Catamenial pneumothorax: Not only VATS diagnosis

Thoracic Endometriosis Syndrome: A Comprehensive Review and Multidisciplinary Approach to Management

Background: Endometriosis is a systemic, inflammatory, estrogen-dependent condition characterized by endometrial stroma and gland-like lesions outside of the uterus. It causes a range of symptoms, notably chronic pelvic pain, infertility and organ dysfunction. Thoracic endometriosis syndrome (TES) has been described as endometriosis that is found in the lung parenchyma, pleura and diaphragm. It may be asymptomatic or present with symptoms of catamenial pneumothorax, hemothorax, hemoptysis, isolated chest pain, shoulder pain or findings of lung nodules. Aim: The aim of this review is to provide a comprehensive overview of thoracic endometriosis syndrome (TES), including its clinical presentation, diagnostic challenges, and current management strategies. This review aims to highlight the importance of a multidisciplinary approach in the treatment of TES, emphasizing conservative management and the role of minimally invasive surgical techniques for refractory cases. Conclusions: Thoracic endometriosis syndrome appears to be a marker of severe endometriosis. As much as possible, the patient with TES is managed conservatively, with surgery reserved for refractory cases. When surgery is recommended, the procedure is conducted through a multidisciplinary minimally invasive approach, with video-assisted thoracoscopic surgery (VATS) and video-assisted laparoscopy. Meticulous intraoperative survey, the removal of endometriosis implants with and without robotic assistance and post-operative hormonal therapy may be recommended to prevent recurrence.

Catamenial Pneumothorax-Still an Unveiled Disease

This review presents current opinions on an uncommon condition called catamenial pneumothorax (CP), which is usually associated with thoracic endometriosis syndrome (TES). TES is characterized by the presence of endometriotic lesions in pleura and lung parenchyma and presents with various clinical signs and symptoms, including catamenial pneumothorax. Their diagnosis is often delayed. Pulmonary endometric lesions, however, often detected in patients with hemothorax and hemoptysis, may be absent in a proportion of cases of pneumothorax. The typical presentation of CP includes signs and symptoms of pneumothorax, which occur along with menstruation, most commonly around 24 h before and 48-72 h after its onset. However, they may not occur during every menstrual cycle. Suggestive CP lesions on conventional radiography (RTG) include pneumoperitoneum accompanying right-sided pneumothorax, lung opacities, pleural effusion, and nodular infiltrates. Chest and abdomen computed tomography (CT), particularly contrast-enhanced, may additionally show pneumoperitoneum and diaphragmatic lesions. The management of CP includes supportive treatment of acute symptoms and causal treatment to prevent recurrent disease. This article presents the pathophysiology of CP, an overview of the diagnostic methods, and the current therapeutic approaches. The necessity for a multidisciplinary approach to the diagnosis of CP and to the choice of the best treatment modality is underlined (promising new therapeutic options are also mentioned); however, international guidelines are still missing.

A bird-eye view of diaphragmatic endometriosis: current practices and future perspectives

Diaphragmatic endometriosis is one of the most common localization of extra-pelvic endometriosis and may cause debilitating symptoms such as cyclic shoulder pain, right upper abdominal pain, and right-sided chest pain. Diaphragmatic endometriosis may also be asymptomatic. The exact mechanisms by which diaphragmatic endometriosis originates are unknown. The high correlation between severe pelvic endometriosis and diaphragmatic endometriosis suggests that the latter originates from endometriotic cells that reach the upper abdomen by circulating with the peritoneal fluid current. Robust evidence regarding the preoperative diagnosis and optimal management of diaphragmatic endometriosis is lacking. Most reports rely on Magnetic Resonance Imaging (MRI) for the radiologic diagnosis of diaphragmatic endometriosis. Although its sensitivity ranged between 78% and 83%, MRI was found to underestimate the extent of diaphragmatic endometriosis in comparison with the surgical findings. Accumulating evidence indicates that asymptomatic diaphragmatic endometriosis is very unlikely to progress, and therefore, could be left in situ when incidentally found. The efficiency of ablative and excisional approaches for symptomatic endometriosis has not been assessed thoroughly to date. In addition, it is unclear whether combining the laparoscopic approach with video-assisted thoracoscopy (VATS) may result in an optimized result. This gap exists due to the lack of data about the association between diaphragmatic and thoracic endometriosis. In this review, we aimed to provide a state of the art description of the current knowledge and gaps about the pathogenesis, diagnostics, and treatment modalities of diaphragmatic endometriosis.

Outcomes and Trends of Open Thoracotomy and Video-Assisted Thoracic Surgery for Surgical Management of Catamenial Pneumothorax: A 10-Year Retrospective Cohort Study of a Thai Population

Background Catamenial pneumothorax (CP) is characterized by pneumothorax associated with menstrual cycles and thoracic endometriosis. This study aimed to review the outcomes and trends for surgical treatment of CP in King Chulalongkorn Memorial Hospital. Methodology We included females aged 18 to 50 years who underwent surgery for CP between January 2012 and December 2022. A total of 17 patients were identified. A retrospective data collection from each patient was done, including demographic data, surgery type (open vs. video-assisted thoracic surgery (VATS)), pleural procedures, length of stay, and complications. Results The mean age at surgery was 36.29 years (±6.78). The median follow-up period was 36 months (range = 12-122). Pneumothorax occurred predominantly on the right side (94.12%), and pelvic endometriosis was present in all patients. All 17 patients underwent surgery, with open surgery in six and VATS in 11 patients. Diaphragmatic procedures were performed in 15 patients, with pleurectomy in nine, lung resection in 11, and pleurodesis in 10 patients. Pleurectomy was significantly associated with a reduced recurrence rate (p = 0.029). Diaphragmatic lesions were absent in two cases, and four patients experienced recurrence. Conclusions This cohort study of CP in the Thai population demonstrated that pleurectomy is associated with lower recurrence. There was no difference in recurrence between open surgery and VATS. Corresponding to the British Thoracic Society Guideline 2023, pleurectomy may help reduce recurrence.

Spontaneous recurrent menstrual pneumothorax: a case report

Introduction and importance

Endometriosis is most commonly found in the pelvic area, ~12% of people have it in other areas or organs, which is known as extrapelvic endometriosis. Thoracic endometriosis, which is also classified as extrapelvic endometriosis, manifests with four distinct forms: catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis, or lung nodules. Catamenial pneumothorax is the most common clinical symptom of these; however, it is frequently neglected by clinicians and goes undiagnosed and untreated. As a result, it is critical to raise awareness of this medical condition among clinicians.

Case presentation

The authors present a case report of a 34-year-old woman of reproductive age who had recurrent episodes of spontaneous pneumothorax during menstruation and underwent treatment with thoracoscopic surgery as well as gynaecological hormonal drugs including oral progesterone and dienogest throughout this time. Based on her symptoms, a catamenial pneumothorax caused by thoracic endometriosis was suspected.

Clinical discussion

The clinical symptoms, pathogenesis, diagnosis, and treatment of Catamenial Pneumothorax are analyzed. Furthermore, the usage of gynaecological hormone medications in this condition has been discussed. The mechanisms of oral contraceptives and progestin-based medications are evaluated by comparing the patient's treatment process, highlighting their pros and cons.

Conclusions

Thoracoscopic surgery combined with postoperative gynaecological hormonal medications may be the most effective treatment for this issue. Several gynaecological hormonal medicines are available, each of which has its own set of pros and cons, and must be thoroughly evaluated as well as correctly tailored to the patient's specific circumstances to have a positive therapeutic outcome.

Intrathoracic endometriosis resulting in catamenial pneumothorax

A woman in her early 40s presented with right-side chest pain radiating to the ipsilateral shoulder coinciding with her menstrual periods. She complained of worsening dysmenorrhoea over the preceding 6 months. Chest radiograph was notable for pneumothorax. Conservative management through hormonal suppression was initially pursued but proved ineffective for preventing recurrence. The patient ultimately underwent video-assisted diagnostic thoracoscopic surgery through robotic approach; intraoperative findings confirmed the presence of endometrial deposits of the diaphragm, confirming the cause of the patient's catamenial pneumothorax. The patient recovered well and was started on a gonadotropin-releasing hormone antagonist 3 weeks following her operation.

Diaphragmatic Endometriosis-A Single-Center Retrospective Analysis of the Patients' Demographics, Symptomatology, and Long-Term Treatment Outcomes

Diaphragmatic endometriosis is rare and forms 0.67-4.7% of all endometriosis cases. Evidence regarding its optimal management is lacking. In this study, we retrospectively analyzed the patient characteristics and long-term treatment outcomes of diaphragmatic endometriosis patients. Over a 4-year period, 23 patients were diagnosed with diaphragmatic endometriosis. The majority of patients had coexisting deep pelvic endometriosis. Cyclic upper abdominal pain was reported by 60.9% of patients, while cyclic chest and shoulder pain were reported by 43.5% and 34.8% of patients, respectively. Most patients were treated with laparoscopic lesion ablation, while 21.1% were treated with minimally invasive excision. The mean follow-up time was 23.7 months. Long-lasting resolution of the chest, abdominal, and shoulder pain occurred in 50%, 35.7%, and 25% of patients, respectively. Nonetheless, 78.9% of patients reported major improvement in their symptoms postoperatively. Significantly higher rates of postoperative shoulder, abdominal, and chest pain were observed in patients who received postoperative hormonal therapy compared with those who did not. All patients treated expectantly remained stable. Therefore, we recommend treating diaphragmatic endometriosis only in symptomatic patients. The risk of incomplete surgery should be minimized by a multidisciplinary diagnostic and therapeutic approach with a careful assessment of the diaphragm and the thoracic cavity.

Robotic-Assisted Thoracic Surgery Approach to Thoracic Endometriosis Syndrome with Unilateral Diaphragmatic Palsy

Endometriosis is characterized by endometrial-like glands and stroma outside the uterine cavity, affecting women of reproductive age. Thoracic endometriosis syndrome (TES) is an entity producing a range of clinical and radiological manifestations, including catamenial pneumothorax, haemothorax, haemoptysis, and pulmonary nodules within the thoracic cavity or on the diaphragm. TES symptoms are nonspecific, warranting a high degree of clinical suspicion. Management includes hormone replacement therapy, surgical management, or a combination of both. We present a case of a 37-year-old woman who presented with TES and unilateral diaphragmatic palsy, managed with robotic-assisted thoracoscopic surgery and hormone replacement.

Iatrogenic Pneumothorax during Acupuncture: Case Report

Acupuncture treatment in local areas is commonly used to treat pain or soreness; however, acupuncture around the neck or shoulder may be a risk factor for pneumothorax. Herein, we report two cases of iatrogenic pneumothorax after acupuncture. These points indicate that physicians should be aware of these risk factors through history-taking before acupuncture. Chronic pulmonary diseases, such as chronic bronchitis, emphysema, tuberculosis, lung cancer, pneumonia, and thoracic surgery, may be associated with a higher risk of iatrogenic pneumothorax after acupuncture. Even if the incidence of pneumothorax should be low under caution and fully evaluated, it is still recommended to arrange further imaging examinations to rule out the possibility of iatrogenic pneumothorax.