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We read with great interest the article by Vogl et al. published in the Journal of Gastrointestinal Oncology on a twocentre experience of ramucirumab (RAM) plus paclitaxel or FOLFIRI in advanced gastric/gastroesophageal junction (GEJ) cancer (1). The authors could show a favourable outcome for RAM plus FOLFIRI in a selected cohort (n=16) of taxane-refractory patients or patients with pre-existing neurotoxicity. We can corroborate these findings with a retrospective analysis of 16 patients treated with RAM plus irinotecan or FOLFIRI at our tertiary cancer centre. The addition of the anti-vascular endothelial growth factor receptor 2 antibody RAM to paclitaxel has been shown to prolong survival in advanced or metastatic gastric/GEJ cancer with disease progression on or after fluoropyrimidineor platinum-containing chemotherapy (2). The results of the RAINBOW trial led to the approval of RAM in this indication by the Food and Drug Administration as well as by the European Medicines Agency and RAM plus paclitaxel nowadays constitutes the standard second-line therapy. Since the conduction of this pivotal trial, the treatment landscape of localized gastric/GEJ cancer has changed considerably. The FLOT regimen (fluorouracil, oxaliplatin, docetaxel) has replaced EOX (epirubicin, oxaliplatin, capecitabin) as standard perioperative chemotherapy for operable localized gastric/ GEJ cancer (3). This regimen has also been adopted by many centres as first-line therapy in patients with advanced/ metastatic disease and high tumour volume and/or symptomatic disease (4). However, approximately 70% of patients undergoing FLOT therapy will suffer from peripheral neuropathy (PNP), which impedes further application of potentially neurotoxic agents in clinical practice (3). In addition, progression under or rapid disease recurrence after FLOT in the perioperative or first-line setting raises the demand for an alternative chemotherapy backbone in subsequent treatment other than paclitaxel (5). We—as others—have therefore combined RAM with FOLFIRI or with irinotecan in analogy to the RAISE trial in colorectal cancer (6).

Ramucirumab plus FOLFIRI or irinotecan as second-line therapy in advanced or metastatic gastric or gastroesophageal junction adenocarcinoma