The Study: Before FLOT4, MAGIC established perioperative ECF/ECX as the standard regimen for resectable gastric cancer. However, the preliminary results of FLOT4 blew MAGIC out of the water. As elucidated in the manuscript, eligible patients had cT2+ and/or cN1+ gastric / GEJ adenocarcinoma with a pretty even distribution: 24% Siewert I, 33% Siewert II/III, and 44% gastric tumors. Over two-thirds were cT3 and 80% were node-positive. Epirubicin, cisplatin, and fluorouracil or capecitabine were given every 3 weeks for three cycles before and after surgery. Fluorouracil, leucovorin, oxaliplatin, and docetaxel were given every 2 weeks for 4 cycles before and after surgery. Roughly 90% in each group completed neoadjuvant therapy. Importantly, D2 node dissections were required. The FLOT group had a higher rate of R0 resections (85%) compared to the ECF group (78%). And median survival with FLOT (50 months) was way higher than with ECF (35 months,) as was the hefty 10% absolute improvement in survival that was maintained across patient subsets through years 2, 3, and 5. Given the strong representation of GEJ tumors, one wonders how chemoradiation would fare against—or why not with? (we see you, TNT)—FLOT. The ongoing ESOPEC, basically FLOT vs CROSS, should answer that. In the meantime, good luck arguing your side at tumor board (cue Bran Stark stare).
Bottom Line: Perioperative FLOT is still superior to ECF/ECX for resectable gastric and GEJ adenocarcinomas. | Al-Battran, Lancet 2019