Total versus subtotal gastrectomy following neoadjuvant flot chemotherapy for distal diffuse gastric adenocarcinoma: an international cohort study
To compare perioperative, oncological, and survival outcomes of total gastrectomy (TG) versus subtotal gastrectomy (SG) in patients with locally advanced distal diffuse gastric adenocarcinoma treated with perioperative 5-fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT) chemotherapy. Diffuse distal gastric cancer is characterized by infiltrative growth patterns and early nodal metastasis. Whilst radical resection remains the cornerstone of curative treatment, the optimal extent of surgery with TG or SG, remains debated. This international multicenter cohort study analyzed data from patients with histologically confirmed diffuse gastric adenocarcinoma, located > 5 cm from the gastroesophageal junction. Endpoints included surgical margin status, nodal yield, perioperative morbidity, recurrence patterns, time-to-recurrence (TTR), and overall survival (OS). Outcomes were compared using multivariate analyses. In total, 188 (39.0%) patients underwent TG and 294 (61.0%) underwent SG. After multivariable adjustment, surgical margin positivity was comparable between groups (OR 1.28, 95%CI 0.70–2.34). TG was associated with higher total nodal yield [Median(IQR) 31 (23–41) vs 28 (18–36), p < 0.001] but not metastatic nodal yield [Median(IQR) 1 (0–8) vs 1 (0–6), p = 0.065]. TG had longer operative time [Mean(SD) 318.5 (93.6) vs 301.0 (105.2) minutes, p = 0.040], extended hospital stay [Median(IQR) 8.5 (7.0–11.0) vs 7.0 (6.0–9.0), p < 0.001], and more complications (OR 1.55, 95%CI 1.05–2.30). Recurrence patterns and adjusted TTR (HR 1.29, 95%CI 0.95–1.75) were similar between groups. Adjusted OS was superior in the SG group (HR 1.69, 95%CI 1.20–2.38). In appropriately selected patients, SG has comparable oncological efficacy to TG with lower surgical morbidity for distal diffuse gastric adenocarcinoma post FLOT chemotherapy.
Authors
- Geraldine Ooi (ORCID: https://orcid.org/0000-0002-4540-408X)
- David I. Watson (ORCID: https://orcid.org/0000-0002-7683-2693)
- Harsh Kanhere (ORCID: https://orcid.org/0000-0002-0181-6461)
- Matthew Read (ORCID: https://orcid.org/0000-0001-7178-1973)
- Nicholas Evennett
- Sivakumar Gananadha (ORCID: https://orcid.org/0000-0003-4603-089X)
- Michael Bozin (ORCID: https://orcid.org/0000-0001-8483-0674)
- Ahmad Aly (ORCID: https://orcid.org/0000-0001-8181-7386)
- Margaret M. Lee
- Mo Ballal
- Rukshan Ranjan
- Andrew D. MacCormick (ORCID: https://orcid.org/0000-0002-6255-4792)
- Jonathan Sivakumar (ORCID: https://orcid.org/0000-0003-1756-5780)
- Enoch Wong (ORCID: https://orcid.org/0000-0002-2983-4768)
- Inian Samarasam (ORCID: https://orcid.org/0000-0002-7800-9318)
- Ramesh Gurunathan
- Jurstine Daruwalla (ORCID: https://orcid.org/0000-0002-2615-1750)
- Ewen A. Griffiths (ORCID: https://orcid.org/0000-0001-6630-3547)
- Tim Bright (ORCID: https://orcid.org/0000-0003-3700-5262)
- Sharon Pattison (ORCID: https://orcid.org/0000-0003-2188-3423)
- Alexander W. Phillips (ORCID: https://orcid.org/0000-0001-9826-3949)
- B M Smithers
- Yick Ho Lam (ORCID: https://orcid.org/0000-0002-6924-4201)
- Robert Böhmer
- Yahya Al-Habbal
- Chon Hann Liew
- Reynolds
- S Bann
- Katheryn Hall
- James Tan
- Neil Merrett
- SPACE-FLOT Investigators
- Kevin Chan
- Sheraz R. Markar
- Thomas Murphy
- Bas Wijnhoven
- Guillaume Piessen
- Alexandra Gordon
- David L. Chan
- Sarah A. Martin
- Krinal Mori
- Darren J. Wong
- Jimmy So
- Richard van Hillegersberg
- David S. Liu
- Jason Robertson
- Mary-Ann Johnson
- Jonathan Yeung
- Mark I. van Berge Henegouwen
- Claire L. Donohoe
- Magnus Nilsson
- Lorenzo Ferri
- Pietro M. Lombardi
- Cuong P. Duong
Institutions
- Camden and Campbelltown Hospitals (AU)
- The University of Sydney (AU)
- Royal Adelaide Hospital (AU)
- Karolinska University Hospital (SE)
- Box Hill Hospital (AU)
- University of Auckland (NZ)
- The University of Melbourne (AU)
- National University of Singapore (SG)
- Flinders University (AU)
- Christian Medical College, Vellore (IN)
- Queen Elizabeth Hospital Birmingham (GB)
- Royal Brisbane and Women's Hospital (AU)
- Launceston General Hospital (AU)
- Royal North Shore Hospital (AU)
- Middlemore Hospital (NZ)
- Austin Hospital (AU)
- Royal Victoria Infirmary (GB)
- Peter MacCallum Cancer Centre (AU)
- Bankstown Lidcombe Hospital (AU)
- Fiona Stanley Hospital (AU)
- Wellington Hospital (NZ)
- Monash Medical Centre (AU)
- Auckland City Hospital (NZ)
- University Kebangsaan Malaysia Medical Centre (MY)
- McGill University Health Centre (CA)
- Lyell McEwin Hospital (AU)
- Nuffield Orthopaedic Centre (GB)
- Princess Alexandra Hospital (AU)
- Toronto General Hospital (CA)
- Erasmus MC (NL)
- North Shore Hospital (NZ)
- Christchurch Hospital (NZ)
- Northern Hospital (AU)
- Flinders Medical Centre (AU)
- Canberra Hospital (AU)
- Royal Hobart Hospital (AU)
- University Medical Center Utrecht (NL)
- St Vincent's Hospital Melbourne (AU)
- Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda (IT)
- Mercy University Hospital (IE)
- Palmerston North Hospital (NZ)
- National University Cancer Institute, Singapore (SG)
- Christian Medical College (IN)
- Footscray Hospital (AU)
- Northern Sydney Local Health District (AU)
- Southern District Health Board (NZ)
- Institute of Immunology (HR)
- National University Hospital (SG)
- Bendigo Health (AU)
- Amsterdam University Medical Centers (NL)
- St. James's Hospital (IE)
- Austin Health (AU)
- University Hospitals Plymouth NHS Trust (GB)
- Monash University (AU)
- Western Sydney University (AU)
- University of Birmingham (GB)
- University of Otago (NZ)
Publication Details
- Journal
- Gastric Cancer
- Published
- 2026-04-27
- DOI
- https://doi.org/10.1007/s10120-026-01746-7
- Primary Topic
- Gastric Cancer Management and Outcomes
- Type
- article
- Field-Weighted Citation Impact
- 0.00
Funders
- University of Melbourne