Thoracic endometriosis syndrome: new observations from an analysis of 110 cases

[Pneumothorax in women and thoracic endometriosis]

Thoracic endometriosis has been considered a rare clinical condition but it is probably underestimated in the literature. Various clinical symptoms may occur but the most frequent are catamenial pneumothoraces. Four main clinical conditions may reveal thoracic endometriosis: catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and endometrial nodules in the lung. Catamenial pneumothoraces are the most frequent manifestation, characterized, in the majority of the cases, by right side localization and diaphragmatic abnormalities (perforations and/or nodules). The resection of suspected areas of visceral or parietal pleural endometriosis, as well as partial resection of the diaphragm in the case of nodules and/or perforations, allows the histological diagnosis of endometriosis. Because of the high recurrence rate, treatment of catamenial pneumothoraces should combine surgery and hormonal therapy.

[Imaging findings in catamenial pneumothorax]

OBJECTIVE

To show the presentation and imaging findings of catamenial pneumothorax.

MATERIAL AND METHODS

We reviewed the imaging tests (plain-film radiography, computed tomography [CT], magnetic resonance [MR]) performed in six women aged between 28 and 44 years with recurrent pneumothorax associated to menstruation. All patients underwent videothoracoscopic surgery and thoracotomy was necessary in three due to the recurrence of the pneumothorax.

RESULTS

CT was performed in three cases and found pleural nodules in two; one of these was confirmed at MR. Pleural endometriosis was only demonstrated at histological examination in one case. Diaphragmatic blebs and bullae were found in five of the six patients.

DISCUSSION

The most common symptoms of catamenial pneumothorax are chest pain, dyspnea, and hemoptysis. The right side is affected in 90% of cases. The radiological findings are pneumothorax, hemothorax, or hydropneumothorax. CT and MR can help to identify the pleural lesions that are not visible on plain-film radiographs and are a very common finding at surgery.

CONCLUSION

The diagnosis of catamenial pneumothorax should be suspected in fertile-aged women with a history of recurrent pneumothorax coinciding with menstruation. CT and MR can help to identify lesions suspicious of endometriosis.

Catamenial pneumothorax: a case report and review of the literature

A 39-year-old woman presented with the chief complaint of right-sided chest pressure and shortness of breath with dry cough for 3 days. These symptoms coincided with the onset of her menstrual cycle. Her physical examination was significant for decreased breath sounds at the right lung base. Her chest x-ray showed a moderate sized right pneumothorax extending from the apex to the lung base and a small amount of pleural fluid, findings that were verified by chest CT. The patient was seen by consultants from the pulmonary, obstetrics/gynecology, and thoracic surgery services, who agreed that the clinical diagnosis was catamenial pneumothorax, probably associated with thoracic endometriosis. The patient was discharged on levonorgestrel/ethinyl estradiol tablets, which she opted not to take. Three months later, she had similar symptoms that occurred again at the time of menstruation. Her chest x-ray now showed a 10% right-sided pneumothorax. Catamenial pneumothorax is a rare condition affecting women in their reproductive years. Women with this condition most commonly have right-sided pneumothorax. The proper diagnosis is based on being aware of the existence of this relatively rare condition and relating the symptoms of pneumothorax temporally to the menses.

[Thoracic endometriosis]

Thoracic endometriosis is defined by the presence of endometrial tissue in the lungs or pleura, and is characterised by cyclic hemoptysis or recurrent hemothorax or pneumothorax occurring with the menstruation. Being a rare clinical entity, it is not always considered in the differential diagnosis when these symptoms are evaluated. The exams performed during the diagnostic work-up frequently show nonspecific alterations, however a presumptive diagnosis can be made based on the typical clinical history. The key to the diagnosis are the catamenial symptoms, so a thorough clinical history is essential to promptly reach the correct diagnosis. Hormonal treatment and surgery are the two mainstays of therapy for this pathology. The authors present the case of a 27 year-old female patient presenting with cyclic hemoptysis during the menstruation. The diagnostic workup was inconclusive. Based on the clinical history, the diagnosis of pulmonary endometriosis was assumed and treatment was initiated with oral contraceptives with total resolution of symptoms. The authors make a brief review of the main symptoms, pathogenesis, diagnosis and treatment of thoracic endometriosis.

Diaphragmatic laceration, partial liver herniation and catamenial pneumothorax

Catamenial pneumothorax is a recurrent pneumothorax temporally associated with menstruation. Pathogenesis remains debated however pleural endometriosis or diaphragmatic abnormalities are almost always present. We report the case of a 35-year-old woman with recurrent right catamenial pneumothorax. At thoracoscopy a large laceration of the diaphragm with partial intrathoracic liver herniation was seen. Treatment involved repair of the diaphragmatic lacerations, and pleurodesis. This report shows that large diaphragmatic defects may be observed in patients with catamenial pneumothorax.

The value of pleural fluid analysis

Pleural fluid analysis in isolation may have clinical value. To have the greatest diagnostic impact, the clinician must formulate a prethoracentesis diagnosis based on the clinical presentation, blood tests, and radiographic imaging. With this approach, a definitive or confident clinical diagnosis can be expected in up to 95% of patients. The information in this report should allow the clinician to achieve this goal.

An advanced flexible laparoscope with wide optic angle for observing diaphragmatic lesions associated with catamenial pneumothorax

OBJECTIVE

To explore diaphragmatic lesions that are potentially associated with catamenial pneumothorax by using an advanced flexible laparoscope with wide optic angle.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 30-year-old woman who was scheduled for thoracoscopic surgery because of recurrent right-sided catamenial pneumothorax.

INTERVENTION(S)

The peritoneal surface of the diaphragm was explored with an advanced flexible laparoscope that was equipped with a charge-coupled device on the tip, concurrently with thoracoscopic surgery.

MAIN OUTCOME MEASURE(S)

Lesions associated with endometriosis on the peritoneal surface of the posterior diaphragm abutting the posterior abdominal wall and liver.

RESULT(S)

When the flexible laparoscope was inserted via an umbilical trocar and the peritoneal surface of the right-sided diaphragm was explored, guided by illumination from the thoracoscope, scattered specific lattice lesions and fenestrations were identified in the central tendon of the posterior diaphragm, a region that cannot be visualized with the conventional rigid laparoscope.

CONCLUSION(S)

By using the flexible laparoscope, endometriotic lesions potentially related to catamenial pneumothorax were identified on the posterior diaphragm.

Catamenial and Noncatamenial, Endometriosis-related or Nonendometriosis-related Pneumothorax Referred for Surgery

RATIONALE

Catamenial and endometriosis-related pneumothorax are considered relatively rare entities. Their clinical characteristics and outcome are incompletely known.

OBJECTIVES

To evaluate the frequencies, clinical characteristics, and outcomes of catamenial and endometriosis-related pneumothoraces occurring in women with no underlying lung disease referred for surgical treatment.

METHODS

Clinical files of all the women of reproductive age referred to our center during a 6-year period for surgical treatment of spontaneous pneumothorax were retrospectively reviewed. Catamenial pneumothorax (CP) was defined as recurrent pneumothorax occurring between the day before and within 72 hours after the onset of menses. All histologic slides were reviewed to confirm initial diagnoses.

MEASUREMENTS AND MAIN RESULTS

A total of 114 women underwent video-assisted thoracic surgery; 28 women (24.6%) had CP (right-sided in all but one), and diaphragmatic abnormalities (perforations and/or nodules) were observed in 22 of them. Diaphragmatic abnormalities were seen in 21 of 86 patients with non-CP. Histologic examination found endometriosis, mainly diaphragmatic, in 18 of 28 CPs and 11 of 86 non-CPs. A 6-month antigonadotropic treatment was prescribed postoperatively to women with either CP or endometriosis-related pneumothorax. Mean follow-up was 32.7 (+/-18.5) months. Recurrence rates in CP, non-CP but endometriosis-related, and non-CP non-endometriosis-related pneumothoraces were 32, 27, and 5.3%, respectively.

CONCLUSIONS

Our experience shows that (1) CP and/or endometriosis-related pneumothoraces account for an important percentage of spontaneous pneumothoraces referred for surgery, (2) diaphragmatic abnormalities seem to play a fundamental role in their pathogenesis, and (3) management is difficult because of the high recurrence rate.

Catamenial hemoptysis and pneumothorax in a patient with cystic fibrosis

Hemoptysis or pneumothorax that recurs with the onset of menses is strongly suggestive of thoracic endometriosis syndrome (TES). TES is a rare disorder, with relatively few cases reported in the literature. A 32-year-old woman with cystic fibrosis, who over a period of several months had experienced recurrent catamenial hemoptysis and pneumothoraces, including an episode of life-threatening hemoptysis that coincided with menstruation, is presented. Thoracic computed tomography and magnetic resonance imaging scans, as well as a bronchoscopic evaluation that demonstrated endobronchial lesions that disappeared after menses, support the diagnosis of TES in the present patient. The patient was treated empirically with danazol and subsequently underwent a successful double-lung transplantation. Danazol was discontinued postoperatively, and she was started on an oral contraceptive. Eighteen months post-transplant, she has not experienced a recurrence of her catamenial symptoms, despite having resumed a regular menstrual cycle.

Targeting mast cells in endometriosis with janus kinase 3 inhibitor, JANEX-1

Endometriosis (EMS) is a chronic inflammatory disease of multifactorial etiology characterized by implantation and growth of endometrial glands and stroma outside the uterine cavity. EMS is a significant public health issue as it affects 15-20% of women in their reproductive age. Clinical symptoms may include pelvic pain, dysmenorrhea, dyspareunia, pelvic/abdominal masses, and infertility. Symptomatic treatments such as surgical resection and/or hormonal suppression of ovarian function and analgesics are not as effective as desired. Consequently, there is an enormous unmet need to develop effective medical therapy capable of preventing the occurrence and recurrence of EMS without undesirable side-effects. EMS-associated intra-abdominal bleeding episodes, local inflammation, adhesions, and i.p. immunologic dysfunction leads to pelvic nociception and pelvic pain. Increasing evidence supports the involvement of allergic-type inflammation in EMS. Invasion of mast cells, degranulation, and proliferation of interstitial component are observed in endometriotic lesions. Presence of activated and degranulating mast cells within the nerve structures can contribute to the development of pain and hyperalgesia by direct effects on primary nociceptive neurons. Therefore, treatments targeting endometrial mast cells may prove effective in preventing or alleviating EMS-associated symptoms. The Janus kinase 3 (JAK3) is abundantly expressed in mast cells and is required for the full expression of high-affinity IgE receptor-mediated mast cell inflammatory sequelae. JANEX-1/WHI-P131 is a rationally designed novel JAK3 inhibitor with potent anti-inflammatory activity in several cellular and in vivo animal models of inflammation, including mouse models of peritonitis, colitis, cellulitis, sunburn, and airway inflammation with favorable toxicity and pharmacokinetic profile. We hypothesize that JAK3 inhibitors, especially JANEX-1, may prove useful to prevent or alleviate the symptoms of EMS.

Thoracic endometriosis syndrome

Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity and is usually confined to the pelvis. Thoracic endometriosis syndrome (TES) is a rare disorder characterized by the presence of functioning endometrial tissue in the pleura, the lung parenchyma and the airways. TES may present with hemoptysis, due to the shedding of endometrial tissue in the bronchial tree, or spontaneous pneumothorax or hemothorax if the endometrial tissue is localized peripherally. Patients are of reproductive age, often nulliparous, with long-standing symptoms. The crucial issue for establishing the diagnosis is the cyclicity of the symptoms which occur along with the menstrual cycle. TES is virtually a diagnosis of exclusion, established on clinical grounds, since neither CT nor endoscopy are specific for TES. Treatment consists of gonadotropin-releasing hormone analogues, aiming to suppress the hypophyseal-gonadal axis, so as to ensure a regression of the endometrial implants. If medical treatment fails, surgical resection of the endometriomas is suggested, although relapse rate may be high.

[Catamenial hemoptysis during hormone replacement treatment]

INTRODUCTION

Catamenial haemoptysis is a rare clinical entity resulting from the presence of ectopic intra pulmonary endometrial tissue, either parenchymatous or endobronchial. The main diagnostic criterion is the periodic character of the haemoptysis which is synchronous with menstruation.

CASE REPORT

The authors report a case of catamenial haemoptysis due to endobronchial endometriosis in a 46 year old menopausal woman receiving hormone replacement treatment (HRT). She presented with 3 episodes of haemoptysis synchronous with the first days of her menstrual cycle. A thoracic CT scan showed ground glass lesions with micronodulation. Bronchoscopy showed violacious lesions bleeding on contact. The endobronchial and CT abnormalities had disappeared by day 5. After withdrawal of the HRT the haemoptysis did not recur during a follow-up of 2 years.

CONCLUSION

Endobronchial endometrioisis remains a rare occurrence. This is the first case reported in a menopausal woman with artificial cycles receiving hormone replacement therapy.

Natural history and therapeutic implications of patients with catamenial hemoptysis

Evidence as to whether clinician has to give specific treatment in all patients of catamenial hemoptysis is unclear. We considered that the current treatment such as long-term usage of hormonal agent or surgery might be excessive for the catamenial hemoptysis. Therefore, we developed prospective observation study with observation strategy and follow-up for the patients. In sequential four patients of catamenial hemoptysis between December 2000 and November 2001, physical examination, chest X-ray, pelvic ultrasonogram and chest CT scan were taken at both the diagnosis and last follow-up. All patients were only observed without specific treatment within the limit of the possibility and followed for average 58 months. Mean age of patients was 23.5years (range, 22-25years). All patients have a history of undertaking one or two dilatations and curettages before diagnosis. The chest CT scans of all patients presented with ground-glass opacities of peripheral location that were disappeared without any residual lesion at last follow-up. Hemoptysis of two patients was spontaneously disappeared after 6 months. In the other two patients, it was greatly lessened in amount and frequency, then clinically insignificant in one. It was disappeared after subsequent 2 months and then relapsed two times in the late of follow-up of another patient. This study suggests that observation only may be an alternative option in the treatment of catamenial hemoptysis.

Endometrioma Presenting as a Cavitary Lung Mass With Intense 18F-FDG Uptake on PET-CT

[18F]-fluoro-2-deoxy-D-glucose positron emission tomography computed tomography is a useful tool to suggest the diagnosis of malignant processes. However, false positive results are known to occur in benign lesions that have a high metabolic activity. Here we describe the unusual diagnosis of a pulmonary endometrioma in a 47-year-old woman, presenting as a cavitary lung mass with intense (18)F-FDG uptake on PET-CT.

L'endométriose extragénitale

Parietal, appendiceal, pleuropulmonary and diaphragmatic endometriosis represent 5% of endometriosis cases. Diagnosis and management of these extra-genital localisations are described according to the literature. Parietal endometriosis usually requires large resection of the tumor. Appendiceal endometriosis is frequently observed in cases of digestive endometriosis. Induration or rigidity of the appendix due to the presence of deep infiltrating endometriosis justifies appendicectomy. Thoracic and diaphragmatic endometriosis is characterized by the presence of typical symptoms during the perimenstrual periode. Medical treatment obtaining therapeutic amenorrhea is firstly administered and surgery is indicated in cases of symptoms recurrence.

Catamenial hemoptysis from endobronchial endometriosis in a child with type 1 von Willebrand disease

Catamenial hemoptysis is a rare condition characterized by cyclic pulmonary hemorrhage, synchronous with menses and associated with the presence of intrapulmonary or endobronchial endometrial tissue. Because of the paucity of cases reported in the literature, information regarding the natural history is limited and also the optimal diagnostic workup and management of these patients are not well defined. In this report, we present a case of endobronchial endometriosis in a 12-year-old female diagnosed by bronchoscopy and immunocytochemical assay, associated with type 1 von Willebrand disease.

Successful Video-Assisted Thoracic Surgery for Pulmonary Endometriosis: Report of a Case

Pulmonary endometriosis is a disease in which uterine endometrial cells with stromal components grow in the pulmonary parenchymal tissues or pleura. Surgical resection is considered an effective and radical treatment for pulmonary endometriosis to avoid the adverse effects of long-term hormone therapy in young women of childbearing years with a localized abnormal lesion. We report a case of pulmonary endometriosis with catamenial hemoptysis, an uncommon result of this disease, which was diagnosed histologically and treated successfully by video-assisted thoracic surgery.

Difficult management of recurrent catamenial pneumothorax

Catamenial pneumothorax is an uncommon disease whose management is not consensual. We report the case of a patient who experienced several episodes of pneumothorax. She was initially treated by repair of diaphragmatic defects and hormonal treatment. During the therapeutic amenorrhea, no recurrence occurred. However, each cessation of medical therapy was followed by recurrence. Finally, talc pleurodesis and tubal ligature were performed without any recurrence in the subsequent 12 months. This report outlines the great difficulties that can be encountered in the management of patients with catamenial pneumothorax.

Video-assisted Thoracoscopic Surgery for Catamenial Hemoptysis: the Rationale of Preoperative Computed Tomography-guided Hook-wire Localization

Catamenial hemoptysis is a rare disease. Hormone ablation therapy is the treatment of choice with multiple side effects. We report a case of pulmonary endometriosis with deep and changeable focus. Successful treatment was obtained with the combine use of computed tomography-guided hook-wire localization and video-assisted thoracoscopic surgery. Owing to benign and curable in nature, we suggest a more aggressive attitude toward this disease before proceeding to hormone ablation therapy. The role of preoperative localization in the management of such disease was also discussed.

Immunohistochemical analysis of an ectopic endometriosis in the uterine round ligament

A rare case of the inguinal endometriosis was reported with immunohistochemical analysis. A 28-year-old woman had a thumb-sized tumor in the right groin for two years with a gradual increase in size and pain. An operation revealed an elastic hard tumor with an unclear margin and adhesion to the uterine round ligament. The histology showed irregular proliferation of the endometrial glands and stroma. The glandular epithelium stained weakly positive against CD125 antibody and the stromal matrix stained strongly positive against CD10 antibody. The nucleus in both the epithelial and stromal cells stained strongly positive against progesterone and estrogen receptor antibodies, and the cytoplasm in both types of cells stained moderately positive against COX-2 (cyclooxygenase-2) antibody. In conclusion, the combination of estrogen or progesterone receptor antibody for the nucleus and CD10 or COX-2 antibody for the cytoplasm could enhance the accuracy of diagnosis for ectopic endometriosis.

Catamenial Bernard-Horner’s Syndrome Related to Thoracic Endometriosis

We describe the case of a young woman with a recurrent right Bernard-Horner's syndrome associated with the onset of intermittent supraclavicular mass. Surgical excision of the mass revealed the endometrial pattern of the tumor and the close relationship between Bernard-Horner's syndrome and thoracic endometriosis. No other case of this syndrome has been reported in the literature.

Endometriosis of the vastus lateralis muscle

We report an unusual case of a woman who sought medical attention for a painful mass within her anterolateral left thigh. The patient's symptoms waxed and waned with her menses. Magnetic resonance imaging revealed a 3 cm mass isointense to muscle and surrounded by a rim of decreased signal intensity on T1-weighted images. T2-weighted images with fat saturation revealed a low signal intensity mass with a surrounding rind of high signal intensity edema. Based on its magnetic resonance imaging characteristics, the lesion was initially thought to represent the sequela of prior trauma or perhaps a small fibrous tumor. An excisional biopsy of the mass, however, revealed endometrial tissue, and a pathologic diagnosis of intramuscular endometriosis was rendered.

Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution

BACKGROUND

To investigate whether knowledge of the anatomical distribution of histologically proven deeply infiltrating endometriosis (DIE) lesions contributes to understanding the pathogenesis.

METHODS

Observational study between June 1992 and December 2004 (retrospective study between 1992 and 2000; prospective study between 2001 and 2004). Continuous series of 426 patients suffering from pelvic pain who underwent complete surgical exeresis of DIE. DIE lesions were classified according to four different possibilities: (i) Firstly, DIE lesions were classified as located in the anterior or posterior pelvic compartment. (ii) Secondly, DIE were classified as left, median and right. (iii) Thirdly, DIE lesions were classified as pelvic or abdominal. (iv) Fourthly, DIE lesions that could present in a right and/or left location were classified as unilateral or bilateral.

RESULTS

These 426 patients presented 759 histologically proven DIE lesions: bladder (48 lesions; 6.3%); uterosacral (USL) (400 lesions; 52.7%); vagina (123 lesions; 16.2%); ureter (16 lesions; 2.1%) and intestine (172, 22.7%). DIE lesions are significantly more often located in the pelvis (n=730 lesions) than in the abdomen (n=29 lesions) (P<0.0001). Pelvic DIE lesions are significantly more often located in the posterior compartment of the pelvis [682 DIE lesions (93.4%) versus 48 DIE lesions (6.6%); P<0.0001]. Pelvic DIE lesions are significantly more frequently located on the left side. For patients with unilateral pelvic DIE lesions, the anatomical distribution is significantly different in the three groups: left (172 lesions; 32.0%), median (284 lesions; 52.8%) and right (82 lesions; 15.2%) (P<0.0001). For patients with lateral lesions, left DIE lesions (172 lesions; 67.8%) were found significantly more frequently than right DIE lesions (82 lesions; 32.2%) (P<0.0001). A similar predisposition was observed when we included patients with bilateral pelvic DIE lesions (P=0.0031). The same significantly asymmetric distribution is observed for total (pelvic and abdominal) DIE lesions.

CONCLUSIONS

Our results demonstrate that distribution of DIE lesions is asymmetric. It is possible that this is related to the anatomical difference between the left and right hemipelvis and to the flow of peritoneal fluid. These findings support the hypothesis that retrograde menstruation of regurgitated endometrial cells is implicated in the pathogenesis of DIE.

What we see is not what we get in catamenial haemoptysis

Catamenial haemoptysis is rare entity, a part of thoracic endometriosis syndrome. We present a young woman who was timely diagnosed, successfully treated using video-assisted thoracoscopic surgery and pathologically confirmed the case. The change in lung parenchyma over time in the computed tomography is highlighted.

Bilateral pleural endometriosis

The patient was a 40-year-old woman with a 1-year history of catamenial chest pain and a recent bilateral hemothorax. She underwent a left thoracotomy for surgical pleurodesis, and a pleural biopsy. Subsequently, she had a hysterectomy in conjunction with an oophorectomy. The pathologic investigation of the pleura revealed an endometrial implant. The postoperative course was uneventful with no recurrence of hemothorax and chest pain during the first 6 months and at the patient's follow-up. This is a very rare case of a patient with thoracic endometriosis presenting with bilateral hemothorax.

Thoracic Endometriosis: Current Knowledge

Thoracic endometriosis syndrome includes four well-recognized clinical entities, namely catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis and lung nodules, as well as some exceptional presentations. The etiological mechanisms of this syndrome are not well understood, and different theories have been proposed. Controversies exist about optimal management, as experience has been drawn from case reports and small clinical series. Surgery, hormonal treatments and combined approaches have all been proposed, with variable results in terms of short and long term outcome.

Computed tomography findings of pathologically confirmed pulmonary parenchymal endometriosis

OBJECTIVE

To evaluate the usefulness of computed tomography (CT) in the localization of parenchymal pulmonary endometriosis and to correlate the CT findings with fiberoptic bronchoscopic and pathologic findings.

METHODS

A prospective study of 5 patients presenting with catamenial hemoptysis was conducted. The CT scans and fiberoptic bronchoscopy were performed twice during and 2 weeks after menstruation. After the localization of the presumed bleeding focus, surgical resection was performed.

RESULTS

The CT scans obtained during menstruation revealed a well-demarcated area of consolidation (n = 4) and ground-glass opacity (n = 5), whereas CT scans obtained after menstruation demonstrated ground-glass opacity (n = 4) or complete resolution of the previously noted lesion (n = 1). Fiberoptic bronchoscopy exhibited trails of blood clot at the orifice of the involved bronchi unilaterally (n = 4) or a thin bloody secretion in the bronchi bilaterally. Histopathologic examination of the resected specimens showed typical findings of pulmonary endometriosis.

CONCLUSION

Computed tomography scans during and after menstruation were useful for the precise preoperative localization of parenchymal pulmonary endometriosis.

Diagnosis of endometriosis with imaging: a review

Endometriosis corresponds to ectopic endometrial glands and stroma outside the uterine cavity. Clinical symptoms include dysmenorrhoea, dyspareunia, infertility, painful defecation or cyclic urinary symptoms. Pelvic ultrasound is the primary imaging modality to identify and differentiate locations to the ovary (endometriomas) and the bladder wall. Characteristic sonographic features of endometriomas are diffuse low-level internal echos, multilocularity and hyperchoic foci in the wall. Differential diagnoses include corpus luteum, teratoma, cystadenoma, fibroma, tubo-ovarian abscess and carcinoma. Repeated ultrasound is highly recommended for unilocular cysts with low-level internal echoes to differentiate functional corpus luteum from endometriomas. Posterior locations of endometriosis include utero-sacral ligaments, torus uterinus, vagina and recto-sigmoid. Sonographic and MRI features are discussed for each location. Although ultrasound is able to diagnose most locations, its limited sensitivity for posterior lesions does not allow management decision in all patients. MRI has shown high accuracies for both anterior and posterior endometriosis and enables complete lesion mapping before surgery. Posterior locations demonstrate abnormal T2-hypointense, nodules with occasional T1-hyperintense spots and are easier to identify when peristaltic inhibitors and intravenous contrast media are used. Anterior locations benefit from the possibility of MRI urography sequences within the same examination. Rare locations and possible transformation into malignancy are discussed.

Endométriose pleurale : une présentation inhabituelle

INTRODUCTION

Numerous conditions can produce chronic exudative pleural effusions. Pleural endometriosis is a rare cause of unilateral effusion with diffuse pleural thickening.

CLINICAL CASE

We report the case of chronic pleural effusion in a thirty year old African woman, where pleural endometriosis was diagnosed only following pleuro-pulmonary decortication, with the diagnosis being confirmed by immunohistochemistry.

CONCLUSION

Pleural endometriosis must be considered as a possible diagnosis in women with pleural effusions of unknown aetiology. The presence of endometrial glands or of chorionic cells within the pleura is characteristic. Immunohistochemistry is an important diagnostic tool.

Catamenial pneumothorax

Catamenial pneumothorax is defined as spontaneous pneumothorax occurring within 72 hours before or after onset of menstruation. Although catamenial pneumothorax is the most common clinical manifestation of intrathoracic endometriosis, this latter condition is not universally identified in women with catamenial pneumothorax and cannot fully explain the recurrent and cyclical episodes of pneumothorax. Therefore, the etiology of this syndrome is unknown, although many theories have been proposed to explain it. We describe a 37-year-old woman with recurrent episodes of spontaneous right-sided pneumothorax and chest pain that occurred close to her menstrual periods. The patient's condition did not abate after initial surgical exploration with abrasive mechanical pleurodesis or after hormonal suppressive therapy at an institution elsewhere. The patient was referred to our institution for further evaluation. A second surgical inspection of the pleural cavity and diaphragm disclosed the presence of multiple diaphragmatic fenestrations that were closed surgically at that time. Postoperatively, the patient discontinued hormonal suppressive therapy, and menstrual cycles became regular. Six months after surgery, the patient remains asymptomatic with no evidence of recurrence of pneumothorax. This case supports recent reports that diaphragmatic defects are often present in patients with catamenial pneumothorax. Surgical exploration to inspect the diaphragm and to close all Identified defects should be performed in patients who continue to experience pneumothorax despite effective hormonal suppression.

Catamenial pneumothorax revisited: Clinical approach and systematic review of the literature

BACKGROUND

Catamenial pneumothorax is a rare entity of spontaneous, recurring pneumothorax in women. It has been associated with thoracic endometriosis, yet varying clinical courses and the lack of consistent intraoperative findings have led to conflicting etiologic theories.

METHODS

We discuss etiology, clinical course, and surgical treatment of 3 women with catamenial pneumothorax. In addition, the world literature since the first description is reviewed.

RESULTS

Three women (31, 32, and 39 years old) had recurrent, menses-associated, right-sided spontaneous pneumothoraces. They had undergone video-assisted thoracoscopic surgery previously, with various unsuccessful procedures. Finally, with video-assisted thoracoscopic surgery multiple small perforations in the tendinous part of the right diaphragm with adjacent endometrial implants were detected. After plication of the involved area, 2 patients have been free of recurrence for 22 and 13 months, respectively. Laparoscopic evaluation in 1 woman with a further recurrence revealed asymptomatic pelvic endometriosis. This patient has been free of recurrence since initiation of luteinizing hormone-releasing hormone analog therapy for 17 months. In a review of 229 cases of catamenial pneumothorax in the literature, adequate information was given for 195 patients (85.2%). One hundred fifty-four (79%) were treated surgically, with detailed findings reported for 140 (91%). Thoracic endometriosis was diagnosed in 73 patients (52.1%), and 54 (38.8%) showed diaphragmatic lesions. Pleurodesis, with or without diaphragmatic repair or wedge resection, was performed in 81.7% of the cases.

CONCLUSIONS

Catamenial pneumothorax may be suspected in ovulating women with spontaneous pneumothorax, even in the absence of symptoms associated with pelvic endometriosis. During video-assisted thoracoscopic surgery, inspection of the diaphragmatic surface is paramount. Plication of the involved area alone can be successful. In complicated cases, hormonal suppression therapy is a helpful adjunct.

Catamenial pneumothorax and other thoracic manifestations of endometriosis

Thoracic endometriosis syndrome is an uncommon entity with varied clinical manifestations. Its pathogenesis is not understood completely. Recurrent unilateral right-sided pneumothorax that occurs within days of the onset of menstruation is the most common presentation. Clinical suspicion and recognition of the temporal relationship of the patient's symptoms with menses are essential to establish the diagnosis. Radiographic studies, bronchoscopy, and thoracoscopy may support the diagnosis. Pathologic evidence of thoracic endometrial tissue is not present universally. Therapeutic interventions, which include medical and surgical options, must be individualized for each patient.