Bronchogenic carcinoma involving the proximal main bronchus (within 2 cm of the carina) is classified as a T3 lesion and that extending to the carina as T4. As surgical experience has grown, T3N0M0 lesions (including T3 lesions other than bronchial) have been moved to stage IIB, but T4N0M0 lesions remain in stage IIIB. The latter was based upon lack of familiarity with techniques of carinal resection and, in particular, of carinal pneumonectomy. A T4N0M0 lesion, by virtue of the carinal location, should be stage IIIA. T3 lesions due to main bronchial involvement, especially on the right, also usually require carinal resection in order to obtain an acceptable surgical margin. Squamous cell lesions centered at the carina may perhaps be considered as primary carinal neoplasms, in the way that a slightly more proximal lesion is a primary low tracheal carcinoma. The division is arbitrary but a localized central lesion is potentially treatable without loss of lung rather than by carinal pneumonectomy.
Tumors suitable for excision by carinal pneumonectomy (or tracheal sleeve pneumonectomy) are predominantly squamous in type and right sided. Mathey and Jensik and their colleagues were among the earliest to practice sleeve pneumonectomy for bronchogenic carcinoma other than episodically.32,33 (For a fuller account, see Introduction, "Development of Tracheal Surgery: An Historical Review.") Over a 15-year period, carinal resection for bronchogenic carcinoma was reported in North America by Deslauriers and colleagues, Jensik and colleagues, and Mathisen and Grillo, in Europe by Dartevelle and colleagues, Perelman and Koroleva, and Roviaro and colleagues, and in Japan by Isihara and colleagues and Watanabe and colleagues, among others.34-41 Excessive mortality initially accompanied this surgery but has improved with time (Table 8-1).
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