Total versus subtotal gastrectomy following neoadjuvant flot chemotherapy for distal diffuse gastric adenocarcinoma: an international cohort study

Sivakumar, J; Wong, DJ; Hall, K; Lee, MM; Duong, CP; Watson, DI; Donohoe, CL; Bright, T; Aly, A; Chan, K; Chan, DL; Merrett, N; Gananadha, S; Lam, YH; Kanhere, H; Smithers, B; Bozin, M; Read, M; Mori, K; Johnson, MA; Wong, E; Martin, SA; Ooi, G; Al-Habbal, Y; Liew, CH; Bohmer, R; Daruwalla, J; Ballal, M; Ranjan, R; MacCormick, AD; Pattison, S; Evennett, N; Robertson, J; Tan, J; Gordon, A; Bann, S; Samarasam, I; Gurunathan, R; So, J; Yeung, J; Ferri, L; Griffiths, EA; Phillips, AW; Markar, SR; Chan, D; Murphy, T; Reynolds, J; Nilsson, M; Piessen, G; Wijnhoven, B; van Hillegersberg, R; van Berge Henegouwen, MI; Lombardi, PM; SPACE-FLOT Investigators; Liu, DS

Author(s): Sivakumar, J; Wong, DJ; Hall, K; Lee, MM; Duong, CP; Watson, DI; Donohoe, CL; Bright, T; Aly, A; Chan, K; Chan, DL; Merrett, N; Gananadha, S; Lam, YH; Kanhere, H; Smithers, B; Bozin, M; Read, M; Mori, K; Johnson, MA; Wong, E; Martin, SA; Ooi, G; Al-Habbal, Y; Liew, CH; Bohmer, R; Daruwalla, J; Ballal, M; Ranjan, R; MacCormick, AD; Pattison, S; Evennett, N; Robertson, J; Tan, J; Gordon, A; Bann, S; Samarasam, I; Gurunathan, R; So, J; Yeung, J; Ferri, L; Griffiths, EA; Phillips, AW; Markar, SR; Chan, D; Murphy, T; Reynolds, J; Nilsson, M; Piessen, G; Wijnhoven, B; van Hillegersberg, R; van Berge Henegouwen, MI; Lombardi, PM; SPACE-FLOT Investigators; Liu, DS;
Details: Publication Year 2026-07,Volume 29,Issue #4,Page 827-840
Journal Title: Gastric Cancer
Publication Type: Research article
Abstract: OBJECTIVE: 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. BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: In appropriately selected patients, SG has comparable oncological efficacy to TG with lower surgical morbidity for distal diffuse gastric adenocarcinoma post FLOT chemotherapy. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10120-026-01746-7.
Publisher: Springer Nature
Keywords: Diffuse gastric cancer; Gastrectomy
Department(s): Surgical Oncology
Publisher's Version: https://doi.org/10.1007/s10120-026-01746-7
Open Access at Publisher's Site: https://doi.org/10.1007/s10120-026-01746-7
Terms of Use/Rights Notice: Refer to copyright notice on published article.

Creation Date: 2026-05-21 11:17:47

Last Modified: 2026-07-14 12:09:29