Which of the following patients would be the most appropriate candidate for a standard pneumonectomy (assuming normal pulmonary function)?

A. A 45-year-old woman with a 4 cm adenocarcinoma of the medial left upper lobe with hoarseness 
due to involvement of the recurrent laryngeal nerve.
B. A 68-year-old man with an endobronchial squamous cell carcinoma of the distal left mainstem 
bronchus (3.5 cm from carina) and one positive left paratracheal lymph node.
C. A 72-year-old woman with a 7 cm adenocarcinoma of the left upper lobe. The tumor is 
contained in the left upper lobe, and sampled mediastinal lymph nodes are negative for 
malignancy.
D. A 75-year-old man with a 5 cm central squamous cell carcinoma in the left upper lobe that 
crosses the fissure into the lower lobe. One interlobar lymph node is positive for metastatic 
disease.
E. An 85-year-old man with a squamous cell carcinoma in the right mainstem bronchus 0.5 cm from 
the carina. Mediastinal nodes are negative clinically.

Answer C

Pneumonectomy is associated with a 3-7% operative mortality, so careful patient selection is mandatory. Involvement of a recurrent laryngeal nerve is usually a sign that there is advanced cancer and a curative resection in unlikely.

Positive ipsilateral paratracheal lymph nodes (Ns) portend a poor prognosis with or without resection. Multimodality therapy with chemotherapy, radiation therapy with or without surgery is a more appropriate treatment plan than pneumonectomy alone.

Patients with tumors confined to a single lobe do not obtain further benefit from a pneumonectomy (compared with lobectomy) and therefore this would be an inappropriate choice.

Centrally located tumors that erode across the fissure and have positive interlobar lymph nodes require a pneumonectomy for adequate resection.

A tumor that is only 5 mm from the main carina cannot be resected with an adequate margin by a standard pneumonectomy. Thus, tumors in this location require a sleeve or carinal pneumonectomy for complete resection.


Shields TW, Humphrey EW, Matthews M et al. Pathological stage grouping of patients with resected carcinoma of the lung. J Thorac Cardiovasc Surg 1980;80:400-405.
Data from a series of 569 patients with "curative" resection of non-oat cell tumors were 
analyzed by the life-table method to evaluate the validity of the post-resection pathological 
staging classification suggested by the American joint Committee. The cell types were as 
follows: squamous, 305; adenocarcinoma, 172; large cell, 73; and mixed, 19. Each patient was 
assigned a pathological TN classification on examination of the resected specimen (all patients 
were judged clinically to have no distant metastases--M0). There were 173 lesions classified as 
T1 N0, 37 as T1 N1, 212 as T2 N0, 115 as T2 N1, and 32 as either T3 with any N or N2 with any T. 
In analyzing the data, we identified a subset of lesions (25), initially staged as T2 N0, which 
were small central lesions, 3 cm or less, located distal to a lobar takeoff. Regardless of the 
presence of atelectasis or pneumonitis to the hilar area, patients with these lesions had a 
survival rate similar to that of patients with more peripherally located lesions of similar size. 
Three-year survival rates of 66.5% and 68.5% respectively, were noted in these two groups of 
patients, as compared to a 53.6% rate for the patients with lesions larger than 3 cm, which could 
be classified as T2 N0 regardless of their location. When lymph nodes were affected (N1), 
patients with small central lesions (20) had a better survival rate than the patients with either 
T1 N1 or other T2 N1 lesions. It is therefore suggested that all small central lesions, 3 cm or 
less, distal to a lobar takeoff be considered T1 lesions. Patients with T1 N1 lesions had a 3 
year survival rate of only 36.7%, which is similar to the 39.8% 3-year survival rate of those 
with T2 N1 lesions. The other patients in Stage I had a much better survival rate: Patients 
with T1 N0 lesions had 3 and 5 year survival rates of 68.5% and 54.4%, and those with T2 N0 
lesions, 53.6% and 40.0%, respectively. Therefore, it would appear more appropriate to classify 
these patients as having Stage II rather than Stage I disease. 

Naruke T, Suemasu K, Ishikawa S. Lymph node mapping and curability at various levels of 
metastasis in resected lung cancer. J Thorac Cardiovasc Surg 1978;76:832-839.
By means of lymph mapping, the prognosis significance of lymph node metastasis in lung 
cancer was studied in 270 patients who had undergone radical operations--pulmonary resection 
combined with complete mediastinal lymph node dissection, which is used for patients in whom all 
cancer could thereby be ablated. Mediastinal lymph node metastasis was found in 64 patients, and 
12 patients lived 5 years or more (an absolute 5 year survival rate of 18.8 percent). After 
radical surgery, there was a significant difference between the prognosis for patients who had 
metastases to the subcarinal lymph nodes as compared to the prognosis for those who did not. The 
5 years survival rates were 9.1 percent and 29.0 percent, respectively. On the other hand, 
prognosis was not significantly affected by involvement or noninvolvement of the superior 
mediastinal, paratracheal, tracheobronchial, pretracheal, and the subaortic and para-aortic lymph 
nodes. No significant difference in survival was detected between patients who were given 
adjuvant therapy and those who were not. Lymph node mapping gives valuable prognostic 
information.

Naruke T, Goya T, Tsuchiya R, Suemasu K. Prognosis and survival in resected lung carcinoma based 
on the new international staging system. J Thorac Cardiovasc Surg 1988;96:440-447.
A new TNM staging system was proposed and the previous system has been revised recently. 
To evaluate the new TNM staging system for lung cancer, we analyzed records of 1737 patients who 
underwent pulmonary resection at the National Cancer Center Hospital, Tokyo. With regard to 
clinical stages, three patients had occult carcinoma; 821 patients had stage I disease; 248 
patients, stage II; 465 patients, stage IIIA; 82 patients, stage IIIB; and 118 patients, stage 
IV. The 5-year survival rates for the respective stages were 50.1% for stage I, 31.2% for stage 
II, 20.2% for stage IIIA, 5.1% for stage IIIB, and 7.9% for stage IV. In terms of postoperative 
stages, four patients were classified in stage 0, 536 in stage I, 221 in stage II, 559 in stage 
IIIA, 159 in stage IIIB, and 258 in stage IV. The 5-year survival rates were as follows: stage I, 
65.0%; stage II, 42.9%; stage IIIA, 22.2%; stage IIIB, 5.6%; and stage IV, 7.5%. In both the 
clinical stage and the postoperative stage, there were significant prognostic differences between 
stage I and stage II, stage II and stage IIIA, and stage IIIA and stage IIIB, but there was no 
significant difference in 5-year survival rates between stage IIIB and stage IV.

Mountain CF: Revisions in the International System for Staging Lung Cancer. Chest 1997;111:1710-1717.
Revisions in stage grouping of the TNM subsets (T=primary tumor, N=regional lymph nodes, 
M=distant metastasis) in the International System for Staging Lung Cancer have been adopted by 
the American Joint Committee on Cancer and the Union Internationale Contre le Cancer. These 
revisions were made to provide greater specificity for identifying patient groups with similar 
prognoses and treatment options with the least disruption of the present classification: T1N0M0, 
stage IA; T2N0M0, stage IB; T1N1M0, stage IIA; T2N1M0 and T3N0M0, stage IIB; and T3N1M0, T1N2M0, T2N2M0, T3N2M0, stage IIIA. The TNM subsets in stage IIIB-T4 any N M0, any T N3M0, and in stage IV-any T any N M1, remain the same. Analysis of a collected database representing all clinical, 
surgical-pathologic, and follow-up information for 5,319 patients treated for primary lung cancer 
confirmed the validity of the TNM and stage grouping classification schema.