Annals of Surgical Oncology

, Volume 21, Issue 5, pp 1739–1748 | Cite as

Is Preoperative Chemotherapy Followed by Surgery the Appropriate Treatment for Signet Ring Cell Containing Adenocarcinomas of the Esophagogastric Junction and Stomach?

  • Ulrike Heger
  • Susanne Blank
  • Christiane Wiecha
  • Rupert Langer
  • Wilko Weichert
  • Florian Lordick
  • Thomas Bruckner
  • Martin Dobritz
  • Maria Burian
  • Christoph Springfeld
  • Lars Grenacher
  • Jörg-Rüdiger Siewert
  • Markus Büchler
  • Katja OttEmail author
Thoracic Oncology


Recent data suggest primary resection as the preferable approach in patients with signet ring cell gastric cancer (SRC). The aim of our retrospective exploratory study was to evaluate the influence of SRC on prognosis and response in esophagogastric adenocarcinoma treated with neoadjuvant chemotherapy.


A total of 723 locally advanced esophagogastric adenocarcinomas (cT3/4 N any) documented in a prospective database from two academic centers were classified according to the WHO definition for SRC (more than 50 % SRC) and analyzed for their association with response and prognosis after neoadjuvant treatment.


A total of 235 tumors (32.5 %) contained SRC. Median survival of SRC was 26.3 compared with 46.6 months (p < 0.001) for non-SRC. SRC were significantly associated with female gender, gastric localization, advanced ypT and R1/2 categories, and lower risk of surgical complications and anastomotic leakage (each p < 0.001). Clinical (21.1 vs. 33.7 %, p = 0.001) and histopathological response (less than 10 % residual tumor: 16.3 vs. 28.9 %, p < 0.001) were significantly less frequent in SRC. Clinical response (p = 0.003) and complete histopathological response (pCR) (3.4 %) (p = 0.003) were associated with improved prognosis in SRC. Clinical response, surgical complications, ypTN categories, but not SRC were independent prognostic factors in forward Cox regression analysis in R0 resected patients. Risk of peritoneal carcinomatosis was increased (p < 0.001), while local (p = 0.015) and distant metastases (p = 0.02) were less frequent than in non-SRC.


Prognosis of SRC is unfavorable. Although response to neoadjuvant chemotherapy is rare in SRC, it is associated with improved outcome. Thus, chemotherapy might not generally be abandoned in SRC. A stratification based on SRC should be included in clinical trials.


Gastric Cancer Peritoneal Carcinomatosis Signet Ring Cell Circumferential Resection Margin Signet Ring Cell Carcinoma 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Catherine Bernaciak PhD for revising the manuscript.


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Copyright information

© Society of Surgical Oncology 2014

Authors and Affiliations

  • Ulrike Heger
    • 1
  • Susanne Blank
    • 1
  • Christiane Wiecha
    • 1
  • Rupert Langer
    • 2
  • Wilko Weichert
    • 3
  • Florian Lordick
    • 4
  • Thomas Bruckner
    • 5
  • Martin Dobritz
    • 6
  • Maria Burian
    • 1
  • Christoph Springfeld
    • 7
  • Lars Grenacher
    • 8
  • Jörg-Rüdiger Siewert
    • 9
  • Markus Büchler
    • 1
  • Katja Ott
    • 1
    Email author
  1. 1.Department of SurgeryHeidelberg University Hospital, University of HeidelbergHeidelbergGermany
  2. 2.Department of PathologyUniversity of BernBernSwitzerland
  3. 3.Department of PathologyHeidelberg University HospitalHeidelbergGermany
  4. 4.University Cancer Center Leipzig (UCCL)University of LeipzigLeipzigGermany
  5. 5.Data Management, Institute of Medical Biometry and StatisticsIMBIHeidelbergGermany
  6. 6.Department of RadiologyTechnische Universitaet MuenchenMunichGermany
  7. 7.Department of Medical OncologyNational Center for Tumor DiseasesHeidelbergGermany
  8. 8.Department of Diagnostic and Interventional RadiologyHeidelberg University HospitalHeidelbergGermany
  9. 9.DirectorateUniversity of FreiburgFreiburgGermany

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