Borrmann type IV gastric cancer exhibits distinct clinicopathological features and extremely poor prognosis

Borrmann type IV gastric cancer (Bor-IV) is clinically recognized as an aggressive phenotype; however, its prognostic burden relative to contemporary TNM staging and its radiological correlates remain incompletely characterized.

We retrospectively analyzed 1236 patients with advanced gastric adenocarcinoma who underwent radical gastrectomy, including 124 Bor-IV and 1112 Non Bor-IV cases. Clinicopathological features, multimodal imaging characteristics, and survival outcomes were compared. Overall survival (OS) and disease-free survival (DFS) were analyzed using Kaplan-Meier methods and Cox proportional hazards models.

Among 1236 patients, 124 (10.03%) were Bor-IV and 1112 (89.97%) were Non Bor-IV. Bor-IV was associated with more advanced T stage, N stage, pathological stage, larger tumor size, and a higher proportion of signet-ring cell components (all p < 0.001). Multivariate Cox regression analysis confirmed Bor-IV as an independent prognostic factor for poor OS after adjusting for TNM and other clinicopathological factors (HR = 3.837, 95% CI: 2.900-5.080, P < 0.001). Patients with Bor-IV had a median OS of 21.3 months and a 5-year OS rate of 20.24%, significantly worse than Non Bor-IV across all pathological stages, T stages, and N stages. Notably, the survival of Bor-IV patients approached that of stage IV disease. In the Bor-IV subgroup, age > 60 years and advanced T stage were independent predictors of poor OS. Among treatment modalities, only R0 resection was significantly associated with improved DFS and OS.

Bor-IV is characterized by distinctive imaging features and an exceptionally poor prognosis that is not fully captured by conventional TNM staging. Bor-IV may represent a clinically aggressive phenotype within advanced gastric cancer, underscoring the need for refined risk stratification and optimized multimodal treatment strategies in future prospective studies.