancer. The impact of pathologic nodal status on adjuvant treatment was evaluated. RESULTS:The study population included 175 patients with a total of 38 invasive cancers identified. Of those with pT1 malignancies, 3 had a positive sentinel node. One patient was recommended for additional adjuvant treatment, in the form of radiation therapy, as a result of axillary staging. No patients were recommended for chemotherapy based solely on sentinel lymph node biopsy results. CONCLUSION:Despite current recommendations to perform sentinel lymph node biopsy in ductal carcinoma in situ treated with mastectomy in the event invasive cancer is identified on final pathology, our outcomes suggest nodal status has limited impact on adjuvant therapy offerings. These findings indicate that sentinel lymph node biopsy may not be requisite for every patient undergoing mastectomy for ductal carcinoma in situ.

BACKGROUND:Gene expression profiling of cutaneous melanoma has become pervasive in clinical practice, with minimal independent, nonindustry-sponsored, data to guide implementation and influence practice patterns. We developed a scoring system on the basis of anatomic staging and molecular profiling to risk stratify patients into 4 categories for prospective surveillance. METHODS:Patients with cutaneous melanoma were recruited from 2019 to 2023 for enrollment into the study. Inclusion criteria included pathologic stage IA-IIC and use of a commercialized 31-gene expression profile system. Patients were stratified into 1 or 4 surveillance groups: A1 (stage IA-IIA/gene expression profiling class 1), A2 (stage IA-IIA/gene expression profiling class 2), B1 (stage IIB-IIC/gene expression profiling class 1), and B2 (stage IIB-IIC/gene expression profiling class 2). The primary outcome measure is rate of asymptomatic imaging-detected recurrence. Interim analysis has been performed at median follow-up of 24 months. RESULTS:A total of 200 patients were enrolled. Mean age was 61.0 years (standard deviation, 14.6 years) and 55.5% of the population was male. Primary lesions were distributed between the head and neck (n = 40, 20%), trunk (n = 76, 38%), and extremity (n = 84, 42%). Median depth was 1.1 mm (range, 0.3-8.8 mm) and 14% had ulceration present. Stage distribution was as follows: IA (n = 82, 41.0%), IB (n = 71, 35.5%), IIA (n = 27, 13.5%), IIB (n = 16, 8.0%), and IIC (n = 4, 2.0%). Gene expression profiling classification was class 1 (n = 145, 72.5%) and class 2 (n = 55, 27.5%). This provided a distribution of 71.0% in A1, 19.5% in A2, 2.0% in B1, and 7.5% in B2. Recurrences have been detected in 16 patients (8.0%) including 12 local/regional (6.0%) and 4 distant (2.0%) recurrences. Recurrence rates by surveillance group are: A1 = 4.9%, A2 = 10.3%, B1 = 0%, and B2 = 33.3%. Recurrences were detected by surveillance imaging in 3 (1.5%), history and physical examination in 10 (5.0%), and symptoms in 3 patient (1.5%), respectively. CONCLUSION:Pragmatic implementation of a risk-stratified surveillance strategy has resulted in few instances of asymptomatic, imaging-detected recurrences among early-stage cutaneous melanoma patients at short-term follow-up benchmarks. Further follow-up is necessary to determine the validity of this approach.

BACKGROUND:Breast cancer management requires complex decision-making and varies widely at international, national, and institutional levels. Our study evaluates the impact of nonpunitive, real-time reviews of individual surgeons' practice patterns within a single institution. METHODS:Data from a prospective breast cancer database from the prior 12-month period were reviewed every 6 months in unblinded sessions. Surgeons compared their practices with those of their colleagues during three review sessions, without any benchmarks or punitive measures. RESULTS:A mean of 663 cases were reviewed for each 12-month period. Significant changes in practice patterns were observed, including notable reductions in re-excision rates (20.1% vs. 11.2%, p < 0.001), sentinel lymph node (SLN) biopsy utilization in patients over 70 with favorable biology (24.2% vs. 12.2%, p = 0.037), intraoperative SLN analysis in surgery-first patients (28.7% vs. 2.7%, p < 0.001), and immediate breast reconstruction (46.2% vs. 34.7%, p = 0.027). Additionally, there were significant increases in the use of breast conserving therapy (75.3% vs. 83.1%, p = 0.006) and outpatient mastectomy (58.4% vs. 79.9%, p < 0.001). Clinical variation in intraoperative SLN analysis and prophylactic measures was notably reduced. These adjustments resulted in an estimated annual cost saving of $467 619. CONCLUSIONS:Practice pattern reviews significantly altered surgical practices, reducing clinical variation and demonstrating that strategic investments in quality initiatives can greatly enhance resource utilization and generate substantial cost savings.

Background Telemedicine has gained traction in surgical subspecialties, particularly since the COVID-19 pandemic. This study aims to identify whether telemedicine can be appropriately integrated within surgical oncology practice. Methods This retrospective study evaluated patients who received either telemedicine or office follow-up after undergoing surgical oncology operations between 2016 and 2021. The telemedicine group (TG) and office group (OG) received a 15-question survey regarding their satisfaction with their care. Patient outcomes and responses were analyzed utilizing propensity-score matching in 1:1 fashion. Results Telemedicine group and OG each had 21 patients. Length of stay, complication frequency, follow-up frequency, and readmissions frequency within 90-days were comparable between groups. Telemedicine group expressed comparable satisfaction with postoperative care relative to OG (95.2% vs. 85.7%, p = 0.61). All telemedicine patients said they would utilize telemedicine again in the future and would recommend its use to others. Conclusion Patient satisfaction with postoperative telemedicine follow-up is comparable to those with in-person follow-up.

BACKGROUND:For women at increased risk of breast cancer, the National Comprehensive Cancer Network (NCCN) guidelines recommend clinical encounters every 6-12 months. While screening mammography has corresponded with a relative risk reduction in breast cancer mortality of approximately 20%, evidence validating clinical breast examination (CBE) as an efficacious screening modality is deficient. Our study aimed to assess the conventional merit of regular CBE for breast cancer detection among individuals at increased risk of breast cancer development. METHODS:Women > 18 years with documented high-risk encounters at Corewell Health West from 1 January 2018 to 31 December 22 were retrospectively reviewed. High-risk criteria included genetic predisposition, 5-year (> 1.7%) or lifetime (> 20%) Tyrer-Cuzick and/or Gail Model risk estimations, thoracic radiotherapy before age 30 years, lobular carcinoma in-situ, or atypical hyperplasia. Patients with a history of breast cancer or bilateral prophylactic mastectomy prior to 2018 were excluded. RESULTS:Of the 9171 cumulative high-risk encounters among 2493 women, only one breast cancer was detected by CBE. CBE resulted in 1 (0.04%) cancer diagnosis compared with 30 (1.2%) detected on screening imaging and 10 (0.4%) self-reported. Of the 30 image-detected cancers, 28 (93.3%) had no detectable clinical findings at the time of preoperative consultation. Self-reported and CBE-detected cancers were more likely to be of higher clinical stage compared with imaging-detected malignancies. CONCLUSIONS:The role of routine CBE as a cancer detection modality in the high-risk patient population appears to be limited. Telemedicine can be offered to individuals who have completed screening imaging but are unable to commit and/or are inconvenienced by in-person high-risk breast cancer assessments.