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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.

From January 1963 to December 1968, 148 patients underwent thoracotomy for bronchogenic carcinoma. In 123 patients either lobectomy or pneumonectomy was performed (resectability rate of 84 per cent). The over-all operative mortality was 3.4 per cent. Forty of the patients undergoing resection (34 per cent) are alive and free of cancer five years after surgery. Tumor size, nodal involvement, cell type, location, symptoms, and extent of surgery were studied in relation to the long-term results. Five year survival was directly related to the size of the tumor and the extent of nodal involvement. No patients with mediastinal nodal involvement or with lesions larger than 7 cm in diameter were among the long-term survivors.

Patients with unresectable or inoperable bronchial carcinoma were treated with en-bloc irradiation of the tumour and the mediastinal lymph nodes to a total target absorbed dose of 40 Gy in 20 fractions. The first 52 patients were treated in one series and the last 45 patients in two series (split-course). Radiation adverse effects were only mild. The two regimens gave the same palliative results. The median survival was the same for the 2 groups (8 months). Most patients died in disseminated disease.

Sixty-four (14.7 percent) of 434 consecutive patients having pulmonary resection for bronchogenic carcinoma were found to have microscopic residual tumor on the cut margins of the resected specimens. These subjects were further subdivided histologically into those with direct extension of the tumor (34 patients), lymphatic permeation (14 patients), clumps of cancer cells in parabronchial tissues (six patients), and the presence of carcinoma in situ change (10 patients). Bronchopleural fistulas developed in eight (12.5 percent) of 64 patients. The operative mortality rate was 15.6 percent, with four of the deaths occurring as the result of bronchopleural fistulas. Thirty-two patients (50 percent) survived 1 year, 21 (32.8 percent) survived 3 years, and 15 (23.4 percent) lived for 5 years or more. The patients with tumor in the submucosal and peribronchial lymphatics had the worst prognosis. 78.6 percent having died within 1 year and the remainder within 3 years. All 5-year survivors were men with squamous cell carcinoma and had relatively small tumors (mean diameter 2.9 cm). No direct relationship between the length of the resected bronchial stump and survival could be established; a short stump did not preclude long survival. The possible factors involved in the relatively high 5 year survival rate in this group of patients and the therapeutic implications of these factors are discussed.

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 disection, 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 subcrainal 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.