Surgical Considerations With IO In Perioperative GC/GEJC

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The addition of immunotherapy to perioperative FLOT does not appear to significantly complicate surgical procedures or patient eligibility for surgery. Although surgeons have limited direct experience with the specific D-FLOT regimen in standard practice, existing experience with immunotherapy in other tumor types suggests that no major surgical complications should be expected. The FLOT backbone itself is already a challenging regimen with known toxicity profiles, but administering it for the limited neoadjuvant period has historically not presented insurmountable surgical challenges. The MATTERHORN trial data support this perspective, showing no indication that adding durvalumab to FLOT interfered with patients’ ability to proceed to surgery as planned.

Patient concerns about whether enhanced tumor response rates and downstaging might allow for less extensive surgical procedures represent common questions in clinical practice. However, the trial data suggest this may not significantly alter surgical approaches, as R0 resection rates remained identical between treatment arms. Surgeons typically plan operations based on original imaging to ensure adequate margins, particularly given the standard requirement for 5-cm margins in normal tissue for gastric cancer (GC) surgery. Although some specialized centers are exploring procedures like proximal gastrectomy with double tract reconstruction as alternatives to total gastrectomy for selected proximal tumors, the trial results do not provide clear evidence for routine surgical de-escalation.

The surgical approach remains focused on achieving optimal oncologic outcomes through complete resection with negative margins. The enhanced pathologic responses observed with D-FLOT, although encouraging for overall prognosis, do not necessarily translate to opportunities for less extensive surgery. GC surgery remains a complex, major operation requiring specialized expertise regardless of the perioperative therapy received. The consistency of R0 resection rates between arms in MATTERHORN reinforces that surgical standards should remain unchanged, with the primary benefit of enhanced perioperative therapy being improved long-term outcomes rather than reduced surgical complexity or extent.