The aim of the study was to verify the indications for surgery in T4 tracheo-bronchial carcinomas. Forty-eight tracheal-sleeve pneumonectomies for T4 bronchogenic carcinoma were performed in our unit from 1986 to 2003. The patients were 42 males and 6 females. A postero-lateral thoracotomy was preferred (46 right, 2 left). Bronchial reimplantation was performed additionally (tracheal-sleeve lobectomy) in 2 patients on the right side. The morbidity was 25% and the mortality 6.2% (1 acute respiratory distress syndrome, 1 myocardial infarction, 1 anastomotic fistula). Twenty-three cases were sT4N2M0, 14 sT4N1M0, and 11 sT4N0M0. The sT4N2M0 and sT4N1M0 cases were not associated with more than 3 year survival, despite adjuvant therapies; sT4N0M0 squamous cell carcinomas, on the other hand, had > 40% 10-year survival with no adjuvant therapy. Associated prosthetic replacement of the superior vena cava neither affected the risk nor improved the prognosis. Surgery for T4 tracheo-bronchial carcinoma appears feasible for well differentiated sT4N0 squamous cell carcinomas; at more advanced stages this procedure is no more than a dangerous form of palliation.