Too FLOT to handle.

Top Line: Perioperative FLOT is cemented as the current standard of care for locally-advanced gastric cancer, but is the post-op component really needed..?

The Study: After all, pre-op FLOT alone has never been prospectively pitted against the established peri-op approach, and only roughly half of patients end up being eligible to start post-op chemo. In fact, a recent NCDB analysis reported equivalent survival outcomes whether or not a patient proceeded with post-op chemo. This study started with a retrospective look at 353 patients planned for perioperative fluorouracil-based chemo for gastric cancer at one of two Chinese medical centers between 2006-2017. After propensity score matching, overall survival at 3 years was better for those receiving the post-op component versus those not (60% v 49%). Even with matching, this screams bias in favor of those well enough to get chemo. More interesting was that the ratio of lymph nodes involved to lymph nodes evaluated was a standout among over a dozen clinicopathologic variables assessed for an interaction with benefit from post-op chemo. When plotted, a lymph node ratio <9% versus ≥9% best dichotomized benefit such that survival with and without post-op chemo was 74% v 71%, respectively, when the ratio was <9% (n=141) and 47% v 22% when ≥9% (n=132). What’s more, this was externally validated among a cohort of 109 patients treated in the US and Italy between 2006-2013 where overall survival at 3 years was clearly better with post-op chemo among those with a lymph node ratio ≥9% (53% v 26%).

TBL: It’s time to evaluate pre-op FLOT alone for patients with no to low nodal burden at time of surgery for initially locally-advanced gastric cancer. | Lin, JAMA Netw Open 2022