Response: Do Nutritional and Inflammatory Indices Predict Response in Geriatric Gastric Cancer Patients Treated With Neoadjuvant FLOT Regimen?

Dear Editor,

We would like to extend our sincere thanks to the authors of the Letter to the Editor for their careful reading of our article and for their insightful comments regarding our study.

We acknowledge that systemic factors such as corticosteroid administration, immunosuppressive diseases, and subclinical infections can influence immune-inflammatory markers like neutrophil-to-lymphocyte ratio (NLR), lymphocyte count, and serum albumin.^1,2 While the retrospective nature of our study limited our ability to capture the full extent of these variables, we excluded patients with overt infections or immunosuppressive therapy when such data were available in clinical records. Nonetheless, the possibility of unmeasured subclinical or undiagnosed immunosuppressive states remains, and we clearly noted this as a limitation in the manuscript. We concur with the suggestion that future prospective studies should systematically account for these variables to better isolate the effects of inflammatory and nutritional indices on treatment outcomes.

We appreciate the emphasis placed on the apparent discrepancy between our findings and prior literature. While most studies associate lymphopenia and elevated NLR with worse long-term survival, our primary endpoint was pathological response to neoadjuvant therapy, not overall prognosis. The immune milieu of elderly patients receiving cytotoxic chemotherapy may behave differently compared to younger cohorts. ³ It is plausible that transient systemic inflammation, characterized by lower lymphocyte counts or elevated NLR, could reflect heightened immune activation or tumor susceptibility to chemotherapy-induced cytotoxicity. ⁴ We acknowledged in our discussion that this observation requires further exploration and may not directly translate into long-term benefit.

Once again, we thank the authors for their constructive critique. Their observations highlight the complexity of host-tumor interactions in the geriatric population and underscore the need for well-controlled prospective trials that examine these indices in relation to both treatment response and survival.