Purpose <p>Neoadjuvant treatment (NAT) has become the standard treatment for locally advanced gastric cancer (LAGC). A small number of patients could achieve pathological complete response (pCR) after NAT. This study was performed to determine the factors predicting pCR and recurrence, and to investigate the pattern of recurrence in patients with pCR after NAT followed by surgery.</p> Methods <p>We collected 488 LAGC patients who underwent surgery in three hospitals between September 2015 and October 2022. The primary endpoint was overall survival (OS) and recurrence-free survival (RFS). Logistic regression analyses were performed to identify independent variables associated with pCR and the nomogram was created.</p> Result <p>Eighty (16.4%) patients were found with pCR and had significantly better OS and RFS than non-pCR group. The recurrence rates in the pCR and non-pCR groups were 7.5% (6 of 80) and 40.2% (164 of 408) respectively. However, the recurrence time and location had no significant difference between these two groups. Interestingly, all the 6 pCR patients who had recurrences received adjuvant therapy. Chemotherapy combined with immunotherapy as NAT significantly increased the pCR rate, but did not prolong RFS or OS compared to chemotherapy alone. Moreover, there was no significant difference in both OS and RFS between patients who received adjuvant chemotherapy and those who were observed only. Histological type and NAT regimen were independent factors to predict pCR in the nomogram.</p> Conclusion <p>Patients with pCR had a lower recurrence rate and better prognosis than the non-pCR group. Patients receiving chemo-immunotherapy as NAT had a higher pCR rate than those receiving chemotherapy alone, but this did not translate into significant improvement in long-term survival.</p>