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Background  Chemotherapy may improve outcomes in gastric cancer (GC), especially for the patients with advanced stage. To explore useful predictive factor for GC performing chemotherapy, we compared the tumor responses assessed using computed tomography (CT) with endoscopy based criteria.    Methods  192 GC patients performing chemotherapy were retrospectively studied. CT based response assessment was performed after 2 courses of treatment. Endoscopic evaluation according to The Japanese classification of gastric carcinoma was also performed at same period. Data were correlated with overall survival (OS) and progression-free survival (PFS).    Results  Majority of the cases (n = 178, 93%) received S-1 based chemotherapy as the first line treatment. 55 (29%) and 91 (47%) cases were considered to be CT and endoscopic responders. Endoscopic responder was more clearly associated with better OS and PFS compared to CT based responder by the log-rank test ( P <0.0001  vs . 0.01 and  P <0.0001  vs . 0.008, respectively). The association was more striking among patients performing neoadjuvant chemotherapy ( P <0.0001  vs . 0.15 and  P <0.0001  vs . 0.1, respectively). Multivariate survival analysis using Cox's regression model revealed that endoscopic non-responder was the independent predictive factor, being more strongly associated with worse OS when compared to CT non-responder (hazard ratio: 4.60  vs . 1.77, 95% confidence interval: 2.83–7.49  vs .1.08–2.89,  P <0.0001  vs . 0.02). More advanced T, N stage and cases who had peritoneal dissemination were significantly associated with endoscopic non-responder (all  P  values <0.01).    Conclusion  Endoscopy based evaluation of primary lesions are clearly associated with prognosis in patients with GC who perform chemotherapy.

Evaluations of primary lesions by endoscopy clearly distinguishes prognosis in patients with gastric cancer who receive chemotherapy