Response letter: Bronchial sleeve resection or pneumonectomy for non-small cell lung cancer? Pneumonectomy is still a valid choice

We appreciate the comments and concerns (TCR-2016-253) expressed by Dr. Lococo and co-workers regarding our article titled ”Bronchial sleeve resection or pneumonectomy (PN) for non-small cell lung cancer: a propensity-matched analysis of long-term results, survival and quality of life” (1). In lung cancer, sleeve lobectomy (SL) has been introduced as a surgical option for patients who cannot tolerate a PN due to poor lung function. Originally, SL was considered only as an alternative procedure, because of the somewhat more complex surgical technique, even with experience, and the possibility of an incomplete resection compared to PN (2,3). The main concern with SL has been the possible increase in loco-regional recurrence. Suture line recurrence may be related to lung preservation, if the adequate bronchial margins are compromised (4). In literature, the incidence of local recurrence has ranged from 5% to 51% (5,6). In our material, we did not find a significant difference in the rates of distant metastasis and loco-regional recurrence between the SL-group and the PN-group. At our institution, we perform a frozen section analysis of the resection margin in all lung cancer operations. This might be one reason for our low local recurrence rate. Many papers have established a relationship between high surgical volume and centralization, and improved perioperative outcomes (7). In our hospital, which is a tertiary center of excellence, all SL operations are done by two surgeons, who are dedicated to surgical treatment of lung cancer. Careful patient selection also plays a significant role. It takes commitment to thoracic surgery to perform the right operations on suitable patients. This dedication is, in our opinion, crucial for good oncological results, which is our main objective. In our opinion, PN is still a valid choice for properly selected patients with central tumors whose postoperative lung function will remain reasonable, and if sleeve resection might compromise the surgical and oncological results (1)