Conversion surgery in gastric cancer a response driven strategy in the era of immunotherapy

Conversion surgery has emerged as a treatment strategy for selected patients with initially unresectable or metastatic gastric cancer who achieve a favourable response to systemic therapy. Advances in chemotherapy, immunotherapy, and targeted therapies have increased response rates and expanded the population of potential surgical candidates. However, clinical response does not reliably reflect pathological eradication of disease, particularly in patients with peritoneal metastases. This review presents a clinically oriented, response-driven framework for conversion surgery, emphasizing tumour biology rather than baseline staging. We discuss current evidence, limitations of response assessment, and the impact of modern systemic therapies. Conversion surgery should be considered an opportunity emerging in selected responders rather than a predefined treatment strategy.