Pneumonectomy has been the surgical procedure of

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1 Bronchovascular Versus Bronchial Sleeve Resection for Central Lung Tumors Henning F. Lausberg, MD, Thomas P. Graeter, MD, Dietmar Tscholl, MD, Olaf Wendler, MD, PhD, and Hans-Joachim Schäfers, MD, PhD Department of Thoracic and Cardiovascular Surgery, University Hospitals, University of Saarland, Homburg/Saar, Germany GENERAL THORACIC Background. Pneumonectomy has traditionally been the treatment of choice for central lung tumors. Bronchial sleeve resections are increasingly considered as a reasonable alternative. For tumor involvement of both central airways and pulmonary artery, bronchovascular sleeve resections are possible, but considered to be technically demanding and associated with a higher perioperative risk. In addition, their role as adequate oncologic treatment for lung cancer is unclear. We have compared the early and long-term results of bronchovascular sleeve resection with those of bronchial sleeve resection and pneumonectomy. Methods. We retrospectively analyzed all patients who underwent bronchial sleeve resection (group I, n 104), bronchovascular sleeve resection (group II, n 67), and pneumonectomy (group III, n 63) for central lung cancer in our institution. Results. The groups were comparable regarding demographics and tumor, node, and metastasis (TNM) stage. Early mortality was 1.9% in group I, 1.5% in group II, and 6.3% in group III (p 0.19). The rate of bronchial complications was 0.96% in group I, 0% in group II, and 7.9% in group III (p 0.006). Five-year survival was 46.1% in group I, 42.9% in group II, and 30.4% in group III (p 0.16). Freedom from local recurrence of disease (5 years) was 83.8% in group I, 84.2% in group II, and 88.7% in group III (p 0.56). Conclusions. Bronchovascular sleeve resections are as safe as bronchial sleeve resections for the treatment of central lung cancer. Both procedures have comparable early and long-term results, which are similar to those of pneumonectomy. It appears reasonable to apply bronchovascular sleeve resections more liberally. (Ann Thorac Surg 2005;79: ) 2005 by The Society of Thoracic Surgeons Pneumonectomy has been the surgical procedure of choice in the treatment of central lung tumors. Although it has been a standard approach for decades it is also commonly accepted that it is associated with a morbidity and mortality risk significantly higher than that of lobectomy [1, 2]. The reason is most likely related to the limited physiologic reserve after pneumonectomy [3 5]. For patients with impaired pulmonary reserve, bronchial sleeve resections have been used as a surgical alternative to pneumonectomy in the presence of central lung tumors [6 8]. More recently, parenchyma-sparing lung resection has been applied more widely also in patients with unimpaired pulmonary function [9 11]. The perioperative risk of bronchial sleeve resection has repeatedly been shown to be comparable to that of standard lobectomy [9 11]. Whenever central lung tumors involve not only the airway but also the central vascular structures, in particular the pulmonary artery, bronchovascular sleeve resection remains as the only alternative to pneumonectomy. In view of the traditionally high perioperative mortality of this form of parenchyma-sparing resection [12] pneumonectomy is still the preferred approach for most surgeons. In addition, the long-term oncologic success of bronchovascular sleeve resections has been the subject of concern. Encouraged by the positive short and long-term results of bronchial sleeve resection [9 11] we have extended our systematic approach of parenchymasparing surgery also to bronchogenic carcinoma involving the central pulmonary arteries. Whenever distal resection margins were macroscopically and microscopically free of tumor, the distal parenchyma was preserved utilizing the standard techniques [13] of bronchovascular sleeve resection. We retrospectively analyzed our experience with bronchovascular sleeve resections regarding morbidity, mortality, and disease-free survival. We compared the patients to those undergoing bronchial sleeve resections and pneumonectomy during the same interval. Accepted for publication Sept 3, Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26 28, Address reprint requests to Dr Lausberg, Department of Thoracic and Cardiovascular Surgery, University Hospitals, University of Saarland, Homburg/Saar, Germany; henning.lausberg@unikliniksaarland.de. Patients and Methods All patients undergoing resection for central non-small cell lung cancer in our department between October 1995 and December 2002 were studied. For us, central location was present whenever the distance of the primary tumor or invasive lymph node growth to the main bronchus was 2005 by The Society of Thoracic Surgeons /05/$30.00 Published by Elsevier Inc doi: /j.athoracsur

2 GENERAL THORACIC 1148 LAUSBERG ET AL Ann Thorac Surg BRONCHOVASCULAR SLEEVE RESECTION 2005;79: Table 1. Preoperative Data Group I Group II Group III n Age (years) Men 88 (85%) 48 (72%) 56 (89%) Women 16 (15%) 19 (28%) a 7 (11%) a Mediastinoscopy 27 (26%) 18 (27%) 19 (30%) FEV (33%) 20 (30%) 15 (24%) Table 2. Staging According to Postoperative Histopathological TNM Stage Group I Group II Group III p I 11 (16%) 22 (11%) 7 (11%) 0.24 II 30 (46%) 50 (48%) 32 (51%) 0.79 IIIA 19 (28%) 23 (22%) 9 (14%) 0.15 IIIB 6 (9%) 7 (7%) 12 (19%) IV 1 (1%) 2 (2%) 3 (5%) 0.42 a p All data show absolute values if not indicated. 10 mm or less. Preoperatively, all patients underwent standardized diagnostic and staging procedures. Specimens for cytopathology and histopathology were obtained by fiberoptic bronchoscopy. Computed tomography (CT) of chest and abdomen, bone scintigraphy, and abdominal ultrasound were performed for noninvasive staging. Every patient underwent a pulmonary function test and calculation of the predicted postoperative lung function to assess the surgical risk. If there was suspicion of N2 or N3 disease according to the CT scan, cervical mediastinoscopy with histopathological examination of the mediastinal lymph nodes was performed. If involvement of mediastinal N2 lymph nodes was documented histologically by mediastinoscopy, the patient underwent combined radiation and chemotherapy according to current study protocols. After reassessment of tumor stage, patients with complete or partial remission were scheduled for surgery. All patients with preoperative documented N3 or M1 disease were primarily excluded from any form of surgical therapy. The surgical technique included primary exploration of the hilar structures followed by a complete dissection of the fissure(s). When the distal parenchyma was free of tumor and/or invasive growth of lymph nodes, a sleeve resection was performed. Frozen sections of the resected bronchi and/or pulmonary artery were taken to ensure resection margins of at least 1 cm. The technique of bronchial sleeve resection has been described previously [14]. In the presence of involvement of the proximal pulmonary artery either by malignant tissue (tumor or invasive growth of lymph nodes), heparin (5,000 IU) was given intravenously and the pulmonary artery clamped proximally. The superior pulmonary vein was ligated, and the inferior pulmonary vein or the distal part of the pulmonary artery were occluded with a vascular clamp. Resection of the tumor-bearing lobe was performed en bloc with the involved portion of the pulmonary artery. The artery was reconstructed by implantation of a pericardial patch after tangential resection or end-to-end anastomosis (Prolene 5-0, Ethicon Inc, Hamburg, Germany) after segmental resection. In all patients the bronchial anastomosis (interrupted PDS 4-0, Ethicon Inc) was created first followed by vascular reconstruction. Following pneumonectomy, closure of the bronchial stump was TNM tumor, node, metastasis. performed with interrupted PDS 3-0 sutures (Ethicon Inc, Hamburg, Germany). In earlier patients, the bronchial stump was not covered routinely. In the recent patients, the bronchial stump was covered with pericardium or mediastinal tissue. In all patients, a radical mediastinal lymphadenectomy was included. Patients were extubated in the operating room whenever possible. Mechanical ventilation was continued for hemodynamic instability or inadequate respiratory status or hypothermia of 35.5 C or less. Our postoperative treatment used for all patients undergoing parenchymasparing procedures has been previously described [15]. All patients underwent routine bronchoscopy one week postoperatively if they had undergone any form of parenchyma-sparing procedure. Based on the operative specimens, all patients were staged according to the tumor, node, metastasis (TNM) classification of the American Joint Committee for Cancer Staging and End Results Reporting [16]. The duration of mechanical ventilation was used as a global indicator of operative morbidity. In addition, the duration of intensive care unit (ICU) stay and hospitalization were recorded. Surgical mortality was defined as any death occurring within 30 days after surgery or any death in a patient who never left the hospital. Episodes of respiratory infections were defined as any symptomatic infection of the airways requiring antibiotic treatment. Furthermore the need for therapeutic fiberoptic bronchoscopy due to mucus retention was documented. Both factors were used as indicators for the operative morbidity. Follow-up data were obtained from follow-up examination or direct contact with the referring physicians. Local recurrence of disease was defined as appearance of a tumor of the original type as judged by histopathology at any site within the same hemithorax. Survival and recurrence of disease were estimated according to the Kaplan-Meier method with the date of surgery as a starting point. The curves of survival and local recurrence of disease were compared using the Mantel-Haenszel log-rank test (Prism 3.0, GraphPad Software Inc, San Diego, CA). The comparison of the demographic data and tumor stages was performed using the contingency table and 2 test. All other data were compared using the analysis of variance test (SigmaStat 2.0, SPSS Inc, Chicago, IL). The p values of less than 0.05 were considered statistically significant.

3 Ann Thorac Surg LAUSBERG ET AL 2005;79: BRONCHOVASCULAR SLEEVE RESECTION Table 3. Indicators of Operative Morbidity Group I Group II Group III p Time of ventilation (d) Mean SD a a 0.02 Median Time of ICU stay (d) Mean SD Median Time of hospitalization (d) Mean SD Median Respiratory infection 29 (28%) 23 (34%) 36 (57%) a Therapeutic bronchoscopy 14 (13%) 8 (12%) 25 (40%) a GENERAL THORACIC a Indicates significant difference. d days; ICU intensive care unit; SD standard deviation. Results All 234 patients with typical lung resections for central bronchogenic carcinoma were analyzed. The patients were retrospectively divided into three groups according to the surgical procedure. A bronchial sleeve resection was performed in 104 patients (group I), a bronchovascular sleeve resection in 67 patients (group II), and a pneumonectomy in 63 patients. In group III, there were significantly more men when compared to group II (p 0.025). Preoperative vital capacity (VC) was comparable in all groups (VC: group I: ; group II: ; group III: ; p 0.23). Forced expiratory volume in one second (FEV 1 ) was significantly lower in groups II and III compared to group I (FEV 1 : group I: ; group II: ; group III: ; p 0.001). All other demographics were without significant difference (Table 1). Because of preoperative N2 lymph node involvement, a neoadjuvant treatment with combined radiotherapy and chemotherapy was performed in a comparable proportion of patients in the groups (group I: n 9of104 patients; group II: n 6 of 67 patients; group III: n 2of 63 patients; p 0.33). In group I, the most frequent resection was a bronchial sleeve resection of either upper lobe (left upper lobe, n 18; right upper lobe, n 51). Of the bronchovascular sleeve resections (group II), there were 38 left upper lobe and 9 right upper lobe resections. Of the remaining patients, 6 combined lower and middle lobe and 14 combined upper and middle lobe resections were performed as bronchovascular sleeve resections. Of the angioplastic procedures, the pulmonary artery (PA) was resected tangentially in 28 patients. For these, an autologous pericardial patch was used for PA reconstruction. All other patients (n 39) underwent a segmental vascular sleeve resection with end-to-end anastomosis. In no patient was the use of a conduit interposition necessary. Group III had a significantly higher proportion of patients in stage IIIB in comparison with group I (p 0.029; Table 2). All other tumor stages were comparable between the groups. Approximately half of the patients had stage II disease in the three groups. The higher proportion of patients in group III in more advanced tumor stages were due to either T4 extension (stage IIIB) or ipsilateral pulmonary metastasis (M1 PUL; stage IV). No patient had N3 lymph node involvement. Operative mortality was 1.9% in group I (n 2). One patient suffered an acute posterior wall myocardial infarction resulting in intraoperative cardiac arrest. Despite intraoperative insertion of an intraaortic balloon pump and immediate percutaneous transluminal coronary angioplasty after his pulmonary resection he died on postoperative day 9 from multiorgan failure. The other patient developed pneumonia and died from sepsis and multiorgan failure on postoperative day 16. In group II one patient died from pneumonia and after sepsis on postoperative day 13 accounting for an early mortality of 1.5%. In group III operative mortality was 6.3% (n 4). One patient developed intraoperative myocardial infarction and could not be stabilized. The three remaining deaths occurred due to sepsis and multiorgan failure after pneumonia on postoperative days 3, 5, and 8. There was no significant difference in mortality between the groups (p 0.185). The duration of mechanical ventilation after pneumonectomy was significantly longer than after bronchial sleeve resection ( vs days, p 0.029). Groups I and II, and II and III did not differ significantly (Table 3). There were no significant differences between the groups regarding ICU and hospital stay (Table 3). The Fig 1. Survival analysis according to surgical procedure (Kaplan- Meier). e group I; group II; Πgroup III.

4 GENERAL THORACIC 1150 LAUSBERG ET AL Ann Thorac Surg BRONCHOVASCULAR SLEEVE RESECTION 2005;79: Fig 2. Analysis of freedom from local tumor recurrence (Kaplan- Meier). e group I; group II; Πgroup III. incidences of respiratory infections and the need for invasive mucus clearance were significantly higher after pneumonectomy (Table 3). In group I, one patient (0.96%) developed dehiscence of the bronchial anastomosis 12 days after sleeve resection of the right upper lobe. This was treated successfully by completion into a superior bilobectomy with reanastomosis of the remaining right lower lobe. In group II, there were no bronchial complications. In group III, there were 5 instances (7.9%) of bronchial dehiscence as diagnosed by fiberoptic bronchoscopy. In two patients, this was treated interventionally with local application of fibrin glue by bronchoscopy. Three patients underwent direct surgical closure of the defect and protection of the bronchial stump using either a pedicled pericardial flap or intercostal muscle. None of these patients developed empyema. No patient developed stenosis of the bronchial anastomosis. The incidence of bronchial complications in group III was significantly higher when compared to both groups I and II (p 0.006). There was no significant difference between groups I and II Follow-up ranged from 11 to 97 months with a mean follow-up of 46 months (cumulative follow-up: 10,446 patient-months). Some patients were lost to follow-up between 3 and 5 years postoperatively. Follow-up was complete in 94 patients in group I (90.4%), 62 patients in group II (92.5%), and 56 patients in group III (88.9%). Overall five-year survival was 46.1% in group I, 42.9% in group II, and 30.4% in group III (p 0.16, Fig 1). Five-year survival for stage II disease was 50.5% in group I, 36.7% in group II, and 46.3% in group III (p 0.7). Freedom from local recurrence of disease at 5 years was 83.8% in group I, 84.2% in group II, and 88.7% in group III (p 0.56; Fig 2). Comment Despite the advances that have been made in the multimodality therapy of lung cancer, surgical therapy still remains the most important tool if cure is attempted. Complete resection of bronchogenic carcinoma, if possible, not only removes all malignant tissue but also improves long-term prognosis. The completeness and extent of resection directly correlate with the probability of tumor recurrence and survival [17, 18] but also with perioperative morbidity and mortality [3, 17]. A secondary, but not unimportant aspect of surgery is quality of life, which, at least in the presence of preexistent pulmonary dysfunction, depends on the amount of pulmonary tissue resected [19, 20]. Pneumonectomy has been the standard surgical approach in patients with central lung cancer. This extensive pulmonary resection has offered curative treatment in a large proportion of cases. This procedure, however, is associated with a significantly higher morbidity and mortality compared to lobectomy [1, 2]. Long-term complications are the development of pulmonary hypertension or respiratory failure. Parenchyma-sparing bronchial and bronchovascular sleeve resections were primarily intended to offer a surgical alternative to those individuals who would not tolerate a pneumonectomy due to impairment of their pulmonary reserve. Initial reports indicated that this form of resection was associated with an increased mortality and morbidity associated with the bronchial and vascular anastomosis [12, 21]. There has been additional concern of a possibly higher risk of tumor recurrence with consecutive limitations of survival [7, 22]. Several series have been published in recent years indicating that bronchial sleeve resection applied irrespective of pulmonary function was associated with a mortality risk lower than that of pneumonectomy, and in most instances was comparable to standard lobe resection [9, 10, 15]. The incidence of bronchial anastomotic complications has consistently been lower than that of pneumonectomy [9, 10, 15]. The published 5-year survival and tumor recurrence data have not been inferior to those after pneumonectomy. A recent metaanalysis on parenchyma-sparing resections versus pneumonectomy in stages I and II lung cancer revealed a significant advantage in quality-adjusted life years for sleeve resections [23]. While the use of bronchial sleeve resections is thus gaining wider acceptance, concern continues regarding the routine application of bronchovascular sleeve resections for the treatment of central lung cancer involving the pulmonary artery. In a series of 37 sleeve resections of the pulmonary artery, Vogt-Moykopf and colleagues [12, 24] reported acceptable long-term results but an operative mortality of up to 14%. Major complications of the vascular anastomosis have been described [12, 24]. With the impression that angioplasty was not a safe procedure, apparently many surgeons have been reluctant to employ this technique. Only recently has it become apparent that angioplastic resections could be performed with favorable early results [13, 25]. In addition, lessons learned from lung transplantation not only pointed out potential pitfalls of the vascular anastomosis but also showed ways to avoid them [25 27]. Our current results indicate that not only bronchial but also bronchovascular sleeve resections for the treatment

5 Ann Thorac Surg LAUSBERG ET AL 2005;79: BRONCHOVASCULAR SLEEVE RESECTION of central lung tumors can be performed with a low perioperative risk. Most importantly, the long-term data regarding survival and tumor recurrence are identical to those of bronchial sleeve resection and pneumonectomy in our patient population. Thus, we believe that this surgical option does not compromise oncologic success. A definite conclusion regarding oncologic results is, however, hampered by the relatively limited number of individuals in our study. In a recent metaanalysis an increased risk of local tumor recurrence was found after sleeve lobectomy compared to pneumonectomy. Interestingly, this increase in tumor recurrence did not affect long-term survival [23]. It is unclear whether routine application of adjuvant radiotherapy for all parenchymasparing operations could be of benefit. It may be argued that a relatively high proportion of our patients treated surgically were in more advanced tumor stages; ie, IIIB and IV. In all instances stage IIIB was defined by mediastinal involvement or metastasis within the tumor-bearing lobe, which was found intraoperatively. In view of the promising results in resection tumors of T4 stage, we attempt to resect these tumors whenever possible without incurring major morbidity. In view of other results [28 30] this appears justified in selected patients. All patients with an unequivocal preoperative T4 stage are considered as candidates for neoadjuvant protocols. In only 6 of 234 patients (2.6%) was stage IV disease diagnosed intraoperatively. In all instances, the tumor stage was determined by a single metastasis in the nontumor-bearing lobe, which had not been diagnosed preoperatively. All patients had preoperatively expressed a definite wish in favor of resection. We thus conclude that bronchovascular sleeve resections are as safe as bronchial sleeve resections for the treatment of central lung cancer. Both procedures have comparable early and long-term results, which are similar to those of pneumonectomy. It appears reasonable to also apply bronchovascular sleeve resections more liberally. References 1. Ginsberg RJ, Hill LD, Eagan RT, et al. Modern 30 day mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg 1983;86: Klempnerer J, Ginsberg RJ. Morbidity and mortality after pneumonectomy. Chest Surg Clin N Am 1999;9: Bernard A, Ferrand L, Hagry O, Benoit L, Cheynel N, Favre JP. Identification of prognostic risk factors determining risk groups for lung resection. Ann Thorac Surg 2000;70: Harrison RW, Adams WE, Long ET, et al. The clinical significance of cor pulmonale in the reduction of cardiopulmonary reserve following extensive pulmonary resection. J Thorac Cardiovasc Surg 1958;36: Putnam JB, Lammermeier DE, Colon R, et al. Predicted pulmonary function and survival after pneumonectomy for primary lung cancer. Ann Thorac Surg 1990;49: Naruke T. Bronchoplastic and bronchovascular procedures of the tracheobronchial tree in the management of primary lung cancer. Chest 1989;96(suppl):53S 56S Tedder M, Anstadt MP, Tedder SD, Lowe JE. Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy. Ann Thorac Surg 1992;54: Van Schil PE, Brutel de la Riviere A, Knaepen PJ, van Swieten HA, Defauw JJ, van den Bosch JM. TNM staging and long-term follow-up after sleeve resection for bronchogenic tumors. Ann Thorac Surg 1991;52: Tronc F, Gregoire J, Rouleau J, Deslauriers J. Long-term results of sleeve lobectomy for lung cancer. Eur J Cardiothorac Surg 2000;17: Suen HC, Meyers BF, Guthrie T, et al. Favorable results after sleeve lobectomy or bronchoplasty for bronchial malignancies. Ann Thorac Surg 1999;67: Yoshino I, Yokoyama H, Yano T, et al. Comparison of surgical results of lobectomy with bronchoplasty and pneumonectomy for lung cancer. J Surg Oncol 1997;64: Vogt-Moykopf I, Fritz TH, Meyer G, Bülzerbruck H, Daskos G. Bronchoplastic and angioplastic operation in bronchial carcinoma: long-term results of a retrospective analysis from Int Surg 1986;71: Rendina EA, Venuta F, Ciriaco P, Ricci C. Bronchovascular sleeve resection. J Thorac Cardiovasc Surg 1993;106: Weisel RD, Cooper JD, Delarue NC, Theman TE, Todd TRJ, Pearson FG. Sleeve lobectomy for carcinoma of the lung. J Thorac Cardiovasc Surg 1979;78: Lausberg HF, Graeter TP, Wendler O, Demertzis S, Ukena D, Schäfers HJ. Bronchial and bronchovascular sleeve resection for treatment of central lung tumors. Ann Thorac Surg 2000;70: Mountain CF. Revisions in the international system for staging lung cancer. Chest 1997;111: Suzuki K, Nagai K, Yoshida J, et al. Conventional clinicopathologic prognostic factors in surgically resected nonsmall cell lung carcinoma. Cancer 1999;86: Wada H, Fukuse T, Hitomi S. Long-term survival of surgical cases of lung cancer. Lung Cancer 1995;13: Zieren HU, Müller JM, Hamberger U, Pichlmaier H. Quality of life after surgical therapy of bronchogenic carcinoma. Eur J Cardiothorac Surg 1996;10: Handy JR Jr, Asaph JW, Skokan L, et al. What happens to patients undergoing lung cancer surgery? Outcomes and quality of life before and after surgery. Chest 2002;122: Faber JP, Jensik RJ, Kittle CF. Results of sleeve lobectomy for bronchogenic carcinoma in 101 patients. Ann Thorac Surg 1984;37: Fadel E, Yildizeli B, Chapelier AR, Dicenta I, Mussot S, Dartvelle P. Sleeve lobectomy for bronchogenic cancer: factors affecting survival. Ann Thorac Surg 2002;74: Ferguson MK, Lehman AG. Sleeve lobectomy or pneumonectomy: optimal management strategy using decision analysis techniques. Ann Thorac Surg 2003;76: Vogt-Moykopf I, Fritz T, Bülzebruck H, Merkle N, Daskos G, Meyer G. Bronchoplastic and angioplastic operations in bronchial carcinoma. Langenbecks Arch Chir 1987;371: Rendina EA, Venuta F, De Giacomo T, et al. Sleeve resection and prosthetic reconstruction of the pulmonary artery for lung cancer. Ann Thorac Surg 1999;68: Griffith BP, Magee MJ, Gonzalez IF, et al. Anastomotic pitfalls in lung transplantation. J Thorac Cardiovasc Surg 1994;107: Kawahara K, Akamine S, Takahashi T, et al. Management of anastomotic complications after sleeve lobectomy for lung cancer. Ann Thorac Surg 1994;57: Okada M, Tsubota N, Yoshimura M, Miyamoto Y, Nakai R. Evaluation of TNM classification for lung carcinoma with ipsilateral intrapulmonary metastasis. Ann Thorac Surgery 1999;68: Fadel E, Missenard G, Chapelier A, et al. En bloc resection of GENERAL THORACIC

6 GENERAL THORACIC 1152 LAUSBERG ET AL Ann Thorac Surg BRONCHOVASCULAR SLEEVE RESECTION 2005;79: non-small cell lung cancer invading the thoracic inlet and intervertebral foramina. J Thorac Cardiovasc Surg 2002;123: Osaki T, Sugio K, Hanagiri T, et al. Survival and prognostic factors of surgically resected T4 non-small cell lung cancer. Ann Thorac Surg 2003;75: DISCUSSION DR BRYAN MEYERS (St. Louis, MO): Congratulations to Dr Lausberg and his colleagues for this excellent work. This experience updates the authors previous report in the Annals of Thoracic Surgery in 2000, which included 81 sleeve resections and 40 pneumonectomies. They have added 90 sleeve resections and 23 pneumonectomies in fewer than four years. This impressive number of central tumor resections, a caseload of 2.7 sleeves or pneumonectomies per month, is identical to the productivity that they described in their previous paper. There are no bronchial wedges or tangential resections included in this report. These were all full bronchial sleeve resections. The bronchovascular sleeve operations were either segmental arterial sleeves or tangential resection using patch angioplasty to reconstruct the pericardium. The authors initially used sleeve resection as an alternative to pneumonectomy but recently have been using the sleeve resection in all patients where the anatomy was appropriate. The pneumonectomy rate has decreased from 34% to 20%, confirming their liberalized use of sleeve resection. Based on the rates from their previous paper, I would have expected 77 sleeve resections in the 117 cases added. Instead, they have added 94 sleeve resections, thus sparing 17 patients from a pneumonectomy. All this has been done with very low rates of death or complications. The authors did state that they had about 10% of patients who were lost to follow-up, and I think that the authors need to think carefully about what to do about the analysis of missing patients, since 10% missing in a study like this is a substantial loss. Being lost to follow-up is, more often than not, a bad thing. What can Dr Lausberg tell us about incomplete resections? Were there any cases done in this time period that were excluded from the paper because of positive margins? It seems unusual in a population of patients with advanced central tumors that there were not resections that resulted in microscopic or gross positive margins. Twenty-six of the reported patients, or about 10%, are stage IIIb due to T4 local invasion, and this would seem to put many at risk for an incomplete resection. Next, the authors have not specifically looked at patient outcomes with regard to the vascular anastomosis or reconstruction. This is a complication of the vascular sleeve resection that is difficult to detect unless one looks for it specifically. It won t change the chest x-ray, it won t change spirometry, and when bronchovascular sleeve is applied to patients who had physiologically tolerated pneumonectomy, they might also be expected to tolerate the insult of vascular thrombosis at the arterioplasty site. The authors should present whatever information they have with regard to vascular patency. Finally, systemic recurrence is not addressed, and it should be. In these central tumors, this will be the greatest hazard to the patients with regard to risk of cancer death. It would be worthwhile to report this, and it would be reassuring to see that the rate of distant failure in all three groups was comparable. What additional treatment for local or distant recurrence has been required: completion pneumonectomy, adjuvant radiation therapy, or adjuvant chemotherapy? I commend you on your results and for your presentation. DR PAUL VAN SCHIL (Edegem, Antwerp, Belgium): I enjoyed your presentation very much. It would be interesting to know how many of your patients had induction therapy, especially before undergoing a bronchovascular sleeve resection. Did you encounter any technical difficulties in these patients? As known from recent literature, dissection of the pulmonary artery can be very tedious after induction or neoadjuvant therapy, especially chemoradiotherapy. DR PETER C. PAIROLERO (Rochester, MN): Did you know that you were going to do a bronchovascular sleeve resection before you were inside the chest? If so, what type of imaging studies were done to indicate that this procedure would be necessary? DR REX STANBRIDGE (London, UK): In this complex series of cases you would obviously have quite a narrow margin of resection from the tumor. What minimum margin of resection were you aiming for? DR LAUSBERG: Thank you very much for these comments. I would like to answer Dr Meyers questions first: There were 11 patients who were incompletely resected who were shown to be stage R1, and, of course, they had adjuvant therapy postoperatively. No, we did not see any vascular problems, but we did not systematically look for those, for example, by angiography. It is a very interesting comment. Clinically no patient had any symptoms suggestive for a complication of the vascular anastomosis. The incidence of completion pneumonectomy of either bronchial or bronchovascular sleeve resection was between 7% and 8% in the long term. Next I would like to comment on Dr van Schil s remarks. About 10% of patients had preoperative downstaging for N2 disease before either bronchial and bronchovascular sleeve resections. Of course, dissecting in an irradiated field is more difficult, but using the standard technique we are comfortable to do the anastomoses. I remember two cases in the past in which the patients had to be placed on cardiopulmonary bypass because of tears in the central pulmonary artery. Both patients could be resected successfully. Dr Pairolero, we try to perform a sleeve resection whenever possible. If we can achieve a resection margin of at least one centimeter in the absence of tumor or invasive lymph nodes in the distal parenchyma we do a parenchyma-sparing operation. I believe this should also answer Dr Stanbridge s question. Again, thank you very much.