Among several chemotherapeutic agents, 5-fluorouracil (5-FU) has been widely used as a key drug in adjuvant chemotherapy for gastric cancer. However, no reliable marker, which predicts the response to 5-FU in an adjuvant setting, has been identified. Hypoxia-induced drug resistance, via upregulation of HIF-1a, is a major obstacle in the development of effective cancer therapy. However, few clinical studies have so far assessed the relationship between the HIF-1a expression and the chemo-resistance of gastric cancer patients in an adjuvant setting. We established 2 HIF-1a knockdown gastric cancer cell lines in order to clarify the role of HIF-1a in chemo-resistance against 5-FU. Furthermore, expression of HIF-1a was immunohistochemically assessed in 91 resected specimens. Sixty-four of 91 patients received 5-FU adjuvant chemotherapy after surgery. HIF-1a expression was associated with the significantly shorter relapse-free survival and disease-specific survival in the 64 patients of adjuvant group (p 5 0.026, 0.014, respectively), but not in the 27 of surgery group. Multivariate analysis showed that HIF-1a was an independent risk factor for relapse in 64 patients in the adjuvant group (p 5 0.029). In conclusion, the current study confirmed, for the first time that HIF-1a expression is an independent risk factor for relapse in high-risk gastric cancer patients who underwent curative surgery followed by adjuvant 5-FU chemotherapy. A favorable effect of 5-FU might therefore be expected in patients that do not express HIF-1a, whereas, other types of chemotherapy or additional treatments, such as HIF-1a inhibitors, should be considered in patients that do express HIF-1a.Despite its declining incidence, gastric cancer remains a worldwide health problem that is the fourth most common cancer and the second most frequent cause of cancer-related deaths. 1 Although curative surgery is essential in the treatment of gastric cancer, this single modality treatment seems to have reached its maximal achievable effect for local control and survival. 2 Various regimens of adjuvant chemotherapy, either with or without radiotherapy, have therefore been administered in the hope of preventing a disease relapse and improving the survival rate. [3][4][5] One early meta-analysis concluded that adjuvant chemotherapy did not improve survival, 6 whereas in the last decade, several meta-analyses have confirmed that adjuvant chemotherapy led to statistically significant reductions in mortality and the rate of relapse in comparison to surgery alone. 7-13 However, a consensus regarding a standard regimen has not been obtained among the world.Many drug combinations that include 5-fluorouracil (5-FU), platinum compounds, anthracyclines, taxanes and/or irinotecan have demonstrated promising activity in advanced gastric cancer. Among these chemotherapeutic agents, 5-FU has been widely used as a key drug in adjuvant chemotherapy. Thymidylate synthase (TS), thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD) are important enzymes in...