When new therapies arrive, we should think more: The unseen challenges of immunotherapy-induced remodeling

Figure 2 Surgical risk stratification algorithm. Evidence-based decision pathway for resection planning in immune checkpoint inhibitor-treated patients. High-risk criteria (red) include: > 12 immune checkpoint inhibitor cycles, initial tumor > 5 cm, or radiologic fibrosis signs (loss of mural stratification, SUVmax 2-4 on fluorodeoxyglucose-positron emission tomography, or elastography stiffness > 8 kPa). Mandatory intraoperative indocyanine green perfusion assessment guides anastomotic safety: Segments with perfusion delay > 30 seconds or bursting pressure < 25 mmHg require diversion. Prophylactic stoma is indicated when ≥ 2 major risk factors coexist. ICI: Immune checkpoint inhibitor; ICG: Indocyanine green.