I agree that perioperative FLOT is the preferred strategy for this Siewert II GEJ adenocarcinoma, particularly given the ESOPEC results and the high risk of systemic relapse in cT3N1 disease. I also agree that the patient's severe dysphagia, 14-kg weight loss and out-of-pocket funding make nutritional optimization and treatment feasibility critical considerations.
However, I would be cautious about describing FLOT as equivalent to CROSS followed by adjuvant nivolumab. CheckMate 577 demonstrated a disease-free survival benefit for adjuvant nivolumab in patients with residual pathological disease after neoadjuvant CROSS and surgery, but it did not directly compare this strategy with perioperative FLOT. Therefore, equivalence cannot be inferred.
I would also not give FLOT immediately to a severely dehydrated and malnourished patient who cannot swallow water. I would interpret the urgency as a reason to expedite nutritional and supportive intervention and commence systemic therapy as soon as he is sufficiently optimized, rather than proceeding directly to surgery.
Regarding neuropathy, I agree that CTCAE grading and functional assessment should be performed at baseline and before each cycle. Oxaliplatin should be modified according to the severity and persistence of neuropathy rather than automatically omitted. Finally, I would use a simple patient-reported toxicity diary and telephone/WhatsApp nurse follow-up between cycles to monitor fever, diarrhoea, vomiting, oral intake, pain, weight and neuropathy. This seems particularly appropriate for a patient travelling from Ile-Ife and funding treatment himself.
Overall, I would favour perioperative FLOT with individualized oxaliplatin management, aggressive nutritional optimization, structured toxicity monitoring and expedited biomarker testing, while avoiding the assumption that pending HER2/PD-L1 results should automatically delay chemotherapy or that a positive PD-L1 result necessarily mandates immunotherapy in this perioperative setting.
However, I would be cautious about describing FLOT as equivalent to CROSS followed by adjuvant nivolumab. CheckMate 577 demonstrated a disease-free survival benefit for adjuvant nivolumab in patients with residual pathological disease after neoadjuvant CROSS and surgery, but it did not directly compare this strategy with perioperative FLOT. Therefore, equivalence cannot be inferred.
I would also not give FLOT immediately to a severely dehydrated and malnourished patient who cannot swallow water. I would interpret the urgency as a reason to expedite nutritional and supportive intervention and commence systemic therapy as soon as he is sufficiently optimized, rather than proceeding directly to surgery.
Regarding neuropathy, I agree that CTCAE grading and functional assessment should be performed at baseline and before each cycle. Oxaliplatin should be modified according to the severity and persistence of neuropathy rather than automatically omitted. Finally, I would use a simple patient-reported toxicity diary and telephone/WhatsApp nurse follow-up between cycles to monitor fever, diarrhoea, vomiting, oral intake, pain, weight and neuropathy. This seems particularly appropriate for a patient travelling from Ile-Ife and funding treatment himself.
Overall, I would favour perioperative FLOT with individualized oxaliplatin management, aggressive nutritional optimization, structured toxicity monitoring and expedited biomarker testing, while avoiding the assumption that pending HER2/PD-L1 results should automatically delay chemotherapy or that a positive PD-L1 result necessarily mandates immunotherapy in this perioperative setting.