FLOT Neoadjuvant Treatment for Oesophageal Adenocarcinoma

FLOT Regimen Components and Schedule

The American Society of Clinical Oncology recognizes FLOT as the standard of care for perioperative chemotherapy in oesophageal adenocarcinoma, consisting of docetaxel, oxaliplatin, leucovorin, and fluorouracil 1, 2
The FLOT regimen includes fluorouracil 2,600 mg/m² as 24-hour infusion on day 1, with each cycle administered every 2 weeks 1, 2, 3, 4

The standard duration of FLOT neoadjuvant treatment is 4 preoperative cycles (8 weeks total) before surgery, with an additional 4 postoperative cycles typically administered 1, 2, 3

The ASCO Expert Panel recognizes FLOT as the standard of care for perioperative chemotherapy in oesophageal adenocarcinoma, with superior overall survival compared to previous regimens 1, 2
FLOT shows better pathologic response rates compared to ECX in patients with locally advanced gastric cancer including oesophagogastric junction adenocarcinomas 5

Where FLOT is not available or feasible, the Expert Panel suggests cisplatin and fluorouracil (CF) or a similar platinum-based regimen, with 2 three-weekly cycles of cisplatin and fluorouracil 1, 2

For bulky tumors with proximal extension, preoperative chemoradiotherapy may be preferred, while for smaller tumors at the gastroesophageal junction, perioperative chemotherapy (FLOT) may be preferred 3, 4
Even after complete clinical tumor response to preoperative chemotherapy, patients with resectable oesophageal adenocarcinoma should proceed to surgery 6, 7

Adequate quality and extent of surgery following neoadjuvant therapy should include clear surgical margins and adequate nodal dissection with a goal of obtaining at least 16-18 and preferably 20 lymph nodes 3, 4

The standard FLOT perioperative regimen, as established by the FLOT4-AIO trial, consists of a 4+4 cycle approach, with 4 preoperative and 4 postoperative cycles of FLOT, representing a total of 8 cycles of perioperative chemotherapy, according to the European Society for Medical Oncology 8
The FLOT4-AIO trial demonstrated superior overall survival with 4+4 cycles of FLOT compared to 3+3 cycles of ECF/ECX, with a median overall survival of 50 months versus 35 months, and a hazard ratio of 0.77 (P = 0.012), as recommended by the European Society for Medical Oncology 8