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The FLOT4 trial compared perioperative FLOT chemotherapy with the older ECF/ECX approach in patients with resectable gastric or gastro-oesophageal junction adenocarcinoma. FLOT combines fluorouracil, leucovorin, oxaliplatin and docetaxel and was designed to improve systemic disease control before and after surgery. The study demonstrated a clinically meaningful benefit for FLOT, helping establish it as a leading perioperative chemotherapy strategy for fit patients with resectable, locally advanced gastric or gastro-oesophageal junction cancer. The trial also reinforced an important reality of upper GI surgery: surgery alone is rarely sufficient when the risk of micrometastatic disease is substantial. For surgeons, the implications extend into multidisciplinary planning. The quality of the operation, timing of chemotherapy, nutritional optimization and management of treatment-related toxicity all influence whether patients receive the intended perioperative pathway. Close coordination between surgery, medical oncology, radiology, nutrition and anaesthesia is therefore essential. FLOT4 is a good example of evidence changing surgical practice without changing the core role of surgery itself. Instead, surgery becomes one component of a planned oncological sequence designed to maximize the chance of cure while maintaining fitness for definitive resection.
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The FLOT4 trial compared perioperative FLOT chemotherapy with the older ECF/ECX approach in patients with resectable gastric or gastro-oesophageal junction adenocarcinoma. FLOT combines fluorouracil, leucovorin, oxaliplatin and docetaxel and was designed to improve systemic disease control before and after surgery. The study demonstrated a clinically meaningful benefit for FLOT, helping establish it as a leading perioperative chemotherapy strategy for fit patients with resectable, locally advanced gastric or gastro-oesophageal junction cancer. The trial also reinforced an important reality of upper GI surgery: surgery alone is rarely sufficient when the risk of micrometastatic disease is substantial. For surgeons, the implications extend into multidisciplinary planning. The quality of the operation, timing of chemotherapy, nutritional optimization and management of treatment-related toxicity all influence whether patients receive the intended perioperative pathway. Close coordination between surgery, medical oncology, radiology, nutrition and anaesthesia is therefore essential. FLOT4 is a good example of evidence changing surgical practice without changing the core role of surgery itself. Instead, surgery becomes one component of a planned oncological sequence designed to maximize the chance of cure while maintaining fitness for definitive resection.
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