Relationship between Catamenial Pneumothorax or Non-catamenial Pneumothorax and Endometriosis

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of the literature according to the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥ 2 cm at the hilum level on frontal chest X-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Endometriosis of the lung: A case report and review of literature

BACKGROUND

Lung endometriosis is an extremely rare gynecological disease. Current literature reports suggest that the majority of patients will present with only generic symptoms, such as hemoptysis, pneumothorax, and hemopneumothorax, which often leads to misdiagnosis. To date, there are 18 case reports of lung endometriosis that describe the clinical manifestation, imaging changes, treatment, and prognosis of the disease. To provide further insights into this rare disease, we present a new case report and a brief review of pulmonary endometriosis.

CASE SUMMARY

We report here about a 19-year-old woman who was admitted to the hospital for repeated catamenial hemoptysis over a 3-mo period. computed tomography (CT) imaging during menstruation revealed patchy high-density shadows, approximately 0.5 cm³ in size, in the right middle lobe of the lung. The patient’s hemoptysis and changes in the CT scans resolved after menstruation. Thoracoscopic right middle lobectomy, right lower lung repair, and closed thoracic drainage were performed. Postoperative histopathology confirmed lung endometriosis. There was no recurrence of symptoms at the 6 mo follow-up.

CONCLUSION

We propose diagnosing lung endometriosis by thoroughly taking reproductive history, clinical details, imaging, and histopathology followed by treatment with surgical resection.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV)

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Recommandations formalisées d’experts pour la prise en charge des pneumothorax spontanés primaires

Introduction : Le pneumothorax spontané primaire (PSP) est un épanchement gazeux dans la cavité pleurale, survenant hors traumatisme et pathologie respiratoire connue. Des recommandations formalisées d'experts sur le sujet sont justifiées par les pluralités de moyens diagnostiques, stratégies thérapeutiques et disciplines médicochirurgicales intervenant dans leur prise en charge.

Méthodes : Revue bibliographique, analyse de la littérature selon méthodologie GRADE (Grading of Recommendation Assessment, Development and Evaluation) ; propositions de recommandations cotées par experts, patients et organisateurs pour obtenir un consensus. Seuls les avis d'experts avec accord fort ont été retenus.

Résultats : Un décollement sur toute la hauteur de la ligne axillaire et supérieur ou égal à 2 cm au niveau du hile à la radiographie thoracique de face définit la grande abondance. La stratégie thérapeutique dépend de la présentation clinique : exsufflation en urgence pour PSP suffocant ; en l'absence de signe de gravité : prise en charge conservatrice (faible abondance), exsufflation ou drainage (grande abondance). Le traitement ambulatoire est possible si organisation en amont de la filière. Les indications, procédures chirurgicales et l'analgésie périopératoire sont détaillées. Les mesures associées, notamment le sevrage tabagique, sont décrites.

Conclusion : Ces recommandations sont une étape de l'optimisation des stratégies de traitement et de suivi des PSP en France.

Extragenital Endometriosis in the Differential Diagnosis of Non- Gynecological Diseases

BACKGROUND

Endometriosis is a chronic, benign disease that affects approximately 10% of women of childbearing age. Its characteristic clinical features are dysmenorrhea, dyschezia, dysuria, dyspareunia, and infertility. The manifestations of extragenital endometriosis (EE) are a diagnostic challenge, as this disease can mimic other diseases due to its unusual location with infiltration of various organs and corresponding symptoms.

METHODS

This review is based on publications retrieved by a selective search of the literature on the commonest extragenital sites of endometriosis, including the relevant current guideline.

RESULTS

Current evidence on the treatment of extragenital endometriosis consists largely of cohort studies and cross-sectional studies. The treatment is either surgical and/or conservative (e.g., hormonal therapy). Gastrointestinal endometriosis is the most common form of EE, affecting the rectum and sigmoid colon in nearly 90% of cases and typically presenting with dyschezia. Urogenital endometriosis is the second most common form of EE. It affects the bladder in more than 85% of cases and may present with dysuria, hematuria, or irritable bladder syndrome. The diaphragm is the most common site of thoracic endometri - osis, potentially presenting with period-associated shoulder pain or catamenial pneumothorax. Endometriosis affecting a nerve often presents with sciatica. In abdominal wall endometriosis, painful nodules arise in scars from prior abdominal surgery.

CONCLUSION

There is, as yet, no causally directed treatment for chronic endometriosis. The treatment is decided upon individually in discussion with the patient, in consideration of risk factors and after assessment of the benefits and risks. Timely diagnosis is essential.

[Mystery of endometriosis - catamenial pneumothorax]

The review is devoted to clinical picture, main theories of pathogenesis, traditional and innovative methods of diagnosis and surgical treatment of catamenial pneumothorax. Currently, clinicians prefer magnetic resonance imaging and thoracoscopy for diagnosis of this disease. Various researchers are actively searching for laboratory diagnostic methods that can confirm endometrioid nature of pneumothorax. Treatment and prevention of catamenial pneumothorax are a controversial issue depending both clinical picture and preferences of the attending physician. Currently, the majority of authors believe that hormonal therapy combined with diaphragm resection ensures optimal anti-relapse effect in patients with thoracic endometriosis.

Catamenial Pneumothorax as the First Expression of Thoracic Endometriosis Syndrome and Pelvic Endometriosis

Objective: The menstrual-related catamenial pneumothorax (CP) can be the first expression of thoracic endometriosis syndrome (TES), which is the presence of endometriotic lesions in the lungs and pleura, and pelvic endometriosis (PE). This study aims to analyze our experience with this specific correlation describing our multidisciplinary approach to CP. Methods: Hospital records of 32 women, operated for CP at our Department from January 2001 to December 2021 were reviewed. Surgical treatment consisted of videothoracoscopy and laparoscopy when indicated. Results: TES and PE were diagnosed in 13 (40.6%) and 12 (37.5%) women, respectively. The association of TES and PE was present in 11 cases (34%). Fifteen patients (46.9%) underwent laparoscopy, of which 11 concurrently with videothoracoscopy. Most of the patients affected had stage III–IV endometriosis (40.6%). All patients received hormonal therapy after surgery. Five patients with PE conceived spontaneously resulting in six live births. The mean follow-up was 117 ± 71 months (range 8–244). Pneumothorax recurrence occurred in six patients (18.8%). At present, all women are asymptomatic, with no sign of pneumothorax recurrence. Conclusions: CP might be the first expression of TES and/or PE. A multidisciplinary approach is advocated for optimal management of the disease.

A unique case of thoracic endometriosis syndrome and pulmonary Langerhans’ cell histiocytosis: Six recurrent pneumothoraces

Spontaneous pneumothorax (SP) in women of reproductive age with causes such as thoracic endometriosis syndrome (TES) presents a diagnostic and therapeutic challenge. A 33-year-old women was treated conservatively with chest tube insertion for a first occurrence of a right-sided pneumothorax in September 2015. In January 2016, a right-sided video-assisted thoracoscopic surgery (VATS) wedge resection and partial parietal pleurectomy was performed due to a recurrence. A right-sided VATS was again performed in December 2016 with multiple wedge resections and a total pleurectomy revealing a pulmonary Langerhans’ cell histiocytosis (PLCH) in the histological and immunohistochemical examinations. The patient was recommended an abstinence of smoking and further course was unremarkable until May 2019, when due to a recurrent pneumothorax, she received a talc pleurodesis via right-sided VATS. Due to yet another recurrence, she underwent a talc slurry pleurodesis over a right sided chest drain. In March 2020 due to recurrence, a right-sided VATS was performed and a blueish nodular lesion was resected from the diaphragm. The histological examination revealed an endometriosis with a diagnosis of TES. Since the patient did not exhibit a temporal relationship between her periods and the onset of pneumothorax symptoms, a final diagnosis of non-catamenial endometriosis-related pneumothorax was made. The patient is currently continuing smoking abstinence and is under hormone therapy. She has not presented with a recurrence. In clinical practice, it is important not to just relay on the information available to us, but to reevaluate the patient history to uncover new clues leading to a new diagnosis.

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A rare combination of two rare diagnoses, PLHC and TES, only recognized through multiple hospital stays and operations.

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Symptoms of endometriosis-related pneumothorax are not always directly related to the menstrual cycle.

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As clinicians, we should remember that it is not impossible to suffer from two rare disorders.

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A thorough history taking and a precise intraoperative evaluation might reveal clues towards diagnosis and correct treatment.

Thoracic Endometriosis: A Review Comparing 480 Patients Based on Catamenial and Noncatamenial Symptoms

OBJECTIVE

This review aimed to categorize thoracic endometriosis syndrome (TES) according to whether the presenting symptoms were catamenial and to evaluate whether such a categorization enables a better management strategy.

DATA SOURCES

An electronic search was conducted using the PubMed/Medline database.

METHODS OF STUDY SELECTION

The following keywords were used in combination with the Boolean operators AND OR: "thoracic endometriosis syndrome," "thoracic endometriosis," "diaphragm endometriosis," and "catamenial pneumothorax."

TABULATION, INTEGRATION, AND RESULTS

The initial search yielded 445 articles. Articles in non-English languages, those whose full texts were unavailable, and those that did not present the symptomatology clearly were further excluded. After these exclusions, the review included 240 articles and 480 patients: 61 patients in the noncatamenial group and 419 patients in the catamenial group. The groups differed significantly in presenting symptoms, surgical treatment techniques, and observed localization of endometriotic loci (p <.05).

CONCLUSION

This review points out the significant differences between patients with TES with catamenial and noncatamenial symptoms. Such categorization and awareness by clinicians of these differences among patients with TES can be helpful in designing a management strategy. When constructing management guidelines, these differences between patients with catamenial and noncatamenial symptoms should be taken into consideration.

The Importance of Stromal Endometriosis in Thoracic Endometriosis

Thoracic endometriosis (TE) is a rare type of endometriosis, where endometrial tissue is found in or around the lungs and is frequent among extra-pelvic endometriosis patients. Catamenial pneumothorax (CP) is the most common form of TE and is characterized by recurrent lung collapses around menstruation. In addition to histology, immunohistochemical evaluation of endometrial implants is used more frequently. In this review, we compared immunohistochemical (CPE) with histological (CPH) characterizations of TE/CP and reevaluated arguments in favor of the implantation theory of Sampson. A summary since the first immunohistochemical description in 1998 until 2019 is provided. The emphasis was on classification of endometrial implants into glands, stroma, and both together. The most remarkable finding is the very high percentage of stromal endometriosis of 52.7% (CPE) compared to 10.2% (CPH). Chest pain, dyspnea, right-sided preference, and diaphragmatic endometrial implants showed the highest percentages in both groups. No significant association was found between the recurrence rate and the various appearances of endometriosis. Sometimes in CPE (6.8%) and CPH (30.6%) no endometrial implants were identified underlining the importance of sensitive detection of endometriosis during and after surgery. We suggest that immunohistochemical evaluation should become mandatory and will improve diagnosis and classification of the disease.

Treatment of Thoracic Endometriosis Syndrome: A Meta-Analysis and Review

BACKGROUND

Thoracic endometriosis syndrome (TES) is a rare disorder characterized by the presence of functional endometrial tissue within the chest cavity. Up to 80% of women with TES present with concomitant pelvic endometriosis. The diagnostic-curative path is defined by both thoracic surgeons and gynecologists, consistent with the manifestation of the disease. The aim of the study was to analyze the different approaches to generate an ideal diagnosis-treatment algorithm that can be shared by both specialties.

METHODS

We searched PubMed and Scopus for studies that were completed by March 2019 and that included at least 8 patients with TES. Information on preoperative exams, surgical technique, postoperative management, and recurrence of disease was collected for meta-analysis.

RESULTS

Twenty-five studies including a total of 732 patients were eligible. Almost all of the patients underwent radiologic pelvis investigation (96%; confidence interval [CI], 87%-100%). Videothoracoscopy was the preferred surgical technique (84%; 95% CI, 66%-96%). Intraoperative evaluation revealed the presence of diaphragmatic anomalies in 84% of cases (95% CI, 73%-93%). The overall pooled prevalence of concomitant or staged laparoscopy was 52% (95% CI, 18%-85%). Postoperative hormone therapy was heterogeneous with a pooled prevalence of 61% (95% CI, 33%-86%; I² = 95.6%; P < .01). Recurrence of symptoms was documented in 27% of patients (95% CI, 20%-34%; I² = 54.7%; P < .01).

CONCLUSIONS

TES should be managed jointly by thoracic surgeons and gynecologists. Chest-abdomen magnetic resonance imaging seems to offer the most details for TES. Combined or staged videothoracoscopy and laparoscopy can provide adequate information to fine-tune proper surgical treatment and postoperative medical therapy.

Extra-pelvic endometriosis: A review

Background

Extra‐pelvic endometriosis is a rare type of endometriosis, which occurs in a distant site from gynecological organs. The diagnosis of extra‐pelvic endometriosis can be extremely challenging and may result in a delay in diagnosis. The main objective of this review was to characterize abdominal wall endometriosis (AWE) and thoracic endometriosis (TE).

Methods

The authors performed a literature search to provide an overview of AWE and TE, which are the major types of extra‐pelvic endometriosis.

Main findings

Abdominal wall endometriosis includes scar endometriosis secondary to the surgical wound and spontaneous AWE, most of which occur in the umbilicus or groin. Surgical treatment appeared to be effective for AWE. Case reports indicated that the diagnosis and treatment of catamenial pneumothorax or endometriosis‐related pneumothorax (CP/ERP) are challenging, and a combination of surgery and postoperative hormonal therapy is essential. Further, catamenial hemoptysis (CH) can be adequately managed by hormonal treatment, unlike CP/ERP.

Conclusion

Evidence‐based approaches to diagnosis and treatment of extra‐pelvic endometriosis remain immature given the low prevalence and limited quality of research available in the literature. To gain a better understanding of extra‐pelvic endometriosis, it would be advisable to develop a registry involving a multidisciplinary collaboration with gynecologists, general surgeons, and thoracic surgeons.

Endometriosis: An Unusual Cause of Bilateral Pneumothoraces

A 27-year-old female presented to the emergency department with sudden onset shortness of breath. A diagnosis of bilateral catamenial pneumothoraces was made following chest radiograph. Catamenial pneumothorax is a recurrent spontaneous pneumothorax that occurs in 90% of affected women 24–48 hours after the onset of their menstruation; 30–50% of cases have associated pelvic endometriosis. Symptoms can be as simple as chest pain or as severe as the presentation of this patient who was initially found to be in significant respiratory distress.

Circulating Endometrial Cells in Women With Spontaneous Pneumothorax

BACKGROUND

The occurrence of catamenial pneumothorax (CP) is rare, and the awareness of this diagnosis among physicians is insufficient. CP is highly correlated with pelvic endometriosis and remains the most common form of thoracic endometriosis syndrome. Circulating endometrial cells (CECs) have been previously detected in patients with pelvic endometriosis. Could CECs bring new insights into pneumothorax management?

METHODS

This study aims to describe the occurrence and molecular characteristics of CECs in women with spontaneous pneumothorax (SP) (N = 20) with high suspicion of its catamenial character. CECs were enriched from peripheral blood by size-based separation (MetaCell). In addition to cytomorphology, gene expression profiling of captured cells was performed for 24 endometriosis-associated genes.

RESULTS

CECs were present in all 20 patients with SP. Enriched CECs exhibited four character features: epithelial, stem cell-like, stroma-like, and glandular. However, not all of them were present in every sampling. Gene expression profiling revealed two distinct phenotypes of CECs in SP and/or CP: one of them refers to the diaphragm openings syndrome and the other to endometrial tissue pleural implantations. Comparisons of the gene expression profiles of CECs in pneumothorax (CECs-SP group) with CECs in pelvic endometriosis (CECs-non-SP group) have revealed significantly higher expression of HER2 in the CECs-SP group compared with the CECs-non-SP group.

CONCLUSIONS

This proof-of-concept study demonstrates successful isolation and characterization of CECs in patients with SP. Identification of CECs in SP could alert endometriosis involvement and help early referral to gynecologic consultation for further examination and treatment.