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The presence of signet ring cells (SRCs) is related with advanced tumor stage and poor prognosis and could serve as a reliable and effective parameter for the prediction of postoperative survival and formulation of therapy strategy in esophagogastric junction adenocarcinoma (EEGJA) patients. However, more high-quality studies are still needed to verify the above findings [1].

Their histology on pretreatment biopsy predicts a decreased likelihood of complete pathologic response and survival for patients with esophageal adenocarcinoma treated with preoperative chemoradiation and surgery [2].

Among surgically managed patients SRC appears to have a worse prognosis than ACA, which may reflect the tendency of SRC tumors to be higher grade and more locally advanced. However SRC histology does not appear to diminish the role of esophagectomy in the management of locoregionally confined esophageal cancer [3].

High-grade histology was found in most patients with EAC and predicted poor survival and treatment response. SRC features in patients with G3 disease were associated with lower OS. The benefit of NAT for G3 EAC in patients with SRC histology appears limited. Most esophageal carcinomas containing signet-ring cell carcinoma are aggressive neoplasms associated with a poor prognosis after esophagectomy [4,5].

First, the proportion of SRC might play an essential role in the prognostic value of SRC in EGJA patients. In the study by Nafteux et al., no significant difference in prognosis between patients with (SRC\50%) and without SRC was observed (P=0.87). However, patients with SRC\50% had much poor prognosis than patients with usual-type adenocarcinoma (P\0.001).

(A) Second, SRC might be an effective predictor of response to neoadjuvant treatment. Solomon et al. manifested that patients with SRC were more insensitive to neo-adjuvant treatment than patients without SRC (P=0.022) and less likely to experience down staging after neo-adjuvant chemo-radio therapy.

(B) However, Chirieac et al. reported opposite results, where patients with SRC had better prognosis than those with usual-type adenocarcinoma (P=0.02) after neo-adjuvant chemo-radiation and surgery

(C) Which indicates that patients with SRC might be more sensitive to neo-adjuvant chemo-radio therapy [6].

A 40 years old female not known to have any medical illness presented at the Gastroentrology clinic on early November 2021 with histroy of epigastric discomfort since 2 months, progressed to dysphagia, initially for solid then for liquid, associated with weight loss and vomiting of blood in the last 2 weeks.

She had EGD done outside, showed circumferential esophageal mass starting from 33 cm and extending to the cardia, biopsies taken, Histopathology results showed poorly differentiated adenocarcinoma with signet ring cells Her-2 negative.

Unremarkable past medical or surgical history, no history of blood transfusion, no known allergies

Referred to the Thoracic and UGI surgical Unite for Jejunostomy Feeding tube insertion and MDT, Case discussed in GI tumor board on late November 2021.

Decision

1. Treat as siewert-3 GEJ adenocarcinoma with neo-adjuvant chemotherapy

2. Feeding jejunostomy done by thoracic surgery on Dec 2021

3. Port-cath: inserted on Dec 2021

4. Post Completed 4 cycles chemotherapy (FLOT) on Jan 2022

Re-assessment

EGD: Esophagus: There was mid esophageal circular stricture at 24 cm from the teeth with normal mucosa adult scope pass through it with mild resistance. GE junction at 34 cm from the teeth, irregular line with grade a esophagitis.

Stomach: Ulcerated malignant looking ulcer not bleeding extending from the cardia to the lesser curvature.

CT-CAP

• No specific evidence of intra-thoracic metastases.

• Mid-Esophageal thickening about 5 cm in distance and 4 cm-5 cm from the EGJ mass

• Non opacification of the right brachial cephalic vein including the right sub-clavian and internal jugular veins with distention of the latter two venous structures.

• Mild interval improvement of the previously noted circumferential wall thickening of the stomach involving the proximal part of the gastric body, fundus and gastro-esophageal junction.

• Interval insertion of left lower abdomen jejunostomy tube,

• No CT evidence of abdominal/pelvic metastasis.

MDT, Case discussed in GI tumor board on (Feb 2022): GEJ mass with skip lesion to the Mid-Esophagus. For surgical intervention Gastroesophagectomy with reconstruction (Figure 1).

Figure 1: All CT images Obtained from the PAC system of the patient

Operation

Patient taken to the OR after proper consenting and pre-op anesthesia assessment in Operation last for almost 24 hours started with (Ivory- Lewis) trying to salvage as much of the esophageal length but came back posistive in the frozen section for the proximal margin with small remanent of stomach left, then converted to Tri-Incisional complete Gastro- Esophagectomy reaching to negative margin both proximal and distal. Reconstruction done with transposition of the colonic reconstruction with Jejunostomy feeding tube insertion.

Histopathology

Reported as clear margin with tumor of poorly differentiated adenocarcinoma, diffuse type with areas of signet ring component, pT3, pN0.

Recovery post-OP

Patient admitted to ICU for close observation where she spent 16 days with good recovery, then shifted to regular ward where she started on oral along with J-feeding as tolerated, after leak assessment by gastrografin fluoroscopy. Patient then discharged on with improved condition, stable vitals, and good oral intake for the liquid diet. Seen after in the Outpatient clinic progressing with the oral intake, doing well, with no complain. And referred back to Medical oncology for follow up regarding the adjuvant chemotherapy. Till 5^th month post-operative patient doing fine with reassessment showed neither recurrence nor metastasis.

Was obtained in writing form signed by the patient, for the case to be published and discussed in the educational and scientific entities without revealing the personal data.

1. Yi Fan W, Si Yu X, Yan W, Guo-Wei C, Hai-Tao M (2021) . World J Clin Cases 9: 10969-10978.

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2. Viren RP, Wayne LH, Arlene MC, Atin A, Asif R, et al. (2014) . Ann Thorac Surg 98:1064-71.

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3. Tejas SS, Benjamin JR, Jessica RH, Andres FM, Ranjan P, et al. (2020) . Ann Thorac Surg 109:1656-1662.

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4. Daniel S, Muhammad A, Yael F, Riad H, Gali P, et al. (2021) . Ann Surg Oncol 28:4929-4940.

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5. Matsuki A, Nishimaki T, Suzuki T, Kanda T, Hatakeyama K (1999). J Surg Oncol 71(1):54-7.

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6. Yan W, Guowei C (2021) . Ann Surg Oncol 28: 835–836.

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