EP.WE.832A silver lining in the dark COVID cloud: Total neoadjuvant chemotherapy results in complete pathological response in locally advanced distal gastric adenocarcinoma

Aims Perioperative oncological therapies resulting in complete pathological response in diffuse type distal gastric adenocarcinoma are extremely rare. We report the first case of complete pathological regression in a patient with locally advanced diffuse type distal gastric adenocarcinoma (CT3N2M0) who received “total neoadjuvant” chemotherapy with FLOT due to the COVID pandemic. Methods & Results A 73-year-old male patient was diagnosed with cT3N2M0 diffuse type distal gastric adenocarcinoma. He received 4 cycles of neoadjuvant FLOT as planned with immune checkpoint inhibitor Durvlumab and interval PET-CT showed massive reduction in 18F-FDG avidity. However, his surgery was postponed due to the COVID-19 pandemic and given his excellent response to chemotherapy his 4 adjuvant cycles of FLOT were advanced into the preoperative setting. Subsequent PET-CT showed close to zero 18F-FDG uptake and he proceeded to laparoscopic radical subtotal gastrectomy with D2 lymphadenectomy. Histopathology of the resected specimen demonstrated no evidence of residual malignancy, a complete pathological response (TRG1a, ypT0N0 R0). Conclusions Amidst the dark cloud of COVID-19 there was a silver lining for one patient, who due to delayed surgery received total neoadjuvant FLOT (8 cycles). This should generate randomised controlled trials comparing the current standard of care with total neoadjuvant regimens and investigating the utilisation of interval investigations such as CT-PET in monitoring response to preoperative therapy, guiding optimal timing of surgical resection.