{"doi":"10.1002/jso.27483","title":"Reply to: Striking a balance: Deciphering the dilemma of treatment equivalence in cardia gastric cancer","abstract":"We thank the authors at the National Institute of Oncology from Rabat, Morocco for a letter to the editor for our article entitled, “Does nonmetastatic gastric cancer of the cardia warrant a different treatment strategy?”, which was recently published in the Journal of Surgical Oncology.1 In our study, we conducted a retrospective analysis of 2387 patients identified from the National Cancer Database (NCDB) who had resected nonmetastatic gastric cancer located in the cardia. Considering the retrospective nature and utilization of the national database, the lack of granularity in the NCDB was a major inherent limitation of our study as described in our manuscript.2, 3 This encompasses a major part of the authors' comments, including the omission of staging laparoscopy results, rate of surgical complications, and different types of lymphadenectomy (D1–D3).4 To partially address NCDB-associated limitations, we conducted a subgroup analysis of optimally treated patients detailed in the manuscript.1 We will respond to this letter in a similar format: We agree with the authors and acknowledge the absence of large randomized controlled trials involving the same population and treatment groups. Conducting such trials demand substantial resources in terms of funding, personnel, and time.5 This retrospective analysis was undertaken as it is challenging to address questions through randomized controlled trials, primarily due to these resource constraints. Development of novel systemic therapy and targeted agents, as well as establishment of clinical trials focusing on these novel therapies, make it more challenging to compare treatment arms that may be less in favor. According to the National Comprehensive Cancer Network (NCCN) guidelines, staging laparoscopy is recommended to detect radiological occult metastatic disease in patients with cT3 and/or cN+ disease, which is crucial for accurate staging.6 It is worth noting that the NCDB lacks comprehensive information on staging laparoscopy as part of the staging workup for gastric cancer patients.4 To provide some context regarding the patient's disease status, we incorporated clinical and pathological TNM staging as well as histological grading into our analysis. Although these factors do not replace the results of staging laparoscopy, they do provide a basic understanding of the disease status among the patients included in each treatment group. We agree with the authors that checking the impact of each histological subtype specifically signet ring cell carcinoma on overall survival (OS) rates in different treatment arms is crucial. Within each treatment category, the proportion of patients with a diagnosis of signet ring cell histology is notably low (perioperative chemotherapy [PEC]: 10.8%, postoperative chemoradiation [POCR]: 12.5%, and postoperative chemotherapy [POC]: 10.3%). This small representation suggests that it is unlikely for the presence of signet ring cell histology to exert any significant influence on OS of these groups reported in our study. In addition, the MAGIC trial did not exclude or subcategorize patients with signet ring cell histology in the treatment cohorts.7 The FLOT4 trial did not demonstrate any significant impact of signet ring cell histology on overall survival between the two treatment groups.8 To shed some additional light in view of signet ring cell histology, we previously reported on patients with signet ring cell gastric cancer, where upfront surgical resection demonstrated an association with improvement in OS compared to neoadjuvant therapy in patients with clinical stage I disease (71% vs. 38%, p < 0.01). This may suggest relative resistance of this histology to chemotherapy.9 For patients with localized resectable gastric cancer, the NCCN guidelines recommend gastrectomy with the goal of examining more than 15 lymph nodes to accurately stage pN0.6 Although, the NCDB lacks specific information on surgical complications and the type of lymphadenec","journal":"Journal of Surgical Oncology","year":2023,"id":401190,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":1,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9492,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2023-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":1085278,"name":"Pranay S. Ajay","orcid":null,"position":1,"is_corresponding":false},{"id":506614,"name":"Subir Goyal","orcid":"0000-0003-1737-7771","position":2,"is_corresponding":false},{"id":455498,"name":"Mihir M. Shah","orcid":"0000-0002-4665-5534","position":3,"is_corresponding":false},{"id":1177878,"name":"Parit T. Mavani","orcid":"0000-0003-3968-1205","position":0,"is_corresponding":true}],"reference_count":12,"raw_metadata":null,"created_at":"2026-07-19T01:20:08.195423Z","pmid":"37846210","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}