BACKGROUND:Since its inception, surgical oncology training has emphasized the treatment of complex tumors without restriction to a specific anatomic region. As the complexity of cancer care increases, it is unclear whether this broad-based training model remains optimal. We set out to characterize how fellowship prepares graduates for clinical practice and to identify trends in surgical oncology training and practice. METHODS:A 24-item survey was sent to graduates of an academic surgical oncology training program between the years 1981 and 2022. Questions focused on preparedness for practice upon graduation, current clinical and non-clinical activities, and the evolution of respondents' practice since completion of fellowship. RESULTS:Respondents indicated that they felt generally well prepared to treat a wide range of malignancies. Post-2013 graduates, felt significantly better prepared to treat peritoneal surface and gynecologic malignancies and to perform robotic surgery. In contrast, pre-2013 graduates indicated greater preparedness for the treatment of melanoma, extremity sarcoma, head and neck, esophageal and thoracic malignancies (p 0.05). Respondents practiced broadly, treating a median of 5 disease sites, although 36% dedicated more than half of their time to a single site. Despite the lack of formalized leadership training, 40.9% of graduates were involved in leadership positions. CONCLUSIONS:Our findings confirm that the existing surgical oncology training positions trainees well for practice, even in a landscape with many partially overlapping and competing surgical fellowships. In addition, many graduates are engaged in administrative and leadership roles suggesting that surgical oncologists may benefit from formalized leadership training during fellowship.

Purpose/Objective(s) Prior studies have demonstrated that radiolabeled anti-carcinoembryonic antigen (CEA) monoclonal antibody (M5A) can target CEA-expressing cancers. This ongoing pilot study (NCT05245786) evaluates the ability of Cu-64-DOTA-M5A PET imaging to define disease extent before and after neoadjuvant radiotherapy in patients with locally advanced rectal cancer. Materials/Methods Patients with biopsy proven cT3-4, N0 or N+ rectal cancer who were scheduled for neoadjuvant chemoradiation prior to TME or total neoadjuvant therapy underwent PET imaging with Cu-64-M5A within 4 weeks prior to start of neoadjuvant RT and 6-8 weeks after end of all neoadjuvant therapy and prior to planned surgery. Cu-64-M5A PET scans were read by the same nuclear medicine physician. A regional analysis (primary, pelvic nodes, and extra-pelvic) later compared CEA scans to standard of care (SOC) CT and MRI imaging, FDG PET if available, biopsies and surgical findings. Results Nine patients have been imaged to date with Cu-64-M5A PET (ages 46-70 years old). CEA PET imaging prior to RT identified the primary tumor in all 9 patients. For disease involving pelvic nodes, CEA PET imaging was in concordance with SOC imaging in 6 of 9 patients. In 5 patients CEA scans identified suspicious lesions outside the pelvis, which in 2 patients were confirmed by SOC imaging and biopsy (lung metastases; and a single liver metastasis), while in 3 patients PET avid nodes detected (para-aortic, left supraclavicular, mediastinal, porta hepatis, and portacaval) were outside the regions imaged as part of SOC. 4 of 9 patients to date have also been imaged post RT and prior to surgery. 2 patients had radiologic complete response (CR) on CEA scans which correlated with pathologic CR at surgery and with clinical CR on follow-up sigmoidoscopy. Two patients had positive scans; 1 patient at the primary site confirmed as residual disease at surgery; and 1 patient at the primary site, in mediastinal, para-aortic, and pelvic lymph nodes, and a new focus near the hepatic surface with biopsy confirmation of disease at the primary site and liver. Conclusion Results demonstrate that Cu-64-M5A anti-CEA M5A PET imaging in patients with advanced rectal cancer shows promise in identifying known sites of disease at the primary site and regional lymph nodes, as well as identifying extra pelvic sites of disease. In addition, it shows promise for assessing response to neoadjuvant therapy. Cu-64-M5A imaging warrants further evaluation as a way to complement SOC imaging at initial staging, to select patients for local regional therapy and to select patients for non-operative management after neoadjuvant therapy. Given its targeting capabilities, M5A is also being evaluated radiolabeled with Ac-225 as a therapeutic radiopharmaceutical (NCT05204147) and as an anti-CEA-IL2 immunotherapy fusion agent (NCT06130826) in phase 1 trials.

Background and ObjectivesTotal mesorectal excision (TME) remains the standard of care for patients with rectal cancer who have an incomplete response to total neoadjuvant therapy (TNT). A minority of patients will refuse curative intent resection. The aim of this study is to examine the outcomes for these patients.MethodsA retrospective cohort study of stage 1-3 rectal adenocarcinoma patients who underwent neoadjuvant chemoradiation therapy or TNT at a single institution. Patients either underwent TME, watch-and-wait protocol, or if they refused TME, were counseled and watched (RCW). Clinical outcomes and resource utilization were examined in each group.ResultsOne hundred seventy-one patients (Male 59%) were included with a median surveillance of 43 months. Twenty-nine patients (17%) refused TME and had shortened overall survival (OS). Twelve patients who refused TME converted to a complete clinical response (cCR) on subsequent staging with a prolonged OS. 92% of these patients had a near cCR at initial staging endoscopy. Increased physician visits and testing was utilized in RCW and WW groups.ConclusionA significant portion of patients convert to cCR and have prolonged OS. Lengthening the time to declare cCR may be considered in select patients, such as those with a near cCR at initial endoscopic staging.

Background Remote patient telemonitoring programs offer the potential to enhance access and communication with medical providers. This study assessed the patient-reported experience during perioperative telemonitoring for gastrointestinal (GI) oncologic surgery. Methods Between October 2021 and July 2023, patients with GI cancer were enrolled in the remote telemonitoring trial and randomized into the intervention or enhanced usual care arm. Although the enhanced usual care arm adhered to standard protocols for problem reporting, the intervention arm received active nursing support for monitoring data deviations from predetermined thresholds. The program culminated in a 15-minute exit interview comprised 9 total questions to gather insights into the patient experiences with device usage, symptom reporting, and communication with the healthcare team. Thematic analysis was conducted on all responses to present a patient-centric summary. Results Of the 114 patients completing the study, 100 patients (88%) participated in the exit interview. Most enrolled patients (n = 68) were diagnosed as having colorectal cancer. The intervention arm reported greater ease and accessibility in electronic data reporting and communication with healthcare team compared to the enhanced usual care arm (94% vs 69%). Qualitative analysis identified 3 themes used to describe the program: “instilling an affirmative and proactive mindset toward recovery,” “receiving timely attention from healthcare team,” and “benefits of device usage and electronic health surveys.” The subthemes highlighted an appreciative and empowering mindset among most patients. Conclusion Most enrolled patients expressed satisfaction with the program to facilitate their postoperative recovery. These positive testimonials present a promising outlook for future implementation from the patient perspective.

Importance:Serial circulating tumor DNA (ctDNA) has emerged as a routine surveillance strategy for patients with resected colorectal cancer, but how serial ctDNA monitoring is associated with potential curative outcomes has not been formally assessed. Objective:To examine whether there is a benefit of adding serial ctDNA assays to standard-of-care imaging surveillance for potential curative outcomes in patients with resected colorectal cancer. Design, Setting, and Participants:In this single-center (City of Hope Comprehensive Cancer Center, Duarte, California), retrospective, case cohort study, patients with stage II to IV colorectal cancer underwent curative resection and were monitored with serial ctDNA assay and National Cancer Center Network (NCCN)-guided imaging surveillance from September 20, 2019, to April 3, 2024. The median duration of follow-up was 26 months (range, 2-54 months). Interventions:Serial ctDNA assays were performed every 3 months for 2 years and every 6 months for the 3 following years in conjunction with NCCN-guided radiographic surveillance. Main Outcomes and Measures:The primary outcome was the proportion of patients with clinical benefit from ctDNA testing, defined as the proportion of patients with a newly positive ctDNA assay and negative scheduled imaging (most recent or concurrent) that subsequently led to early imaging confirmation of recurrence, followed by curative-intent intervention with no evidence of recurrence at the time of data cutoff. Recurrence was categorized by ctDNA recurrence, radiographic recurrence, or concurrent ctDNA and imaging recurrence. Salvage resections and associated durable remissions were described within each of the 3 categories. Descriptive statistics were used to characterize the patient population. Results:In total, 184 patients (median age, 59 years [range, 32-88 years]; 97 female [52.7%]) were included in this study, and 129 (70.1%) had stage II to III disease. Forty-five patients (24.5%) had ctDNA or imaging-confirmed recurrence. Of these 45 patients, 14 had radiographic recurrence with negative ctDNA, and 11 had concurrent ctDNA and imaging recurrence. Twenty of 45 patients had ctDNA positivity with negative imaging at first ctDNA positivity; 6 had reflex imaging that was positive for recurrence, and 14 continued with serial imaging and ctDNA monitoring. Ten of 14 patients had subsequent recurrent disease, 3 patients had a spontaneous clearance of ctDNA, and 1 patient remained imaging negative 7 months after positive ctDNA, after which she was lost to follow-up. Altogether, 11 of 20 patients with ctDNA recurrence without initial concurrent imaging recurrence had subsequent metastasectomy, and only 3 were disease-free at the cutoff date in April 2024, representing 1.6% of the surveilled population. Conclusions and Relevance:In this cohort study of patients with stage II to IV colorectal cancer who underwent curative-intent resection, the addition of serial tumor-informed ctDNA assay to the standard NCCN-recommended surveillance had limited clinical benefits. Additional prospective research is needed to clarify the value of ctDNA testing in the surveillance setting.

BACKGROUND:There is variation in the probability of nodal metastases from low-grade appendiceal adenocarcinomas, and the role of right colectomy is unclear. We aimed to define the prevalence and utility of lymphovascular invasion in predicting the risk of nodal metastases to help stratify patients who may benefit from right hemicolectomy. METHODS:Patients with nonmetastatic low-grade appendiceal adenocarcinomas were identified from the National Cancer Database (2010-2017). The primary outcome was probability of nodal metastases. Logistic regression was used to identify independent predictors of nodal metastases. A 4-tier risk model-the COH Composite Score-was calculated by assigning 1 point each for a high-risk feature (lymphovascular invasion, T3/T4 T stage, or nonmucinous histology). Survival analysis was performed using the Kaplan-Meier method. Multivariate Cox regression analysis was used to identify independent predictors of survival. RESULTS:A total of 1,303 patients with nonmetastatic low-grade appendiceal adenocarcinomas (64.2% mucinous) were identified. Of the 1,133 patients with known lymphovascular invasion status, 78 (6.9%) were lymphovascular invasion positive. In multivariate analysis, lymphovascular invasion was independently associated with nodal metastases (odds ratio, 8.68; P < .001). Overall accuracy of lymphovascular invasion in predicting nodal metastases was 86%. The COH Composite Score stratified patients in 4 categories with increasing risk of nodal metastases and incrementally worse survival. For patients with the COH Composite Score of 0 (12%), the nodal metastasis rate was 3.1%, and a right hemicolectomy in this group did not improve survival. CONCLUSION:The presence of lymphovascular invasion is strongly predictive of nodal metastases. Lymphovascular invasion as part of the COH Composite Score may help guide the extent of surgery in low-grade appendiceal adenocarcinomas.

Lynch syndrome is a hereditary colorectal cancer caused by mutations in DNA mismatch repair genes. Immune checkpoint therapies have shown promise in treating Lynch syndrome-associated cancers but can lead to immune-related adverse events, such as colitis. In this report, we present a severe case of immune-mediated colitis (IMC) induced by checkpoint inhibitors in a young patient with Lynch syndrome. This 20-year-old male with Lynch syndrome and a history of glioblastoma underwent dual checkpoint therapy, after initial treatment with systemic steroids. Despite this, his condition worsened, resulting in complications, such as toxic megacolon and small bowel obstruction. He was subjected to various treatments, including infliximab and vedolizumab, but ultimately required total abdominal colectomy with J-pouch creation. This case highlights the challenges of managing severe IMC in patients with Lynch syndrome. The patient’s suboptimal response to standard treatments and the development of complications emphasizes the need for a better understanding and alternative therapeutic options for IMC. This case also calls into question whether a subset of patients with IMC should be “treated to target,” even though the current standard of care for IMC is guided by symptom response, and if so, further research is necessary to identify potential therapeutic targets. Further research is also required to understand the mechanisms of IMC and develop effective treatment strategies tailored to patients with Lynch syndrome and immune-related adverse events.

Low anterior resection syndrome represents a clinical state wherein a constellation of gastrointestinal symptoms is a direct result of anatomic changes to the rectum. Patients who undergo operations to create a neorectum often develop persistent symptoms of increased frequency, urgency, diarrhea, and these symptoms are debilitating and impact patients' quality of life. A stepwise approach to treatment can improve many patients' symptoms with the most invasive options reserved for highly refractory symptoms.

BackgroundT4 colon cancers have been underrepresented in randomized trials comparing minimally invasive colectomy (MC) versus open colectomy (OC). Retrospective studies suggest improved survival with MC versus OC, but have not addressed the impact of tumor extent. MethodsUsing the National Cancer Database (NCDB), we analyzed patients undergoing colectomy for T4 colon adenocarcinoma from 2010 to 2014. Propensity score matching was performed between MC and OC patients. Tumor extent was defined by zones based on adjacent organ involvement. ResultsOf the 19 178 eligible patients, 6564 (34%) underwent MC. After matching, MC was associated with improved overall survival (hazard ratios: 0.71, 95% confidence interval: 0.67-0.76; median OS 59 vs. 42 months, p < 0.001). Compared to MC patients, those undergoing OC had: a higher margin positive rate (p = 0.009); lower median nodes examined (p < 0.001); a lower rate of adjuvant chemotherapy (p < 0.001); and a longer median time to chemotherapy (p < 0.001). Stratified survival analyses demonstrated that MC was associated with improved overall survival compared to OC in all zones except zone 3 and 4. ConclusionsCompared to OC, MC for T4 colon cancer is associated with improved oncologic outcomes when performed for zone 0-2 tumors. For, zone 3 and 4 tumors MC and OC have similar oncologic outcomes and patients should be cautiously selected.

Introduction: Existing literature on the safety of combined liver and colorectal resections for synchronous colorectal liver metastases is mixed. Using a retrospective review of our institutional data, we aimed to show that combined colorectal and liver resections for synchronous metastases is both feasible and safe in a quaternary center. Methods: A retrospective review of combined resections for synchronous colorectal liver metastases at a quaternary referral center from 2015 to 2020 was completed. Clinicopathologic and perioperative data was collected. Univariate and multivariable analyses were performed to identify risk factors for major postoperative complications. Results: One hundred one patients were identified, with 35 undergoing major liver resections ( >= 3 segments) and 66 undergoing minor liver resections. The vast majority of patients (94%) received neoadjuvant therapy. There was no difference in postoperative major complications (Clavien-Dindo grade 3+) between major and minor liver resections (23.9% versus 12.1%, P = 0.16). On univariate analysis, Albumin-Bilirubin (ALBI) score >1 (P < 0.05) was predictive of major complication. However, on multivariable regression analysis, no factor was associated with significantly increased odds of major complication. Conclusions: This work demonstrates that with thoughtful patient selection, combined resection for synchronous colorectal liver metastases can be safely performed at a quaternary referral center.

Purpose: Evidence-based models of cancer survivorship care are lacking. Such models should take into account the perspectives of all stakeholders. The purpose of this integrative review is to examine the current state of the literature on cancer survivorship care from the cancer survivor, the oncology care team, and the primary care team perspectives. Methods: Using defined inclusion and exclusion criteria, we conducted a literature search of PubMed, PsycINFO, CINAHL, and Scopus databases to identify relevant articles on the stakeholders’ perspectives on cancer survivorship care published between 2010 and 2021. We reviewed and abstracted eligible articles to synthesize findings. Results: A total of 21 studies were included in the review. Barriers to the receipt and provision of cancer survivorship care quality included challenges with communication, cancer care delivery, and knowledge. Conclusion: Persistent stakeholder-identified barriers continue to hinder the provision of quality cancer survivorship care. Improved communication, delivery of care, knowledge/information, and resources are needed to improve the quality of survivorship care. Novel models of cancer survivorship care that address the needs of survivors, oncology teams, and PCPs are needed.

Key Points Question Is serial analysis of circulating tumor DNA (ctDNA) associated with improved sensitivity and earlier detection of recurrence compared with standard imaging and evaluation of carcinoembryonic antigen (CEA) levels per National Comprehensive Cancer Network guidelines in patients with resected colorectal cancer? Findings In this cohort study of 48 patients with resected colorectal cancer, 15 had confirmed disease recurrence by imaging, of whom only 8 had a concurrent positive ctDNA finding. The combination of imaging and CEA measurement had better sensitivity compared with ctDNA in identifying disease recurrence (73.3% vs 53.3%). Meaning The findings of this cohort study suggest that ctDNA assay provides no definitive advantage compared with standard imaging and CEA measurement in the surveillance of patients with resected colorectal cancer.

Background: The need for gender parity within academic surgery has resulted in an analysis of the trends in female authorship in the American general surgery literature. Methods: Original articles from five American surgical journals from 1997, 2007, and 2017 were reviewed. Trends in the proportion of female authors were evaluated. Results: There was an incremental increase in female first authors over the three time periods (15% in 1997, 32.2% in 2007, and 52.7% in 2017; P < 0.001). The proportion of articles by female senior authors also increased over the study periods (18.7% in 1997, 28.8% in 2007, and 52.6% in 2017; P < 0.001). However, there were fewer female authors with basic science research publications than males (17.4% vs. 82.6%, P < 0.001). Conclusions: The academic productivity of female surgeons have increased over time likely due to an increase in the number of female academic surgeons in recent years. These findings are encouraging and demonstrate progress in female representation in surgery.

200 Background: Signatera (S) assay is a CLIA certified minimal residual disease ctDNA assay that has become widely used for monitoring of disease relapse in patients (pts) with resected colorectal cancer. In a longitudinal study, S+ recurrence (SR) occurred at median > 10 months (mo) prior to radiographic disease recurrence (RDR) in a prospective clinical trial. However, the radiographic surveillance frequency in that study was inadequate by US standard practices. Methods: We retrospectively evaluated, in a single center, the sensitivity (ss), specificity (sp), positive predictive value (ppv) and negative predictive value (npv) of S, CT/MRI imaging (Im), and CEA in curatively resected stage II, III, IV pts against True Disease Recurrence (TDR). We considered TDR as any SR, RDR confirmed by pathology, RDR associated with CEA elevation, or RDR with sequential growth on imaging or regression with chemo. S and CEA were performed Q3 mo x 2 yrs and then Q6 mo x 3 yrs. Im was performed Q3 mo x 2 yrs and then Q6 mo x 3 yrs in resected stage IV, Q6 mo x 2 yrs and then Q yr x 3 in stage III/high-risk stage II, and Q yr x 5 yrs in low-risk stage II. Results: 48 pts underwent curative resection (31 stage II-III, 17 stage IV). 15 patients recurred during surveillance (6 stage II-III, 9 stage IV). The ss, sp, ppv, and npv of S, Im, CEA, and (Im and/or CEA) are tabulated below. S, Im, CEA, and Im or CEA were positive for recurrence at the diagnosis of TDR in 8, 9, 4, and 12, respectively. S sensitivity was poor for lung recurrence with 5/6 pts with lung-only mets (3 confirmed by path) being negative by S at the time of Im relapse. S was negative at the time of CNS recurrence and liver recurrence in 2 pts. 2 Pts with negative imaging at SR developed subsequent liver metastases. 2 Pts, counted as TDR, were SR and remain NED without any therapy, by CEA and Im > 1.5 years from S positivity. Conclusions: S does not appear to provide definitive advantages as a surveillance strategy over standard Im frequency- when performed as per NCCN guidelines. Sensitivity of S is particularly poor for low volume lung-only disease recurrence.[Table: see text]

Background: PET imaging using radiolabeled immunoconstructs shows promise in cancer detection and in assessing tumor response to therapies. The authors report the first-in-human pilot study evaluating M5A, a humanized anti-carcinoembryonic antigen (CEA) monoclonal antibody (mAb), radiolabeled with 64Cu in patients with CEA-expressing malignancies. The purpose of this pilot study was to identify the preferred patient population for further evaluation of this agent in an expanded trial. Methods: Patients with CEA-expressing primary or metastatic cancer received 64Cu-DOTA-hT84.66-M5A with imaging performed at 1 and 2 days postinfusion. 64Cu-DOTA-hT84.66-M5A PET scan findings were correlated with CT, MRI, and/or FDG PET scans and with histopathologic findings from planned surgery or biopsy performed postscan. Results: Twenty patients received 64Cu-DOTA-hT84.66-M5A. Twelve patients demonstrated positive images, which were confirmed in 10 patients as tumor by standard-of-care (SOC) imaging, biopsy, or surgical findings. Four of the 8 patients with negative imaging were confirmed as true negative, with the remaining 4 patients having disease demonstrated by SOC imaging or surgery. All 5 patients with locally advanced rectal cancer underwent planned biopsy or surgery after 64Cu-DOTA-hT84.66-M5A imaging (4 patients imaged 6-8 weeks after completing neoadjuvant chemotherapy and radiation therapy) and demonstrated a high concordance between biopsy findings and 64Cu-DOTA-hT84.66-M5A PET scan results. Three patients demonstrated positive uptake at the primary site later confirmed by biopsy and at surgery as residual disease. Two patients with negative scans each demonstrated complete pathologic response. In 5 patients with medullary thyroid cancer, 64Cu-DOTA-hT84.66-M5A identified disease not seen on initial CT scans in 3 patients, later confirmed to be disease by subsequent surgery or MRI. Conclusions:64Cu-DOTA-hT84.66-M5A demonstrates promise in tumor detection, particularly in patients with locally advanced rectal cancer and medullary thyroid cancer. A successor trial in locally advanced rectal cancer has been initiated to further evaluate this agent's ability to define tumor extent before and assess disease response after neoadjuvant chemotherapy and radiotherapy. clinical trial.gov (NCT02293954).