Postoperative Adjuvant Chemoradiation Therapy for Patients With Resected Gastric Cancer: Intergroup 116

read with great interest, highlights several points that I would certainly agree with, especially the question of whether an adequate operation had been performed in many of the patients who were entered onto this trial. However, his statements on the recommended extent of lymphadenectomy deserve some specification. In Intergroup 116, 54% of patients underwent less than a D1 lymph node dissection (LND), 36%, a D1 lymphadenectomy, and only 10%, a D2 procedure. As a result, 64% of patients in the control group experienced a recurrence, which involved regional sites in 72%, local sites in 29%, and distant sites in 18%. Peritoneal spread was not listed separately. It seems that the benefit of postoperative chemoradiation in relapse pattern and survival was achieved primarily through the radiation component. Although the extent of LND has remained an issue of debate, several centers in the United States have adopted a policy of more radical (D2) dissections in association with potentially curative gastrectomies, despite a lack of survival benefit in two European randomized trials. 3,4 D2 LND has been recommended as the preferred extent of regional resection in the National Comprehensive Cancer Network guidelines (as well as in Intergroup 116), 5 primarily for four reasons: more precise pathologic staging, better regional disease control, a putative survival benefit to a small subset of patients (those with otherwise unrecognized, isolated N2 disease), and its safe performance in experienced hands when splenectomy and pancreatectomy are avoided. 6,7 In an attempt to demystify the complex Japanese LND rules for easier use by surgeons in the United States, this would translate into recommending a retroperitoneal lymphadenectomy of left gastric, common hepatic celiac, and splenic arterial nodes aside from the perigastric (D1) nodes, removal of which is easily included in the process of gastrectomy. Using such an extended retroperitoneal LND approach in association with a potentially curative gastrectomy as surgical standard, our institutional experience with gastric cancer recurrence differs significantly from Intergroup 116 results. Over the past 10 years, 73 patients underwent gastrectomy, and 82% of them had a negative margin (R0) resection. At a median follow-up for survivors of 30 months, recurrent disease was identified in 35 patients (48%). Twenty-nine percent received adjuvant therapy, without a significant impact on survival or recurrence. Isolated local but not regional recurrence was seen in two patients (3%). Locoregional recurrence in the setting of diffuse peritoneal or hematogenous, systemic disease was identified in 16%, while another 11% of patients had peritoneal involvement and another 18% had distant disease without locoregional involvement. A significant predictor of systemic failure was N3 status; for peritoneal failure, it was a T3 or T4 classification. N2 disease had a distant failure risk similar to N1 and a peritoneal recurrence risk similar to N3 categories. These failure patterns resemble those obtained in Asian series 8 and are different from outcomes in Intergroup 116. I would strongly advocate such extended retroperitoneal (D2) LND for every patient undergoing potentially curative gastrectomy. I would have doubts as to whether the Intergroup 116 regimen would present a useful or effective adjuvant treatment regimen for patients treated with such surgical standards, as this extended retroperitoneal dissection seems more likely to decrease the need for additional regional therapy in the form of radiation. Instead, patients primarily at high risk for peritoneal or systemic failure, given these pathologic predictors, should be treated with intraperitoneal or systemic adjuvant chemotherapy approaches as outlined by Kelsen and by others. 1,9,10 Those patients who remain primarily at risk for locoregional but not for diffuse peritoneal or systemic recurrence (eg, with positive margin [R1], few involved lymph nodes, and no serosal invasion 11 ) will likely benefit from the Intergroup 116 regimen.