• Salah-Eddin Al-Batran, Nils Homann, Claudia Pauligk, Thorsten O Goetze, Johannes Meiler, Stefan Kasper, Hans-Georg Kopp, Frank Mayer, Georg Martin Haag, Kim Luley, Udo Lindig, Wolff Schmiegel, Michael Pohl, Jan Stoehlmacher, Gunnar Folprecht, Stephan Probst, Nicole Prasnikar, Wolfgang Fischbach, Rolf Mahlberg, Jörg Trojan, Michael Koenigsmann, Uwe M Martens, Peter Thuss-Patience, Matthias Egger, Andreas Block, Volker Heinemann, Gerald Illerhaus, Markus Moehler, Michael Schenk, Frank Kullmann, Dirk M Behringer, Michael Heike, Daniel Pink, Christian Teschendorf, Carmen Löhr, Helga Bernhard, Gunter Schuch, Volker Rethwisch, Ludwig Fischer von Weikersthal, Jörg T Hartmann, Michael Kneba, Severin Daum, Karsten Schulmann, Jörg Weniger, Sebastian Belle, Timo Gaiser, Fuat S Oduncu, Martina Güntner, Wael Hozaeel, Alexander Reichart, Elke Jäger, Thomas Kraus, Stefan Mönig, Wolf O Bechstein, Martin Schuler, Harald Schmalenberg, Ralf D Hofheinz, and FLOT4-AIO Investigators.
• Institute of Clinical Cancer Research, Krankenhaus Nordwest, UCT-University Cancer Center, Frankfurt, Germany; IKF Klinische Krebsforschung GmbH am Krankenhaus Nordwest, Frankfurt, Germany. Electronic address: albatran@ikf-khnw.de.
• Lancet. 2019 May 11; 393 (10184): 1948-1957.

BackgroundDocetaxel-based chemotherapy is effective in metastatic gastric and gastro-oesophageal junction adenocarcinoma. This study reports on the safety and efficacy of the docetaxel-based triplet FLOT (fluorouracil plus leucovorin, oxaliplatin and docetaxel) as a perioperative therapy for patients with locally advanced, resectable tumours.MethodsIn this controlled, open-label, phase 2/3 trial, we randomly assigned 716 patients with histologically-confirmed advanced clinical stage cT2 or higher or nodal positive stage (cN+), or both, resectable tumours, with no evidence of distant metastases, via central interactive web-based-response system, to receive either three pre-operative and three postoperative 3-week cycles of 50 mg/m2 epirubicin and 60 mg/m2 cisplatin on day 1 plus either 200 mg/m2 fluorouracil as continuous intravenous infusion or 1250 mg/m2 capecitabine orally on days 1 to 21 (ECF/ECX; control group) or four preoperative and four postoperative 2-week cycles of 50 mg/m2 docetaxel, 85 mg/m2 oxaliplatin, 200 mg/m2 leucovorin and 2600 mg/m2 fluorouracil as 24-h infusion on day 1 (FLOT; experimental group). The primary outcome of the trial was overall survival (superiority) analysed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01216644.FindingsBetween Aug 8, 2010, and Feb 10, 2015, 716 patients were randomly assigned to treatment in 38 German hospitals or with practice-based oncologists. 360 patients were assigned to ECF/ECX and 356 patients to FLOT. Overall survival was increased in the FLOT group compared with the ECF/ECX group (hazard ratio [HR] 0·77; 95% confidence interval [CI; 0.63 to 0·94]; median overall survival, 50 months [38·33 to not reached] vs 35 months [27·35 to 46·26]). The number of patients with related serious adverse events (including those occurring during hospital stay for surgery) was similar in the two groups (96 [27%] in the ECF/ECX group vs 97 [27%] in the FLOT group), as was the number of toxic deaths (two [<1%] in both groups). Hospitalisation for toxicity occurred in 94 patients (26%) in the ECF/ECX group and 89 patients (25%) in the FLOT group.InterpretationIn locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma, perioperative FLOT improved overall survival compared with perioperative ECF/ECX.FundingThe German Cancer Aid (Deutsche Krebshilfe), Sanofi-Aventis, Chugai, and Stiftung Leben mit Krebs Foundation.Copyright © 2019 Elsevier Ltd. All rights reserved.

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