In the present study, we suggested the Performance Status of Spontaneous Pneumothorax (PSSP) and retrospectively investigated the predictors of postoperative complications in secondary spontaneous pneumothorax. PSSP was added to the previously published risk factors for postoperative complications, and statistical analysis was performed of patients with secondary pneumothorax who underwent surgery at our hospital between January 1, 2015 and May 31, 2021. The complication rate of PSSP (0/1/2/3/4) was 0/8.6/27.3/56.3/66.7%, and the mortality rate was 0/0/0/6.3/33.3%. The independent risk factors for postoperative complications were: PSSP (3-4), BMI (<16), and the serum albumin level (<3.5). The probability of postoperative complications was significantly higher in patients with PSSP: 3 or higher, low BMI, and low albumin.

Segmentectomy is a standard surgical treatment option for stage IA non-small cell lung cancer (NSCLC). However, segmentectomy is only an oncologically safe and reasonable alternative to lobectomy when the intraoperative lymph node staging and surgical margin are adequate. The aim of the present study was to compare the outcomes (frequency, reasons, and prognosis) of patients converted from segmentectomy to lobectomy at the intraoperative direction of the surgical team. This retrospective study analyzed the outcomes of 121 patients who were scheduled to undergo segmentectomy for clinical stage IA NSCLC between January 2014 and August 2020. Eight of the 121 patients were converted from segmentectomy to lobectomy based on the intraoperative diagnosis and surgeon's judgment. Among the 8 converted cases, 4 were diagnosed with lymph nodes metastasis based on analysis of frozen sections and 4 had a problem related to the surgical technique (e.g., surgical margin or uncontrollable bleeding). Diagnosis of the 3 node malignant-positive patients was guided by rapid-immunohistochemistry using noncontact alternating current electric field mixing. There was no significant difference in overall survival between patients with completed segmentectomy (n=113) and those converted to lobectomy (n=8) (P=0.5828). In clinical stage IA NSCLC patients, lobectomy can be selected instead of segmentectomy, if appropriate judgement/diagnosis is intraoperatively achieved.

The patient was a 56-year-old woman who visited her previous clinic with complaints of wheezing and right chest and back pain. Massive right pleural effusion was noted on a chest radiograph, and she was transferred to our hospital, after which chest drainage was started. Chest computed tomography (CT) showed an irregularly enhanced tumor of 9 cm in diameter in the right thoracic cavity, which was suspected of being primary lung cancer. However, pleural effusion cytology did not reveal any evidence of malignancy. There was no elevation of tumor markers, but an abnormally high amylase level was noted in the pleural fluid. An operation was performed for diagnostic purposes, with amylase-producing lung cancer in mind. Severe intrathoracic adhesions were observed, and further dissection revealed a pedunculated tumor with mixed solid and cystic components from the anterior mediastinum into the right thoracic cavity. The tumor was completely resected and diagnosed as a mature teratoma both by intraoperative rapid examination and histopathological findings of the permanent specimen.

Although there are many reports of mature teratoma with intrathoracic perforation, a case of intrathoracic perforation with pedunculated growth has never been published, and so the present case is considered to be extremely rare.

A 48-year-old man who was pointed out as showing an abnormal shadow on a chest radiograph during a medical check-up was admitted to our hospital. Contrast enhanced computed tomography revealed a tumor with capsule measuring 5.5×5.3×5.0 cm in the left posterior mediastinum. Because a benign cystic tumor was suspected, surgical resection was performed. Intraoperative findings showed that the tumor originated from the intrathoracic vagus nerve. The histopathological diagnosis was ancient schwannoma with extensive cystic degeneration. We report a rare case of ancient schwannoma originating from the vagus nerve in the posterior mediastinum.

The tool 4D flow MRI is valuable for diagnosing pulmonary hypertension. In this study, we identified vortex flow in the pulmonary arterial trunk on 4D flow MRI, suggestive of pulmonary hypertension, in a patient who had undergone pulmonary lobectomy and who subsequently developed postoperative respiratory failure. The patient was a 68-year-old man. Eight years after left lower lobectomy, the patient was newly diagnosed with right upper lobe lung cancer. Japan National Clinical Database risk assessment showed an incidence of respiratory failure of 0.2%. The patient was eventually diagnosed with respiratory failure 19 days after surgery. We reviewed 4D flow MRI, taken on postoperative day 6, and noted typical vortex flow in the main trunk of the pulmonary artery, suggesting a pulmonary hypertensive state. It has been reported that vortex flow correlates with pulmonary artery pressure in patients with pulmonary hypertension. In the present case, 4D flow MRI after lobectomy showed vortex flow, suggesting a pulmonary hypertensive state. We considered that the postoperative decrease in pulmonary reserve may have prevented improvement in elevated pulmonary arterial pressure. Vortex flow in the pulmonary arteries on 4D flow MRI is suggestive of a pulmonary hypertensive state, which can lead to fatal respiratory failure.

We report a case of pure red cell aplasia (PRCA) and myasthenia gravis (MG) during treatment for thymoma. A 67-year-old female underwent extended thymectomy with partial resections of both upper lobes of the lungs, left phrenic nerve, and pericardium for Masaoka stage IVa thymoma in September 2013 after steroid pulse therapy. After 4 cycles of postoperative chemotherapy with carboplatin and nab-paclitaxel, additional resection was performed for the residual disseminations. The patient followed a favorable course until September 2015, when recurrence of right pleural disseminations was detected. She was re-administered 4 cycles of carboplatin and nab-paclitaxel, followed by maintenance therapy with nab-paclitaxel. In February 2016, she developed severe anemia and was diagnosed with PRCA by bone marrow biopsy. Although anemia was improved by the administration of prednisolone, it was discontinued in April 2017 because of side effects of pulmonary artery thromboembolism, cataract, and osteoporosis. In July 2019, diplopia appeared, and MG was diagnosed. She was started on pyridostigmine bromide and tacrolimus. In February 2021, tacrolimus was discontinued and cyclosporine was introduced because of the recurrence of PRCA. After three weeks, anemia improved and there was no relapse of MG. As of January 2022 (8 years and 4 months after the first surgery), she was following a favorable course as a tumor-bearing patient with good ADLs (Activities of Daily Living).

Thymoma with cardiac tamponade as the initial manifestation is rare. A 74-year-old woman presented to our hospital with shortness of breath on effort. Chest roentgenography demonstrated cardiomegaly, and massive pericardial effusion and an anterior mediastinal tumor were observed on chest CT. Her symptom improved after pericardial drainage. Malignant cells were not detected in pericardial effusion. Based on the possibility of complete resection, surgery was performed. No obvious pericardial dissemination was detected, the anterior mediastinal tumor invaded the pericardial cavity, and thymothymectomy with resection of the pericardium was performed. The postoperative course was uneventful. Histological examinations of the tumor revealed the proliferation of polygonal epithelial cells and lymphocytes in the tumor, and she was diagnosed with type AB thymoma. She was alive without relapse of thymoma or pericardial effusion 12 months postoperatively.

We report a case of high-grade fetal adenocarcinoma involving a 72-year-old woman with idiopathic pulmonary fibrosis. The right lower lobe nodules were detected during treatment for the idiopathic pulmonary fibrosis, and small-cell lung cancer was diagnosed by CT-guided biopsy. The pulmonary functions were severely impaired due to the idiopathic pulmonary fibrosis. The predictive postoperative lung function signified the tolerance level when we considered lower right lobectomy and stage IA small-cell lung cancer. We performed a right lower lobectomy+ND2a-2. The postoperative pathological diagnosis was high-grade fetal-type adenocarcinoma, stage pT1cN0M0. No adjuvant therapy was administered and the patient was recurrence-free two years after surgery. High-grade fetal-type adenocarcinoma is a rare disease, and one with coexistent idiopathic pulmonary fibrosis has not been reported. A literature review was also performed.

Cholesterol granuloma is a type of foreign body granuloma that forms in reaction to cholesterol crystals. This is a well-studied condition affecting the middle ear and paranasal sinuses, whereas other lesions are rare.

We report a cholesterol granuloma in the anterior mediastinum of a 55-year-old asymptomatic man. Chest computed tomography showed a 45 × 25-mm multilocular nodular lesion in the anterior mediastinum. T1- and T2-weighted magnetic resonance images revealed hypo-intense signals with a contrast effect. Positron emission tomography computed tomography showed 18F-fluorodeoxyglucose uptake with a maximum standardized uptake value of 9.4. Therefore, malignant diseases, including thymic cancer and lymphoma were considered for a pre-operative diagnosis.

Video-assisted thoracic surgery was conducted for diagnosis and therapeutic purposes. The pathological diagnosis was a cholesterol granuloma, which originated from the thymus.

Essential thrombocythemia (ET) is a chronic myeloproliferative disorder associated with quantitative, functional, and morphological platelet abnormalities. A 69-year-old man was referred to our hospital after a medical examination revealed a lesion in his right lung, which was suspected as lung cancer, and surgery was scheduled. He presented with a history of deep vein thrombosis and acute myocardial infarction, and he was taking warfarin and aspirin. The blood test at his first visit showed an abnormally high platelet count (154.3 × 10⁴/μL), and the hematology department diagnosed him with ET. His treatment started with oral hydroxyurea, and his platelet count decreased to 77.9 × 10⁴/μL. However, risk stratification revealed a high risk of thrombosis; therefore, we changed his medication from warfarin to heparin. Additionally, we continued aspirin administration before performing a thoracoscopic right lower lobectomy. No ET-related complication occurred, and the patient was discharged on the ninth postoperative day. Optimal perioperative management to prevent deep venous thrombosis, bleeding, and pulmonary vein thrombosis is important for patients with ET who undergo lung cancer surgery.

A 71-year-old male was admitted to our hospital with an abnormal chest radiograph. Chest computed tomography showed a mass (25 mm) in the left upper lobe. On bronchoscopic biopsy, adenosquamous carcinoma was noted, and the resulting diagnosis was cT1bN0M0, stage IA2. The patient underwent a left upper lobectomy. Pathological examination revealed collision cancer consisting of squamous cell carcinoma and adenocarcinoma, pT2aN0M0, stage IB. The patient died four years and two months after surgery, despite chemotherapy. Based on our experience of long-term postoperative follow-up, we report a case of collision carcinoma.

A 71-year-old man sought evaluation for a cough with a primary care physician. He was referred to our hospital for further evaluation of a giant mass detected in the upper-right lung field by chest radiograph. The mass was first observed at another hospital 9 years earlier, but only 2 years of follow-up evaluations were completed. The tumor was 8.4 × 6.5 cm when initially diagnosed 9 years ago, but had increased in size to 16.4 × 13.4 cm at the time he sought evaluation from the primary care physician. We performed surgery through a posterior lateral incision. The second rib, including the tumor, was completely resected and the third rib was partially resected to remove the tumor. The postoperative recovery was uneventful. The pathological diagnosis was fibrous dysplasia without malignant transformation. Fibrous dysplasia is a common benign tumor that is treated conservatively in asymptomatic patients. If fibrous dysplasia involves the femur, resection may be avoided due to the possibility of functional impairment; however, if fibrous dysplasia occurs in the ribs, functional impairment due to rib resection is not significant. Resection after augmentation is more invasive and may lead to malignant transformation. Therefore, fibrous dysplasia occurring in the ribs should be actively resected.

A hematoma-like mass lesion was found in the right upper lobe of a 67-year-old man who had undergone radical surgery for thoracic esophageal cancer 8 months before the appearance. Computed tomography (CT) revealed that the mass lesion measured 5.0 cm in diameter at presentation and subsequently increased to 8.3 cm in 49 days thereafter. Looking back on CT immediately before the surgery for esophageal cancer identified the initial appearance of this lesion as a lung nodule of 0.8 cm in diameter, suggestive of an inflammatory nodule. We skipped biopsy because of concern about airway bleeding and performed right upper lobectomy. Histological examination confirmed the resected specimen to be a pulmonary pleomorphic carcinoma, pathological stage IIA. No signs of recurrence have been detected in the 5 years since surgery. A rapidly-growing mass mimicking an intrapulmonary hematoma may result from an undiagnosed lung cancer, as seen in our case. Therefore, lung resection for a malignant indication should be considered for such cases, even without preoperative histological confirmation.

A 49-year-old female was referred to our hospital presenting with fever, cough, sputum, and left arm edema. Computed tomography revealed a 7.5-cm mediastinal tumor, an obstructed left brachiocephalic vein, a constricted superior vena cava (SVC), the upper lobe of the right lung infiltrated by the tumor, and pericardial effusion. The patient underwent an ultrasound-guided needle biopsy of the tumor, and then she was diagnosed with thymic squamous cell carcinoma (cT3 N0 M1a, cStage IVA). Concurrent chemoradiotherapy led to a marked tumor volume reduction and the disappearance of pericardial effusion (ycT3 N0 M0, ycStage IIIA). Conversion surgery was performed to excise the thymus, pericardium, SVC, upper lobe of the right lung, and right phrenic nerve, and reconstruct SVC. The planed incision was a median sternotomy and an intercostal thoracotomy involving the right thorax. However, an additional transmanubrial approach to the left thorax was needed to reconstruct SVC because the left brachiocephalic vein was obstructed to the point at the venous angle. Curative resection of the tumor was confirmed microscopically. No recurrence was noted for 14 months after the surgery.

Case: A woman in her 40s with multifocal nodules in her anterior mediastinum on the follow-up chest computed tomography (CT) scan 7 years after papillary thyroid carcinoma resection was referred to our department. We suspected that the nodules were due to the recurrence of thyroid carcinoma because both nodules increased slightly in size and measured 2.3 and 2.2 cm, and an accumulation of 18-fluoro-deoxy-d-glucose was observed on positron emission tomography-CT. Resection of the right-sided nodule and right-thymectomy via video-assisted thoracic surgery were performed for definitive diagnosis. The histopathological diagnosis was a type B1 thymoma; thus, the nodule on the left thymus was also suspected to be a thymoma. We performed tumor resection on the left side and thymectomy via a left-thoracic approach. The left nodule was diagnosed as a type B2 thymoma. She was alive without recurrence of the disease 2 years after the second surgery. The possibility of multiple thymomas should be considered for synchronous nodules in the anterior mediastinum. Staged resection may be considered if the possibility of metastasis of other cancers or malignant lymphoma cannot be ruled out or if a diagnosis is difficult before or during surgery.

Intrapulmonary bronchogenic cysts are a type of congenital cystic lung disease, and although thoracoscopic surgery in early childhood is recommended, it is rarely encountered in practice. Here, we report the case of a 17-month-old girl, who received 8K Ultra-High-Definition (UHD) thoracoscope-assisted surgery for a prenatally-detected posterior mediastinal cystic lesion. Intraoperatively, we found a tense cystic lesion arising from segment 8 of the right lower lobe, which was diagnosed as an intrapulmonary bronchogenic cyst. Although our attempts to perform S8 segmentectomy were prevented by the difficulty of dissecting the branches of the inferior pulmonary vein, we completed right lower lobectomy with minimal invasiveness. We were able to present precise anatomical visualization such as microvessels and structures on a 70-inch screen, and safely proceed with the operation. The UHD images and zooming function of the 8K thoracoscope were very useful to provide a sufficient working space in the narrow pediatric chest cavity.

Most cases of pulmonary aplasia are detected during infancy alongside complicated anomalies of other organs. Adult cases of pulmonary aplasia are uncommon, and surgical cases involving the lung with aplasia are even more uncommon. Here, we report a case in which we performed surgery for lung cancer in the right upper lobe of the lung, whose middle lobe was found to be aplastic. A 79-year-old woman, with no history of smoking, was referred to us with an abnormal pulmonary shadow detected on screening. Chest computed tomography revealed an irregular mass measuring 4.7 cm in diameter in the right upper lobe. We suspected lung cancer, with clinical stage IIA (T2bN0M0), and scheduled surgery. Chest computed tomography also revealed the absence of parenchyma and the pulmonary artery and vein in the right middle lobe. The middle lobar bronchus was rudimentary. The diagnosis was therefore middle lobe aplasia. We performed right upper lobectomy. During the operation, we noted only slight bending of the visceral pleura where the middle lobe was aplastic. The parenchyma of the right middle lobe was completely absent. The pathological diagnosis was lung adenocarcinoma (T2bN0M0 Stage IIA). To our knowledge, there have been no reports of pulmonary aplasia in which the rudimentary structure of the aplastic lobe was confirmed during the operation. Our case is likely the first surgical case with aplastic lung to be reported.

Although traumatic tracheobronchial disruption is rare, the associated mortality is high. A 15-year-old male who had been injured in a traffic accident was transferred to our hospital. On arrival, he was unconscious, but retained a normal blood pressure and spontaneous breathing. A chest radiograph showed no finding of pneumothorax, but computed tomography revealed mediastinal emphysema and obstruction of the right main bronchus, indicating bronchial disruption. Although a chest drain was inserted, no air leakage was found. Intracranial injury did not require surgery, so he underwent emergency thoracotomy. Because tracheal intubation using a double-lumen tube was unsuccessful, tracheostomy was carried out to insert a 6.5-mm spiral tube into the left main bronchus. We performed posterolateral thoracotomy, divided the azygos vein following mediastinal pleurotomy, and found complete transection of the right main bronchus. The main bronchus was repaired by end-to-end anastomosis with partial debridement of the edges. No postoperative anastomotic complication occurred. He was transferred for neurological rehabilitation due to prolonged disturbance of consciousness nineteen weeks after surgery.