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Clinical correlations with IgG-rheumatoid factor (IgG-RF) were evaluated in 41 patients with rheumatoid arthritis (RA). The patients with positive IgG-RF with disease duration of less than two years showed increased levels in ESR, C-reactive protein, serum IgG concentrations and Lansbury's index, but they had neither extra-articular disorders nor vascular damage. However, four of eight patients with positive IgG-RF with disease duration of over five years had extra-articular disorders and vascular damage (especially interstitial pneumonia). In one early RA patient with positive IgG-RF who showed decreased levels of ESR and C-reactive protein and serum IgG concentrations, a high titer of IgG-RF was revealed over six months and joint damage progressed. In conclusion, we suggested that measurment of IgG-RF is useful in the clinical evaluation of rheumatoid arthritis associated with extra-articular disorders, vascular damage, and joint damage progression.

98 Background: Postoperative pulmonary complications (PPCs) are the most common cause of serious morbidity following esophageal cancer resection and are associated with a poorer prognosis in esophagectomized patients (pts). We have recently reported that thoracoscopic esophagectomy (TSE) decreases PPC frequency. However, it remains unclear whether the frequency is further decreased by the combination with laparoscopic esophagectomy (LSE). This study aimed to clarify the combined effect of TSE with LSE on the prevention of PPCs and to determine the preventive factors for PPCs following esophagectomy using data from JCOG0502. Methods: JCOG0502 is a four-arm prospective study comparing esophagectomy with definitive chemoradiotherapy for T1bN0M0 cancer, with randomized and patient preference arms. The primary endpoint is overall survival, which will be analyzed in 2018. PPCs were defined as one or more of the following ≥ grade 2 postoperative morbidities per CTCAE v3.0: pneumonia, atelectasis, and acute respiratory distress syndrome. The use of TSE and/or LSE was decided at the surgeon’s discretion. Results: Totally, 379 pts (11 in the randomized and 368 in the patient preference arm) were enrolled between 2006 and 2013 from 37 institutions. Of the 210 pts who underwent esophagectomy, TSE was performed in 101 pts (TSE with laparotomy in 43 pts and TSE with LSE in 58 pts), while esophagectomy via thoracotomy was performed in 109 pts. PPCs occurred less often in pts who underwent TSE than esophagectomy via thoracotomy (15.8% vs 30.3%, p = 0.01); however, there was no difference in the frequency of PPCs between those who underwent TSE with laparotomy and TSE with LSE (16.3% vs 15.5%). In univariate analysis, both TSE (shown above) and less blood loss ( < 350 mL) were associated with the prevention of PPCs (16.3% vs 30.2%, p = 0.02). Multivariate analysis showed that TSE was associated with the prevention of PPCs [Odds ratio, 0.33; 95% confidence interval (0.12-0.88); p = 0.03]. Conclusions: This study indicated that TSE was the only independent preventive factor for PPCs following esophagectomy, and LSE had limited effectiveness in the prevention of PPCs when it is combined with TSE. Clinical trial information: UMIN000000551.

A novel cytotoxic compound, nakiterpiosin (1), was isolated from the Okinawan sponge Terpios hoshinota. Its structure was determined by spectroscopic analysis. The absolute stereostructure of 1 was also determined by a modified Mosher's method. Nakiterpiosin showed potent cytotoxicity against P388 cells.

Background/aims Pylorus-preserving gastrectomy (PPG) was introduced as a function preserving and minimally-invasive surgery for early gastric cancer (ECG). We investigated the long-term clinical and oncological outcomes of the procedure. Methodology A total of 433 patients who underwent PPG between 1993 and 2009 were assessed retrospectively. Results The accuracy of the preoperative diagnosis of EGC was 93.1%. The incidence of lymph node metastasis was 3.7%. The median follow-up period was 77 (9-201) months. The overall 5-year survival rate was 96.6%. Three patients with advanced cancer developed recurrence and died. Thirteen patients developed a second primary gastric cancer in the remnant stomach. Four patients were treated by endoscopic resection, and nine underwent gastrectomy all with curative intent. The incidence of regurgitation and gastric-fullness at 5 years after PPG were 6.1% and 1.5%. Endoscopic findings of residual food, gastritis, bile reflex and reflux esophagitis were 19.1%, 11.0%, 3.0%, 10.0%, respectively. The mean relative body weight recovered up to 94.0% of that prior to surgery after 1 year and maintained. Conclusions PPG is a safe operative procedure for patients with EGC. It is important to improve the accuracy of preoperative diagnosis, and patients should be carefully followed-up to detect remnant stomach cancer.

A 69-year-old man suffering from heart-burn was referred to our hospital, and diagnosed as type 3 advanced gastric cancer with lymph node metastasis. Neoadjuvant chemotherapy (NAC) with docetaxel, cisplatin and S-1 was attempted. After two courses of chemotherapy were completed, distal gastrectomy with D2 lymphadenectomy was performed. Pathologically, there were no viable cancer cells remaining in the primary lesion and lymph nodes. The pathological response of NAC was judged to be grade 3. The postoperative course was uneventful, and the patient is currently visiting our outpatient clinic for treatment with S-1 as postoperative adjuvant chemotherapy.

Novel imidazole compounds, catharsitoxins A, B, C, D, E and F, were isolated from the Chinese remedy qiung laug. Their structures were determined by 2D NMR. To confirm their structures and to ensure an adequate supply for further biological studies, catharsitoxins A and D were synthesized.

Terpiodiene (1), a novel tricyclic alcohol, was isolated from the Okinawan sponge Terpios hoshinota, which overgrows and kills corals. Its structure was determined by spectroscopic analysis and the modified Mosher’s method. This compound exhibited moderate cytotoxicity against P388 cells.

Background The clinical significance of operative treatment for metachronous pulmonary metastasis from esophageal carcinoma is unclear. Methods We retrospectively reviewed 23 consecutive patients who underwent operative resection for metachronous pulmonary metastasis from esophageal carcinoma from 1991 to 2008. Patient baseline characteristics, survival probability, and prognostic factors were analyzed. The median follow-up period was 31 months for surviving patients. Results There were 19 men and 4 women, with a median age of 66 years at the time of pulmonary resection. The median disease-free interval was 15.5 months. Cervical or mediastinal lymph node metastases preceded pulmonary metastases in 4 patients. Seven patients (30.4%) had multiple metastases with a maximum number of 4. The median operative time and blood loss were 94.5 minutes and 18 mL, respectively. The median length of postoperative stay was 12.5 days. The predicted 1-, 3-, and 5-year survival rates using the Kaplan-Meier method were 73.9%, 43.5%, and 43.5%, respectively, with a median survival time of 28.7 months. Univariate analysis revealed that an extrapulmonary metastasis as the initial recurrence site was an unfavorable prognostic factor (P = .0411). Multivariate analyses, however, did not identify the initial recurrence site as an independent prognostic factor (P = .0542). Conclusion Operative resection for metachronous pulmonary metastasis from esophageal carcinoma is an acceptable treatment. This study of a limited number of patients may have created a constitutional selection bias. An antecedent extrapulmonary metastasis was found to be an unfavorable prognostic factor.

A 73-year-old woman had a laparoscopic cholecystectomy for unexpected gallbladder cancer and 9 days later underwent both a liver bed resection and lymph node dissection. Four years later, she underwent a further resection of a port site recurrence of gallbladder cancer and no other site of recurrence was observed. The seeding of cancer cells during the removal of the resected gallbladder might have caused this tumor. This case may show that the port site recurrence did not necessarily indicate an incurable stage of the disease. In addition, an excision of the recurrent tumor also appeared to eliminate the disease in the patient.

To evaluate the effect of hepatic resection for synchronous liver metastasis from gastric cancer, the clinicopathological factors of gastric cancer, the size and number of liver metastasis and surgical procedures for liver metastasis were studied. Between 1977 and 2006, a total of 49 patients (38 men and 11 women) underwent hepatic resections and gastrectomy. The median age was 70 years old (range 41-81). As for pathological type, intestinal/diffuse was 26/23. T1/T2/T3/T4 was 4/14/23/8. For lymph node metastasis, N0/N1/N2/N3 was 4/15/18/12. The number of liver metastasis: 27 patients had 1 lesion, 9 patients had 2 lesions, and 13 patients had more than 3 lesions. A partial resection was performed for 37 patients. MST was 663 days. The 5-year survival rate was 19.7%. Univariate analysis pointed out several prognostic factors such as histological type of primary lesion, T-factor, lymph node metastasis, the number and size of liver metastasis and the procedures for hepatic resection. Multivariate analysis revealed that two factors of N0 or N1 in lymph node metastasis and partial resection of liver metastasis were favorable independent prognostic factors (p=0.0108 and p=0.0192). In conclusion, N0 and N1 state and partial resection of the liver metastasis would be good candidates for gastrectomy and synchronous resection of liver metastatic lesions.

Feasibility and efficacy of S-1 and cisplatin followed by surgery was evaluated, and factors contributing to survival benefit were analyzed.In total, 120 consecutive patients with highly advanced gastric cancer were treated with S-1 (80 mg/m(2) for 21 consecutive days) and cisplatin (50 mg/m(2) on day 8).The response rate was 62.5% overall, and 75.7% for these with metastatic lymph nodes. Grade 3/4 adverse events were less than 10%. The median survival time was 41.9 months among 93 patients whose primary lesion was resected. Liver metastasis, R2 resection, poor performance status and lack of response were identified as independent risk factors by a multivariate analysis.Preoperative chemotherapy with S-1 and cisplatin was effective. The results show the need for different approaches in the treatment of patients with metastases and these without.

Although the prognosis of gastric cancer after R0 resection is considered to be comparatively satisfactory , some patients experience cancer recurrence according to their stage. Recurrence patterns after curative gastrectomy and follow-up surveillance were studied. An analysis was done in about 307 (8.0%) patients with recurrences of 3,861 primary gastric cancers who underwent R0 resection with sufficient lymph node dissection from 1990 to 2006.The median age was 64 years old, and there were 211 men and 96 women. The recurrence rates were hematological 41%, peritoneal 33%, and remote lymph nodal 24%, though peritoneal recurrence was most frequent in references. There were many peritoneal and remote lymph nodal recurrences in undifferentiated adenocarcinomas, and hematological recurrences in differentiated adenocarcinomas. In pT1, hematological recurrences were 83% and lymph nodal recurrences were 17%, even after 5 years. In more than half, remnant stomach cancers were found, and these cases underwent surgery again 5 years after primary surgery. The frequency of peritoneal recurrence was increased remarkably in pT3 and pT4. The proportion of recurrence was 77% within 2 years and 91% within 3 years, respectively. There was no difference between lymph nodal, hematological and peritoneal recurrence in survival time after primary surgery and even after recurrence. Referring to these results, follow-up surveillance plans for early and advanced gastric cancers were made. Surveillance was to be continued for 10 years after surgery in the early cancers and 5 years after surgery in the advanced cancers. Moreover, a mass surveyor complete medical checkup was recommended at 5 years after surgery. A standard follow-up plan will be made soon for early and advanced gastric cancer patients, respectively, though it is not necessarily the same in several institutes. There is no consensus yet regarding the intensive follow-up plan after R0 resection, because the evidence of efficacy is not yet confirmed. In conclusion, an intensive scientific investigation of the follow-up plan is required to determine wether or not there are survival benefits.

Prognostic factors after radical operation for middle and distal bile duct cancer are not fully understood. The aim of this study is to identify prognostic factors for patients undergoing radical operation for middle and distal bile duct cancer.The records of 57 patients with middle (n=22) and distal (n=35) bile duct cancer who had undergone radical surgery were reviewed (pancreaticoduodenectomy in 46 patients, extrahepatic bile duct resection in 6, and major hemihepatectomy in 5). The clinicopathological prognostic factors affecting survival were examined.The 5 years survival rate was 36% (median survival time, 34 months). Significant prognostic factors according to univariate analysis include pT classification, papillary type, number of metastatic lymph node, positive radial margin, pancreatic invasion, lymphatic invasion, venous invasion, common hepatic node metastasis, paraaortic node metastasis, and combined vascular resection. Independent significant prognostic factors according to multivariate analysis include the number of metastatic lymph nodes (5 or more), positive radial margin, and common hepatic node metastasis.The number of metastatic lymph nodes, common hepatic node metastasis, and positive radial margin are independent prognostic factors for middle and distal bile duct cancer. The surgical treatment of middle and bile duct cancer should achieve a negative radial margin for a favorable outcome.

We report three cases of complete response (CR) after treatment with UFT/LV for recurrent colorectal cancer. Case 1: A 44-year-old man was diagnosed with multiple liver metastases after resection of cecal cancer. UFT (500 mg/day)/Leucovorin (75 mg/day) was administered. Metastatic lesions of the liver completely disappeared on computed tomography(CT)one month after chemotherapy. Grade 2 hyperbilirubinemia and grade 1 diarrhea, pigmentation and rash were recognized. No signs of recurrence were observed for 35 months. Case 2: A 66-year-old man who underwent left colectomy and partial hepatectomy for transverse colon cancer and descending colon cancer with liver metastasis was determined to have multiple lung metastases. UFT/LV therapy was started. The lung lesions became only scars 7 months later. Adverse events were not seen. No other recurrence was found over 20 months. Case 3: A 66- year-old woman was detected with a lymph node recurrence after surgery for rectal cancer. CT revealed the disappearance of the tumor after 7 courses of UFT/LV therapy. Grade 2 hyperbilirubinemia appeared. Recurrence was not observed for 22 months, and the treatment has been discontinued.

A 77-year-old male had complaints of epigastralgia. Gastrointestinal endoscopic examination revealed type 2 advanced gastric cancer. Computed tomography revealed metastatic Bulkey group 2 lymph nodes. The diagnosis was sStage IIIB gastric cancer (sT3 sN2sH0 sP0 CY0) at staging laparoscopy. S-1 (100 mg/body/day) was orally administered for 3 weeks followed by a drug-free 2 weeks, and CDDP (74 mg/body/day) was given intravenously on day 8. After 3 courses of chemotherapy, the primary lesion and the regional lymph nodes were significantly reduced in size. He was judged as clinical PR, followed by total gastrectomy, splenectomy and lymph node dissection. The pathological findings showed that there were very few cancer cells in the primary lesion, and lymph nodes had become scarred and fibrous. The final diagnosis was T2N0 H0 P0, fStageIB and curability A.

The aim of this study was to evaluate the strategy for patients with cytology positive and peritoneal dissemination from gastric cancer. Thirty eight of POCY1, three of P1, eight of P2 and thirty six of P3 from advanced gastric adenocarcinoma at staging laparoscopy were studied. Gastrectomy after staging laparoscopy was performed in 10 patients (Surgery group). NAC following gastrectomy after staging laparoscopy was performed in 31 patients (NAC group) in POCY1, P1. The overall response rate was 29%, twenty of the 31 patients (65%) in the NAC group revealed no free cancer cells at the operation. The overall 5-year survival rate in 41 patients of POCY1, P1 was 15%. There was a significant deference in the overall survival curves between Surgery and NAC groups. The overall 2-year survival rate in 44 patients of P2, P3 was 9%. NAC for patients with positive cytology could lead into free cancer cells at a high rate, but not to improve their prognoses. An intensive chemotherapy including intra-abdominal chemotherapy should be necessary for these patients.

In the present study, we demonstrated a surgical submucosal resection (SSR) with an early stage gastric cancer for 212 patients. We assessed the results of SSR in 212 patients based on the outcome of surgery, recurrent cases and prognoses.The mean operation time was 93 +/- 36 minutes, bleeding volume was 34.6 +/- 12.0 mL, and postoperative hospitalization in days was 11 +/- 4 days. Pathological examination revealed a tumor invasion of the mucosal layer in 155 cases, submucosal layer in 55 cases, and proper muscle in 2 cases. There were 14 cases (6.6%) of incomplete resection. We performed a curative resection for 6 cases and a frequent follow-up for 7 cases of incomplete resection. There was one gastric cancer death case in incomplete resection. There were no recurrent cases in complete resection. However, we found 3 missing diagnosis cases of synchronous multiple gastric cancer and 10 metachronous multiple gastric cancer cases.SSR is a useful option of minimally invasive surgery for an early stage gastric cancer.

From the standpoint of the surgery, the treatment strategy for the type IV gastric cancer (GC) was studied. Recently, the resected rate of type IV GC has been increasing, though the number of operated GC patients is decreasing. The five-year survival rate was about 20% in all and around 30% in the curatively resected pts. As a result of examination of our pts with type 4 GC, multimodality therapy including neoadjuvant chemotherapy and extended surgery is recommended for pts with P 0/CY 0 or P 0/CY 1 but without other remaining GC lesions. Palliative gastrectomy and postoperative chemotherapy are recommended if performed safely to prevent such symptoms in spite of unresectable metastasis for pts with urgent symptoms such as bleeding, stricture, pain or malnutrition. For pts with P 2/P 3 but without passage disturbance, intensive chemotherapy is selected. But the propriety for selection of reduction surgery for pts with P 2/P 3 is controversial. The results of the prospective randomized controlled study of reduction surgery in non-curative advanced gastric cancer by the Gastric Cancer Surgical Study Group in Japan Clinical Oncology Group (JCOG) are expected.

Postoperative morbidity is a significant problem associated with pancreaticoduodenectomy. The clinical value of probiotics in surgical patients remains unclear. This study investigated the effect of probiotics on surgical outcome after pancreaticoduodenectomy.Seventy patients with pancreaticobiliary diseases were randomly allocated to two groups before pancreaticoduodenectomy, one of which received probiotics perioperatively and the other served as controls. Postoperative infectious complications were recorded.Of the 70 patients, 64 completed the trial (30 receiving probiotics and 34 controls). The probiotics used in the study contained Enterococcus faecalis T-110, Clostridium butyricum TO-A, and Bacillus mesentericus TO-A. The probiotics were first administered immediately after admission, 3 to 15 days before the operation, and then reintroduced on the second postoperative day. They were continued until hospital discharge. Infectious complications occurred after pancreaticoduodenectomy in 25 patients (39%). The incidence of infectious complications in the probiotics group (23%, 7/30) was significantly lower than in controls (53%, 18/34) (P = 0.02). Mortality amongst all patients was 1.6% (1 patient in the control group).The use of perioperative probiotics reduced postoperative infectious complications after pancreaticoduodenectomy, making it a promising potential adjunct therapy for patients undergoing high-risk hepato, biliary, and pancreatic surgery.

The aim of this study was to assess whether the sentinel node concept could be applicable to clinically early carcinoma of the esophagus. We studied ten consecutive cT1N0 patients who underwent radical esophagectomy with regional lymph node dissection. On the day before surgery, 99m-Tc tin colloid was injected endoscopically around the primary tumor. Lymphoscintigraphy was also performed about three hours after injection. Immediately after surgery, the radioactivity of all dissected lymph nodes was measured with a hand-held gamma probe. The radioactivity and the metastatic status assessed by routine histopathologic examination were compared. A total of six patients had hot spots detected by lymphoscintigraphy, of which the detection rate was 60% (6 of 10). The ex vivo hot node detection rate was 90% (9 of 10). Three patients were found to have metastatic nodes. In one patient, sentinel node mapping failed to identify any hot spot or hot node. In the other two patients, the metastatic nodes did not correspond to hot nodes. The accuracy of hot node status was 77.8% (7 of 9), and the false-negative rate was 100% (2 of 2). The present study showed that radio-guided sentinel node detection is insufficiently reliable at present due to the high false-negative rate and low accuracy.

Recurrence patterns after curative gastrectomy and follow-up surveillance were studied by referring to the literature. An analysis was done of 151 (11.5%) recurrent patients among 1,323 primary gastric cancer patients after curative (R0) resection. The recurrence rate was hematologic in 43%, peritoneal in 32.5%, and remote lymph node in 22.5%, although peritoneal recurrence was the most frequent in references. There were many peritoneal and remote lymph node recurrences in undifferentiated adenocarcinoma and hematologic recurrence in differentiated adenocarcinoma. In pT1, the hematologic recurrence rate was 90% and lymph node recurrence rate was 10%, which occurred even after 5 years. The frequency of peritoneal recurrence increased markedly in pT3. The rate of recurrence was 74.1% within 2 years and 88.1% within 3 years. There was no difference between lymph node, hematologic, and peritoneal recurrence in terms of survival time after surgery or even after recurrence. Referring to these results, follow-up surveillance programs for early and advanced gastric caner were developed. Surveillance will be continued for 10 years after surgery and mass survey or complete medical checkup is recommended 5 years after surgery. A standard follow-up program should exist, although it is not necessary for it to be the same in different institutes. There is as yet no consensus regarding intensive follow-up after curative gastrectomy because the evidence of efficacy is weak. In conclusion, a randomized, controlled trial of intensive follow-up is required to demonstrate the survival effect of surveillance.

Free cancer cells from advanced gastric cancer are associated with a poor prognosis. The aim of this study was to clarify the role of neoadjuvant chemotherapy (NAC) for patients with positive cytology from advanced gastric cancer. Thirty four patients with positive cytology and no macroscopic peritoneal deposits from advanced gastric adenocarcinoma at staging laparoscopy were studied. Gastrectomy after staging laparoscopy was performed in 9 patients (Surgery group). NAC following gastrectomy after staging laparoscopy was performed in 25 patients (NAC group). The overall response rate was 24% (CR in none, PR in 6, NC in 15, PD in 4). Two of the 4 patients with PD did not undergo surgical resection. Twenty three patients in the NAC group (resection rate 92%) underwent gastrectomy, which resulted in 17 R0, four R1, and two R2 resections. Eighteen of the 23 patients (78%) in the NAC group revealed no free cancer cells at operation. There was no significant deference in the overall survival curves between Surgery and NAC groups. Five of the 17 patients performed curative operation developed recurrence (peritoneum in 1, liver in]1, brain in 1, local and peritoneum in 1, paraaortic lymph node and peritoneum in 1). NAC for patients with positive cytology could lead into no free cancer cells at a high rate, but not to improve their prognoses. An intensive chemotherapy after gastrectomy should be necessary for these patients.

114 Background: Surgery is the standard of care for stage I esophageal squamous cell carcinoma. However, definitive chemoradiothearpy (CRT) is optional treatment which can preserve organ function with cure. The aim of this study was to investigate what factors have influence patients(pts)’ decision on the treatment, surgery or CRT. Methods: JCOG0502 is a randomized controlled trial comparing surgery to CRT. Sufficient information about both treatments was provided for pts before enrollment. Pts who declined to participate in randomized part can choose a preferred treatment and join a non-randomized part of JCOG0502. Between Dec 2006 and Feb 2013, 379 pts were enrolled to JCOG0502 from 37 institutions of Japan Clinical Oncology Group. Among those, 368 pts who enrolled to non-randomized part were analyzed. Clinical baseline data, social data and doctor’s preference which was not mandatory informed to patients were collected on the case report forms and compared between surgery arm and CRT arm. Preference of doctors for each pt was divided into three categories, A: “surgery is preferred”, B: “either is adequate” and C: “CRT is preferred”. This trial was registered as UMIN000000551. Logistic regression were performed to evaluate the influence of each factors. Results: Of the 368 pts, 209 pts chose surgery with their own intention, while 159 pts chose CRT. There were no differences on baseline clinical characteristics between two groups except median age (Surgery: CRT = 62:65 years). Multivariate logistic regression analyses showed that >=65 years (vs

10 Background: Recently, a limited operation to avoid needless lymph node (LN) dissection in clinical T1bN0 esophageal cancer (EC) is considered. However, how LN dissection or radiation field should be decided for such cases has not yet been clarified. The information about prevalence of LN metastases (LNMs) would be valuable when the radiation field and extent of LN dissection are considered in the treatment of T1bN0 EC. Methods: JCOG0502 is a randomized controlled trial including a patient preference arm comparing surgery alone to definitive chemoradiotherapy in clinical T1bN0 EC. By using baseline clinical and pathological data of JCOG0502, diagnosis accuracy of LNM was evaluated by comparing clinical and pathologic findings. Then, the sites of pathologic LNMs were determined and the initial sites and the prevalence of LNM were estimated. Results: Between Dec 2006 and Feb 2013, 213 patients (pts) enrolled to the surgery arm in JCOG0502. Pts with multiple lesions or without esophagectomy were excluded and remaining 186 pts were analyzed. Of the 186 pts of clinical T1bN0, 137 pts were diagnosed as LNM negative (73.7%: accuracy of diagnosis), however, 49 pts (26.3%) had pathologic LNMs. Pathologic LNMs were seen at 106recR, 106recL (all in mediastinal region) in upper thoracic (Ut) EC, 101R, 101L, 104R, 104L (in the neck region), 106recR, 106recL, 106tbL, 105, 107, 108, 109L, 110 (in the mediastinal region), 1,2,3,7, 11 (in the abdominal region) in middle thoracic (Mt) EC, and 105, 106recL, 110 (in the mediastinal region), 1, 2, 3, 7 (in the abdominal region) in lower thoracic (Lt) EC, respectively. Of the 49 pts who had pathologic LNMs, 32 pts (65%) were of pathologically N2 or more. Furthermore, 18 pts (37%) had skip LNM (LNM of N2, N3 or N4 without N1). The solitary pathologic LNM was observed in 25 pts: N1 (106recR, 106recL) in Ut, N1 (106recR, 106recL, 108), N2 (101R, 105, 110, 1, 3, 7), in Mt, N1(110, 1), N2 (106recL, 3, 7) in Lt, respectively. Conclusions: In the current status of clinical diagnosis, limited LN dissection or limited field of radiation are not recommended. In surgery, D2 LN dissection is necessary and three-field LN dissection is recommended especially in middle thoracic EC even for clinical T1bN0. Clinical trial information: UMIN000000551.

155 Background: Although the impact of postoperative complications, especially infectious complications (IC), on long-term survival after transthoracic esophagectomy remains controversial to date, we hypothesized that postoperative IC may affect tumor recurrence and survival of the patients (pts) undergoing transthoracic esophagectomy. Methods: The data from JCOG9907 (Ando N; Ann Surg Oncol 2012) was used to estimate the influence of IC on the outcome of current standard preoperative chemotherapy followed by surgery for clinical stage II/III squamous cell carcinoma of the thoracic esophagus. IC were classified into three: pneumonia, anastomotic leakage, and the others. OS and PFS were estimated by landmark method at 6 months from randomization. Univariate and multivariate analyses using Cox proportional hazard model were performed to assess the impact of postoperative complications on the survival after right-transthoracic esophagectomy with extended lymphadenectomy. Results: Among the 152 analyzed pts, the incidence of overall IC was 36%, among which pneumonia and anastomotic leakage were observed both in 14%. OS of pts with any IC (n=54) was shorter than that of pts without IC (HR 1.66, 95%CI [1.02-2.71]) and PFS also tended to be shorter in pts with any IC (HR 1.44, [0.92-2.23]). OS of pts with pneumonia (n=22) was shorter than that of pts without pneumonia (HR 1.82, [1.01-3.29]), and PFS also tended to be shorter in pts with pneumonia (HR 1.50, [0.85-2.62]). OS of pts with anastomotic leakage (n=21) were nearly identical to that for pts without leakage (HR 1.06, [0.52-2.13]) and PFS was slightly shorter in pts with leakage (HR 1.28, [0.71-2.32]). Multivariate analysis revealed that pneumonia tended to compromise OS and PFS (HR 1.66, [0.87-3.17] and HR 1.37, [0.75-2.51]). Conclusions: This study reveals that postoperative morbidity, especially pneumonia may deteriorate the survival of pts undergoing esophagectomy after preoperative chemotherapy. Achieving esophagectomy without postoperative complications might prolong OS and PFS. Clinical trial information: NCT00190554.

We report a 74-year-old man with advanced gastric cancer that showed a remarkable response to treatment with a combination of paclitaxel and low-dose 5-fluorouracil and cisplatin (FP) as neoadjuvant chemotherapy (NAC). The patient was admitted complaining of epigastral discomfort. Endoscopic examination revealed type 3 advanced gastric cancer with pylorus stenosis. Computed tomography (CT) revealed metastasis to group 2 lymph nodes. Staging laparoscopy was performed for accurate preoperative staging. Although peritoneal seeding was not found, peritoneal washing cytology was positive (Class V). Tumor marker of serum carcinoembryonic antigen (CEA) was elevated to 9 1.2 ng/ml. After the second course of combined chemotherapy, endoscopic examination and CT revealed marked reduction of the primary tumor and metastatic lymph nodes. Shrinkage of the primary tumor was also shown by gastrography. Distal gastrectomy with Billroth-II reconstruction was then performed. The histopathological findings showed disappearance of the carcinoma as primary lesion. Many lymph nodes whose metastatic lesions revealed a complete response, but 6 lymph nodes had remaining viable cancer cells. Paclitaxel and low-dose FP therapy are useful as NAC for advanced gastric cancer.

More accurate preoperative staging is necessary to determine the treatment strategy for locally advanced gastric cancer. Laparoscopy has been suggested as an appropriate staging modality. The aim of this study was to clarify the role of staging laparoscopy in patients with locally advanced gastric cancer.One hundred patients with primary gastric adenocarcinoma underwent laparoscopy with peritoneal lavage cytology. The disease stages determined were compared with those obtained by conventional methods.The disease stages were corrected after laparoscopy for 47 of the 100 patients (47%), with downstaging in 3 (3.0%) and upstaging in 44 (44%). Peritoneal deposits were found in 7 patients with peritoneal dissemination diagnosed by conventional examination. An unsuspected peritoneal deposit was found in 21 of 93 patients (22.6%), and unsuspected free cancer cells without deposits were found in 27 of 93 patients (29.0%). Gastrectomy after staging laparoscopy was performed in 39 patients. Laparoscopy showed no peritoneal deposits in any of these patients. Free cancer cells were found in 9 patients (23.1%), but 4 of these had peritoneal deposits at operation. R0 resection was performed in 34 of the 39 patients (87.2%). Neoadjuvant chemotherapy after staging laparoscopy was performed in 35 patients. All 35 patients underwent gastrectomy, which resulted in 27 R0 and 8 R2 resections. Of 18 patients with positive cytology at laparoscopy, 11 had no free cancer cells at operation. Neoadjuvant chemotherapy induced downstaging of the disease in 11 of the 18 patients with positive cytology (61.1%). Of 26 patients with massive peritoneal deposits, 4 underwent palliative resection because of pyloric stenosis. Twenty-two patients (22.0%) were able to avoid unnecessary laparotomy because of the staging laparoscopy.Staging laparoscopy with peritoneal lavage cytology is a safe, effective tool in patients with locally advanced gastric cancer, especially in patients receiving neoadjuvant chemotherapy.

A 54-year-old woman with advanced gastric cancer was referred to our hospital. Because it was the yearend, we selected neoadjuvant TS-1 combined with CDDP therapy. TS-1 (60 mg bid) was administered orally for 21 consecutive days, and CDDP (60 mg/m(2)) was infused intravenously on day 8. One course was completed without serious toxicities. The primary tumor revealed partial response (PR) with no lymph node metastasis judged from barium meal study and upper GI endoscopic findings. After 3 weeks, a simple total gastrectomy with lymph node dissection was performed. The pathological diagnosis proved that there were no cancer cells in the primary lesion or regional lymph nodes, suggesting a complete response (CR) to chemotherapy. The postoperative course was uneventful, and she has been fine as an outpatient.

Twenty-one patients with lumbar canal stenosis were treated with intravenous Prostaglandin E1 (PGE 1). 8 cases were judged by patients to be satisfactory, but PGE 1 was not effective in 13 cases. All patients had Myelography and CT imaging before the treatment. In order to evaluate any correlation between the canal dimension and the effectiveness of PGE 1, we reviewed the computed tomography scans. A significant difference was found between the effectiveness of PGE 1 in the group with root tunnel stenosis compared to the group with no root tunnel stenosis. It was suggested that the autonomic nerve system arround the root had something to do with the effectiveness of PGE 1 for lumbar canal stenosis.

Since 1988, we have performed intraoperative peritoneal washing cytology (CY) of the Douglas pouch in 1,255 patients (pts) with gastric cancer to diagnose latent peritoneal dissemination. Patients were classified as follows: 914 pts in P0, CY0; 100 pts in P0, CY1; 90 pts in P1; 53 pts in P2; and 98 pts in P3. Usually Papanicolaou's staining method was used and immunocytochemical staining of CEA and MOC-31 was carried out to make a definitive diagnosis. Prognostic factors were determined in 638 pts without liver metastasis by multivariate analysis. Curability, depth of tumor invasion, lymph node metastases, histological type and CY were independent prognostic factors. The survival of P0, CY1 pts who had undergone curative surgery was better than those with non-curative surgery. In conclusion, CY can serve as an independent predictor of prognosis, so immunocytochemical staining is important. P0, CY1 pts without residual cancer should be treated with multimodal therapy.

Cancer/testis antigens (CTAs) elicit immune response in cancer patients and are therefore targets of immunotherapy. Current information on CTA expression is primarily based on mRNA assays and little is known about their expression at the protein level. The objectives of our study are to analyze GAGE, NY-ESO-1, MAGE-A and SSX protein expression in esophageal cancer and to correlate their expression patterns with clinicopathologic parameters and survival. We examined CTA protein expression in 213 patients with esophageal cancer by immunohistochemistry. Antigen-positive tumors were evaluated once and antigen-negative tumors were evaluated 3 times by examining different parts of the cancer specimen. GAGE, NY-ESO-1 and MAGE-A were heterogeneously expressed in 42 (20%), 44 (21%) and 111 (52%) tumors, respectively, whereas SSX expression was not detected. Of the 126 (59%) patients expressing CTAs, 70 (33%) expressed 1, 41 (19%) expressed 2 and 15 (7%) expressed 3 antigens. The expression of MAGE-A was correlated with those of GAGE (p = 0.001) and NY-ESO-1 (p = 0.002), and the expression of GAGE was correlated with that of NY-ESO-1 (p = 0.002). One hundred fifty-six (79%) sections were positively stained in the first evaluation, whereas 37 (19%) and 4 (2%) positive sections were identified in the second and third evaluations, respectively. Particularly, MAGE and GAGE expression showed overlaps. GAGE, NY-ESO-1 and MAGE-A protein expression was not correlated with the disease progression, TNM factors or survival. The detection of immunonegative cells in every specimen suggests addition of other drugs such as 5-aza-2'-deoxycytidine to increase the therapeutic effect of CTA-specific cancer vaccines.

Background The aim of this study was to clarify whether preoperative squamous cell carcinoma-antigen messenger RNA (SCC-Ag mRNA) level in peripheral blood can be used to predict tumor recurrence after curative resection for esophageal squamous cell carcinoma. Methods A prospective analysis was conducted for 46 consecutive patients who underwent curative esophagectomy and who had no residual tumor. The SCC-Ag mRNA level in the peripheral blood of each patient was measured preoperatively by using quantitative reverse transcriptase-polymerase chain reaction. Median follow-up period was 34 months. Results Receiver operating characteristic analysis demonstrated that the optimal cutoff level of SCC-Ag mRNA was 40. Patients were divided into the high SCC-Ag mRNA level group (n = 14) and the low SCC-Ag mRNA level group (n = 32). The cumulative probabilities of tumor recurrence were higher in the high SCC-Ag mRNA level group (probability of recurrence was 71% at 2 years) than in the low group (22% at 2 years; P = .0005). SCC-Ag mRNA level (relative risk, 3.00; 95% confidence interval, 1.05-8.54; P = .040) was the strongest independent predictor of recurrence by multivariate analysis. Conclusions Preoperative SCC-Ag mRNA levels in the peripheral blood are the best predictive factor for recurrence in patients with esophageal squamous cell carcinoma who undergo curative resection (R0).

Primary spinal glioblastoma is very rare. This document describes a case of a 44-year-old female who had a history of gait disturbance and low back pain at first admission. Though myelography, metorizamide CT, and MRI showed an intramedullary mass, the expansion of the mass was not identified. Laminectomy and dural decompression were performed at the level of Th1 to Th12, and a necrotic and invasive intramedullary tumor was found. The histological examination revealed glioblastome multiforma. The patient died 2 months after surgery due to respiratory arrest. The course was extraordinarily rapid.

Two new cytotoxic compounds, nakiterpiosin (1) and nakiterpiosinone (2), were isolated from the Okinawan sponge Terpios hoshinota. Their structures were determined by spectroscopic analysis. The absolute stereostructure of 1 was also determined by a modified Mosher's method. Nakiterpiosin (1) and nakiterpiosinone (2) showed potent cytotoxicity against mouse lymphocytic leukemia cell (P388).

To clarify the benefit and indication of resection for metastatic liver tumors from gastric cancer, we reviewed the therapeutic outcomes at the Niigata University Medical Hospital and at a referred institution. From January 1982 to April 2004, thirty-nine patients with synchronous and 40 with metachronous liver metastases from gastric cancer had been treated. In synchronous cases, forty percent of the patients had many metastatic tumors in bilateral hepatic lobes and the majority of them had advanced gastric cancer with serosal invasion and widely spread of lymphatic metastases. On the other hand, over 70% of metachronous patients had unilobar or scattered bilobar metastases and only 20% of them accompanied other types of metastases. A survival analysis showed that the prognoses of patients undergoing hepatic resection were statistically better than other treatments in both synchronous and metachronous cases. And there was no evidence for the benefit of palliative gastrectomy. So we conclude that surgical treatment for hepatic metastases from gastric cancer is a beneficial option if all the lesions including the primary and lymphatic ones can be eradicated in limited candidates of synchronous cases and in more candidates of metachronous cases, especially unilobar and a few scattered bilobar metastases.

We present a case of esophageal carcinoma in which esophagectomy was not possible because of tuberculous fibrosing mediastinitis. A 77-year-old man was diagnosed with carcinoma of the thoracic esophagus and admitted to our hospital. Chest radiography on admission revealed no abnormality except pleural thickening of the pulmonary apices, suggesting a history of subclinical infection of tuberculous pleurisy. The patient underwent surgery with a curative intent. Thoracotomy revealed that the mediastinum had been replaced with dense fibrous tissues and was widely encased with laminar calcification. Esophagectomy was not performed because it was considered impossible to do so safely. Although diagnosis of fibrous mediastinitis was not made preoperatively, review of the preoperative computed tomographic scans revealed proliferation of mediastinal soft tissues that were associated with patchy and laminar calcifications. Tuberculous fibrosing mediastinitis is an uncommon but clinically important disease for physicians who are involved in the diagnosis and treatment of esophageal cancer.

SUMMARY. Self-expandable metallic stents (EMS) provide a common option for malignant esophageal stenosis because of the low complication rate and high dysphagia improvement rate. However, there are few studies on the functional duration of EMS and the extent of improvement of the quality of life. We retrospectively analyzed 18 patients who received EMSs in our division from 1996 to 2002. The median duration of possible food intake and the median survival period were 94.5 and 108 days. The median duration of domiciliary treatment was 56 days. Six of the 18 patients were not discharged from hospital after EMS insertion. The Karnofsky index was found to be a significant determinant of the feasibility of domiciliary treatment. One-third of the patients are incapable of obtaining the benefits of the palliative therapy. EMS deployment should be prudently selected for patients exhibiting low performance status.

Hallux Valgus is a common disorder in women. In addition, it is a typical deformity of the rheumatoid foot.To investigate differences in the deformity pattern between rheumatoid and non-rheumatoid hallux valgus, we carried out radiographical measurements of a number of feet parameters.The RA group consisted of 26 patients (52 feet), who were treated at the Department of Orthopaedic Surgery, Kyushu University.The non-RA group consisted of 70 patients (121 feet), who had a correction osteotomy for hallux valgus at Kyushu Chuo Hospital.The average hallux valgus angle in the RA group was 25.9 degrees, and in the non-RA group was 33.0 degrees. The M1M2 angle was 11.9 degrees in the RA group, and 17.3 degrees in the non-RA group.Investigating relationship between the two angles, the M1M2 angle was found to have a significant influence on the hallux valgus angle in the non-RA group, but not in the RA group.

Gastrointestinal stromal tumors (GISTs) are a group of neoplasms arising from mesenchymal stem cells of the gastrointestinal tract. The prognosis of metastatic or recurrent GISTs is poor, because these tumors resist chemotherapy and radiotherapy. We report a patient with recurrent GIST who underwent molecularly targeted therapy with imatinib, a novel oral tyrosine kinase inhibitor. A 50-year-old woman presented with a huge intra-abdominal mass. The patient had a history of gastrectomy for GIST and hepatectomy for its metastases. She also underwent surgery for resection of peritoneal metastases 9 months before. The abdominal mass was 26 × 17 × 12 cm in size, as determined by magnetic resonance imaging, and was diagnosed as a peritoneal relapse of GIST. Treatment with 400 mg of imatinib daily was started. After 1 week of treatment with imatinib, reduction of the abdominal tumor began to be recognized on palpation. Computed tomographic scanning on day 28 revealed that the tumor had liquefactively regressed and had reduced in size by 66%. The major side effect was leg edema, which was easily manageable with furosemide. The patient has been receiving imatinib treatment in our outpatient clinic, and the tumor regression has continued for 9 months. Imatinib shows promise as a safe and effective drug for the treatment of patients with recurrent GISTs.

Carcinomas of the hypopharynx and the cervical esophagus carry poor prognosis regardless of any treatment modality. To improve long-term survival, prognostic factors for overall survival after surgical resection of these tumors were investigated. Clinical and pathological data from 52 patients undergoing surgical resection for hypopharyngeal (n = 20) and cervical esophageal (n = 32) cancers were reviewed to assess treatment outcomes and prognostic factors. The in-hospital mortality and morbidity rates were 13.5% and 50%, respectively. The 5-year survival rate of the 52 patients was 31.2%. The depth of tumor invasion, quality of tumor clearance, gender of the patients, postoperative complications, and intramural metastasis were revealed by the univariate analysis to be significant prognostic factors. The first four of these factors were specified by the multivariate analysis as independent prognostic factors for overall survival. Complete clearance of loco-regional disease and prevention of postoperative complications are of particular importance for the improvement of long-term survival in patients with these cancers.

Adequate extent of surgical resection of simultaneous primary esophageal and extraesophageal carcinomas is controversial.Clinicopathologic records and treatment outcomes of 57 patients undergoing simultaneous resection of both synchronous esophageal and extraesophageal carcinomas (SC group) were reviewed and compared with those of 316 patients receiving esophagectomy for solitary esophageal carcinoma (EC group).Mortality and morbidity rates were 3.5% and 45.6% in the SC group, and 3.2% and 44.3% in the EC group, respectively. No significant difference was detected in either of the rates between the two patient groups. The overall 5-year survival rate of the SC group was 40%. Survival of the patients undergoing curative resection of both esophageal and extraesophageal tumors (n = 30) was significantly better than that of the patients receiving palliative resection of at least one of the two tumors in the SC group (n=27)(5-year survival, 54.2% versus 19.9%, respectively)(p0.01). Survival of the SC group patients undergoing curative resection of both tumors (n = 30) did not differ from that of the EC group patients receiving curative esophagectomy (n = 182)(5-year survival rates, 54.2% versus 60.0%, respectively).Simultaneous resection of synchronous esophageal and extraesoprhageal carcinomas can be safely performed, and complete tumor clearance of both tumors is needed for favorable long-term results.

82 Background: Esophagectomy for esophageal cancer via the thoracoscopic approach (TA) is expected to reduce the extent of trauma compared with traditional thoracotomy (TT). However, there have been few prospective studies comparing perioperative complications between TA and TT after esophagectomy. Therefore, this study aimed to clarify whether TA is a safe procedure with regard to morbidity and mortality using the data of patients (pts) who underwent esophagectomy in the JCOG0502 trial. Methods: The JCOG0502 trial is a currently on-going randomized trial including a patient preference arm of esophagectomy versus chemoradiotherapy for treatment of clinical stage I esophageal cancer. The primary analysis of overall survival is planned in 2018. In this trial, thoracic squamous cell carcinoma, adenosquamous carcinoma, and basaloid carcinoma of stage T1b/N0/M0 were eligible. When pts were randomized to surgery or selected surgery, esophagectomy with D2–3 lymphadenectomy was performed. TA or TT was selected at the surgeon’s discretion. Perioperative complications were defined as adverse events of grade 2 or greater as per CTCAE v3.0. Results: A total of 379 pts (11 randomized and 368 in the patient preference arm) were enrolled between December 2006 and February 2013 from 37 institutions, and 211 pts underwent surgery. Of these 211 pts, TA was performed in 101 pts while TT was performed in 110 pts. Blood loss was less in the TA group than in the TT group (median, 293 vs. 410 mL, respectively), and the surgical duration was longer in the TA group than in the TT group (median, 510 vs. 398 min). The proportion of intraoperative complications was similarly low in both groups. However, postoperative anastomotic leakage, pneumonia, and atelectasis were less common in the TA group than in the TT group (7%, 8%, and 11% vs. 14%, 17%, and 22%). Moreover, the proportion of recurrent nerve palsy was similar among both groups (15% vs. 16%). Each group had one in-hospital death. Conclusions: This study indicated that TA did not increase morbidity or mortality after esophagectomy and can be safely performed with risks comparable to those with TT. Clinical trial information: UMIN000000551.

Papillary adenocarcinoma is extremely rare in the squamous epithelium-lined esophagus. The histopathologic and immunohistochemical characteristics were examined in a composite tumor showing distinct papillary adenocarcinoma and squamous cell carcinoma of the esophagus resected from a 66-year-old man. The esophageal tumor consisted both grossly and histologically of two distinct components: an ulcerative part showing a squamous cell carcinoma, and a polypoid part corresponding to a papillary adenocarcinoma. In addition, the in situ squamous cell carcinoma was contiguous with the esophageal tumor. Mucin secretion was found only in the papillary adenocarcinoma component. Immunohistochemically, tumor cells of the papillary adenocarcinoma component were positive for carcinoembryonic antigen, secretory component, and lactoferrin. These staining patterns were similar to those of the normal esophageal gland proper. These histologic, mucin-histochemical, and immunohistochemical findings suggest that the papillary adenocarcinoma originated from the submucosal esophageal gland and the squamous cell carcinoma from the squamous epithelium lining the esophagus.

To define the rational extent of dissection in radical esophagectomy for esophageal cancer, survival was studied according to nodal status in 154 patients undergoing extended radical esophagectomy. The incidence of cervical metastasis in patients with upper or middle esophageal tumors did not differ between those with favorable (grade Nor = 4) or unfavorable (grade Nor = 5) lymph node status, at 28.6% vs 20%, respectively. On the other hand, in patients with lower esophageal tumors, the incidence of cervical metastasis was significantly lower in those with favorable grade (grade Nor = 4) node status than in those with unfavorable grade (grade Nor = 5) node status, at 6.5% vs 46.7%, respectively. Survival did not differ in patients with upper or middle esophageal tumors according to whether they had regional (n = 42) or distant (n = 15) lymph node metastases, the 5-year survival rates being 11.6% vs 25%, respectively. However, in patients with lower esophageal tumors, none of 10 patients with distant node metastases survived for more than 4 years, whereas the survival rate was 43.7% at 5 years for 36 patients with regional node metastases. These results show that cervical lymphadenectomy should only be performed as part of radical esophagectomy in those patients with upper or middle esophageal cancer.

TPS4152 Background: Based on the results of JCOG9907, preoperative cisplatin plus 5- fluorouracil (CF) followed by esophagectomy with D2-3 lymphadenectomy has become standard care for advanced esophageal cancer in Japan, while the standard therapy in Western countries is preoperative chemoradiotherapy. A new clinical question has thus arisen of whether CF plus docetaxel (DCF) or CF plus radiotherapy (CF-RT) shows a survival benefit over preoperative CF even with intensive surgery. Methods: Eligibility criteria include histologically proven thoracic esophageal squamous cell carcinoma with stage IB/II/III (excluding T4) based on the 7th UICC-TNM, age 20 to 75, and performance status 0 to 1. No prior chemotherapy, radiotherapy, or hormonal therapy is allowed. Adequate organ function and written informed consent are required. Patients are randomized into any of the following three arms by a minimization method balancing the arms in terms of institution and tumor depth (T1–2 versus T3). Patients in arm A (CF) receive two courses of cisplatin at 80 mg/m2 on day 1 and fluorouracil at 800 mg/m2 on days 1–5, repeated every three weeks. Patients in arm B (DCF) receive three courses of docetaxel at 70 mg/m2, cisplatin at 70 mg/m2 on day 1, and fluorouracil at 750 mg/m2 on days 1–5, repeated every three weeks. Patients in arm C (CF-RT) receive two courses of cisplatin at 75 mg/m2 on day 1 and fluorouracil at 1000 mg/m2 on days 1–4, repeated every four weeks concurrently with radiotherapy at 41.4Gy/23fr. This trial is designed to demonstrate the superiority of preoperative DCF and/or CF-RT over CF in terms of overall survival. We assumed three-year survival with preoperative CF to be 63% and expected a 10% increase in three-year survival for DCF and CF-RT. The sample size was calculated as a total of 501 patients (167 patients per arm) with a study-wise one-sided alpha level of 5%, power of 70% for each pair comparison, an accrual period of 6.25 years, and a follow-up period of three years. This trial was registered as UMIN000009482 and started in December 2012. Clinical trial information: UMIN000009482.

Terpiodiene (1), a novel tricyclic alcohol, was isolated from the Okinawan sponge Terpios hoshinota, which overgrows and kills corals. Its structure was determined by spectroscopic analysis and the modified Mosher’s method. This compound exhibited moderate cytotoxicity against P388 cells.

The cosmetic deformity of the vertical skin incision for median sternotomy was decreased by using a mechanical traction system to increase exposure at the superior margin of a shorter wound. The limited vertical skin incision did not impede technical surgical maneuvers and produced a scar that was more acceptable than submammary incision or right anterior thoracotomy. The limited skin incision is especially useful in young women with congenital heart disease.