Conversion Surgery in Advanced Unresectable Gastric Cancer After Induction Fluorouracil Plus Leucovorin, Oxaliplatin, and Docetaxel

Introduction: Palliative chemotherapy is the standard treatment for unresectable locally advanced gastric cancer (GC) with poor prognosis. We evaluated the safety and efficacy of a multimodality approach with induction fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT) followed by attempted conversion surgery with additional FLOT at a tertiary hospital in Hong Kong. Methods: Medical records of advanced GC patients treated with induction FLOT and attempted conversion surgery between 2017 and 2023 were reviewed. Patients suitable for surgery after chemotherapy underwent resection, followed by adjuvant FLOT for another four cycles. Safety, treatment outcomes and predictive factors for survival were analysed. Results: Thirty-one patients (25 males, median age = 63 years) were included. The median follow-up time was 22.0 months. Disease control rate after induction FLOT was 87.1% (n = 27). Conversion surgery was performed in 23 patients (74.2%), with 20 achieving R0 resection. Patients with conversion surgery had longer median overall survival (OS) and event-free survival than those who could not undergo surgery. Multivariable analysis identified no conversion surgery, higher neutrophil-to-lymphocyte ratio, serum albumin level <35 g/L, body mass index <23 kg/m2, and clinical nodal stage N3 disease with a worse OS. No treatment-related deaths occurred. The incidence of grade =3 toxicities was 51.6%, with neutropenia (29.0%) and febrile neutropenia (12.9%) being most common. Conclusion: Induction FLOT achieved high conversion rates and R0 resections, offering a favourable survival benefit and acceptable safety in unresectable GC. Prospective trials incorporating biomarker-driven therapy may further improve pathological complete response rates and survival.