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

Abstract

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.

引言 緩和性化療是預後差的不可切除局部晚期胃癌的標準治療。患者在接受誘導氟尿嘧啶、亞葉酸鈣、奧沙利鉑及多西他賽（FLOT）治療後嘗試進行轉化手術再配合FLOT是一個多模態治療方式，我們評估這治療方式在香港某所三級醫院的安全性及效用。

方法 我們對在2017至2023年間接受誘導FLOT及嘗試轉化手術治療的晚期胃癌患者的醫療紀錄進行回顧性研究。適合在化療後進行手術的患者接受切除，然後進行另外四個療程的輔助FLOT治療。我們分析了安全性、治療結果及存活的預測因素。

結果 本研究包括31名患者（25名男性，年齡中位數 = 63歲）。隨訪時間中位數為22.0個月。在接受誘導FLOT治療後的疾病控制率為87.1%（n = 27）。共有23名患者（74.2%）接受了轉化手術，當中20名達至完全切除（R0）。與不能接受手術的患者相比，接受了轉化手術的患者的整體存活時間及無事件存活時間均較長。多變量分析識別出沒有接受轉化手術、嗜中性白血球與淋巴球比例（NLR）較高、血清白蛋白水平<35 g/L、體重指標（BMI）<23 kg/m2及臨床第N3期胃癌的整體存活較差。本研究沒有發生與治療相關的死亡事件。毒性≥3的發生率為51.6%，當中以嗜中性白血球減少症（29.0%）及嗜中性白血球減少症合併發熱（12.9%）最為常見。

結論 誘導FLOT治療達至高轉化率及完全切除，為不可切除胃癌患者提供了有利的存活獲益及可接受的安全性。結合生物標記驅動治療的前瞻性試驗可進一步改善病理完全緩解率及存活。