Dr Aje, I agree that perioperative FLOT is preferred for this Siewert II GEJ adenocarcinoma, given the ESOPEC results and high systemic relapse risk in cT3N1 disease. His severe dysphagia, 14-kg weight loss and out-of-pocket funding also make nutritional optimization and treatment feasibility important.
I would also avoid giving FLOT before stabilizing his severe malnutrition and dehydration. The priority is nutritional/supportive care, followed by systemic therapy once he is sufficiently optimized rather than immediate surgery.
Overall, I favour perioperative FLOT with nutritional optimization, individualized oxaliplatin management, structured toxicity monitoring and expedited biomarker testing, without unnecessarily delaying chemotherapy while awaiting HER2/MMR/PD-L1 results.
I would also avoid giving FLOT before stabilizing his severe malnutrition and dehydration. The priority is nutritional/supportive care, followed by systemic therapy once he is sufficiently optimized rather than immediate surgery.
Overall, I favour perioperative FLOT with nutritional optimization, individualized oxaliplatin management, structured toxicity monitoring and expedited biomarker testing, without unnecessarily delaying chemotherapy while awaiting HER2/MMR/PD-L1 results.