Sleeve Lobectomy For Lung Cancer Research Articles

Right Lower Sleeve Lobectomy: Detailed Technique and Perioperative Patient Management.

This report reviews our experience with right lower sleeve lobectomy and describes our technique and approach to perioperative patient management. We retrospectively reviewed 11 patients who underwent right lower sleeve lobectomy for lung cancer. Surgical techniques and perioperative management were also investigated. Bronchoplasty was performed using 4-0 absorbable monofilament sutures. The deepest portion was anastomosed using continuous sutures; interrupted sutures were used for the more superficial portions. The truncus intermedius and right middle lobe bronchus should be anastomosed in a natural position. Anastomosis patency was confirmed using intraoperative bronchoscopy. Separation of the right upper and middle lobes and pericardiotomy at the inferior edge of the superior pulmonary vein are useful for mobilizing the right middle lobe. Death during hospitalization and treatment-related death did not occur. One patient developed pneumonia, and another developed a bronchopleural fistula. We reported our technique of right lower sleeve lobectomy and our approach to perioperative patient management. Sharing knowledge is essential to completing this rare surgery.

Arterial sleeve lobectomy for lung cancer invading chest wall.

Lung cancer is a leading cause of cancer-related deaths worldwide. Non-small cell lung cancer (NSCLC) is a predominant subtype and treatment may include immunotherapy, radiotherapy, chemotherapy, and surgery. Tumors of bigger size infiltrating large bronchi and vessels require more invasive resection such as pneumonectomy. To save lung parenchyma, sleeve lobectomy can be performed in certain patients.We report the case of a patient with NSCLC infiltrating the chest wall who underwent arterial sleeve lobectomy with rib resection. Furthermore, we discuss other surgical treatment strategies.A 58-year-old female patient was admitted to the hospital in 2020 with pain in her left posterolateral chest. Radiological imaging revealed a tumor (5.0×3.5×4.8cm) in the top of the left lung, infiltrating pulmonary artery and ribs. Therefore, left upper sleeve lobectomy together with resection of rib blocks II to V was performed. The surgery was uncomplicated, but a few weeks postoperatively, the patient experienced repeated episodes of consciousness disturbances. Contrast CT revealed a cerebral malformation in the patient who died 3.5 months after surgery.Sleeve lobectomy can be safely performed in patients with lung tumors infiltrating larger bronchi and vessels who would not tolerate pneumonectomy.

Feasibility of sleeve lobectomy after neo-adjuvant chemo-immunotherapy in non-small cell lung cancer.

Immunotherapy is one of the most effective treatments for patients with advanced lung cancer. In many advanced non-small cell lung cancer (NSCLC) cases, the tumor is centrally located. For such patients, sleeve lobectomy has been considered as a more effective therapeutic option compared with pneumonectomy, achieving better long-term survival and quality of life with no increase in morbidity or mortality. Until now, there have been no studies regarding the efficacy and safety of neo-adjuvant chemo-immunotherapy prior to sleeve lobectomy for lung cancer. From January 2019 through October 2019, nine patients were diagnosed as NSCLC and evaluated to undergo sleeve lobectomy surgery (SLS). Of these patients, four received two cycles of pembrolizumab plus paclitaxel and cisplatin (PPC) followed by sleeve lobectomy, while five patients underwent SLS alone. The patients’ clinical characteristics, perioperative parameters, and postoperative outcomes were analyzed. Multiplex fluorescent immunohistochemistry was performed to determine the number of macrophages, CD4+ and CD8 T cells, and Treg cells in the bronchial mucosa. Three of the four patients achieved a complete pathological response [0% viable tumor, pathologic complete response (pCR)]. All of the patients in the PPC group achieved major pathological response (≤10% viable tumor, MPR). No grade 3 or 4 treatment-related adverse events occurred in the PPC group, nor did any of the patients in the group experience treatment-related surgical delays. The mean surgical time and the number of lymph nodes dissected were the same in the two groups. The PPC group had a higher number of CD8 + T cells compared to the SLS group (P<0.01). No postoperative chylothorax, pneumonia, or other postoperative complications occurred in either group. The surgical difficulty and post-surgical complication rate of sleeve lobectomy with neo-adjuvant chemo-immunotherapy were similar to those of SLS alone. Neo-adjuvant chemo-immunotherapy is effective and safe with sleeve lobectomy for NSCLC patients. Additional prospective multi-center randomized studies using larger patient cohorts are necessary to validate our findings.

Left middle and lower sleeve lobectomy for lung cancer in a patient with complete situs inversus

Left middle and lower sleeve lobectomy for lung cancer in a patient with complete situs inversus

Initial experience of sleeve lobectomy under complete video-assisted thoracic surgery.

Review the initial results of a single-center complete video-assisted thoracoscopic surgery (VATS) sleeve lobectomy and discuss the key procedure of this operation, in addition to its safety and feasibility. Retrospectively analyze the perioperative data of 11 patients who accepted complete VATS sleeve lobectomy between May 2013 and Jun 2017 in Peking University Third Hospital, try to evaluate the safety of this procedure. All the patients were followed up and their oncological recurrence and metastasis were observed, and feasibility of VATS sleeve lobectomy for lung cancer was evaluated. All of the 11 cases underwent complete VATS sleeve lobectomy successfully and there is no conversion to thoracotomy. The mean operative time was 338min (range from 243 to 511min), the mean time of bronchial anastomotic was 63min (range from 40 to 96min), the mean blood loss was 205mL (range from 50 to 400mL), and the mean number of lymph nodes dissected is 22.1. There was no other complication except one patient suffered from high-risk pulmonary embolism, and no anastomotic leakage and stricture was found. The mean hospital stay postoperation was 8.7 days. The time of follow-up was between 2 and 38 months, only one out of the 11 cases died of bone metastasis, and the other 10 survived till now. One of these 10 patients had local recurrence 24 months after operation, and one suffered adenocarcinoma of esophageal-gastric junction at 15 months postoperation. The rest of eight patients all survived to June 2017 and no local recurrence and metastasis was found. The mean survival time was 14.8 months. Complete VATS sleeve lobectomy is a safe and feasible procedure, but the advantage of perioperative and long-term survival need prospective randomized controlled large sample trial to be confirmed.

Uniportal sleeve lobectomy for lung cancer.

Over the last years video-assisted thoracic surgery (VATS) has become more popular as it has a number of advantages comparing to the classical thoracotomy (less postoperative pain, reduced blood loss, cosmetic effect, etc.) A short time ago it was generally thought that it was impossible to make certain surgeries (including bronchoplasty) through single port approach. However, improvement of manual skills, more advanced stapling devices, tools and surgical needles have made it possible to perform surgeries practically of any extent observing the oncological principles of operational intervention.

Sleeve lobectomy for lung cancer

Considerable progress has been made in the field of lung cancer surgery since the first sleeve lobectomy was performed 70 years ago. Technology has advanced significantly and a multitude of lung cancer treatments and diagnostic tests is now available. These advancements have led to improved surgical treatments and understanding of this disease. Historically, pneumonectomy was considered the procedure of choice for central or locally advanced non-small cell lung cancer (NSCLC). Sleeve lobectomy was conceived only as an alternative for patients with limited cardiopulmonary reserve. However, the advantages of bronchoplastic resections for NSCLC have long been established (Thomas et al. J R Coll Surg Edinb. 1956;1:169–186; Allison et al. Ann R Coll Surg. 1954; 25:20–22; Thomas et al. Thorax. 1960;15:9–11; Weisel et al. J Thorac Cardiovasc Surg. 1979;78(6):839–849; Jensik et al. J Thorac Cardiovasc Surg. 1972;64(3):400–412. Many reliable studies have published convincing results over the years demonstrating superior outcomes over pneumonectomy when sleeve lobectomy is extended to patients with normal cardiopulmonary reserve (Gaissert et al. Thorac Cardiovasc Surg. 111(5):948–953, 1996). Not only does sleeve lobectomy surgery preserve lung function, but literature over the years has clearly shown this procedure to be associated with comparable morbidity, decreased mortality, and favorable long-term survival and enhanced quality of life (Weisel et al. J Thorac Cardiovasc Surg. 1979;78:839–849; Jensik et al. J Thorac Cardiovasc Surg. 1972;64:400–412, Ferguson et al. Ann Thorac Surg. 2003;76:1782–1788). In this review, we highlight patient selection factors and current indications for considering sleeve lobectomy. In addition, we describe our sleeve lobectomy surgical techniques and review post-operative management strategies and potential associated complications. We also discuss the long-term outcomes, recurrence, and survival rates associated with sleeve lobectomy in more recently available published series.

Impact of Induction Therapy on Airway Complications After Sleeve Lobectomy for Lung Cancer

Sleeve lobectomy is a valid alternative to pneumonectomy for the treatment of centrally located operable non-small cell lung cancer (NSCLC), but concern has been evoked regarding a potentially increased risk of bronchial anastomosis complications after induction therapy. This study examined the impact of induction therapy on airway healing after sleeve lobectomy for NSCLC. Bronchial anastomosis complications were recorded with respect to the induction regimen applied (neoadjuvant chemotherapy vs chemoradiotherapy) in a consecutive series of patients with sleeve lobectomy for NSCLC. Ninety-nine patients underwent sleeve resection, 28 of them after induction therapy. Twelve patients received chemotherapy alone, and 16 patients had radiochemotherapy. There were no significant differences in postoperative 90-day mortality (3.6% vs 2.8%) and morbidity (54% vs 49%) for patients with and without induction therapy. Bronchial anastomosis complications occurred in 3 patients (10.8%) with neoadjuvant therapy and in 2 (2.8%) without (p = 0.3). In the induction therapy group, two bronchial stenoses occurred after radiochemotherapy and one bronchopleural fistula after chemotherapy alone. In patients without induction therapy, one bronchial stenosis and one bronchopleural fistula were observed. All bronchial stenoses were successfully treated by dilatation, and both bronchopleural fistulas occurring after right lower lobectomy were successfully treated by reoperation and completion sleeve bilobectomy with preservation of the upper lobe. Sleeve lobectomy for NSCLC can be safely performed after induction chemotherapy and radiochemotherapy with mortality and incidence of airway complications similar to that observed in nonpretreated patients. The treatment of airway complications does not differ for patients with and without induction therapy.

Reply to the Editor

Reply to the Editor

Induction Chemotherapy Before Sleeve Lobectomy for Lung Cancer: Immediate and Long-Term Results

Induction chemotherapy does not increase the morbidity and mortality rates of bronchoplastic procedures, but the long-term efficiency remains unclear. The purpose of this retrospective study was to analyze the impact of chemotherapy on resectability and long-term survival. From 1984 to 2005, 159 consecutive patients with non-small cell lung cancer underwent sleeve lobectomy without (n = 117) or with induction chemotherapy (n = 42). Indications for chemotherapy were N2 lymph node involvement (n = 15), T3 or T4 tumor invasion with doubtful resectability (n = 13), need for tumor size reduction (n = 8), lung function precluding pneumonectomy (n = 4), and brain metastasis (n = 2). None of the patients received induction radiation therapy. We studied tumor characteristics and immediate and long-term results in both groups. Clinical stage III was predominant in the induction chemotherapy group whereas stage II was predominant in the surgery-only group. Complication rates in the induction chemotherapy group and in the surgery-only group were 23.8% and 24.7%, respectively. We observed a greater rate of 1-month-delay smoking cessation before surgery in the induction chemotherapy group (40% versus 22%). The 5-year survival rates were 65.4% in the surgery-only group and 73.4% in the induction chemotherapy group (p = 0.5). The tumor size in the induction chemotherapy group was lower (17.5 versus 30.6 mm; p = 0.01), which reflected the positive impact of chemotherapy on sleeve resection feasibility. Induction chemotherapy before sleeve lobectomy achieves good long-term results. Tumor reduction and limited resection feasibility seemed to be increased, which justify further prospective trials.

Sleeve lobectomy for patients with non-small cell lung cancer

Purpose A sleeve lobectomy for lung cancer is a procedure intended both for the maintenance of lung function and for radical treatment. We investigated the clinico-pathological features and treatment responses of lung cancer patients who underwent sleeve lobectomy in our department. Subjects Among the 984 patients with non-small cell lung cancer who underwent resection in our department between 1994 and 2007, the subjects were 24 patients in whom a sleeve lobectomy was performed. Results There were 18 male and 6 female patients, with a mean age of 65 years. The histological type was diagnosed as squamous cell carcinoma in 14 patients, and adenocarcinoma in 10. Patients with either mucoepidermoid carcinoma ( n = 1) or carcinoid tumor ( n = 1) were excluded. The pathological stage was evaluated as IA, IB, II, IIIA, IIIB, and IV in 4, 1, 8, 8, 2, and 1 patient, respectively. Regarding post-operative complications, 4 patients required sputum aspiration with a bronchoscope from the 2nd to 7th post-operative day due to sputum retention. The 5-year survival rate in patients who underwent sleeve lobectomy was 70.0%. According to the pathological nodal status, the 5-year survival rates of N0, N1, and N2 were 100.0%, 87.5%, and 41.7%, respectively. The 5-year survival rates in squamous cell carcinoma and adenocarcinoma were 83.0% and 45.7%, respectively. Conclusion Sleeve lobectomy facilitated the maintenance of residual lung function without serious perioperative complications. This finding suggests that patients with direct tumor invasion to the bronchus might be good candidates for a sleeve lobectomy, but not those with extra-nodal invasion.

Sleeve lobectomy for patients with non-small-cell lung cancer: a simplified approach

Pulmonary parenchyma-saving procedures, indicated for central tumours, seem to have better results than pneumonectomy, an alternative procedure. The purpose of this study is to report our experience at our institution with sleeve lobectomy with regard to surgical technique and outcome. We retrospectively reviewed the records of 45 patients who underwent sleeve lobectomy for non-small-cell lung cancer, with a curative intent, during the period of January 2004 and January 2008. Four of these patients underwent bronchovascular reconstructive procedures. A minor modification of the running suture technique used for bronchoplasties is described here. The study identified 40 men and five women with a median age of 64 years (range: 24-80 years). All 45 patients underwent oncological resections with negative results for malignancy bronchial resection margins. Neither bronchial nor vascular complications occurred. Complications were observed in 15% of our patients and included prolonged air leak in three, atelectasis needing daily bronchoscopy in three and respiratory failure due to pneumonia in one patient, who eventually died, accounting for a mortality rate of 2%. The follow-up period ranged from 1 to 52 months, with a median of 26 months, and it was complete for 43 (96%) of the patients. The overall 4-year survival was 57%. Sleeve lobectomy for lung cancer, although technically demanding, is associated with low morbidity and mortality and satisfactory immediate and long-term results. With increasing experience, more lung-sparing procedures should be performed in selected patients.

Sleeve lung resection for lung cancer: Analysis according to the type of procedure

Although sleeve lobectomy for lung cancer is widely accepted as an alternative to pneumonectomy, its use remains controversial. This study aimed to evaluate the surgical results after sleeve lung resection and to compare the outcomes of different procedural approaches. The medical records of 201 patients who underwent sleeve lung resection for lung cancer were retrospectively reviewed. Three groups were compared: a standard group (lobectomy or bilobectomy; n = 173), limited group (segmentectomy; n = 8), and extended group (lobectomy or bilobectomy plus segmentectomy; n = 20). Three patients died postoperatively (1.4%). Anastomotic complications occurred in 7 patients (3.4%; fistula in 4 patients, stenosis in 3 patients), 6 of whom were successfully treated surgically or conservatively. Five-year overall and disease-free survivals were 57.8% and 50.3%, respectively. Sites of recurrence included anastomotic sites (n = 5), ipsilateral thorax (n = 11), mediastinum (n = 10), and distant sites (n = 43). Multivariate analysis showed that the influence of nodal status on both overall and disease-free survival was significant. All patients in the limited group but 1 who underwent lobectomy for recurrence in another lobe are alive without recurrence. Three patients in the extended group experienced distant metastasis, but none experienced local recurrences. Multivariate analysis showed extended group-to-standard group hazard ratios of 0.53 (95% confidence interval, 0.23-1.23) for overall survival and 0.48 (95 confidence interval, 0.22-1.05) for disease-free survival. Sleeve lung resection can achieve local tumor control and long-term survival with low mortality and few anastomotic complications. Nodal status significantly affects long-term survival. Limited and extended resections are also feasible with local and long-term results comparable to those of standard sleeve lobectomy.

M07-01: Pneumonectomy versus sleeve resection for the management of resectable lung cancer

Sleeve lobectomy for lung cancer was first described as a compromise operation for patients whose pulmonary reserve was considered inadequate to permit pneumonectomy. Since then, several authors have suggested that sleeve resection may provide as good if not better results than pneumonectomy in selected cases of primary lung cancer involving the proximal bronchial tree. Whether sleeve resection is radical enough and indicated for patients who could tolerate pneumonectomy continues to be debated among thoracic surgeons and indeed there are only a handful of reports of clinical series comparing operative mortality, survival, and sites of recurrences between these procedures (Table 1).Table 1- Comparison of survival between sleeve resection and pneumonectomyAuthors (yr)No pts5 year survival (%)Sleeve resectionPneumonectomyGaissert (1996)12842 %44 %Yoshino (1997)5866 %59 %Suen (1999)20038 %36 %Ludwig (2005)31039 %27 %Takeda (2006)17254 %33 % Open table in a new tab Operative mortality, survival, and sites of recurrences were compared in 1,346 consecutive patients who underwent pneumonectomy (N: 1,046) or sleeve resection in our institution over a 25-year interval (Table 2).Table 2- Sleeve lobectomy versus pneumonectomy for lung cancerSleeve lobectomyPneumonectomyNo of patients300(1976-2005)1,046 (1980-2000)Mean age61.2 ± 11 years60.7 ± 9.4 yearsOperative mortality2.7 % (8 / 300)5.3 % (55 / 1,046)Overall 5 year survival54 %31 %Locoregional recurrences16 %35 % Open table in a new tab During that period, sleeve resection was always done whenever technically possible while pneumonectomy was reserved for lesions that could not be removed by a bronchoplastic procedure. While lesions in the hilum of the right upper lobe were the commonest indication for sleeve resection, all lobes of either lung could be involved with tumors amenable to some form of lung-sparing bronchoplastic procedure. All patients included in the analysis were staged by nodal sampling and according to the 1997 revised TNM nomenclature. There were 8 operative deaths out of 300 patients who underwent sleeve resection (2.7 %) and 55 operative deaths out of the 1,046 patients who underwent pneumonectomy (5.3 %, p < 0.05) and most causes of death in either group were related to respiratory events. Of note, four patients (1.3 %) had anastomotic complications after sleeve resection but none of these complications lead to mortality. Follow-up was complete for the entire cohort and the overall 5-year survival was significantly better after sleeve resection (54 %) than after pneumonectomy (31 %, p < 0.0001) (see Table 2). For patients with N1 disease, there was also a significant difference in survival favoring sleeve lobectomy (sleeve resection (N: 72): 50 %; pneumonectomy (N: 361): 34 %; p 0.015). When recurrences occurred, the site of first recurrence was locoregional in 16 % after sleeve resection and in 35 % of patients after pneumonectomy. In summary, this analysis demonstrates that sleeve resection is an effective procedure for patients who could tolerate a pneumonectomy but in whom the surgeon judges that a complete resection is possible through a bronchoplastic procedure with conservation of pulmonary function. As a general statement, sleeve lobectomy should be considered in any case of lung cancer which can be completely resected by this technique.

Sleeve Lobectomy in Lung Cancer

Sleeve lobectomy for lung cancer is now commonly performed around the world for central lung cancers that are anatomically suitable regardless of lung function. The morbidity and mortality are low, especially when compared with pneumonectomy. Bronchial complications are quite low. Local control seems to be at least as good as that obtained with pneumonectomy. Survival in most series is better with sleeve lobectomy than with pneumonectomy. Although there is still controversy with the use of sleeve lobectomy in patients with N1 disease, several recent series suggest better survival compared with pneumonectomy. Sleeve lobectomy can be safely performed after induction therapy. Quality of life is better with sleeve lobectomy compared with pneumonectomy.

Double prosthetic replacement of pulmonary artery and superior vena cava and sleeve lobectomy for lung cancer

We present a case of double prosthetic replacement of the right pulmonary artery and superior vena cava combined with upper sleeve bi-lobectomy for a limited pT4N1 adenocarcinoma occurring in a patient with poor pulmonary reserve, which, to the best of our knowledge, has never been reported before.

Pulmonary Artery Bronchial Fistula After Sleeve Lobectomy, A Case Report: A Fatal Complication Of Sleeve Lobectomy

A rare case of pulmonary artery bronchial fistula after sleeve lobectomy for lung cancer is described. Non-aspergillous ulcerative bronchitis was the most considerable cause of death in our case. The patient was once saved by emergency thoracotomy, but finally he died from recurrent massive hemoptysis resulting from newly formed pulmonary artery bronchial fistula. Albeit our case had quite rarely clinical course, we must have a threat for this fatal complication even when we are managing nonimmunosuppressive patients.

Pulmonary Artery Bronchial Fistula After Sleeve Lobectomy, A Case Report: A Fatal Complication Of Sleeve Lobectomy

A rare case of pulmonary artery bronchial fistula after sleeve lobectomy for lung cancer is described. Non-aspergillous ulcerative bronchitis was the most considerable cause of death in our case. The patient was once saved by emergency thoracotomy, but finally he died from recurrent massive hemoptysis resulting from newly formed pulmonary artery bronchial fistula. Albeit our case had quite rarely clinical course, we must have a threat for this fatal complication even when we are managing nonimmunosuppressive patients.

Long-term results of sleeve lobectomy for lung cancer

Sleeve lobectomy is a lung saving procedure indicated for central tumors for which the alternative is a pneumonectomy. Current controversies relate to the safety of the procedure and adequacy as a cancer operation. The aim of the study is to analyze long-term survival after sleeve lobectomy, particularly in relation with nodal status and histological type. The incidence and patterns of recurrences were reviewed. From 1972 to 1998, 184 patients (male 152, female 32) underwent sleeve resection for lung cancer. The mean age was 60+/-10 years (11-78 years), and the indications for operation were a central tumor (79%), peripheral tumor with nodal involvement (13%) and compromised pulmonary function (8%). The histological type was predominantly squamous (n=125, 68%), followed by non-squamous (n=50, 27%) and carcinoid tumors (n=9, 5%). Resection was complete in 161 patients (87%). The operative mortality was 1.6% (n=3). Follow-up was complete for the remaining 181 patients (mean, 5.7 years; range, 1 month-26 years). The survival at 5 and 10 years of all patients was 52 and 33%, respectively. Theses rates for patients with N0 status (n=97) were 63 and 48%, and 48 and 27% for those with N1 status (n=68; N0 vs. N1, P<0.05). An 8% survival rate was observed with N2 status (n=19) at 5 years, with no survivors after 7 years of follow-up. The 5 and 10 year survival was 56 and 34% for squamous carcinoma vs. 33 and 22% for non-squamous carcinoma (P<0.05). These rates were 58 and 38% for complete resection vs. 11 and 6% for incomplete resection at 5 and 10 years, respectively (P<0.05). Local recurrences occurred in 22% of cases, and the prevalence was statistically different between patients with N0 disease (14%) and N1 disease (23%; P=0.03), but not between N1 and N2 disease (42%; P=0.2). When local and distant recurrence were pooled together, the differences were highly significant between N0 (22%) and N1 (41%) disease (P=0.007), and between N0 and N2 (63%) disease (P=0.0002), but not between N1 and N2 disease (P=0.09). Sleeve lobectomy is a safe and effective therapy for patients with resectable lung cancer. The presence of N1 and N2 disease, or of non-squamous carcinoma significantly worsen the prognosis.

Extended sleeve lobectomy for lung cancer: The avoidance of pneumonectomy

Objective: We have tried atypical bronchoplasties in patients with noncompromised lung function with centrally located cancers to avoid pneumonectomy. We evaluated the efficacy of extended sleeve lobectomy in such patients. Methods: Among 157 patients undergoing bronchoplasty for primary non–small cell lung carcinoma, 15 patients underwent extended sleeve lobectomy. Results: According to the mode of reconstruction, the 15 patients were classified into 3 groups: (A) anastomosis between the right main and lower bronchi with resection of the upper and middle lobes (n = 6), (B) anastomosis between the left main and basal segmental bronchi with resection of the upper lobe and superior segment of the lower lobe (n = 4), and (C) anastomosis between the left main and upper division bronchi with resection of the lingular segment and lower lobe (n = 5). The tumors were completely resected in all patients. Pulmonary angioplasty was carried out in 8 patients. Bronchial reconstruction was successful in all patients. Pulmonary vein thrombosis resulting from overstretching of the inferior pulmonary vein occurred in 1 patient of group A and was relieved by completion pneumonectomy. There was neither operative mortality nor local recurrence. Although all patients with stage IIB disease and half of patients with stage IIIA disease were alive without recurrence (12-106 months), half of the patients with stage IIIA disease died of distant metastases within 1 year. Conclusions: We suggest that this extended sleeve lobectomy, which is technically demanding, should be considered in patients with centrally located lung cancer, because this lung-saving operation is safer than pneumonectomy and is equally curative. (J Thorac Cardiovasc Surg 1999;118:710-4)