A 66-year-old, 40 pack-year smoker presents with recurrent episodes of right upper lobe pneumonia. The picture shows the bronchoscopic view of the right upper lobe orifice. Biopsies are taken, and a representative photomicrograph is shown. The patient has satisfactory parameters to withstand a pulmonary resection if deemed appropriate. Which of the following is the most appropriate course of action?

A. institute combination chemo/radiotherapy as primary treatment
B. institute radical radiotherapy as primary treatment
C. neoadjuvant chemotherapy/radiotherapy followed by a pneumonectomy
D. thoracotomy with pneumonectomy
E. thoracotomy with sleeve lobectomy 

Answer E

The patient has an obstructing squamous cell carcinoma in the right upper lobe 
orifice. The lesion appears to be clinical stage II for which surgical resection is the 
treatment of choice. The patient is a good candidate for this approach. There is no evidence 
that chemotherapy or radiotherapy alone or in combination is superior as primary treatment. 
Furthermore, trials of neoadjuvant chemotherapy and/or radiotherapy preoperatively fail to 
demonstrate any benefit. The endoscopic appearance suggests that a right upper lobe sleeve 
resection is possible. Although the lesion could be resected by pneumonectomy, the literature 
confirms that this affords no advantage as long as the lesion is carefully staged and the disease 
is fully resected with negative resection margins.

Sleeve resections of the bronchus 
(bronchoplasty) were originally described in patients with lung cancer with compromised pulmonary 
function. Lung cancer remains the most common indication today, although it is now an accepted 
procedure for patients with good lung function if they have anatomically suitable tumors. Sleeve 
resections are also appropriate for benign stenoses and low-grade airway neoplasms. 

The right 
upper lobe lends itself to a bronchoplastic procedure due the isolation of the right upper lobe 
bronchus and the adequate lengths of right main and intermediate bronchi. However, all lobes of 
the lung may be removed by the sleeve resection technique. Size discrepancies are frequently 
apparent between the two divided ends of the bronchus; interrupted suture technique and 
telescoping are useful to resolve differences in airway diameter. Most sleeve resections entail 
pulmonary parenchymal resection, but either the main bronchus or bronchus intermedius may be 
resected alone. Bronchovascular fistulas complicate about 3% of all sleeve resections and 
usually lead to death. Prevention by separating the bronchial suture line from the pulmonary 
artery with living tissue is an important aspect of the operation. 

Bennett WF, Smith RA. A twenty-year analysis of the results of sleeve resection for primary bronchogenic carcinoma. J Thorac Cardiovasc Surg 1978;76:840-5.
Ninety-six patients with primary bronchogenic carcinoma were treated by lobectomy with 
sleeve resection of the bronchus over a 20-year period (1958 through 1977). In 80 resections 
undertaken prior to 1973, a 5-year survival rate of 34 percent was realized with an operative 
mortality rate of 7.5 percent. Survival at 10 and 15 years has been assessed. A review of 
factors influencing survival has been undertaken and the biologic behavior of these pulmonary 
neoplasms, modified by sleeve resection, has been outlined. Of interest is the high rate of local 
recurrence accounting for death within 5 years postoperatively and the late incidence in the 
survivors of second malignancies and other diseases of surgical interest. Sleeve resection 
represents a surgical alternative in selected cases of bronchogenic carcinoma in which wider 
resection may be hazardous, and the indications should be extended to include some lesions 
commonly managed by pneumonectomy.

Weisel RD, Cooper JD, Delarue NC, Theman TE, Todd TR, Pearson FG. Sleeve lobectomy for carcinoma 
of the lung. J Thorac Cardiovasc Surg 1979;78:839-49.
Sleeve lobectomy for non-oat cell carcinoma involving a major bronchus preserves 
functioning lung tissue and, in carefully selected patients, provides long-term survival 
comparable to pneumonectomy. Seventy patients underwent sleeve lobectomy between 1967 and 1978. 
Twenty-seven patients were considered compromised (Group I) because they had severe respiratory 
impairment which contraindicated pneumonectomy. Forty-three patients were considered 
uncompromised (Group 2) and underwent elective sleeve lobectomy. Seventy patients with a similar 
non-oat cell carcinoma involving the proximal bronchi underwent pneumonectomy (Group 3) during 
this period. Perioperative complications occurred more frequently in Group 1 (59%) than in Group 
2 (21%) or Group 3 (23%). Both preoperative mortality rate and the incidence of bronchial 
disruption (bronchovascular and bronchopleural fistulas) were higher in Group I (19% and 22%) 
than in Group 2 (9% and 5%) or Group 3 (3% and 7%). Survival depended primarily on the surgeon's 
ability to perform a complete resection of the tumor. An incomplete resection resulted when tumor 
was found in the highest lymph node or in the last bronchial resection margin when paraffin 
sections were reviewed. The 5-year survival rate was 18% for compromised patients (Group 1) who 
underwent complete resection, and there were no survivors among patients undergoing incomplete 
resections. Uncompromised patients ( Group 2) had a 5-year survival rate of 36% with complete and 
12% with incomplete resections. Pneumonectomy patients (Group 3) had a 64% 5-year survival rate 
with a complete resection and 16% with an incomplete resection. The stage of the disease at the 
time of operation had a profound effect on the survival. There was no difference in the 5 and 8 
year survival rates between uncompromised patients undergoing sleeve resection ( Group 2) and 
patients undergoing pneumonectomy (Group 3) for comparable stage of their disease. A careful pre- 
and postoperative functional assessment revealed that pulmonary performance was improved in 44% 
of Group 1, 63% of Group 2, and only 14% of Group 3 patients. Patients with impaired pulmonary 
reserve underwent sleeve lobectomy with an adequate disease-free interval when complete tumor 
excision was possible. Uncompromised patients whose extensive disease required incomplete 
resection had palliation by sleeve lobectomy equivalent to that by pneumonectomy. When complete 
tumor resection was possible, patients with uncompromised pulmonary reserve had a perioperative 
complication rate and long-term survival equivalent to that of pneumonectomy while preserving 
pulmonary parenchyma, which permitted an improvement in postoperative pulmonary performance.

Faber LP, Jensik RJ, Kittle CF, et al. Results of sleeve lobectomy for bronchogenic carcinoma in 
101 patients. Ann Thorac Surg 1984;37:279-85.
Sleeve lobectomy for bronchogenic carcinoma is an alternative to pneumonectomy. The 
extent and location of the tumor must be such that a sleeve procedure is feasible. The 
conservation of lung tissue benefits both compromised and uncompromised patients. From 1961 to 
1982, 101 patients underwent sleeve lobectomy for bronchogenic carcinoma of the lung. There were 
58 procedures on the right side and 43 on the left. Life-table analysis of 94 of the patients 
shows a 5-year survival of 30% and a 10-year survival of 22%. Preoperative irradiation was 
utilized in 51 patients with a 5- and 10-year survival of 25% and 16%, respectively. The sleeve 
lobectomy group that did not have radiation therapy demonstrated a 5-year survival of 36% and a 
10-year survival of 28%. There were 2 operative deaths (2%). Completion pneumonectomy was 
required in 7 patients because of anastomotic dehiscence in the early postoperative period in 6 
and tumor at the margin in 1. Other major complications included empyema and granulation tissue 
at the anastomosis that were successfully managed by bronchoscopic dilation and suture removal. 
Tumor recurred locally in the area of the anastomosis in 9 patients. Sleeve lobectomy is a safe 
procedure and when technically feasible can be considered the procedure of choice for 
bronchogenic carcinoma. 

Gaissert HA, Mathisen DJ, Moncure AC, Hilgenberg AD, Grillo HC, Wain JC. Survival and function 
after sleeve lobectomy for lung cancer. J Thorac Cardiovasc Surg 1996;111:948-53.
Between 1962 and 1991, 72 patients (mean age 63.4 years) underwent sleeve lobectomy for 
primary lung cancer. Thirty-seven patients had adequate lung function and 35 were deemed 
unsuitable for pneumonectomy on the basis of inadequate pulmonary reserve (n = 31) or cardiac 
risk factors (n = 4). Squamous cell carcinomas (68%) and adenocarcinomas (26%) predominated. 
Upper lobectomy was performed in 48 patients, lower and middle lobectomy in 13, and right upper 
and middle bilobectomy in 11. Hospital mortality was 4% (3/72) and compares with a hospital 
mortality of 9% in 56 consecutive pneumonectomies between 1986 and 1990. Major complications 
occurred in 11% (bronchopleural fistula 1, persistent atelectasis 4, pneumonia 4). Adjusted 
actuarial survival after sleeve lobectomy at 1 and 5 years was 84% and 42%, compared with 76% and 
44% after pneumonectomy. Five-year survival after lower and middle lobectomy in 13 patients (52%) 
was similar to that after upper lobectomy (46%), suggesting that in carefully selected patients 
the concept of sleeve lobectomy can be applied to all pulmonary lobes. N1 disease and compromised 
lung function were associated with lower survival (N1 38% vs N0 57%; compromised 20% vs adequate 
55%). Comparison of preoperative and postoperative lung function and quantitative 
ventilation-perfusion isotope studies substantiated the preservation of pulmonary function in 
this group of patients. Sleeve lobectomy is the procedure of choice for anatomically suitable 
carcinomas or when reduced pulmonary reserve precludes extensive resection.