Clinical and pathological characteristics of spontaneous pneumothorax in women: a 25-year single-institutional experience

Catamenial pneumothorax: A case report

INTRODUCTION

Catamenial pneumothorax (CN) is a rare type of pneumothorax that affects women of childbearing age. Its etiopathogenesis is controversial and several theories have been proposed, although there is a frequent relationship with intrathoracic endometriosis. The diagnosis can be a challenge, so recurrences can appear until it is found and it can be treated correctly. This document describes a case of catamenial pneumothorax and develops a care plan tailored at a patient suffering from this type of pathology.

CASE DESCRIPTION

A 41-year-old woman, with no personal or family history who attended the emergency department reporting pain in the right hemithorax and dyspnea. The chest X-ray revealed a complete pneumothorax that required placement of a chest drain. During the surgical intervention, cicatricial lesions with gray and black diaphragmatic pores are observed, which suggests a pneumothorax of catamenial origin.

ASSESSMENT

The nursing assessment was designed using the conceptual model of Marjory Gordon, where the patterns of activity-exercise, rest, perception and sexuality-related patterns were identified as altered.

DIAGNOSIS

Using the taxonomy created by NANDA, nursing diagnoses related to impaired gas exchange, pain, rest, skin integrity, and problems related to gynecologic-obstetric aspects were established.

PLANNING

The objectives and interventions were established based on the previously marked diagnoses, using the NOC and NIC taxonomy. Those related to gas exchange, skin care at the level of the chest tube area, pain, rest and those with gynaecological links stand out.

DISCUSSION

CN is a rare entity and it is necessary to know its etiopathogenesis for early detection of the problem and apply care aimed at meeting the needs of the patient and avoiding complications derived from it.

Pulmonary Endometriosis: A Systematic Review

Background/Objectives: Endometriosis is characterized by the presence of ectopic endometrial-like glands and stroma outside the endometrial cavity, which mainly occurs in the pelvic cavity. Pulmonary endometriosis, or thoracic endometriosis syndrome (TES), describes the rare presence of endometrial-like cells in the thoracic cavity and includes catamenial pneumothorax, catamenial hemothorax, hemoptysis, and lung nodules. Our aim is to summarize the results of all reported cases of TES. Methods: Extensive research was conducted through MEDLINE/PUBMED using the keywords "thoracic endometriosis", "thoracic endometriosis syndrome", "catamenial pneumothorax", "catamenial hemoptysis", and "TES". Following PRISMA guidelines, all published cases of TES between January 1950 and March 2024 were included. A systematic review of 202 studies in English, including 592 patients, was performed. Results: The median age of women with TES is 33.8 years old. The most common clinical presentation is catamenial pneumothorax (68.4%), while lesions are mainly found in the right lung unilaterally (79.9%). Chest computed tomography (CT) was used alone or after an X-ray to determine the pathological findings. Ground-glass opacity nodules and cystic lesions represent the most common finding in CT, while pneumothorax is the most common finding in X-rays. Video-assisted thoracoscopic surgery (VATS) is the main therapeutic approach, usually in combination with hormonal therapy, including GnRH analogues, progestins, androgens, or combined oral contraceptives. Hormonal therapy was also administered as monotherapy. Symptom recurrence was reported in 10.1% of all cases after the treatment. Conclusions: High clinical awareness and a multidisciplinary approach are necessary for the best clinical outcome for TES patients. More studies are required to extract safer conclusions.

A surgical series on endometriosis-related diaphragmatic hernia

BACKGROUND

Thoracic endometriosis syndrome gives rise to various clinical and radiological manifestations. We reviewed the records of patients operated for intrathoracic migration of abdominal viscera through a diaphragmatic hernia secondary to thoracic endometriosis.

METHODS

We retrospectively reviewed the single-center prospective collected database of all patients operated for thoracic endometriosis during the twenty years. All cases in which an abdominal organ was found to be herniated into the thoracic cavity were retrieved. Clinical and pathological data are presented and analyzed.

RESULTS

Twenty women of median age 36 (range 25-58) years were operated for endometriosis-related diaphragmatic hernia. The hernia was diagnosed concomitantly with endometriosis-related pneumothorax in 13 cases and during the exploration of catamenial thoracic pain in seven cases. There were 18 cases on the right side and two cases on the left side. The median diameter of the hernia was 8 cm (2.5-20 cm). In seventeen cases, the hernia was repaired by direct suture, and in three cases a heterologous prosthesis was positioned. At follow-up, two patients had an episode of recurrent pneumothorax.

CONCLUSIONS

Diaphragmatic hernia should be ruled out in the presence of endometriosis-related pneumothorax or catamenial thoracic pain. Surgery is indicated to make a pathological diagnosis, restore anatomy, and prevent recurrence in patients presenting with pneumothorax.

Thoracic Endometriosis Syndrome (TES) in Martinique, a French West Indies Island

INTRODUCTION

Endometriosis is a female disease that affects 5-10% of women of childbearing age, with predominantly pelvic manifestations. It is currently declared as a public health priority in France. Thoracic endometriosis syndrome (TES) is the most common extra-pelvic manifestation.

OBJECTIVE

The objective of this study was to describe the epidemiological and clinical characteristics, and outcomes of patients with TES in Martinique.

PATIENTS AND METHODS

We performed a descriptive, retrospective study including all patients managed at the University Hospital of Martinique for TES between 1 January 2004 and 31 December 2020.

RESULTS

During the study period, we identified 479 cases of pneumothorax, of which 212 were women (44%). Sixty-three patients (30% of all female pneumothorax) were catamenial pneumothorax (CP) including 49 pneumothoraxes alone (78% of catamenial pneumothorax) and 14 hemopneumothorax (22% of catamenial pneumothorax). There were 71 cases of TES, including 49 pneumothoraxes (69%), 14 hemopneumothoraxes (20%) and 8 hemothorax (11%). The annual incidence of TES was 1.1 cases/100,000 inhabitants. The prevalence of TES was 1.2/1000 women aged from 15 to 45 years and the annual incidence of TES for this group was 6.9/100,000. The annual incidence of CP was 1 case/100,000 inhabitants. The average age at diagnosis was 36 ± 6 years. Eight patients (11%) had no prior diagnosis of pelvic endometriosis (PE). The mean age at pelvic endometriosis diagnosis was 29 ± 6 years. The mean time from symptom onset to diagnosis was 24 ± 50 weeks, and 53 ± 123 days from diagnosis to surgery. Thirty-two patients (47%) had prior abdominopelvic surgery. Seventeen patients (24%) presented other extra-pelvic localizations. When it came to management, 69/71 patients (97%) underwent surgery. Diaphragmatic nodules or perforations were found in 68/69 patients (98.5%). Histological confirmation was obtained in 55/65 patients who underwent resection (84.6%). Forty-four patients (62%) experienced recurrence. The mean time from the initial treatment to recurrence was 20 ± 33 months. The recurrence rate was 16/19 (84.2%) in patients who received medical therapy only, 11/17 (64.7%) in patients treated by surgery alone, and 17/31 (51.8%) in patients treated with surgery and medical therapy (p = 0.03).

CONCLUSIONS

We observed a very high incidence of TES in Martinique. The factors associated with this high incidence in this specific geographical area remain to be elucidated. The frequency of recurrence was lower in patients who received both hormone therapy and surgery.

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 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.

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.

Trans-diaphragmatic Pathologies: Anatomical Background and Spread of Disease on Cross-sectional Imaging

The diaphragm is not only a sheet of muscle separating the abdominal and thoracic cavities: it plays an essential role in ventilation and can act as a gateway for the spread of different disease processes between the abdominal and the thoracic cavity. Careful attention to the appearance of the diaphragm on various imaging modalities is essential to ensure the accurate diagnosis of diaphragmatic disorders, which may be secondary to functional or anatomical derangements.

Pulmonary capillary haemangiomatosis: a distinct entity?

Pulmonary capillary haemangiomatosis (PCH) is a rare and incompletely understood histopathological finding characterised by abnormal capillary proliferation within the alveolar interstitium, which has long been noted to share many overlapping features with pulmonary veno-occlusive disease (PVOD). But are PCH and PVOD distinct entities that occur in isolation, or are they closely intertwined manifestations along a spectrum of the same disease? The classic clinical features of both PCH and PVOD include signs and symptoms related to pulmonary hypertension, hypoxaemia, markedly impaired diffusion capacity of the lung and abnormal chest imaging with ground glass opacities, septal lines and lymphadenopathy. In recent years, increasing evidence suggests that the clinical presentation, histopathological features, genetic substrate and pathobiological mechanisms of PCH and PVOD are overlapping and usually indistinguishable. The discovery of biallelic mutations in the eukaryotic translation initiation factor 2 α kinase 4 (EIF2AK4) gene in heritable PCH and PVOD greatly advanced our understanding of the overlapping nature of these conditions. Furthermore, recognition of PCH and PVOD-like changes in other pulmonary vascular diseases and in conditions that cause chronic pulmonary venous hyper-perfusion or hypertension suggests that PCH/PVOD may develop as a reactive process to various insults or injuries to the pulmonary vasculature, rather than being primary angiogenic disorders.