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

Jonathan Sivakumar; Darren J. Wong; Katheryn Hall; Margaret M. Lee; Cuong P. Duong; David I. Watson; Claire L. Donohoe; Tim Bright; Ahmad Aly; Kevin Chan; David L. Chan; Neil Merrett; Sivakumar Gananadha; Yick Ho Lam; Harsh Kanhere; BMark Smithers; Michael Bozin; Matthew Read; Krinal Mori; Mary Ann Johnson; Enoch Wong; Sarah A. Martin; Geraldine Ooi; Yahya Al-Habbal; Chon Hann Liew; Robert Bohmer; Jurstine Daruwalla; Mo Ballal; Rukshan Ranjan; Andrew D. MacCormick; Sharon Pattison; Nicholas Evennett; Jason Robertson; James Tan; Alexandra Gordon; Simon Bann; Inian Samarasam; Ramesh Gurunathan; Jimmy So; Jonathan Yeung; Lorenzo Ferri; Ewen A. Griffiths; Alexander W. Phillips; Sheraz R. Markar; David Chan; Thomas Murphy; John Reynolds; Magnus Nilsson; Guillaume Piessen; Bas Wijnhoven; Richard Van Hillegersberg; Mark I. van Berge Henegouwen; Pietro M. Lombardi; David S. Liu; SPACE-FLOT Investigators

doi:10.1007/s10120-026-01746-7

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

Jonathan Sivakumar
, Darren J. Wong
, Katheryn Hall
, Margaret M. Lee
, Cuong P. Duong
, David I. Watson
, Claire L. Donohoe
, Tim Bright
, Ahmad Aly
, Kevin Chan
, David L. Chan
, Neil Merrett
, Sivakumar Gananadha
, Yick Ho Lam
, Harsh Kanhere
, BMark Smithers
, Michael Bozin
, Matthew Read
, Krinal Mori
, Mary Ann Johnson

Enoch Wong, Sarah A. Martin, Geraldine Ooi, Yahya Al-Habbal, Chon Hann Liew, Robert Bohmer, Jurstine Daruwalla, Mo Ballal, Rukshan Ranjan, Andrew D. MacCormick, Sharon Pattison, Nicholas Evennett, Jason Robertson, James Tan, Alexandra Gordon, Simon Bann, Inian Samarasam, Ramesh Gurunathan, Jimmy So, Jonathan Yeung, Lorenzo Ferri, Ewen A. Griffiths, Alexander W. Phillips, Sheraz R. Markar, David Chan, Thomas Murphy, John Reynolds, Magnus Nilsson, Guillaume Piessen, Bas Wijnhoven, Richard Van Hillegersberg, Mark I. van Berge Henegouwen, Pietro M. Lombardi, David S. Liu, SPACE-FLOT Investigators

School of Medicine

Peter Maccallum Cancer Centre
University of Melbourne
Austin Health
Box Hill Hospital
Flinders University
Flinders Medical Centre
St. James’s Hospital
Royal Brisbane and Women's Hospital
Royal Northshore Hospital
The University of Sydney
Bankstown-Lidcombe Hospital
Canberra Hospital
Lyell McEwin Hospital
Royal Adelaide Hospital
University of Queensland
St. Vincent's Hospital Melbourne
Northern Health
Monash Medical Centre
Monash University
Western Health
Bendigo Health
Royal Hobart Hospital
Launceston General Hospital
Fiona Standley Hospital
Christchurch Hospital
Middlemore Hospital
The University of Auckland
Te Whatu Ora Te Toka Tumai
University of Otago
Auckland City Hospital
North Shore Hospital
Palmerston North Hospital
Wellington Regional Hospital
Christian Medical College
Cengild G.I. Medical Center
National University Hospital
National University Cancer Institute
National University of Singapore
Toronto General Hospital
McGill University
University of Birmingham
Queen Elizabeth Hospital Birmingham
Newcastle upon Tyne Hospitals NHS Foundation Trust
University of Oxford
University Hospitals Plymouth NHS Trust
Mercy University Hospital
Karolinska Institutet
Lille University Hospital
Erasmus University Rotterdam
Utrecht University
Amsterdam UMC
Niguarda Cancer Center

Research output: Contribution to journal › Article › peer-review

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.

Original language	English
Pages (from-to)	827-840
Number of pages	14
Journal	Gastric Cancer
Volume	29
Issue number	4
DOIs	https://doi.org/10.1007/s10120-026-01746-7
Publication status	Published - Jul 2026

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

SDG 3 Good Health and Well-being

Keywords

Diffuse gastric cancer
Gastrectomy

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Sivakumar, J., Wong, D. J., Hall, K., Lee, M. M., Duong, C. P., Watson, D. I., Donohoe, C. L., Bright, T., Aly, A., Chan, K., Chan, D. L., Merrett, N., Gananadha, S., Lam, Y. H., Kanhere, H., Smithers, BM., Bozin, M., Read, M., Mori, K., ... SPACE-FLOT Investigators (2026). Total versus subtotal gastrectomy following neoadjuvant flot chemotherapy for distal diffuse gastric adenocarcinoma: an international cohort study. Gastric Cancer, 29(4), 827-840. https://doi.org/10.1007/s10120-026-01746-7

@article{b65f150feaeb4757b38468eb68155c6a,

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

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{\textendash}2.34). TG was associated with higher total nodal yield [Median(IQR) 31 (23{\textendash}41) vs 28 (18{\textendash}36), p < 0.001] but not metastatic nodal yield [Median(IQR) 1 (0{\textendash}8) vs 1 (0{\textendash}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{\textendash}11.0) vs 7.0 (6.0{\textendash}9.0), p < 0.001], and more complications (OR 1.55, 95\%CI 1.05{\textendash}2.30). Recurrence patterns and adjusted TTR (HR 1.29, 95\%CI 0.95{\textendash}1.75) were similar between groups. Adjusted OS was superior in the SG group (HR 1.69, 95\%CI 1.20{\textendash}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.",

keywords = "Diffuse gastric cancer, Gastrectomy",

author = "Jonathan Sivakumar and Wong, \{Darren J.\} and Katheryn Hall and Lee, \{Margaret M.\} and Duong, \{Cuong P.\} and Watson, \{David I.\} and Donohoe, \{Claire L.\} and Tim Bright and Ahmad Aly and Kevin Chan and Chan, \{David L.\} and Neil Merrett and Sivakumar Gananadha and Lam, \{Yick Ho\} and Harsh Kanhere and BMark Smithers and Michael Bozin and Matthew Read and Krinal Mori and Johnson, \{Mary Ann\} and Enoch Wong and Martin, \{Sarah A.\} and Geraldine Ooi and Yahya Al-Habbal and Liew, \{Chon Hann\} and Robert Bohmer and Jurstine Daruwalla and Mo Ballal and Rukshan Ranjan and MacCormick, \{Andrew D.\} and Sharon Pattison and Nicholas Evennett and Jason Robertson and James Tan and Alexandra Gordon and Simon Bann and Inian Samarasam and Ramesh Gurunathan and Jimmy So and Jonathan Yeung and Lorenzo Ferri and Griffiths, \{Ewen A.\} and Phillips, \{Alexander W.\} and Markar, \{Sheraz R.\} and David Chan and Thomas Murphy and John Reynolds and Magnus Nilsson and Guillaume Piessen and Bas Wijnhoven and \{Van Hillegersberg\}, Richard and \{van Berge Henegouwen\}, \{Mark I.\} and Lombardi, \{Pietro M.\} and Liu, \{David S.\} and \{SPACE-FLOT Investigators\}",

year = "2026",

month = jul,

doi = "10.1007/s10120-026-01746-7",

language = "English",

volume = "29",

pages = "827--840",

journal = "Gastric Cancer",

issn = "1436-3291",

publisher = "Springer",

number = "4",

}

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, BM, 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, Liu, DS & SPACE-FLOT Investigators 2026, 'Total versus subtotal gastrectomy following neoadjuvant flot chemotherapy for distal diffuse gastric adenocarcinoma: an international cohort study', Gastric Cancer, vol. 29, no. 4, pp. 827-840. https://doi.org/10.1007/s10120-026-01746-7

TY - JOUR

T1 - Total versus subtotal gastrectomy following neoadjuvant flot chemotherapy for distal diffuse gastric adenocarcinoma

T2 - an international cohort study

AU - Sivakumar, Jonathan

AU - Wong, Darren J.

AU - Hall, Katheryn

AU - Lee, Margaret M.

AU - Duong, Cuong P.

AU - Watson, David I.

AU - Donohoe, Claire L.

AU - Bright, Tim

AU - Aly, Ahmad

AU - Chan, Kevin

AU - Chan, David L.

AU - Merrett, Neil

AU - Gananadha, Sivakumar

AU - Lam, Yick Ho

AU - Kanhere, Harsh

AU - Smithers, BMark

AU - Bozin, Michael

AU - Read, Matthew

AU - Mori, Krinal

AU - Johnson, Mary Ann

AU - Wong, Enoch

AU - Martin, Sarah A.

AU - Ooi, Geraldine

AU - Al-Habbal, Yahya

AU - Liew, Chon Hann

AU - Bohmer, Robert

AU - Daruwalla, Jurstine

AU - Ballal, Mo

AU - Ranjan, Rukshan

AU - MacCormick, Andrew D.

AU - Pattison, Sharon

AU - Evennett, Nicholas

AU - Robertson, Jason

AU - Tan, James

AU - Gordon, Alexandra

AU - Bann, Simon

AU - Samarasam, Inian

AU - Gurunathan, Ramesh

AU - So, Jimmy

AU - Yeung, Jonathan

AU - Ferri, Lorenzo

AU - Griffiths, Ewen A.

AU - Phillips, Alexander W.

AU - Markar, Sheraz R.

AU - Chan, David

AU - Murphy, Thomas

AU - Reynolds, John

AU - Nilsson, Magnus

AU - Piessen, Guillaume

AU - Wijnhoven, Bas

AU - Van Hillegersberg, Richard

AU - van Berge Henegouwen, Mark I.

AU - Lombardi, Pietro M.

AU - Liu, David S.

AU - SPACE-FLOT Investigators,

PY - 2026/7

Y1 - 2026/7

N2 - 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.

AB - 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.

KW - Diffuse gastric cancer

KW - Gastrectomy

UR - https://www.scopus.com/pages/publications/105038665973

U2 - 10.1007/s10120-026-01746-7

DO - 10.1007/s10120-026-01746-7

M3 - Article

C2 - 42043496

AN - SCOPUS:105038665973

SN - 1436-3291

VL - 29

SP - 827

EP - 840

JO - Gastric Cancer

JF - Gastric Cancer

IS - 4

ER -

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

Abstract

UN SDGs

Keywords

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