What treatment regimen would you choose for a patient with gastric adenocarcinoma who is found to have peritoneal and omental implants at the time of surgery after receiving preoperative FLOT?

I think there are 2 ways to answer this question. The more straightforward scenario is if the patient had a diagnostic laparoscopy prior to starting pre-operative chemotherapy and did not have either gross peritoneal disease or positive peritoneal cytology. In this case, this would be clear progression on FLOT and 2nd-line treatment options would apply. The only remaining drug is irinotecan and ramucirumab/FOLFIRI is now an NCCN recommendation.

On the other hand, if the patient did not undergo a diagnostic laparoscopy, whether there is true progression or simply unmasking of small-volume peritoneal carcinomatosis that was present at baseline can be difficult to decipher. If the patient derived clinical benefit from pre-operative FLOT or had ...