R E S E A R C H H I G H L I G H T Can the ARTISTs complete the Schubert Unfinished (Sinfonie Nr. 7 in h moll D. 759 "Die Unvollendete")?

Surgery, chemotherapy, and radiotherapy are proven treatment options for gastric cancer. D2 lymph node dissection has become a standard surgical technique after its usefulness was demonstrated by Sasako and colleagues as well as based on the findings of a 15year follow-up in the Dutch Gastric Cancer Group assessed by Songun and colleagues (1,2). Compared with D2 dissection alone, the survival time was prolonged in the S-1 monotherapy arm in the ACTS-GC study by Sakuramoto and colleagues and in the XELOX therapy arm in the CLASSIC study by Bang and colleagues. Both studies reported the usefulness of adjuvant chemotherapy even in patients treated with D2 dissection. The subgroup analysis in the ACTS-GC study showed the surgery/adjuvant chemotherapy combination was useful for the treatment of stage II to IIIA gastric cancer treated with S-1 alone but not for cancer of stage IIIB or higher. On the other hand, the CLASSIC study showed the usefulness of XELOX therapy in all cancer stages (II to IIIB), suggesting the combination therapy will be required for the treatment of stage IIIA or higher gastric cancer (3,4). The Intergroup 0116 study reported a prolonged survival time in patients treated with chemotherapy in combination with radiotherapy. However, most enrolled patients were treated with D1 dissection (5). In this context, the ARTIST study, performed to evaluate the usef ulness of adjuvant chemoradiotherapy in patients treated with the standard D2 dissection, is interesting (6). The 53.2-month follow-up data from the ARTIST study revealed that the treatment completion rate was 75.4% in the XP arm and 81.7% in the XP/XRT/XP arm. While the XP/XRT/XP therapy was shown to be highly tolerable, no prolonged diseasefree survival (DFS), the primary endpoint, was unfortunately demonstrated in this treatment arm. Although the subset analysis showed the DFS was longer in lymph node positive patients in the XP/XRT/XP arm, the ARTIST study has certain limitations. First, do patients with stage IB or II cancer treated with D2 dissection really require chemoradiotherapy? These patients may be overtreated with postoperative chemoradiotherapy. Sasako and colleagues reported a 5-year DFS of 79.2% in patients with stage II cancer treated with D2 dissection followed by S-1 monotherapy only for 1 year (7). Japanese epidemiological data showed the 5-year survival rate from 80% to 90% in patients with stage IB cancer with the primary lesion in the gastric antrum and body (8). Second, was XP appropriate adjuvant chemotherapy? The treatment completion rate was 81.7% in the XP/XRT/XP arm; however, grade 3 or higher adverse reactions were reported at much higher frequencies in the study arms compared with in patients with advanced gastric cancer treated with XP therapy (with CDDP at 80 mg/m