Objective: Sternal tumors are rare. In sternum resection, the clavicle and ribs are often resected to maintain distance from the tumor. Reconstruction using artificial materials or soft tissue is selected depending on the extent of the defect.

Methods: We performed a retrospective chart review of all patients with sternal tumors who underwent surgical treatment from January 2009 to December 2019. We aimed to elucidate optimal management by reviewing cases of sternal tumor resection.

Results: Seven patients were included in this study. The pathological diagnoses were metastatic cancer (n=5), chondrosarcoma (n=1), and undifferentiated pleomorphic sarcoma (n=1). In all cases, multiple ribs were resected in addition to sternal pedicle resection or partial sternal resection. The proximal clavicle was also resected in 4 cases. Reconstruction was performed in 5 cases. One case was reconstructed with artificial material. Reconstruction was performed when a skin defect occurred or the sternum body was resected.

Conclusion: Rigid reconstruction is not always necessary for sternal resection. A good course was acheived by soft tissue reconstruction alone.

A 51-year-old woman maintained long-term remission of ulcerative colitis for 19 years. Chest computed tomography revealed a pulmonary mass with a low-density area in the left lower lobe. Because the mass was growing, the preoperative diagnosis was lung cancer, and lobectomy was performed. Histopathological findings showed inflammatory cell infiltration, an abscess, and a decrease in the number of goblet cells resembling intestinal lesions of active ulcerative colitis. Considering the clinical course of the patient, she was diagnosed with pulmonary granuloma associated with ulcerative colitis. Inflammatory bowel disease is associated with systemic extraintestinal manifestations, and it is difficult to diagnose a pulmonary lesion as a pulmonary manifestation of inflammatory bowel disease based on imaging findings. As pulmonary manifestations show varying histopathological findings, a definite diagnosis is often difficult with a small specimen; therefore, a surgical biopsy specimen is necessary for diagnosis.

Descending necrotizing mediastinitis (DNM) is a severe acute mediastinitis caused by oropharyngeal infections. A 61-year-old man with left peritonsillar abscess and laryngeal edema underwent emergency pharyngeal drainage and tracheotomy. Four days later, he developed descending necrotizing mediastinitis, and we performed emergency thoracoscopic mediastinal drainage. However, six days after the surgery, we re-attempted mediastinal drainage due to drainage failure caused by displacement of the drainage tube and adhesion of the lungs. We performed mediastinal and thoracic irrigation for ten days, and the patient was discharged on postoperative day 55. Appropriate drainage is essential for the treatment of patients with DNM, a severe life-threatening disease, in spite of its rarity. We report effective drainage methods for DNM by stabilizing the mediastinal drainage tube through the azygos arch.

We present the case of a 64-year-old female patient who underwent total hysterectomy and pelvic lymph node dissection due to uterine cancer. She suffered from dyspnea on post-operative day (POD) 5 and right pleural effusion was observed on a chest radiograph. After thoracocentesis, the plural effusion was not milky and there were no malignant findings. Although a right thoracic drain was placed on POD 10, the amount of discharge did not decrease.

The subcutaneous injection of indocyanine green suggested the presence of a pleuroperitoneal communication. In addition, lymphatic scintigraphy showed lymphatic leakage in the pelvic cavity. Lipiodol lymphangiography of the inguinal lymph nodes was performed on POD 28. The pleural effusion then gradually decreased and the thoracic drain was removed on POD 35. At the last follow-up examination at 1 year after discharge, there were no signs of pleural effusion.

The causes of right plural effusion in this case were pleuroperitoneal communication and injury of the lymphatic vessels due to lymph node dissection in the pelvic cavity. Whether the lymphatic leakage is chylous depends on the site of lymphatic vessel injury.

A 77-year-old female was referred to our department with abnormal medical examination and chest CT, showing a part-solid ground grass nodule measuring 20 × 15 mm in the left upper lobe, and the tumor was diagnosed as lung cancer (cT1miN0M0 stage1A1). We performed video-assisted lingulectomy with hilar lymph node dissection (ND1b). The operative time was 130 minutes and the bleeding amount was small. Bradycardia and low blood pressure were observed 1 hour after returning to the room, and they were considered to be associated with sinus node dysfunction syndrome. Vital signs were stable with vasopressor administration and fluid loading, but anemia progressed slowly over the next few days. Chest tube output indicated a small amount of intrathoracic bleeding. On the 7^th postoperative day, a blood test showed a high inflammatory response and abdominal CT revealed a large amount of bloody ascites, probably due to splenic injury. Since no obvious active bleeding was observed, careful follow-up was performed, and after confirming that there was no progression of anemia, the patient was discharged on the 25^th postoperative day. If vital sign changes or progressing anemia are observed after thoracic surgery, it is necessary to suspect intra-abdominal bleeding.

A 55-year-old man had undergone curative surgery for ampullary cancer 8 years ago. The pathological stage of the cancer was stage III, and computed tomography (CT) 8 years postoperatively revealed an irregular surfaced nodule with spicula and pleural indentation within the right middle lobe of the lung. Fluorodeoxyglucose-positron emission tomography (FDG-PET) /CT showed accumulation of FDG (maximum standardized uptake value: 2.31) but no evidence of distant metastasis; thus, primary lung cancer was suspected. Right middle lobectomy by robot-assisted thoracoscopic surgery was planned. During the operation, the middle lobar and interlobar lymph nodes were found to have invaded the pulmonary artery and bronchi, and an intraoperative pathological diagnosis of metastasis of adenocarcinoma was made. The ongoing surgery was successfully converted to middle and lower bilobectomy with radical mediastinal lymph node dissection. The pulmonary nodules were identified as lung metastases of the cancer of the ampulla of Vater on pathological examination, and the surgical margin was negative. TS-1 was administered postoperatively, and no recurrence was observed on CT 10 months postoperatively. Recurrence of cancer of the ampulla of Vater more than 5 years after the occurrence of the primary tumor is not rare, but there are no reports on the resection of lung metastases. We report such a case with a review of the literature.

A 55-year-old female who had stroke and uterine myoma was admitted to our hospital with multiple small bilateral nodules identified on computed tomography. The preoperative differential diagnoses included: tuberculosis, nontuberculous mycobacterial infection, and sarcoidosis. Thoracoscopic biopsy was performed for diagnosis. Histologically, the tumor was diagnosed as a benign metastasizing leiomyoma. We have followed her up with no medication because she was just before menopause, and she has been doing well without tumor growth. It is important to consider BML as a differential diagnosis in females who have or had uterine myoma.

The patient was a male in his 80s who had a history of left lung cancer 8 years ago. Chest computed tomography during postoperative surveillance showed a 22-mm pleural nodule adjacent to the right seventh rib. Video-assisted thoracic surgery was conducted to resect and diagnose the lesion. Intraoperative findings showed a localized tumor arising in the right parietal pleura. Partial resection of the right lower lobe was needed because of tight adhesion to the lung; however, the tumor could be easily peeled from the ribs and intercostal muscles, and the chest wall was preserved. Histological and immunohistochemical findings supported the diagnosis of epithelioid pleural mesothelioma. No clinical or histological evidence of diffuse serosal spread was observed, and the tumor was finally diagnosed as localized pleural mesothelioma. A close tumor margin in the chest wall side may suggest the necessity of additional resection of the chest wall, but the patient has remained free of tumor relapse for 2 postoperative years without any adjuvant treatment.

Amyloidosis is the deposition of a fibrous protein called amyloid in an organ. We present a case of localized pulmonary amyloidosis in a 56-year-old Brazilian man whose chest radiograph showed an abnormal shadow in the right hilar region, and computed tomography revealed a 3-cm tumor in the right hilar region, accompanied by a high-absorption area with suspected calcification inside. A definitive diagnosis could not be reached with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Thoracoscopic right lung tumor resection was performed for diagnosis and treatment of the tumor. The pathological diagnosis was type AA amyloidosis containing ossification foci.

A 46-year-old man presented to our hospital with a complaint of fever. He was emergently admitted to our hospital. Chest computed tomography (CT) showed a lung abscess and pneumonia in the middle lobe of the right lung. On the second day, hemoptysis was observed, and chest contrast-enhanced CT showed that the pulmonary artery had dilated to a diameter of 10 mm, indicating an infected pseudoaneurysm associated with a lung abscess. Transcatheter arterial embolization (TAE) was performed for the pseudoaneurysm but was unsuccessful. Because of persistent hemoptysis, bronchoscopy was performed under tracheal intubation. The middle lobe bronchus underwent Endobronchial Watanabe spigot (EWS) insertion to stop bleeding. On the 5th day of hospitalization, a right middle lobectomy was performed to remove the pulmonary abscess and pseudoaneurysm. After surgery, the patient developed pulmonary thromboembolism, was started on anticoagulation therapy, and discharged on the 37th day. A pulmonary artery pseudoaneurysm secondary to lung abscess is rare and can be critical. Thus, we describe this case with a review of the literature.

This case involved a man in his 60s. He presented to our hospital with a complaint of sudden-onset dyspnea. He received a diagnosis of right-severe and left-moderate simultaneous bilateral pneumothorax based on a chest radiograph. Thoracoscopic extended thymectomy had been performed for a thymic carcinoid tumor 9 years prior to the patient's arrival at our hospital, and bilateral lung dilation was noted with only drainage of the right thoracic cavity; thus, a pleural window communicating between both pleural cavities was suspected. On the eighth day after admission, thoracoscopic partial resection of both lungs and pleural coverings was performed, and simultaneously, closure of the pleural window was conducted. A 4-cm-long pleural window was detected at the anterior mediastinum, which we covered with polyglycolic acid (PGA) sheets and fibrin glue.

Although pleuro-pleural communication is a rare condition, we should consider its possibility in patients with a history of mediastinal surgery, and it is useful to check whether unilateral thoracic drainage can improve bilateral pneumothorax if the respiratory status is not emergent. Surgery should be considered to prevent the recurrence of pneumothorax, and closure of the pleural window should also be considered in addition to bullectomy and pleural covering. The method and effect of such a surgery should be studied in the future.

Anesthetic and surgical management of tracheal tumors is very challenging. Here, we report a 55-year-old female patient who underwent a 2-cm tracheal sleeve resection (the lower half of the 1st-2nd tracheal rings) and reconstruction safely and effectively with no complications on venovenous extracorporeal membrane oxygenation (VV-ECMO) support. Preoperative bronchoscopy revealed an 18-mm polypoid tumor with a smooth surface on the membranous portion of the upper trachea, where it caused airway obstruction and stridor. The tracheal tumor was histopathologically diagnosed as an inflammatory myofibroblastic tumor. ECMO set up during spontaneous breathing before the induction of general anesthesia is very useful for patients at high risk of airway blockage by a tracheal tumor. ECMO markedly contributed to securing respiratory control during the airway surgery and surgical field control. Its rate of associated complications, such as bleeding, is acceptable.

A 75-year-old man presented with dyspnea on exertion persisting for two weeks and was hospitalized due to a left pneumothorax. A thoracoscopic bullectomy was performed because of persistent air leakage without improvement. The patient was discharged from our hospital on the fourth postoperative day. The pathological diagnosis of the surgical specimen was confirmed as metastatic lung angiosarcoma. On careful examination, hemorrhagic lesions were found on his scalp. Subsequently, the patient received three courses of docetaxel chemotherapy, during which metachronous bilateral pneumothorax occurred several times, and pleurodesis was successfully performed each time. Chemotherapy demonstrated limited efficacy in this patient. However, he developed hemoptysis and died from respiratory failure due to aspiration pneumonia. Although angiosarcoma is a dermatological condition, thoracic surgeons should have a good understanding of the disease to provide careful management, as angiosarcoma is frequently accompanied by pulmonary metastasis presenting as recurrent secondary pneumothorax.

The patient was a 58-year-old man. He fell down on the street after drinking alcohol and visited a local hospital. Although his condition improved with thoracic drainage, right pneumothorax recurred after discharge, and he was referred to our hospital for surgery. He was diagnosed with lung injury due to bone fragment protrusion at the fracture site of the right tenth rib. The next day, thoracoscopic surgery was performed, and a rib fragment was removed. The injured right lower lobe of the lung was resected partially. The patient was discharged on the third postoperative day with good progress. The most common reason for traumatic pneumothorax is lung injury caused by fractured ribs, and surgery is usually considered when air leaks persist after thoracic drainage alone. We encountered a case in which a rib fragment was identified and removed by thoracoscopic surgery, but no similar case was found in our search of the literature. We report this case because we feel that our experience is valuable.

A 62-year-old man visited our emergency room for dyspnea. The blood hemoglobin level was 4.1 g/dL. Bone marrow examination showed only hypoplasia of erythroblasts. Chest computed tomography revealed a nodular shadow in the right upper lobe of the lung and a mass shadow in the anterior mediastinum. He was diagnosed with pure red cell aplasia with thymoma, and underwent video-assisted thoracoscopic thymomectomy and partial lung resection. Pathological examination showed a type AB thymoma and pulmonary hamartoma. We introduced cyclosporine eight days after the operation. Complete remission of pure red cell aplasia was obtained after gradual reduction of cyclosporine, and the administration of cyclosporine was ceased one year and four months after surgery. The remission of pure red cell aplasia was maintained and the thymoma had not recurred at five years after surgery. In general, the effect of a thymomectomy on pure red cell aplasia with a thymoma is poor, while cyclosporine is highly effective for the induction and maintenance of pure red cell aplasia. Our case is rare in maintaining remission of pure red cell aplasia after stopping cyclosporine and showing the contribution of thymomectomy.

Thoracoscopic resection of right anterior phrenic lymph node metastasis of hepatocellular carcinoma with diaphragmatic infiltration is reported. A 64-year-old man underwent transcatheter arterial embolization and hepatectomy for hepatocellular carcinoma and hepatitis. Follow-up CT showed a nodular shadow in the right cardiophrenic angle that tended to become larger. This tumor was suspected to be metastasis of hepatocellular carcinoma. Mediastinal tumor resection was performed with VATS under CO2 insufflation at 8 mmHg. The tumor was attached to the right middle lobe of the lung and diaphragm. Because infiltration was suspected, combined resection was performed. Pathological examination showed metastasis of hepatocellular carcinoma to the right anterior phrenic lymph node with infiltration in the diaphragm. Isolated mediastinal lymph node metastasis of hepatocellular carcinoma is very rare. It has been reported that resection may improve the prognosis.

In 2015, the name "sclerosing hemangioma" was changed to "sclerosing pneumocytoma" in the World Health Organization classification of lung tumors. Sclerosing pneumocytoma is a rare tumor that accounts for approximately 1 to 5% of lung tumors. It is frequently noted in middle-aged women, and lymph node metastasis and multiple nodules occur in nearly 1 and 4% of cases, respectively. We report a case of surgical resection for sclerosing pneumocytoma with multiple nodules and lymph node metastasis.

A 25-year-old woman presented with an abnormal chest shadow on a chest radiograph. Chest computed tomography revealed multiple nodular shadows distributed in the lower left lobe (S10). Sclerosing pneumocytoma was diagnosed through transbronchial lung biopsy, surgical resection was selected, and thoracoscopic left S10 segmentectomy was performed. The operation lasted for 5 hours 26 minutes, and the patient lost 20 mL of blood preoperatively. The patient recovered without complications and was discharged from the hospital on postoperative day 2. Pathological diagnosis also revealed sclerosing pneumocytoma, and metastasis was observed in LN#13.

Owing to its pathological diversity, sclerosing pneumocytoma is difficult to diagnose before surgery or even with frozen sectioning during surgery. In the current case, a definitive diagnosis was obtained preoperatively, and we selected surgical resection. Reportedly, lymph node metastasis typically occurs when the lesion is larger than 3 cm, but in the current case, the lesion size was approximately 12 mm, and tumor sizes associated with lymph node metastasis were not observed on CT. Therefore, lymph node dissection was not performed. However, even with small lesions, lymph node dissection should be considered if there are multiple nodules. There were multiple nodules in the current case, and it was a very rare case as lymph node metastasis was also recognized. An extensive literature search failed to reveal similar reports. Although uncommon, there have been reports of recurrence but no reports of relapse-related deaths in patients with sclerosing pneumocytoma. Nevertheless, careful long-term follow-up remains necessary.

Pulmonary artery sarcoma is a rare disease with a poor prognosis. A 60- year-old man who complained of dyspnea on exertion was referred to us. Chest enhanced CT and MRI revealed a tumor obliterating the left main pulmonary artery. A primary tumor of pulmonary artery sarcoma was suspected. Concomitant surgery was performed. Through a median sternotomy, cardiopulmonary bypass was established. The pulmonary trunk was opened and a solid tumor that occluded the left main pulmonary artery was noted. The left pulmonary artery was divided from the pulmonary trunk with a macroscopic margin. Intraoperative frozen-section diagnosis of the resected margin was finally negative for the tumor on the third try, so the pulmonary trunk was sutured with a bovine pericardial patch and continuously the left pulmonary vein was divided in the pericardium. After cardiopulmonary bypass termination, left pneumonectomy was performed. Permanent histopathologic examination of the tumor revealed pulmonary artery sarcoma, with partial direct invasion to the lung parenchyma and metastasis to the hilar lymph node. The stump of the artery was negative. He received no adjuvant therapy. He now continues intensive follow-up, with no evidence of recurrence for 10 months since the operation.