FLOT Chemotherapy Regimen - Stomach Cancer Treatment
In this article
FLOT is used in resectable gastric and gastroesophageal junction (GEJ) adenocarcinomas before surgery and afterward as a perioperative chemotherapy approach. It aims to shrink the tumor, improve surgical success and increase long-term survival.
📌 Why Is It Important?
Perioperative FLOT has shown better survival than conventional ECF/ECX regimens (example: 3-year overall survival %57 vs %48). It is therefore, in cT2+ and/or N+ resectable cases, one of the current standards.
What Is FLOT, and How Does It Work?
FLOT combines folinic acid (leucovorin), fluorouracil (5-FU), oxaliplatin and docetaxel . These drugs target cancer cells’ capacity to grow and proliferate at different points to reduce tumor burden and suppress microscopic residual disease.
| Component | Drug | Brief action |
|---|---|---|
| F | Folinic acid (leucovorin) | Enhances 5-FU effectiveness (modulation) |
| FL | Fluorouracil (5-FU) | Disrupts DNA/RNA synthesis (antimetabolite) |
| O | Oxaliplatin | DNA cross-links (platinum compound) |
| T | Docetaxel | Stops mitosis (microtubule stabilization) |
Which Patients Receive It, and How?
Perioperative Approach (Standard Framework)
- Indication: Resectable cT2+ and/or N+ gastric/GEJ adenocarcinoma.
- Plan: 4 neoadjuvant cycles (before surgery) + surgery + 4 adjuvant cycles (after surgery) FLOT.
- Aim: Shrink the tumor, increase R0 resections and improve long-term survival.
⚠️ Important Note (Adjuvant Terminology)
“Adjuvant FLOT” should not be understood as an independent standard on its own. FLOT is given as part of a perioperative approach before and after surgery. Guidelines (NCCN, ESMO) also include alternatives in the adjuvant phase such as CAPOX, FOLFOX or 5-FU -based regimens.
Further background: results from FLOT4, comparing perioperative FLOT with ECF/ECX (phase 2/3), support a survival advantage. Individual patient characteristics and multidisciplinary board advice always guide clinical decisions.
🩺 Administration, Dose and Schedule
FLOT is generally administered in an outpatient chemotherapy unit . For maintenance 5-FU, a 24-hour infusion pump is used. Doses and durations may vary according to your physician’s assessment.
| Drug | Standard dose | Day | Administration | Approximate duration |
|---|---|---|---|---|
| Oxaliplatin | 85 mg/m² | 1 | Intravenous infusion | ~2 hours |
| Docetaxel | 50 mg/m² | 1 | Intravenous infusion | ~1 hour |
| Folinic acid (leucovorin) | 200 mg/m² | 1 | Intravenous infusion | ~2 hours |
| 5-Fluorouracil (5-FU) maintenance | 2600 mg/m² | 1–2 | Continuous IV (by pump) | 24 hours |
Note: Premedications, hydration and additional support may extend visit duration. Dose/duration adjustments are individualized according to tolerance and organ function.
⏱️ Total Duration and Cycle Plan
- Cycle interval: Every 14 days (q14).
- Perioperative structure: Before surgery, 4 cycles FLOT → Surgery → After surgery, 4 cycles FLOT.
- Total duration: Generally approximately 6 months (may vary with clinical circumstances).
- Infusion duration: Total visit ~5 hours (after pump connection, the remaining 5-FU is completed at home).
⚠️ Side Effects
The most important hematological toxicity in FLOT is neutropenia. In clinical practice, diarrhea (~%14.9), weakness (~%12.7) and peripheral neuropathy (~%8.5) may occur. Febrile neutropenia (fever + low white blood cells) risk is ~%2.1 approximately.
| Toxicity | Clinical manifestation | Practical note |
|---|---|---|
| Neutropenia | Increased infection risk | Fever ≥38°C → urgent medical assessment |
| Febrile neutropenia (~%2.1) | May require urgent antibiotics | Prophylactic/therapeutic G-CSF may be considered |
| Peripheral neuropathy (~%8.5) | Numbness/tingling, cold sensitivity | Avoid cold, modify dose |
| Diarrhea (~%14.9) | Fluid-electrolyte loss | Early antidiarrheal treatment and hydration |
| Weakness (~%12.7) | Decline in performance status | Nutrition/sleep routine, support between doses if needed |
- Oxaliplatin & cold: In the first days, avoid cold drinks/environments.
- Docetaxel premedication: To reduce allergic reactions and edema, dexamethasone and antihistamine protocols are used.
- G-CSF: With high risk or a relevant history, prophylaxis may be considered.
📅 Monitoring: Blood Tests and Imaging
Blood Tests
- Before every cycle, complete blood count and comprehensive biochemistry.
- When needed, additional tests (e.g., kidney/liver function).
Imaging
- Treatment baseline imaging beforehand: CT/MRI and, where appropriate, PET-CT.
- During neoadjuvant treatment, interim assessment (depending on clinical circumstances).
- At the end of perioperative treatment, response assessment.
🧭 Precautions
- 5-FU pump: For the 24-hour infusion, the pump is at the end of day 1 connected, on day 2 removed.
- Drug interactions: The oncology pharmacist/team should check regularly.
- Fever ≥38°C: For infection, urgent assessment is required.
- Cold sensitivity: For several days after oxaliplatin, avoid contact with cold.
- Premedication: Allergy prophylaxis before docetaxel (dexamethasone + antihistamine) is part of treatment.
- Individualization: Dose intervals and modifications are adjusted according to tolerance and comorbidities .
This is a guideline-based general framework; treatment decisions depend on multidisciplinary board assessment and the patient’s clinical characteristics.
💊 Individual Drug Label Information
For each drug in the FLOT regimen, the mechanism of action, side effects and practical warnings differ. Open the boxes below for detailed information.
📚 References
- Al-Batran S-E, et al. FLOT4 perioperative chemotherapy vs ECF/ECX in resectable gastric/GEJ adenocarcinoma. Lancet. 2019;393:1948–1957. doi:10.1016/S0140-6736(18)32557-1
- Cunningham D, et al. Perioperative ECF vs surgery alone in gastric cancer (MAGIC). N Engl J Med. 2006;355:11–20. doi:10.1056/NEJMoa055531
- NCCN Clinical Practice Guidelines in Oncology: Gastric Cancer (v3.2025). nccn.org
- ESMO Guidelines Committee. Gastric cancer: ESMO Clinical Practice Guideline (latest updates). esmo.org/guidelines
- Al-Batran S-E, et al. Perioperative FLOT in patients with resectable gastric/GEJ cancer: phase 2/3 program updates. Supplementary/Conference materials (ASCO/ESMO session presentations). ASCO • ESMO
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