Clinical presentation and treatment of catameinal pneumothorax and endometriosis-related pneumothorax

Catamenial Pneumothorax in the Setting of a Recent Stroke

Catamenial pneumothorax is a unique condition associated with thoracic endometriosis. It often presents in females of reproductive age as a recurrent pneumothorax aligned with the menstrual cycle. We present a case of a young female diagnosed with catamenial pneumothorax within one year of experiencing a stroke. The clinical presentation related to the stroke allowed for a unique diagnostic process and management considerations. The patient was successfully treated with progesterone-based contraception in the setting of an estrogen contraindication.

The importance of diaphragmatic surgery, chemical pleurodesis and postoperative hormonal therapy in preventing recurrence in catamenial pneumothorax: a retrospective cohort study

BACKGROUND

Catamenial pneumothorax (CP) is defined as a recurrent, spontaneous pneumothorax occurring within a day before or 72 h after the onset of menstruation. Most first episodes go undiagnosed and treated as primary spontaneous pneumothorax, and only after recurrence is the clinical suspicion of CP raised. No gold-standard management approach exists, especially in terms of managing diaphragmatic involvement.

METHODS

This study is a single-centre cohort retrospective study of 24 female patients who underwent surgery for pneumothorax due to diaphragmatic endometriosis between January 2008 and December 2016. Two groups were compared: a group that underwent pleurodesis alone (8 patients) and a group that underwent diaphragmatic surgery and pleurodesis (16 patients).

RESULTS

There were differences in BMI and smoking habits between the two groups. The right diaphragm was involved more often (6vs15, p = 0.190). VATS was the preferred surgical approach and only one conversion occurred in the diaphragmatic surgery group (p = 0.470). Diaphragmatic abnormalities were present in all the patients, brown/violet spots (100%) in the pleurodesis group and perforations (100%) in the diaphragmatic surgery group (p < 0.001). There were no differences in days of chest tube removal and length of stay. The recurrence rate was 100% in the pleurodesis alone group while it was only 12.5% in the diaphragmatic surgery group (< 0.001).

CONCLUSIONS

In our experience, diaphragmatic surgery and pleurodesis followed by hormonal therapy was an effective approach in preventing recurrence in patients with catamenial pneumothorax and diaphragmatic involvement.

Thoracic Endometriosis: a Clinical Review and Update of Current and Evolving Diagnostic and Therapeutic Techniques

Purpose of Review

The goal of this review is to provide a comprehensive understanding of the pathophysiology, clinical presentation, diagnostic workup, and clinical management of thoracic endometriosis (TE), as well as highlight our personal experience with TE workup and management.

Recent Findings

TE can present in a wide range of clinical manifestations. Without high clinical suspicion, diagnosis can be delayed. Since no specific laboratory testing is available, diagnosis is often based on careful history taking, imaging, and direct visualization of endometrial lesions through video-assisted thoracoscopic surgery (VATS). Medical thoracoscopy (MT) may also be a useful tool in the diagnostic workup of TE.

Summary

The diagnosis and management of TE require a multidisciplinary approach and a high index of clinical suspicion. While VATS remains the gold standard for diagnosis, we share our experience using MT to diagnose and manage a case of TE-related hemothorax.

Chest Tube Drainage Versus Conservative Management as the Initial Treatment of Primary Spontaneous Pneumothorax: A Systematic Review and Meta-Analysis

Objectives: This systematic review and meta-analysis aimed to compare chest tube drainage and conservative management as the initial treatment of primary spontaneous pneumothorax (PSP). Methods: Studies including PSP patients who received tube drainage or conservative management as the initial treatment were searched in OVID-MEDLINE and Embase through 14 February 2020. The primary outcome was the relative risk (RR) of PSP recurrence, and secondary outcomes were RRs of PSP resolution and adverse events during treatment. A random-effect model using the Mantel–Haenszel method was used to pool RRs. Subgroup and meta-regression analyses were performed to investigate significant predictors of PSP recurrence. Results: In total, 11,922 PSP cases from eight studies were analysed, of which 6344 were treated with tube drainage and 5578 were treated with conservative management. The pooled RR of PSP recurrence for conservative management against tube drainage was 0.98 (95% confidence interval [CI], 0.75–1.28; p = 0.894). Subgroup and meta-regression analyses revealed that study design (p = 0.816), allocation of the PSP amount in each management group (p = 0.191), and assessment time for recurrence had no significant impact on PSP recurrence (p = 0.816). There was no publication bias (p = 0.475). The risk of adverse events of conservative management was significantly lower than that of tube drainage (pooled RR, 0.22; 95% CI, 0.08–1.15; p = 0.003). However, no difference was found between the two groups in terms of PSP resolution (pooled RR, 1.01; 95% CI, 0.9–1.15; p = 0.814). Conclusions: As the initial treatment for PSP, conservative management is comparable to chest tube drainage in terms of PSP recurrence and resolution after treatment, with fewer adverse events during treatment.

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.