Clinical features of thoracic endometriosis: A single center analysis

Photodynamic therapy for treatment of recurrent hemoptysis secondary to pulmonary endometriosis: a case report

Pulmonary endometriosis (PEM) is rare, and drug therapy remains the primary treatment. However, patients with PEM frequently experience recurrent hemoptysis that is refractory to pharmacological intervention. We herein describe a patient with PEM who developed recurrent hemoptysis and was successfully treated with photodynamic therapy (PDT) after drug withdrawal. The patient was admitted to our hospital because of recurrent hemoptysis despite repeated drug treatments for more than 1 year. Given that PDT targets specific tissues and destroys vascular endothelial cells through the cytotoxic effect produced by the photodynamic reaction of the photosensitizer, we considered that it may effectively control hemoptysis secondary to vascular morphological changes in PEM. Therefore, we performed PDT in this case, and the patient's recurrent hemoptysis regressed. Approximately 2 years following PDT, the patient had recovered well and reported no discomfort. We recommend consideration of PDT as a treatment option for patients with PEM who develop recurrent hemoptysis after drug withdrawal. Notably, the patient's lung lesions should be superficial and limited, and no contraindications should be present.

Endometriosis-associated infertility: From pathophysiology to tailored treatment

Despite the clinically recognized association between endometriosis and infertility, the mechanisms implicated in endometriosis-associated infertility are not fully understood. Endometriosis is a multifactorial and systemic disease that has pleiotropic direct and indirect effects on reproduction. A complex interaction between endometriosis subtype, pain, inflammation, altered pelvic anatomy, adhesions, disrupted ovarian reserve/function, and compromised endometrial receptivity as well as systemic effects of the disease define endometriosis-associated infertility. The population of infertile women with endometriosis is heterogeneous, and diverse patients' phenotypes can be observed in the clinical setting, thus making difficult to establish a precise diagnosis and a single mechanism of endometriosis related infertility. Moreover, clinical management of infertility associated with endometriosis can be challenging due to this heterogeneity. Innovative non-invasive diagnostic tools are on the horizon that may allow us to target the specific dysfunctional alteration in the reproduction process. Currently the treatment should be individualized according to the clinical situation and to the suspected level of impairment. Here we review the etiology of endometriosis related infertility as well as current treatment options, including the roles of surgery and assisted reproductive technologies.

Is hormonal manipulation after surgical treatment of catamenial pneumothorax effective in reducing the rate of recurrence? A systematic review and meta-analysis

OBJECTIVES

Catamenial pneumothorax CP is a rare form of spontaneous pneumothorax in females forming part of thoracic endometriosis syndrome. Studies have suggested possible benefit from postoperative hormonal administration. As this treatment is inconsistent, we aimed at performing the first meta-analysis to study the efficacy of adding hormonal treatment after surgery to reduce the chances of recurrent catamenial pneumothorax.

METHODS

CENTRAL, MEDLINE/PubMed, Cochrane Library, and Scopus were systematically searched from inception up to December 15, 2021. Studies reporting five or more patients with end point outcome were included. The main outcome assessed was postoperative recurrence of CP after hormonal manipulation. Baseline, procedural, outcome, and validity data were systematically appraised and pooled with random-effect methods. meta- regression for the effect of patient age and follow up period were tested. Publication bias was examined. This trial was registered with PROSPERO under registration number CRD42022325377.

RESULTS

Our electronic search retrieved 644 citations, 48 of which were selected for full-text review. Eleven studies with a combined population of 111 patients fulfilled the inclusion criteria. All patients reached an endpoint of follow up for postoperative recurrence of catamenial pneumothorax after receiving hormonal treatment. Overall study validity was acceptable, with a median score of 6 on the Newcastle Ottawa scale NOS appraising the quality of observational studies. CP is almost always a right-side disease (107/111 = 96.3 %). The risk of postoperative recurrence with hormonal treatment was 17.3 % (8.9 - 25.8 %) with moderate non-significant heterogeneity (I2 = 40.85 %; P = 0.076). The cumulative risk of recurrence for all patients not receiving postoperative hormonal therapy included in our study was 54.2 % (19/35 patients). Meta regression showed age to be a significant predictor of postoperative recurrence (p = 0.03). As the age increases one year, the risk of recurrence decreases by 6 % (0.2 - 3 %). Publication bias was detected by visualizing the funnel plot of standard error, Egger's test with p < 0.01 and Begg & Mazumdar test with p < 0.01.

CONCLUSION

The study included the largest number of CP patients with outcome findings of postoperative recurrence with hormonal treatment despite the small number of studies, non-randomised fashion and publication bias. Our findings recommend the use of hormonal manipulation after thoracic surgical intervention for catamenial pneumothorax unless evident contraindications. Younger patients are at a higher risk of recurrence after surgery.

A rare pneumothorax case: catamenial pneumothorax

Endometriosis can be defined as the presence of endometrial glands and stroma outside the uterus. Pulmonary involvement of endometriosis can also be seen, and it is most frequently encountered with catamenial pneumothorax clinic. In our report, a 38-year-old woman operated due to recurrent pneumothorax is presented. In this case undergoing lung resection with Video-Assisted Thoracoscopic Surgery for the purpose of surgical treatment, lesions thought to be related to endometriosis were detected in the diaphragmatic pleura. These lesions, which caused pneumothorax, were treated with videothoracoscopic surgery and no recurrence was detected in the 2-year follow-up of the patient. Catamenial pneumothorax should be kept in mind when pneumothorax develops in patients with endometriosis, and in case of recurrence, it should not be forgotten that success in diagnosis and treatment can be achieved with videothoracoscopic surgery.

Dynamics of thoracic endometriosis in the pleural cavity

Background

Thoracic endometriosis-related pneumothorax is a secondary spontaneous pneumothorax caused by thoracic endometriosis. Diaphragmatic endometriosis is well-studied, but visceral and/or parietal pleural lesions are not. Although surgery is an effective treatment, postoperative recurrence rates are unsatisfactory probably due to inadequate understanding of underlying pathophysiology. We aimed to clarify the clinicopathological features of thoracic endometriosis.

Methods

In total, 160 patients who underwent thoracoscopic surgery from a single institution with histopathologically proven thoracic endometriosis from January 2015 to December 2019 were included. Clinicopathological characteristics and surgical outcomes were assessed retrospectively.

Results

The cohort median age was 41 (range 22–53) years. Pneumothorax was right-sided in 159 (99.4%) and left-sided in only 1 (0.6%) case. Visceral and parietal pleural lesions were diagnosed in 79 (49.4%) and 71 (44.4%) patients, respectively. In total, 104 visceral pleural lesions and 101 parietal pleural lesions were detected. The S⁴ region and the dorsal 6^th intercostal space contained the largest number of visceral pleural (66 lesions) and parietal pleural lesions (25 lesions), respectively. Histopathological evaluation revealed endometriotic tissues, existing in the outer external elastic layer in all lesions, were localized or invaded deeply. The median follow-up period was 370 (range, 6–1824) days. The Kaplan-Meier method revealed that the 1- and 2-year postoperative recurrence rates were 13.8% and 19.3%, respectively.

Conclusions

Visceral pleural endometriotic lesions may be disseminated from the visceral pleural surface and infiltrate into the pleura. Intraoperatively, careful observation of the specific sites, such as the visceral pleura of S⁴ and the parietal pleura of 6^th intercostal space, is important to reduce postoperative recurrence.

Pulmonary cavitations with increased 18F-FDG uptake revealing a thoracic endometriosis: A case report

RATIONALE

Thoracic endometriosis is a rare disorder that can involve airways, pleura and lung parenchyma. It is the most frequent form of extra-abdominopelvic endometriosis. Multiple lung cavitations are a rare feature of thoracic endometriosis.

PATIENT CONCERNS

A 46-year-old woman was referred to our hospital after incidental finding of multiple pulmonary cavitations with surrounding areas of ground glass opacity on a thoraco-abdominal computed tomography-scan performed for abdominal pain. Retrospectively, the patient also reported mild hemoptysis occurring 4 months ago.

DIAGNOSES

Positron emission tomography-computed tomography scan revealed moderate and homogeneous [18F] fluoro-2-deoxy-D-glucose (18F-FDG) uptake in pulmonary cavitations (maximum standardized uptake value 5.7). The diagnosis of thoracic endometriosis was confirmed by histological examination of surgical resection of a left lower lobe cavitation.

INTERVENTIONS AND OUTCOME

Gonadotropin-releasing hormone analogues associated with add-back therapy was started. Four months after initiating pharmacological treatment, the chest computed tomography-scan showed a dramatic decrease in lung cavitations size.

LESSONS

Thoracic endometriosis is a rare disorder requiring a multidisciplinary management including gynaecologist, pulmonologist, radiologist, nuclear physician, pathologist and thoracic surgeon for early diagnosis and treatment. Our case report highlights that an increased 18F-FDG uptake can be found in thoracic endometriosis syndrome presenting as multiple lung cavitations.

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.

Clinical Presentation and Management of Endometriosis-Related Hemorrhagic Ascites: A Case Report and Systematic Review of the Literature

This study aims to analyze the patient profile and presentation of endometriosis-related hemorrhagic ascites and review its management to raise awareness among gynecologists and improve treatment strategies. We present a case report and engage in a systematic review involving human cases of histologically proven endometriosis with hemorrhagic ascites. Keywords were searched in PubMed/MEDLINE, Cochrane Library, EMBASE, and Ovid Discovery databases from inception until December 2018. Studies that did not include a description of ascites or histopathologic results confirming endometriosis or those that involved patients with other conditions that may contribute to ascites were excluded. The review yielded 73 articles describing 84 premenopausal women with histologically proven endometriosis-related hemorrhagic ascites. Of note, 83% (65/78) of the patients were nulliparous and 69.35% (43/62) were of African descent. The most common chief complaint was abdominal enlargement (58.33%, 49/84) but a host of other symptoms were also reported. Pleural effusion was reported in 32.14% (27/84), and elevated CA-125 was seen in 74.42% (32/43). The majority (64.29%, 54/84) of the patients underwent laparotomy, and an increasing trend of minimally invasive surgical approaches (p<0.001) and fertility-sparing techniques (p<0.001) was observed. The mean ascites volume was 4228.27 mL (SD: 2625.66). Moderate to severe endometriosis was seen in 97.44% (76/78) of cases. The majority of the patients who received medical treatment were given gonadotropin-releasing hormone (GnRH) agonists (63.79%, 37/58). The rate of recurrence after termination or suppression of ovarian function was 8.33% (7/84), and there was a mortality rate of 1.19% (1/84). Diagnosis of endometriosis-related hemorrhagic ascites may be challenging because it mimics several disease entities that cause ascites, thereby warranting a heightened clinical suspicion. Minimally invasive techniques are usually employed to establish a histologic diagnosis. The prevention of recurrence involves the recognition of endometriosis-related hemorrhagic ascites as a manifestation of severe endometriosis, which should prompt therapies directed at suppressing ovarian function. Since affected women are of childbearing age, ovary-preserving surgeries are generally preferred. The rate of recurrence is low after appropriate surgical and medical interventions.

Thoracic endometriosis presented as catamental hemoptysis: a case series of a rare disease

OBJECTIVE

Thoracic endometriosis syndrome (TES) is a rare disease in which a functioning endometrial tissue is observed in the pleura, lung, parenchyma, airways, and/or diaphragm. The optimal management of this disease remains a matter of debate. We aimed to report TES cases and their effective hormonal treatment and management.

METHODS

In this retrospective study, women presented as catamenial hemoptysis (CH) diagnosed with thoracic endometriosis were included. The main outcome of measure was cessation or recurrence of the clinical manifestations of thoracic endometriosis.

RESULTS

The mean onset age of the 14 patients was 30.21 ± 5.40 years. CH was characteristic symptom of these patients. All patients underwent chest computed tomography (CT) scan during menstruation and 2 or 3 weeks after menstruation, which showed the obvious shrinking or disappearance of the lesions. All of the patients were given Gonadotropin releasing hormone agonists (GnRHa) for 3 to 6 months, eleven of them were administered with combined oral contraceptives (COC) cyclically after GnRHa. The median follow-up duration was 24 months. Hemoptysis recurrence was observed in one patient.

CONCLUSIONS

CH is a rare clinical entity of thoracic endometriosis, the change of CT images during and after menstruation or the response to GnRHa were helpful for accurate diagnosis. Hormonal treatment with GnRHa followed by COCs cyclically could be employed for efficient management of thoracic endometriosis.

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.

Catamenial hemoptysis: A case report of pulmonary endometriosis

We report a case of a patient diagnosed with pulmonary endometriosis and successfully treated with a GnRH agonist. This 34-year-old mother presented cyclic hemoptysis since 4-month. A non-enhanced computed tomography made at the end of the luteal phase revealed a solitary lung nodule with no other abnormalities. A contrast enhanced computed tomography conducted during menses revealed a ground glass opacity extending from the nodule towards hilum. The diagnosis of pulmonary endometriosis was established taking into account the clinical presentation and the imaging findings. Medical treatment by Triptorelin pamoate (Decapeptyl LP® 3 mg Ipsen Pharma, France), a GnRH agonist, was proposed for a period of 6 months. A CT scan performed 3 months after the end of the treatment shows a complete disappearance of the endometriosis nodular lesion.

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.

Clinical practice guidelines for the treatment of extragenital endometriosis in Japan, 2018

The aim of this publication is to disseminate the clinical practice guidelines for the treatment of intestinal, bladder/ureteral, thoracic and umbilical endometriosis, already published in Japanese, to non-Japanese speakers. For developing the original Japanese guidelines, the clinical practice guideline committee was formed by the research team for extragenital endometriosis, which is part of the research program of intractable disease of the Japanese Ministry of Health, Labor and Welfare. The clinical practice guideline committee formulated eight clinical questions for the treatment of extragenital endometriosis, which were intestinal, bladder/ureteral, thoracic and umbilical endometriosis. The committee performed a systematic review of the literature to provide responses to clinical questions and developed clinical guidelines for extragenital endometriosis, according to the process proposed by the Medical Information Network Distribution Service. The recommendation level was determined using modified Delphi methods. The clinical practice guidelines were officially approved by the Japan Society of Obstetrics and Gynecology and the Japan Society of Endometriosis. This English version was translated from the Japanese version.

The pleura and the endocrine system

The functioning of the pleura and the endocrine system are not entirely independent of each other. Some hormones can reach a greater concentration in the pleural exudate than in the blood. However, the clinical significance of this finding remains unknown. In some circumstances, hormonal changes are responsible for pathological manifestations in the pleura. Hypothyroidism is one of the most common diseases that can cause a pleural effusion, likely resulting from alterations in capillary permeability. The presence of ectopic endometrial tissue within the lung parenchyma, pleura, pericardium or diaphragm is known as thoracic endometriosis and is one of the causes of catamenial pneumothorax and /or catamenial hemothorax, which can affect women of childbearing age and arises within 72 h from the onset of menstruation. Treatment and prevention of recurrent catamenial pneumothorax / hemothorax usually requires an approach that combines surgery and hormone therapy. Malignant pleural effusion from breast cancer may contain estrogen receptor-positive cells. In such a case, endocrine treatment may be effective in reducing the amount of pleural fluid and the associated symptoms. Thyroid cancer and lymphangioleiomyomatosis (LAM) are further hormone-sensitive malignancies in which pleura is frequently involved. The solitary fibrous tumor of pleura (SFPT) is an example of a pleural disease that can cause hormonal balance disorders. It can lead to a rise in the releasing factor for growth hormone (GHRH), human beta chorionic gonadotropin (Beta-hCG), and insulin-like growth factor 2 (IGF2). The consequence of such hormonal imbalance include hypertrophic pulmonary osteoarthropathy, gynecomastia, and refractory hypoglycemia, respectively.

Multimodality Thoracoabdominal Imaging Findings in a Rare Case of Thoracic Endometriosis Syndrome

Thoracic endometriosis syndrome (TES) is an extremely rare disorder, and it is defined as the presence of functional endometrial tissue in pleura, airways, and lung parenchyma. We describe a rare case of a 29-year-old nulliparous female who presented with abdominal pain, dyspareunia, and shortness of breath. She complained of worsening of symptoms around the menstrual cycle. Initial workup showed markedly elevated CA-125 levels. A chest radiograph and CT of the chest, abdomen, and pelvis demonstrated large tension hydrothorax, ascites, and bilateral ovarian cysts. A chest tube was placed to decompress the tension hydrothorax, which drained copious amounts of blood. In view of the unexplained etiology of large hemothorax and elevated CA-125 levels, an MRI of the abdomen and pelvis was performed. This revealed advanced pelvic endometriosis, a right pleural nodule, and ipsilateral hydropneumothorax. Based on these findings, a diagnosis of TES was presumed. The patient was then referred to video-assisted thoracoscopy (VATS) and continuous estrogen suppression for optimal treatment. On early follow-up, she presented with recurrent hydropneumothorax, which was successfully managed with CT-guided chest tube placement and remained stable on further follow-ups. TES diagnosis is often challenging and delayed, demanding a high index of suspicion in patients with risk factors and characteristic clinical presentation. Radiologists should be aware of key imaging findings to help in early diagnosis for timely clinical and surgical management.

Should surgical treatment of catamenial pneumothorax include diaphragmatic repair?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether treatment with hormones or pleural symphysis is better than operative procedures such as diaphragmatic repair with mesh to surgically manage recurrent pneumothoraces in patients with catamenial pneumothorax. Diaphragmatic repair with synthetic meshes, hormonal treatment and pleural symphysis are all accepted interventions for the treatment of recurrent catamenial pneumothoraces; however, there is uncertainty over the best combination of treatment. Altogether, 396 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. However, it should be noted that the studies included were small in terms of sample size, and have demonstrated significant bias and surgical heterogeneity. Our literature review found that the recurrence rates of pneumothorax were greatly reduced in the treatment group where surgery and hormone therapy were combined (pooled average recurrence rate of 0%); however, the recurrence rates were significantly higher when these interventions were used alone: hormone therapy alone (58.5%), diaphragmatic repair alone (33.3%) and surgery alone (63.3%). Our results therefore demonstrate that a multimodality approach is required to reduce pneumothorax recurrence rates in patients with catamenial pneumothorax.

Thoracic endometriosis syndrome: Cutting the gordian knot - A case report and review of the literature

INTRODUCTION

Thoracic Endometriosis Syndrome (TES) is a rare disorder characterized by the presence of functional endometrial tissue in the thoracic cavity, often associated with the visceral or parietal pleura, lung parenchyma or airways. The aim of this case report is to illustrate the classic manner of presentation of TES and the modalities of therapy employed in a low-resource setting in the South-Western region of Nigeria.

CASE PRESENTATION

We report the case of a 37-year old woman who presented with right-sided pleuritic chest pain, cough and dyspnea closely associated with her menstrual cycle. On examination, there were reduced breath sounds and decreased air entry on the right hemithorax as well as dull percussion notes on the right middle and lower lung zones. Chest X-ray revealed signs of right-sided pleural effusion. Working diagnosis of right-sided Catamenial Pneumothorax was made for which she had 3 sessions of chemical pleurodesis which failed to close the air leaks. She eventually has a right-sided posterolateral thoracotomy and was co-managed by the O&G team with monthly Goserelin injections.

CONCLUSION

This case illustrates the difficulties physicians in low-resource settings face in the diagnosis and treatment of TES and the importance of a high index of suspicion as well as a multidisciplinary approach in patient care.

Recurrent hemoptysis in a 26-year-old woman with a ground-glass opacity lesion of the lung

Hemoptysis is a major reason for emergency department (ED) visits. Catamenial hemoptysis (CH), a rare condition of thoracic endometriosis, can cause recurrent hemoptysis but is difficult to diagnose in the ED due to the scarcity of cases and nonspecific clinical findings. We report a case of a 26-year-old woman who presented to the ED with recurrent hemoptysis since 2 years without a definite cause. Her vital signs and blood test findings were unremarkable. Chest computed tomography (CT) did not show any specific lesions other than a non-specific ground-glass opacity pattern in her right lung. She was on day 4 of her menstrual cycle and her hemoptysis frequently occurred during menstruation. Although there was no histological confirmation, based on her history of hemoptysis during menstruation and no other cause of the hemoptysis, the patient was tentatively diagnosed with CH and was administered gonadotropin-releasing hormone. She had no recurrence of hemoptysis for 3 months. While CH is difficult to diagnose in the ED, the patient’s recurrent hemoptysis related to menstruation was a clue to the presence of CH. Therefore, physicians should determine the relationship between hemoptysis and menstruation for women of childbearing age presenting with repeated hemoptysis without a definite cause.

Micrometastasis of endometriosis to distant organs in a murine model

Endometriosis is an inflammatory gynecological disorder among reproductive-aged women caused by the engraftment and proliferation of endometrial cells outside the uterus, most commonly in the pelvis. It is thought that the disease arises primarily from retrograde menstruation where cells from the endometrium travel through the fallopian tubes to the peritoneal cavity. However, migration of endometriosis-derived cells to distant organs outside of the peritoneal cavity have not been explored. In the present study, we developed and validated a mouse model of disseminated endometriosis using syngeneic DsRed endometrial tissue introduced into the peritoneum of immunocompetent mice. Flow cytometry and immunofluorescence analysis, demonstrated the presence of endometriosis-derived cells in multiple organs (including lung, spleen, liver and brain) in the murine endometriosis model. Immunostaining revealed the presence of DsRed+/CD45- cells in brain, liver and lung. Engraftment occurred in all experimental animals examined. Cells from endometriotic lesions are capable of migration to and engraftment of multiple organs outside of the peritoneal cavity. Micrometastasis of endometriosis is a novel and frequent phenomenon. These data suggest that widespread dissemination of endometriosis may be common, clinically unrecognized and contribute to the diffuse clinical manifestations of this disease.

Atypical Sites of Deeply Infiltrative Endometriosis: Clinical Characteristics and Imaging Findings

Endometriosis is defined as the presence of endometrial tissue that is located outside the uterine cavity and associated with fibrosis and inflammatory reaction. It is a polymorphic and multifocal disease with no known cure or preventive mechanisms. Patients may be asymptomatic or may experience chronic pelvic pain, dysmenorrhea, dyspareunia, or infertility. The pelvic cavity is the most common location for endometriotic implants, which usually affect the retrocervical space, ovaries, vagina, rectosigmoid colon, bladder dome, and round ligaments. Atypical endometriosis is rare and difficult to diagnose. The most common atypical locations are the gastrointestinal tract, urinary tract, lung, umbilicus, inguinal area, breast, and pelvic nerves, as well as abdominal surgical scars. Gastrointestinal lesions are the most common extragenital manifestation, and the diaphragm is the most frequent extrapelvic site. The catamenial nature of the symptoms (occurring between 24 hours before and 72 hours after the onset of menstruation) may help suggest the diagnosis, but imaging by specialists is fundamental to evaluation. Depending on the area affected, radiography, ultrasonography, thin-section computed tomography, or magnetic resonance imaging can be used to assess suspected lesions. Because isolated extragenital endometriosis is rare, concomitant evaluation of the pelvic cavity is mandatory. Surgical excision is the only therapeutic option for definitive treatment, and comprehensive disease mapping is necessary to avoid residual disease. The authors review atypical locations for endometriosis and emphasize the most appropriate imaging protocols for investigation of various clinical manifestations. Online supplemental material is available for this article. ^©RSNA, 2018.

Nine cases of catamenial pneumothorax: a report of a single-center experience

Background

Catamenial pneumothorax (CP) is defined as repeated pneumothorax related to menses and thoracic endometriosis. We performed a retrospective analysis of nine patients with CP to determine the clinical features as well as the effects of treatment and recurrence rates.

Methods

A retrospective review was conducted of the clinical and pathologic data in all CP patients undergoing treatment at our institution. Nine patients underwent treatment for CP. Of these, six underwent surgical treatment 8 times.

Results

The median age was 36 years. Six patients had experienced delivery. The laterality of the pneumothorax was right in all patients. Pelvic endometriosis was diagnosed in five patients. Six patients underwent surgical treatment. Partial resection of the lung was performed in four patients and partial resection of the diaphragm in five. Of these, both resections were performed in four patients. A pathological diagnosis of endometriosis was achieved in only three patients. The observation period was 16.7 months. In the six patients with surgical resection, five experienced recurrence at various intervals. Onset of pneumothorax occurred pre- or menstrual period in most cases.

Conclusions

The diagnosis and treatment of CP is not easy. A multidisciplinary approach and skillful management are required. Recurrence of CP is common following a temporary cure of pneumothorax by surgical treatment.

Thoracic endometriosis syndrome at University of Ilorin Teaching Hospital

Background

Endometriosis is defined as the presence of endometrial tissue (stroma and functional glands) outside the uterine cavity in women of reproductive age. Ectopic sites are frequently located in the pelvis; extrapelvic sites have been reported in the gastrointestinal tract and thoracic cavity. Thoracic manifestation of endometriosis constitutes thoracic endometriosis syndrome (TES).

Objectives

To examine the presentation pattern and outcome of in the management of TES.

Methods

This study is a retrospective review of medical records of patients diagnosed with endometriosis at the University of Ilorin Teaching Hospital over a 3.5-year period from January 2014 to June 2017.

Results

A total of 21 patients presented with endometriosis, of whom 8 (38.1%) presented with TES. The most common variety of TES was catamenial pleural effusion (CPE) accounting for 75%, followed by catamenial chest pain (37.5%). Two patients (25%) each presented with catamenial pneumothorax and catamenial haemoptysis, while 1 (12.5%) had catamenial surgical emphysema. Closed thoracostomy tube drainage plus chemical pleurodesis was the most frequent intervention technique, accounting for 62.5%.

Conclusion

TES remains an uncommon entity, despite being the most common extrapelvic manifestation of endometriosis. CPE appeared to be the most common variant of TES in our environment. Currently available treatment options need to be improved, and more use made of video-assisted thoracoscopic surgery.

[Extragenital endometriosis: Parietal, thoracic, diaphragmatic and nervous lesions. CNGOF-HAS Endometriosis Guidelines]

According to some studies, extragenital endometriosis represents 5% of the localisations. Its prevalence seems to be underestimated. The extra pelvic localisation can make the diagnosis more difficult. Nevertheless, the recurrent and catamenial symptomatology can evoke this pathology. Surgery seems to be the unique efficient treatment for parietal lesions. Pain linked to nervous lesions (peripheric and sacral roots) seems to be underestimated and difficult to diagnose because of various localisations. Neurolysis seems to have encouraging results. Diaphragmatic lesions are often discovered either incidentally during laparoscopy, or by pulmonary symptomatology as recurrent catamenial pneumothorax or cyclic thoracic pain. Surgical treatment seems as well to be efficient.

Refractory thoracic endometriosis syndrome with bilateral hemothorax

Thoracic endometriosis syndrome (TES) is a rare disorder presenting with catamenial pneumothorax, hemothorax, hemoptysis or pulmonary nodules. Bilateral involvement is uncommon, and only a very few cases have been reported in the literature. We report a case of bilateral catamenial hemothorax in a patient with recurrent thoracic endometriosis. Despite multiple surgical interventions, the patient continued to develop hemopneumothorax coinciding with menses. Remission was finally achieved with the addition of gonadotropin-releasing hormone agonist, highlighting the effectiveness of postoperative adjuvant hormone therapy and supporting a combined surgical and medical approach in the treatment of TES in patients who desire future fertility.

Catamenial hemoptysis accompanied by subcutaneous endometriosis treated with combination therapy

Extra pelvic endometriosis is considered to be rare. This paper reports a case of catamenial hemoptysis accompanied by subcutaneous endometriosis in 26-year-old woman. A computed tomography scan of the chest revealed a focal ground-glass opacity lesion in the posterior segment of the right upper lobe. Histopathology confirmed the diagnosis of endometriosis of right lung and concurrent subcutaneous endometriosis. She was treated with surgical resection of the endometriosis lesions on two different sites and perioperative gonadotropin-releasing hormone agonist therapy. The 6-month follow-up after combination treatment showed no recurrence. Though long-term follow-up result is needed, aggressive treatment using combination treatment (surgery and perioperative medication) should be considered for symptomatic extra pelvic endometriosis.

A case report of thoracic endometriosis - A rare cause of haemothorax

•

The diagnosis of thoracic endometriosis is complicated, because it has no specific symptoms and signs, and often delayed. TES should be suspected in a reproductive age woman with exacerbating symptoms during the menstruation.

•

TES treatment should be started with medicine. If medical therapy fails, surgical treatment should be performed.

•

Our case report shows that TES may be the cause of dangerous situation when an urgent operation must be performed. It is the first case of TES that has required urgent surgical treatment in our hospital in past fifteen years. Not all clinicians know that TES sometimes might complicate to pneumothorax or massive bleeding, which might cost a patient’s life. We suggest performing VATS as soon as possible for reproductive age woman with unknown aetiology of pneumothorax or haemothorax to find out the lesions in pleural cavity and start appropriate treatment on time.

Introduction

The presence of endometrial tissue in airways, pleura and lung parenchyma is called thoracic endometriosis syndrome (TES). It is a rare pathology, and typically consists of catamenial pneumothorax, haemothorax, haemoptysis, and pulmonary nodules. We report a case of a 36-year-old woman with thoracic endometriosis causing catamenial haemothorax.

Conclusions

The diagnosis of thoracic endometriosis is complicated and often delayed. TES should be suspected in a reproductive age woman with exacerbating symptoms during the menstruation.

Treatment may be medical and surgical.

Pulmonary Endometriosis which Probably Occurred through Hematogenous Metastasis after Artificial Abortion

Pulmonary endometriosis (PEM) is a rare disease characterized by the proliferation of ectopic endometrial tissue in the lungs, which presents as catamenial hemoptysis. A 20-year-old-woman was admitted for repeated hemoptysis. Chest CT revealed a ground-glass opacity that appeared consistently with her menstrual cycle. Our detailed inquiry revealed a history of artificial abortion, which was followed by the use of oral contraceptives and catamenial hemoptysis after the discontinuation of these medications. Surgical removal was performed and histopathological examinations confirmed PEM. This clinical course suggested hematogenous metastasis. An inquiry regarding the patient's history of uterine procedures and use of oral contraceptives was suggestive for the diagnosis of this disease.

The Role of Stem Cells in the Etiology and Pathophysiology of Endometriosis

Human endometrium is a dynamic organ that normally undergoes repetitive cyclic regeneration. To enable this rapid regeneration, it is not surprising that the endometrium contains a reservoir of progenitor stem cells. However, this pool of cells that allows the growth of the endometrium also allows for unrestrained growth that can reach beyond the endometrium. In this review, we will address the role of stem cells in endometriosis. Recent characterization of stem cell populations within human endometrium has opened the possibility of understanding their physiologic as well as their pathologic roles. While stem cells are critical to the cyclic regeneration of a healthy endometrium, we have shown that both endometrium-derived and bone marrow-derived stem cells can migrate to ectopic sites and contribute to the development of endometriosis. Furthermore, endometriosis interferes with the normal stem cell trafficking to the uterus that is necessary for endometrial growth and repair. Altered stem cell mobility and engraftment characterize this disease.

The Role of Stem Cells in the Etiology and Pathophysiology of Endometriosis

Human endometrium is a dynamic organ that normally undergoes repetitive cyclic regeneration. To enable this rapid regeneration, it is not surprising that the endometrium contains a reservoir of progenitor stem cells. However, this pool of cells that allows the growth of the endometrium also allows for unrestrained growth that can reach beyond the endometrium. In this review, we will address the role of stem cells in endometriosis. Recent characterization of stem cell populations within human endometrium has opened the possibility of understanding their physiologic as well as their pathologic roles. While stem cells are critical to the cyclic regeneration of a healthy endometrium, we have shown that both endometrium-derived and bone marrow-derived stem cells can migrate to ectopic sites and contribute to the development of endometriosis. Furthermore, endometriosis interferes with the normal stem cell trafficking to the uterus that is necessary for endometrial growth and repair. Altered stem cell mobility and engraftment characterize this disease.