Pancoast's Tumor: Irradiation or Surgery?

Seventy-three patients with Pancoast's tumor treated at the University of Maryland Hospital between 1955 and 1978 were reviewed. There were 34 squamous cell carcinomas, 13 undifferentiated, 10 adenocarcinomas, 4 mixed adeno-squamous, 1 alveolar cell, and 11 undetermined. Twenty-nine patients received irradiation, with 7% survival at 3 years; 19 patients underwent preoperative irradiation followed by en bloc resection of chest wall, with 23% survival at 3 years; 5 patients underwent extended resection, with 60% survival at 3 years; and 18 patients underwent operation followed by irradiation, with 7% survival at 3 years. Retrospective staging of 42 patients undergoing operation indicated that 22 (52%) were inoperable. Prognosis was related to staging of the disease, the extent of local invasion, nodal involvement, cell type, and adequacy of operation.     

The value of chest wall resection in the treatment of superior sulcus tumors of the lung

The diagnosis of superior sulcus tumor was established in 35 patients at the University of Michigan Medical Center over the sixteen-year period from 1955 through 1970. Twelve patients underwent preoperative irradiation with cobalt 60 followed by radical en bloc excision of the chest wall. None of these patients survived five years. Twenty-three patients received radiation therapy with cobalt 60 only. Three of these patients survived five years free of disease. The absolute five-year survival in the entire group of patients was 8.6%. This study raises the question of the role of radical chest wall excision in the treatment of superior sulcus tumor.     

Surgery and the management of peripheral lung tumors adherent to the parietal pleura.

Among 37 patients with peripheral T3 lung lesions, preoperative clinical and imaging evidence was suggestive of T3 disease in 28 and of T2 disease in nine. Intraoperatively, the T2 designation was changed to T3 on the basis of adherence of the tumor to the parietal pleura. All had mediastinoscopy followed by resection and complete lymph node dissection. There were 17 lobectomies and 20 pneumonectomies. The chest wall was resected in continuity with the lung in 21 patients, and in 16 only an extrapleural resection was done. Follow-up was completed in all patients (range 2 to 14 years, median 7 years). The 5-year actuarial survival rate for all patients was 30%. As expected, the presence of lymph node metastasis affected the 5-year actuarial survival rate: N0 = 41%; N1 = 29%, and N2 = 0%. Histologic examination of the resected specimen confirmed a T3 lesion in 30 patients. The tumor was removed completely in 100% of patients whose chest wall was resected in continuity with the lung but in only 31% in whom an extrapleural resection was done. In the absence of lymph node metastasis, the 5-year survival rate of patients after en bloc resection of the chest wall was 50% compared with 33% for those with extrapleural resection (p less than 0.05). The finding of a peripheral lung tumor adherent to the parietal pleura indicates, in most instances, extension through the parietal pleura. When tumor is firmly adherent to the parietal pleura, an en bloc resection of the chest wall rather than an extrapleural dissection should be performed. This assures complete tumor removal and improves the probability of long-term survival.     

Effect of preoperative chemotherapy for bulky N2 non-small-cell lung cancer]

The effect of chemotherapy as the adjuvant therapy to bulky N2 disease (stage IIIA) non-small-cell lung cancer was examined. From January 1992 to December 1996, 464 patients with non-small-cell lung cancer underwent surgery. Seven patients (1.5%) with N2 disease (stage IIIA) received two cycles of preresectional cisplatin and vindesin chemotherapy, followed by standardized surgical resection (Group A). 46 patients (9.9%) had pathological N2 disease (T1-3, M0) after surgery (Group B). In Group A a complete resection was accomplished in two patients (28.6%), and five patients had incomplete resection with a deseased margin, followed thoracic irradiation 60 to 75 Gy. In three patients in Group A the N2 disease was pathologically downstaged to N1 or N0 disease. Overall survival at five years in Group A and in Group B was 48% and 39%, and median survival time was 49 months and 38 months. Although complete resection rate was lower in Group A (28.6%) than in Group B (78.2%), there was no significant difference between five year survival and median survival time in Group A and Group B. These data may be thought to suggest that induction chemotherapy in Group A was effective on occult micrometastatic disease.     

Midline anterior craniofacial approach for malignancy: results of en bloc versus piecemeal resections

Thirty consecutive cases of midline anterior craniofacial procedures for the treatment of malignant neoplasms arising from the paranasal sinuses were reviewed. Posterior and lateral base craniofacial procedures were specifically excluded. This review compares the results, in terms of survival and major complication rate, between en bloc and piecemeal resections. The average follow-up was 4 years and 3 months. Sixteen patients were treated with an en bloc resection. The major complication rate was 31%. One-year survival rate was 94% for the en bloc resection group, 67% for patients with positive margins, and 100% for patients with clear margins. Three-year survival for en bloc resection dropped to 56, 33, and 67%, respectively. Fourteen patients were treated with piecemeal resections. The major complication rate was 21%. One-year survival rate was 83% for the piecemeal resection group, 60% for patients with positive margins, and 100% for patients with clear margins. Three-year survival dropped to 70, 60, and 80%, respectively. Although it is considered desirable to obtain an en bloc resection in some craniofacial procedures, we conclude that a piecemeal resection is a viable alternative in situations where an en bloc procedure is difficult to obtain safely.     

Midline Anterior Craniofacial Approach for Malignancy: Results of En Bloc Versus Piecemeal Resections

Thirty consecutive cases of midline anterior craniofacial procedures for the treatment of malignant neoplasms arising from the paranasal sinuses were reviewed. Posterior and lateral base craniofacial procedures were specifically excluded. This review compares the results, in terms of survival and major complication rate, between en bloc and piecemeal resections. The average follow-up was 4 years and 3 months. Sixteen patients were treated with an en bloc resection. The major complication rate was 31%. One-year survival rate was 94% for the en bloc resection group, 67% for patients with positive margins, and 100% for patients with clear margins. Three-year survival for en bloc resection dropped to 56, 33, and 67%, respectively. Fourteen patients were treated with piecemeal resections. The major complication rate was 21%. One-year survival rate was 83% for the piecemeal resection group, 60% for patients with positive margins, and 100% for patients with clear margins. Three-year survival dropped to 70, 60, and 80%, respectively. Although it is considered desirable to obtain an en bloc resection in some craniofacial procedures, we conclude that a piecemeal resection is a viable alternative in situations where an en bloc procedure is difficult to obtain safely.     

Surgical treatment of lung carcinoma involving the chest wall

From 1969 to 1986, 97 patients with chest wall invasion by lung carcinoma (excluding superior sulcus tumours) underwent surgical resection in two hospitals, La Paz (Madrid) and La Fé (Valencia). The same surgical policy was used in both thoracic surgical units: extrapleural pulmonary resection when tumour involved only the parietal pleura (N = 36), and en bloc chest wall resection when the carcinoma extended into the ribs and intercostal muscles (N = 61). The tumour histology was classified according the WHO criteria. Lobectomy or bilobectomy was carried out in 72%, pneumonectomy in 18% and segmentectomy or wedge resection in 10% of the patients. The perioperative mortality was higher in the en bloc resection group 9/61 (15%) versus 2/36 (6%) for extrapleural dissection. The node staging was NO in 58/97 (60%), N1 in 16/97 (16%) and N2 in 23/97 (24%). The probability of survival was calculated by the Kaplan-Meier method collecting data from the perioperative survivors only. The overall 5-year survival was 23% with no significant differences between the en bloc resection and the extrapleural lung resection groups. The most important predictor of survival was the node stage. The 5-year survival for N1 and N2 were 8% and 6%, respectively. These percentages increased to 34% when N0 patients were considered. Other predictors of survival were not significant. The authors conclude that either extrapleural or en bloc chest wall resection are both valid procedures which may be used depending on the depth of local invasion.     

Selective therapeutic approach to cancer of the lower esophagus and cardia

The role of curative en bloc resection for carcinoma of the lower esophagus and cardia is still controversial. The experience with a selective approach in 52 patients with cancer in this location is reviewed. Thirty-two of the cancers were squamous cell, 13 adenocarcinoma, and seven adenocarcinoma associated with Barrett's esophagus. In 19, the tumor was not resectable and all of these patients died within a year. In 19 patients, a palliative resection could be done. Actuarial survival was 31% at 1 year. Only one patient was alive after 5 years. Initially, 16 patients with noncircumferential lesions on endoscopy and/or no evidence of spread to mediastinal lymph nodes on computed tomographic scan were considered to have potentially curable lesions. All were less than 75 years old and had a forced expiratory volume in 1 second greater than 1.5 L and a resting ejection fraction greater than 40%. A curative resection consisting of an en bloc thoracic esophagectomy, mediastinal lymphadenectomy, and an 80% gastrectomy with abdominal lymphadenectomy was performed in 14. The left colon was used to reestablish the gastrointestinal continuity. Two patients had more extensive disease discovered at operation, and the curative en bloc resection was abandoned. Absence of full wall penetration or involvement of four or fewer regional nodes, or both, was correctly predicted by preoperative and intraoperative staging in 86% of the patients. Operative mortality of a curative en bloc resection was 7% (1/14), and the actuarial survival rates were 76%, 66%, and 53% at 1, 2, and 5 years. Inferences are made from these results on tumor characteristics associated with survival, the extent of resection necessary for cure, the difficulty of accomplishing a curative en bloc resection by the transhiatal approach, the contraindication to curative en bloc resection, and the need for a surveillance program for patients with Barrett's esophagus.     

Chest wall invasion in non-small cell lung carcinoma: a rationale for en bloc resection

OBJECTIVE: The choice of surgical approach to non-small cell lung cancer invading the chest wall, extrapleural resection versus en bloc chest wall resection, is much more related to the experience of the surgeon than to objective criteria. The aim of the present study is to help to establish a rationale for en bloc chest wall resection in lung cancer invading the chest wall. METHODS: From January 1990 to June 1999, of 1855 patients having major pulmonary resections for non-small cell lung carcinoma, 104 (5.6%) patients with neoplasms involving the chest wall underwent en bloc chest wall and lung resection plus radical mediastinal lymphadenectomy. RESULTS: All patients underwent complete resection with microscopically disease-free tissue margins. Depth of invasion was into the parietal pleura only in 28 (26.92%), into the pleura and soft tissue in 36 (34.62%), and into the pleura, soft tissue, and bone in 40 (38.46%). No operative mortality was reported. Follow-up was completed in 96 patients. One patient had a local recurrence. The overall 5-year estimated survival was 61.4%. Survival in the subsets T3 N0 and T3 N2 were, respectively, 67.3% and 17.9% (P =.007). The 5-year survival was 79.1% in involvement of parietal pleura only and 54.0% in involvement of soft tissue with or without bone invasion (P =.014). Five-year survival was 53.0% in adenocarcinoma versus 71.8% in squamous cell carcinoma (P =.329) and 74.1% in patients who did undergo radiation therapy versus 46.7% in patients who did not undergo radiation therapy (P =.023). CONCLUSIONS: En bloc resection of the chest wall and lung is the procedure of choice to obtain complete resection in lung carcinoma invading the chest wall. Survival is highly dependent on the completeness of resection, nodal involvement, and depth of chest wall invasion.     

Superior sulcus lung tumors. Results of combined treatment (irradiation and radical resection)

Twenty-one patients underwent combined therapy (irradiation and radical resection) for a Pancoast tumor at the Massachusetts General Hospital between 1976 and 1985. All patients underwent en bloc removal of the apical chest wall and underlying lung. In addition four patients required subclavian artery resection, and in five patients a portion of the vertebral body was resected. There were three operative deaths. Median survival was 24 months and actuarial survival rate was 55% at 3 years and 27% at 5 years. Long-term palliation of pain was achieved in 72% of the patients. Involvement of the subclavian artery, vertebral body, or rib did not preclude long-term survival. Computed tomographic scanning in these patients is often indeterminate regarding invasion of chest wall structures but is more helpful than plain films alone. When compared to recent series in which irradiation alone was used, the combined approach appears to produce better results.     

High-dose radiotherapy in trimodality treatment of Pancoast tumors results in high pathologic complete response rates and excellent long-term survival

OBJECTIVE: We sought to study the clinical characteristics and outcomes of patients treated with a surgery-inclusive multimodality approach for Pancoast tumors. METHODS: Clinical records of patients with Pancoast lung cancer who were enrolled for multimodality treatment between 1993 and 2003 at our institution were reviewed retrospectively. RESULTS: Thirty-six patients completed neodjuvant chemoradiation followed by en bloc surgical resection, whereas one patient received high-dose radiation alone followed by surgical intervention. There were 22 men and 15 women. Thirty-four lobectomies and 3 pneumonectomies were performed. Pretreatment non-small cell lung cancer stages were IIB, IIIA, IIIB, and IV (presenting with solitary brain metastasis) in 18, 8, 6, and 5 cases, respectively. R0 resection was achieved in 36 (97.3%) patients. Operative mortality was 2.7% (n = 1). High-dose radiotherapy was successfully tolerated in all but 1 patient. Mean total radiation dose was 56.9 Gy. Pathologic complete response was found in 40.5% (n = 15) of patients. Recurrences were found in 50% (n = 18) of patients. Brain metastasis was the most common recurrence (n = 9), followed by other distant recurrences (n = 4) and local recurrences (n = 5). Median survival time for the group is 2.6 years, and median survival time (pathologic complete response) is 7.8 years. It is noteworthy that median survival time of patients with positive pretreatment lymph nodes (12 patients) was not reached. CONCLUSIONS: Surgical resection of Pancoast tumors after neoadjuvant high-dose radiation and chemotherapy can be safely performed. High-dose radiation in trimodality treatment is well tolerated and might be beneficial. Similar to other studies, late central nervous system relapse is problematic and indicates a need for assessing the role of prophylactic cranial irradiation in this disease.     

Selection of operation for esophageal cancer based on staging.

The concept of en bloc removal of tissue surrounding the esophagus was applied to intrathoracic esophageal cancers, and the first 80 cases were operated on by this technique between 1969 and 1981. Analysis of prognostic factors showed that only penetration through the esophageal wall and lymph node spread influenced survival. Since 1981, a new staging system based on wall penetration (W) and lymph nodes (N), as well as systemic metastases (M), and similar to the modified Dukes' system for colon cancer has been used to select patients before and during surgery for en bloc resection if favorable pathology (W1, N0, or N1) could be anticipated. When curative resection was not attainable, based on preoperative and operative staging, a standard esophagectomy was considered for relief of symptoms when necessary. From July 1981 to June 1984, 68 esophageal cancers were referred to us, and 31 were resected by the en bloc method, 21 by standard esophagectomy, and 16 were not resected. The success of preoperative staging was confirmed, as only nine of the 31 en bloc cases demonstrated both W2 and N2 pathology. The proportion of W2N2 cases subjected to en bloc esophagectomy was less (p less than 0.01) than that in the preceding series. This selection of cases showed a favorable deviation in the survival curve following en bloc esophagectomy since 1981 compared to the earlier interval. Patients treated by en bloc esophagectomy had a significantly greater survival than they did following standard esophagectomy at all time intervals after 6 months. There was no difference in hospital mortality or complications between the two operations. Further evidence for the value of the new staging system was shown by the significant difference in survival curves between those with favorable versus unfavorable staging and treated by en bloc esophagectomy. Among all cases resected between 1981 and 1984, 18-month survival in W1 stage was 67% compared to 35% for W2 disease. Survival with N0 disease was 58% versus 43% for N1 stage and 21% for N2 stage. The favorable survival rates after en bloc resection in those with limited (less than W2N2) disease support the concept of selecting patients for curative surgery based on preoperative and operative staging. Preoperative radiation therapy caused a significant decline in patient survival at 6 and 12 months and has been abandoned.(ABSTRACT TRUNCATED AT 400 WORDS)     

Management of tumor adherent to the vertebral column

Twelve patients with non-small cell lung cancer had tumors that were adherent to the vertebral column and clinically suspected of invading the bone. All were free of mediastinal node involvement as assessed by pretreatment mediastinoscopy. All received 3000 rads of preoperative radiation followed by en bloc resection of the lung and a tangential portion of the involved vertebral bodies. A complete mediastinal lymphadenectomy was also performed. Three patients had true Pancoast's syndrome and in the remaining nine the tumor was located above T6 with the majority in the apex of the chest. Resectability was based on the absence of tumor extension into the costotransverse foramen and the extent of vertebral body involvement. Detailed studies of the decalcified surgical specimen show that the tumor extended into the cortex in two patients, periosteum in six, parietal in three, and up to the visceral pleura in one. Six patients are alive after 1 to 11 years (four beyond 5 years) without evidence of recurrent tumor and arthritic pain. The overall 5- and 10-year survival rate (Kaplan-Meier method) was 42%. In patients with tumors adherent to the vertebral body and no evidence of roentgenographic erosion, the en bloc removal of the lung and the involved portion of the vertebral body is required for complete excision and is associated with long-term survival without sequelae.     

Resection of chest wall invasion in patients with non-small cell lung cancer

Objective: The treatment of patients with non-small cell lung cancer invading the parietal pleura or chest wall is still debated. It is unsolved whether the depth of chest wall involvement or the type of resection (extrapleural or en bloc) affects long-term survival. Methods: design, retrospective analysis; setting, Hyogo Medical Center for Adults, patients: the 97 patients who underwent surgical resection for non-small cell lung cancer involving the parietal pleura or chest wall between 1985 and 1997 were reviewed. Results: Of the 97 patients, 76 had apparently complete resection, 21 had incomplete resection. The overall 5-year survival of completely resected patients was 34.2%, and that of incompletely resected patients was 14.3% (P=0.0489). In complete resection cases, the chest wall involvement was limited to the parietal pleura in 40, extended into the subpleural soft tissues in 10, and extended into the ribs in 26. The 5-year survivals were 32.5, 30.0 and 38.5%, respectively (no significant difference). The 5-year survival of completely resected patients with T3 N0 M0 disease was 44.2%, T3 N1 M0 disease 40.0%, and T3N2 M0 disease 6.2% (P=0.0019). The 5-year survival of completely resected patients with extrapleural resections was 30.0%, that of en bloc resections 38.9% (no significant difference). Conclusions: Survival of patients with lung cancer invading the chest wall or parietal pleura after resection is highly dependent on the completeness of resection and the extent of nodal involvement, but not so much on the depth of chest wall invasion or type of resection.     

Transfer factor in the treatment of carcinoma of the lung

From 1976 to 1982, 63 patients with carcinoma of the lung underwent curative pulmonary resection, mediastinal lymph node dissection, and postoperative mediastinal irradiation when indicated. After operation, the patients were randomized by cell type and stage of disease into two groups. Beginning 1 month postoperatively, Group 1 patients (N = 28) received 1 ml of transfer factor that had been extracted from the blood of normal individuals. Subsequent doses were administered at 3-month intervals. Group 2 patients (N = 35) served as controls. There were no significant differences between the two groups with respect to age, sex, extent of resection, histological cell type, or stage of disease. Twenty of the 28 treated patients were alive and free from disease from 7 to 77 months after treatment, whereas 17 of the 35 control patients were free from disease. The 1-year survival for Group 1 was 84% and for Group 2, 81%. The 2-year survival was 78% for Group 1 and 46% for Group 2 (p = 0.045). The survival rates by stage of disease were as follows: Stage I, 15 out of 17 or 88% in Group 1 and 15 out of 23 or 65% in Group 2 (p = 0.097); Stages II and III, 5 out of 11 or 45% in Group 1 and 3 out of 12 or 25% in Group 2 (p = 0.304). The results of the study suggest that the administration of transfer factor to patients who have undergone pulmonary resection for carcinoma of the lung can have a significant impact on the prolongation of life.     

Chest wall resection and reconstruction for lung cancer

Patients who have lung cancer that invades the chest wall should undergo careful preoperative screening to ensure there is no distant disease. A preoperative mediastinoscopy is generally indicated to exclude the presence of mediastinal nodal metastases. At the time of exploration, the surgeon should open the chest away from the tumor and carefully assess whether it can be resected. If there is a question of invasion into the chest wall, an en bloc chest wall resection should be performed. The risks of postoperative complications are low, and a favorable long-term survival is definitely possible in this subgroup of patients who have lung cancer.     

Surgical Treatment of Superior Sulcus Tumors

Purpose To access the clinical outcome of patients with superior sulcus tumor.Methods We reviewed the records of 16 patients who underwent surgery for a superior sulcus tumor between 1988 and 2003, focusing on the type of surgery.Results All 16 patients underwent en bloc lung and chest wall resection, which was done as pneumonectomy in 1 patient and lobectomy in 15. Complete resection was achieved in 11 patients, but incomplete resection was done in 5 patients because microscopic examination revealed positive surgical margins. Eight patients underwent partial vertebrectomy and 1 patient had combined resection of the subclavian artery. There was no postoperative mortality. All patients received pre- or postoperative adjuvant therapy, or both. The overall 5-year survival rate was 31.0%. The 5-year survival rate was higher after complete resection than after incomplete resection (59.3% vs 0%, P = 0.08). Patients who underwent complete resection for vertebral invasion and those who did not had 5-year survival rates of 66.7% and 0%, respectively (P = 0.17). Patients who underwent preoperative induction therapy followed by complete resection and those who did not had 5-year survival rates of 80% and 0%, respectively (P = 0.009).Conclusion Although superior sulcus tumors are still complex, preoperative induction therapy followed by complete resection seemed effective for prolonging survival.     

Surgical treatment of T3 lung cancer invading the chest wall

Lung tumors invading the chest wall are classed as belonging to the T3 group and are considered potentially resectable. Their management, however, is controversial, and extrapleural resection, when possible, is preferred to en bloc resection which is regarded as a far more invasive and dangerous operation. Five year survival rates for completely resected cases range in the literature from 25 to 35%, but survival rates are much worse if lymph node metastases are present. These poor outcomes have prompted the development of combined surgical approaches: preoperative radiation therapy, with or without chemotherapy, has been used with an improvement in resectability rates, but only modest results in terms of median survival; in a number of case series, increased operative morbidity and mortality have been reported with this approach. The present report relates to 122 patients treated by en bloc (20 cases) or extrapleural (102 cases) resection, 31 of whom also received neoadjuvant treatment. The operative mortality was 4.6%. Median survival was 17 months after en bloc resection and 19 months after extrapleural resection. Though no statistically significant difference was found, extrapleural resection would appear to yield better results than the en bloc procedure.     

肢体原发成骨肉瘤综合治疗的远期结果

目的　对肢体原发成骨肉瘤综合治疗及非综合治疗的结果进行比较和评估。　方法　术前无远处转移的肢体成骨肉瘤患者 170例 ,年龄 6～ 5 2岁 ,平均年龄 2 1岁 ,男性 112例 ,女性 5 8例 ;肿瘤部位 :股骨远端 80例 ,胫骨近端 5 1例 ,股骨近端 7例 ,肱骨近端 10例 ,四肢其它部位 2 2例。施行术前化疗 手术切除肿瘤 术后化疗综合治疗 (综合治疗组 ) 10 4例 ,单纯手术切除肿瘤 (非综合治疗组 )6 6例 ;行保留肢体手术 94例 ,其中施行化疗者 71例 ,未行化疗者 2 3例 ;行截肢术 76例 ,其中行化疗者 33例 ,未行化疗者 43例。　结果　 5年生存率 :综合治疗组为 6 1% ,非综合治疗组为 2 8% ;10年生存率 :综合治疗组为 5 3% ,非综合治疗组为 2 6 % ;局部复发率 :综合治疗保肢组为 2 0 % ,截肢组为 3% ;非综合治疗保肢组为 44 % ,截肢组为 7% ;综合治疗组和非综合治疗组肺转移的发生率无明显差异。80例患者按照MSTS评分系统进行功能评定 ,其中保肢组 (5 6例 )平均分值为 71% ,截肢组 (2 4例 )平均分值为 5 3%。　结论　综合治疗可以提高骨肉瘤的存活率 ;肿瘤局部切除及重建手术可以为患者提供比较满意的肢体功能。     

Hiläres Cholangiokarzinom

The increasingly performed en bloc resection of liver and hilar tumor has contributed to the improvement of long-term survival in patients with hilar cholangiocarcinoma. Based on preoperative definition of operative strategy we tried to avoid any traumatization of the hilar region. Between September 1997 and September 2002, 82 patients with hilar cholangiocarcinoma were treated at our department. Three patients were excluded from any surgery. The resection rate was 75% (59 of 79); 79% (38 of 48) of en bloc resections of the hilar tumor and adjacent liver were formally curative. The hospital mortality was 7%. The 1- and 3-year survival rates of patients after explorative laparotomy, palliative and curative resection was 27 and 7%, 67 and 26%, 89 and 45% ( p<0.001), respectively. The 1- and 3-year survival rates of patients after en bloc resection were 78 and 49%, respectively. In patients with formally curative en bloc resection ( n=38), the 3-year survival rate was 63%; in patients with N0/R0 resection ( n=31) it was 71%. Lymph node involvement proved to be the only independent prognostic marker if patients who underwent hilar and en bloc resection were included in the multivariate analysis. The R situation was the only significant predictor for patients after en bloc resection. These data justify the extended diagnostic work-up and the principal liver resection in hilar cholangiocarcinoma.