Thoracic endometriosis syndrome: new observations from an analysis of 110 cases

Endometriosis, a common but enigmatic disease with many faces: current concept of pathophysiology, and diagnostic strategy

Endometriosis is a benign, common, but controversial disease due to its enigmatic etiopathogenesis and biological behavior. Recent studies suggest multiple genetic, and environmental factors may affect its onset and development. Genomic analysis revealed the presence of cancer-associated gene mutations, which may reflect the neoplastic aspect of endometriosis. The management has changed dramatically with the development of fertility-preserving, minimally invasive therapies. Diagnostic strategies based on these recent basic and clinical findings are reviewed. With a focus on the presentation of clinical cases, we discuss the imaging manifestations of endometriomas, deep endometriosis, less common site and rare site endometriosis, various complications, endometriosis-associated tumor-like lesions, and malignant transformation, with pathophysiologic conditions.

Pictorial Review of Pleural Disease: Multimodality Imaging and Differential Diagnosis

The pleura is a thin, smooth, soft-tissue structure that lines the pleural cavity and separates the lungs from the chest wall, consisting of the visceral and parietal pleurae and physiologic pleural fluid. There is a broad spectrum of normal variations and abnormalities in the pleura, including pneumothorax, pleural effusion, and pleural thickening. Pneumothorax is associated with pulmonary diseases and is caused by iatrogenic or traumatic factors. Chest radiography and US help detect pneumothorax with various signs, and CT can also help assess the causes. Pleural effusion occurs in a wide spectrum of diseases, such as heart failure, cirrhosis, asbestos-related diseases, infections, chylothorax, and malignancies. Chest US allows detection of a small pleural effusion and evaluation of echogenicity or septa in pleural effusion. Pleural thickening may manifest as unilateral or bilateral and as focal, multifocal, or diffuse. Various diseases can demonstrate pleural thickening, such as asbestos-related diseases, neoplasms, and systemic diseases. CT, MRI, and fluorodeoxyglucose (FDG) PET/CT can help differentiate between benign and malignant lesions. Knowledge of these features can aid radiologists in suggesting diagnoses and recommending further examinations with other imaging modalities. The authors provide a comprehensive review of the clinical and multimodality imaging findings of pleural diseases and their differential diagnoses. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Endometriosis first presenting in pleural fluid cytology

Most patients with thoracic endometriosis present with catamenial pneumothorax, a rare condition in which recurrent episodes occur within 72 h before or after the start of menstruation. We report a case of thoracic endometriosis presenting with recurrent bloody pleural effusions without pneumothorax diagnosed on pleural fluid cytology. We describe the cytomorphology and immunoprofile of thoracic endometriosis and discuss the differential diagnoses, including neoplastic processes. We also highlight the importance of communication with clinicians for timeliness of diagnosis and treatment, especially when thoracic endometriosis is not suspected.

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.

Diaphragm endometriosis: Random localization or extended form of pelvis endometriosis. A large comparative analysis of 202 cases

OBJECTIVE

The aim of this study was to investigate and present the clinical characteristics of diaphragm endometriosis, to approach the pathogenetic mechanisms, and to answer the question of whether this disease can be considered an extended form of pelvic endometriosis.

STUDY DESIGN

It was a retrospective comparative one-to-one analysis of 202 cases. Two groups of patients were compared: Group 1 patients with diaphragm endometriosis vs Group 2 (control group) with pelvis endometriosis, each with 101 patients.

RESULTS

Patients with diaphragm endometriosis had extreme significantly higher prevalence of severe pelvis endometriosis included deep infiltrated endometriosis and severe adhesions in term of complete Douglas obliteration (p value = 0.0001). There was neither age nor BMI difference in two groups. Besides of cyclic shoulder or upper abdomen pain there was no difference of symptoms.

CONCLUSION

Diaphragm endometriosis is a rare condition with an approximate prevalence of 1.1% of all endometriosis cases. Since the symptoms are very specific and patients do not associate the pain with diaphragmatic endometriosis, the symptoms should be asked about explicitly. If patients with diaphragmatic endometriosis have no symptoms, the lesions do not necessarily need to be removed. The pathogenesis is still unclear. The authors of this study consider this disease to be an extended form of severe pelvic and deep infiltrated endometriosis. However, the right-side dominance still cannot be explained. Further research is needed to fully understand the origin of diaphragmatic endometriosis.

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.

Catamenial haemothorax-A rare cause of pleural effusion

Common causes of haemorrhagic pleural effusions include malignancy (primary or metastatic), tuberculosis, pulmonary embolism, collagen vascular diseases, trauma and iatrogenic causes. Clinical history along with pathologic, microbiologic and biochemical evaluation of pleural fluid confirms the diagnosis in most cases. However, if there is recurrent haemorrhagic effusion without corroborative history or mass lesion in lung, or evidence of microorganisms, then we should think of uncommon causes. Catamenial haemothorax (CHt) is a rare cause of haemorrhagic pleural effusion, which recurs during each menstrual cycle. This is a manifestation of thoracic endometriosis syndrome (TES) caused by ectopic endometrial tissue in the thoracic cavity in women of child-bearing age. This extremely rare condition is difficult to diagnose, unless direct correlation with the menstrual cycle is established. TES consists of pleural forms such as catamenial pneumothorax, non-catamenial endometriosis-related pneumothorax and haemothorax; and parenchymal forms such as catamenial haemoptysis and lung nodules. Here we report a case of CHt in a 43-year-old female whose diagnosis was established by thoracoscopic pleural biopsy.

Postoperative hormonal therapies reduce the recurrence of thoracic endometriosis-related pneumothorax

OBJECTIVES

Thoracic endometriosis-related pneumothorax (TERP) frequently recurs even after surgery. Meanwhile, postoperative hormonal therapies (HTx) are believed to be effective for pelvic endometriosis. Therefore, we evaluated the relationship between postoperative TERP recurrence and postoperative HTx in a retrospective observational study.

METHODS

We retrospectively reviewed the data of patients with TERP who underwent the first video-assisted thoracoscopic surgery between January 2011 and February 2022.

RESULTS

Of the 248 patients eligible for this study, 67 (27.0%) experienced postoperative TERP recurrence. Postoperative HTx were administered to 70 patients (28.2%). Dienogest was the most frequently administered drug, given to 56.7% of patients. Following univariable analysis, postoperative hormonal therapies was closely related to reduce postoperative recurrence (P = 0.003). Likewise, the multivariable analysis revealed postoperative hormonal therapies were significantly associated with the risk reduction of recurrence (hazard ratio 0.28, P < 0.001).

CONCLUSIONS

Postoperative HTx reduced TERP recurrence. We hypothesize that HTx may control residual endometrial tissues to avoid TERP if pleural endometrial tissues are resected as much as possible.

Pleural effusion secondary to endometriosis: A systematic review

BACKGROUND

Endometriosis-associated pleural effusion is a rare occurrence with poorly defined clinical characteristics.

METHODS

A systematic review was performed to examine all articles on endometriosis-associated pleural effusion extracted from 4 databases (PubMed, Embase, Web of Science and Scopus) from inception until November 2022.

RESULTS

A total of 142 articles (isolated cases and small retrospective series) involving 176 patients (median age 33 years) with endometriosis-associated pleural effusion were included. The most frequent symptoms were dyspnea (67%), chest pain (55%) and abdominal pain (40%). Pleural effusion was predominantly unilateral (89%), right-sided (88.5%) and massive (56%). Ascites was evident in 42% of the cases. Pleural fluid had a bloody appearance in 99% of cases and always met the exudate criteria. Pleural fluid cytology identified only 9% of the patients, with pleural biopsy being the most common diagnostic procedure (74%). Most patients were treated with hormones (76%), thoracic surgery (60%) and abdominal surgery (27%). Effusion recurrence was observed in 26% of cases after a median follow-up of 1 year.

CONCLUSIONS

The presence of right-sided hemorrhagic pleural effusion in a young woman warrants an assessment for the possibility of endometriosis. Despite conventional treatment, effusion recurs in approximately a quarter of patients.

Catamenial Pneumothorax: A Rare Diagnosis Among Menstruating Women

Catamenial Pneumothorax is a rare condition often associated with endometriosis in menstruating women. Due to the rarity of this condition, its etiology is not well studied and, thus, effective treatment regimens have not been well established. We present a case of a 21-year-old female with no significant past medical history who developed recurrent episodes of spontaneous pneumothorax, chronologically associated with her menstrual cycle. This pattern is known as the sine qua non criteria and is one of the only established criteria in current literature for diagnosing catamenial pneumothorax. Our aim with this case report is to expand the current collection of published knowledge about this rare condition and to bring awareness so that those affected by catamenial pneumothorax can be diagnosed and treated more efficiently. Additional research on the pathophysiology of this disease needs to be done to aid in the development of effective treatment regimens.

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.

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.

Video‐assisted surgical diagnosis and pleural adhesion management in catamenial pneumothorax: A case and literature review

Catamenial pneumothorax is a rare primary spontaneous pneumothorax associated with the menstrual phase and is the most common manifestation of thoracic endometriosis syndrome. We report a case of a 32‐year‐old woman with a history of endometriosis who presented to the emergency ward with a chief complaint of dyspnea and right‐sided chest pain, and a chest X‐ray showed a right pneumothorax. Initial management was by placing a chest tube to expand the right lung. The patient underwent a video‐assisted thoracoscopy and talc pleurodesis, during which we found multiple perforations in the tendinous part of the diaphragm. A partial resection of the tendinous part of the diaphragm was done. Our review indicated that primary spontaneous pneumothorax in women should be suspected as catamenial pneumothorax due to thoracic endometriosis. The gold standard procedure for diagnosis and treatment is surgery. Hormonal therapy is an effective choice to prevent and reduce post‐operative recurrence.

Pleural Endometriosis: An Atypical Cause of Hemoptysis

Endometriosis is a benign, inflammatory disease characterized by the presence of dysfunctional endometrial tissue outside the uterus. Typically confined to the pelvis, endometriosis is frequently associated with pain, dysmenorrhea, and infertility. Rarely, endometrial tissue has been documented to implant within the lung parenchyma and involve both parietal and visceral pleura of the thorax. Manifestations of thoracic endometriosis include catamenial pneumothorax, hemothorax, and hemoptysis. We present a case of thoracic endometriosis in a 43-year-old female who was found to have a loculated pleural effusion with an associated pleural nodule after gynecologic surgery. The patient underwent thoracotomy, decortication, and nodule excision. Pathology of the pleural nodule showed evidence of endometrial tissue within the parietal pleural. Thoracic endometriosis is a medical problem that is frequently undiagnosed and encountered by the practicing surgeon. Early diagnosis reduces both disease progression and late complications, allowing for early initiation of appropriate medical and surgical therapy.

True Prevalence of Diaphragmatic Endometriosis and Its Association with Severe Endometriosis: A Call for Awareness and Investigation

STUDY OBJECTIVE

To identify characteristics indicating preoperatively the presence of diaphragmatic endometriosis (DE).

DESIGN

Comparison of characteristics of patients with diaphragmatic endometriosis (DE) with characteristics of patients with abdominal endometriosis without diaphragmatic involvement, in a prospective cohort study.

SETTING

Tertiary referral center; endometriosis center.

PATIENTS

A total of 1372 patients with histologically proven endometriosis.

INTERVENTIONS

Surgery performed laparoscopically under general anesthesia. All patients with suspected endometriosis underwent a complete bilateral inspection of the diaphragm.

MEASUREMENTS AND MAIN RESULTS

Demographic and clinical pathologic characteristics were evaluated using basic descriptive statistics (comparison of the groups using the χ2 test and the Mann-Whitney t test). A logistic regression analysis was performed to evaluate the relationship (hazard ratio) between symptoms and the presence of DE. DE was diagnosed in 4.7% of the patients (65 of 1372). There was no significant difference between the 2 groups (patients with abdominal endometriosis with or without DE) with regard to typical endometriosis pain (dysmenorrhea, dyschezia, dysuria, and/or dyspareunia). However, in the DE group, diaphragmatic pain was present significantly more often preoperatively (27.7% vs 1.8%, p <.001). Four DE patients (6.1 %) were asymptomatic (with infertility the indication for surgery). In the DE group, 78.4 % had advanced stages of endometriosis (revised American Fertility Society III° or IV°); the left lower pelvis was affected in more patients (73.8%). In cases of ovarian endometriosis, patients with DE showed a significantly higher prevalence of left ovaries involvement (left 63% vs right 35.7%, p <.001). Patients with DE had a significantly higher rate of infertility (49.2% vs 28.7%, p <.05).

CONCLUSION

Patients with shoulder pain, infertility, and/or endometriosis in the left pelvis have a significant higher risk of DE and therefore need specific preoperative counseling and if indicated surgical treatment.

Catamenial pneumothorax: Not only VATS diagnosis

Background

Catamenial pneumothorax (CP) is a rare type of spontaneous, recurring pneumothorax occurring in women, from the day before menstruation until 72 hours after its beginning. Conservative treatment is generally associated with recurrence of CP. Video-assisted thoracic surgery (VATS) approach allows not only to obtain diagnosis but also to guide definitive treatment of causing lesions, such as ectopic endometrial implants or diaphragmatic defects and fenestrations. We report our experience in VATS management of CP to focus on its role in CP.

Materials and methods

In this retrospective observational study, we collected data from women referred to our center for CP, from January 2019 to April 2022. All patients underwent VATS approach, with muscle-sparing thoracotomy when diaphragmatic fenestrations were detected, to perform selective diaphragmatic plication and/or partial diaphragmatic resection. Results were analyzed in terms of pneumothorax recurrence after surgical treatment. All patients were referred to gynecologists for medical therapy.

Results

Eight women (median age 36 years, range: 21-45), all with right side CP, were included; three already had pelvic endometriosis and two had already undergone lung apicectomy at other institutions. VATS allowed us to detect diaphragmatic fenestrations in seven patients (87.5%) and apical bullae in five (62.5%). Apicectomy was performed in five cases (62.5%), selective diaphragmatic plication in two (25%), and partial diaphragmatic resection in five (62.5%). Chemical pleurodesis with talc was performed in all to minimize the risk of recurrence. Pathological diagnosis of endometriosis on the resected diaphragm was achieved in five patients (62.5%). No recurrence occurred, except for one woman who stopped medical treatment for endometriosis.

Conclusions

In the management of patients with CP, VATS should be recommended not only to obtain an explorative diagnosis of ectopic endometrial implants or diaphragmatic fenestrations but also to allow the most appropriate surgical treatment and obtain pathological specimens for confirmation and definitive diagnosis of thoracic endometriosis. Medical therapy to achieve ovarian rest is mandatory in the postoperative period and should not be discontinued.

Thoracic endometriosis masquerading as Meigs' syndrome in a young woman: A case report and literature review

Thoracic endometriosis is an exceedingly rare condition characterized by the presence of endometriotic deposits on the diaphragm, lungs or pleural space. Patients may present with massive hemothorax, pneumothorax, hemoptysis or pulmonary nodules. It is a complex condition that often proves to be a diagnostic challenge, resulting in under-diagnosis, delays in treatment and significant morbidity in women of reproductive age. We report a case of endometriosis causing massive pleural effusion and ascites, with a left adnexal fibroid mass mimicking Meigs' syndrome in a nulliparous woman in her late 30s. The patient was successfully managed with hormonal therapy following fertility-sparing surgical treatment. This case highlights the diagnostic and therapeutic challenges associated with thoracic endometriosis because of its close resemblance to more sinister gynecological conditions. Hormonal therapy is the long-term treatment of choice in patients with thoracic endometriosis to reduce the risk of symptom recurrence and preserve fertility.

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The most common presentation of thoracic endometriosis is catamenial pneumothorax followed by catamenial hemothorax.

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Thoracic endometriosis should be considered in a woman presenting with a haemothorax and other stigmata of endometriosis

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Although video-assisted thoracoscopy provides a definitive diagnosis, thoracic endometriosis can be diagnosed clinically.

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Hormonal therapy is the mainstay of treatment to control symptoms, reduce recurrence and preserve fertility.

Thoracic endometriosis presenting as hemopneumothorax

Thoracic endometriosis is very rare. Usually, the thorax is the most frequent affected site outside the pelvis. Common symptoms include chest pain, dyspnea, and hemoptysis. Common manifestations include pneumothorax, hemothorax, and pulmonary or pleural nodules. In addition, symptoms and manifestations can be “catamenial” happening a few days after menstruation onset. This disease can be debilitating, causing a significant impact on the quality of life of young women. We present a case of a young female who was referred to our hospital with recurrent right-sided pleural effusions and pneumothoraces. Pleural fluid drainage was consistent with hemothorax. Transvaginal ultrasound showed mild intraperitoneal fluid in the Cul-de-Sac. Due to concerns for thoracic endometriosis, video-assisted thoracoscopic surgery was performed confirming the diagnosis by pathology. Therapeutic pleurectomy with diaphragmatic repair and pleurodesis was performed. The patient was started on medroxyprogesterone acetate injections two weeks after with great clinical response.

Thoracic and diaphragmatic endometriosis: an overview of diagnosis and surgical treatment

PURPOSE OF REVIEW

Thoracic endometriosis is a rare disease that can lead to a variety of clinical manifestations. There are currently no guidelines for optimal diagnosis and management of the disease. The purpose of this review is to provide an overview of the diagnosis and surgical treatment of thoracic endometriosis.

RECENT FINDINGS

Various imaging modalities, including computed tomography (CT), MRI and ultrasound, have been reported in the detection of thoracic endometriosis. MRI is the most sensitive imaging study and may aid in preoperative planning. Histopathology of a biopsied lesion remains the gold standard for diagnosis. Surgical management of thoracic endometriosis may involve laparoscopy and/or thoracoscopy, and surgical planning should include preparation for single ventilation capability. A multidisciplinary approach involving a gynaecologic surgeon and thoracic surgeon may be considered. Repairing diaphragm defects and pleurodesis are shown to decrease recurrent symptoms.

SUMMARY

Although optimal diagnostic testing remains uncertain, a high clinical suspicion for thoracic endometriosis is critical to ensure prompt diagnosis and treatment in order to prevent recurrent symptoms and progression to more serious sequalae. Minimally invasive surgical techniques are becoming increasingly utilized and allow for thorough evaluation and treatment of thoracic endometriosis.

Shortness of breath in a young lady, rare case report of thoracic endometriosis

INTRODUCTION AND IMPORTANCE

Endometrial glandular tissue can implant in the thorax of women suffering from endometriosis. The clinical presentation is depends on site of implantation. Complications include pneumothorax, pneumohemothorax or hemothorax.

CASE PRESENTATION

A 31 year old woman with history of infertility presented with shortness of breath and was found to have a significant right sided pneumohemothorax. Drainage was done followed by chemical pleurodesis using bleomycin with resolution of symptoms on her follow up.

CLINICAL DISCUSSION

Thoracic endometriosis tend to present with chronic or sub-acute symptoms which are non-specific symptoms leading to late diagnosis. Video Assisted Thoracoscopic surgery offer both diagnostic and therapeutic in thoracic endometriosis. However in limited settings chemical pleurodesis can be carried out done to prevent recurrence of shortness of breath due to thoracic endometriosis.

CONCLUSION

Therefore, clinical suspicion of thoracic endometriosis in evaluation of shortness of breath in a young lady with history of infertility or pelvic surgery is indispensable.

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.

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.

Thoracic Endometriosis: A Presentation of an Uncommon Disease in a Black African Woman

Introduction. Endometriosis is defined as a chronic gynecologic disease which is characterized by the presence of endometrial glands and stroma in anatomical sites and organs outside the uterine cavity. The exact prevalence of endometriosis is difficult to determine because many women remain asymptomatic. However, endometriosis affects about 10% to 15% of women. Thoracic endometriosis (TES) is the most common endometriosis outside the abdominopelvic cavity. It refers to endometriosis within the thoracic cavity including the lung parenchyma, diaphragm, and pleural surfaces. It can manifest as catamenial chest pain, pneumothorax, hemoptysis, hemothorax, catamenial haemoptysis, and pulmonary nodules. Case Summary. A 39-years-old married female presented with recurrent right-sided chest pain of 22 years duration, recurrent cough of more than 20 years and progressive breathlessness of a month duration. The chest pain is pleuritic, and it often starts few days to the onset of her menses and lasts throughout menstrual flow only to abate after the stoppage of menstrual bleeding. Cough was unproductive, paroxysmal often worse with worsening chest pain. It disappears after the end of menstrual bleed. Breathlessness was initially on mild to moderate exertion before progressing to occasional breathlessness at rest. No history of orthopnea, paroxysmal nocturnal dyspnea, and pedal swelling was found. Over the years, she had presented to several clinics where she was said to have menstrual pain referred to the chest. Conclusion. Diagnosis of extrapelvic endometriosis can be challenging and delayed because it presents in a myriad of ways and in some cases, it may be difficult to link symptoms and the menstrual cycle.

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.

ESHRE guideline: endometriosis

STUDY QUESTION

How should endometriosis be diagnosed and managed based on the best available evidence from published literature?

SUMMARY ANSWER

The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer.

WHAT IS KNOWN ALREADY

Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility.

STUDY DESIGN SIZE DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review.

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected.

LIMITATIONS REASONS FOR CAUTION

The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).

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.

Inguinal endometriosis with a disappearing mass preoperatively: A case report

Introduction

Endometriosis is a common gynecological disease that affects approximately 10% of reproductive-age women. Inguinal endometriosis is uncommon, affecting only 0.6% of all patients with endometriosis. We present a case of inguinal endometriosis with a disappearing mass preoperatively.

Presentation of case

A 44-year-old woman presented with a palpable mass and pain in her left inguinal region. Computed tomography showed a 20-mm mass near the pubic tubercle. After 2 months of observation, the mass became impalpable and could not be confirmed by computed tomography; however, the inguinal pain did not improve regardless of menstrual cycles. Resection of the inguinal mass and the entire extraperitoneal portion of the uterine round ligament was performed. Histopathological examination revealed endometrial glands and stroma with CD10-positive cells, which confirmed inguinal endometriosis diagnosis. Erythrophagocytic macrophages indicated endometriosis-related hematoma absorption. Her symptoms disappeared after surgery, and no postoperative complications occurred.

Discussion

For treating inguinal endometriosis, the complete removal of the mass and the entire extraperitoneal portion of the round ligament by an anterior approach is necessary to prevent postoperative residual symptoms and recurrence. However, the preoperative diagnosis of inguinal endometriosis remains a challenge and is frequently discovered incidentally by intraoperative findings and pathological examination.

Conclusion

Clinicians should have a high suspicion of inguinal endometriosis and improved diagnostic precision to select the appropriate surgical approach. Regardless of menstrual variability, the feature of a decreased mass size caused by endometriosis-related hematoma absorption can serve as a preoperative diagnostic clue.

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Endometriosis affects approximately 10% of reproductive-age women.

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Inguinal endometriosis is uncommon and difficult to diagnose.

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Surgery is the first choice for symptom relief of inguinal endometriosis.

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Diagnostic precision improvement for inguinal endometriosis before surgery is crucial.

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The feature of decreased mass size can serve as a preoperative diagnostic clue.

MRI in the Diagnosis of Endometriosis and Related Diseases

Endometriosis, a common chronic inflammatory disease in female of reproductive age, is closely related to patient symptoms and fertility. Because of its high contrast resolution and objectivity, MRI can contribute to the early and accurate diagnosis of ovarian endometriotic cysts and deeply infiltrating endometriosis without the need for any invasive procedure or radiation exposure. The ovaries, which are the most frequent site of endometriosis, can be afflicted by multiple related conditions and diseases. For the diagnosis of deeply infiltrating endometriosis and secondary adhesions among pelvic organs, fibrosis around the ectopic endometrial gland is usually found as a T2 hypointense lesion. This review summarizes the MRI findings obtained for ovarian endometriotic cysts and their physiologically and pathologically related conditions. This article also includes the key imaging findings of deeply infiltrating endometriosis.

Pneumothorax: Classification and Etiology

Pneumothorax is a common problem worldwide. Pneumothorax develops secondary to diverse aetiologies; in many cases, there may be no recognizable lung abnormality. The pathogenetic mechanism(s) causing spontaneous pneumothorax may be related to an interplay between lung-related abnormalities and environmental factors such as smoking. Tobacco smoking is a major risk factor for primary spontaneous pneumothorax; chronic obstructive pulmonary disease is most frequently associated with secondary spontaneous pneumothorax. This review article provides an overview of the historical perspective, epidemiology, classification, and aetiology of pneumothorax. It also aims to highlight current knowledge and understanding of underlying risks and pathophysiological mechanisms in pneumothorax development.

Management of Pneumothorax

Pneumothorax is a common medical condition encountered in a wide variety of clinical presentations, ranging from asymptomatic to life threatening. When symptomatic, it is important to remove air from the pleural space and provide re-expansion of the lung. Additionally, patients who experience a spontaneous pneumothorax are at high risk for recurrence, so treatment goals also include recurrence prevention. Several recent studies have evaluated less invasive management strategies for pneumothorax, including conservative or outpatient management. Future studies may help to identify who is greatest at risk for recurrence and direct earlier definitive management strategies, including thoracoscopic surgery, to those patients.

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.

A Thoracic Endometriosis-Related Catamenial Hemopneumothorax in a Woman With Premature Ovarian Failure

Endometriosis is the presence of endometrial glands and stroma outside the uterine cavity. It is usually confined to the pelvis, particularly the ovaries, cul-de-sac, broad ligaments, and uterosacral ligaments, but it can also expand outside the pelvis. The thorax is among the common extrapelvic locations. Thoracic endometriosis syndrome (TES) is a rare disorder characterized by the presence of functioning endometrial tissue in the pleura, lung parenchyma, and airways. This report presents a case of a young female patient with advanced endometriosis and premature ovarian failure who was admitted with dyspnea that turned to be due to a rare endometriosis-related complication.

Pathological diagnosis of thoracic endometriosis

A 26-year-old woman, who underwent abdominal surgery because of pelvic endometriosis, suffered from upper abdominal pain, fever and dyspnoea 2 days postoperatively. Paralytic ileus and right-sided pneumothorax were revealed. Treatment with a chest drain was not successful and, thus, a video-assisted thoracoscopic surgery was performed, revealing endometriosis-like lesions. Basic histopathology did not confirm the visual diagnosis, but additional immunohistochemical staining for oestrogen and progesterone receptors showed positive reaction in epithelial lung cells, thus proved the diagnosis thoracic endometriosis. A resection of the apex of the right upper lobe and pleurodesis by talc poudrage was performed after which a mesh graft was applied on the diaphragm. After 5 years of follow-up, no recurrent pneumothorax occurred.

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.

Thoracic endometriosis syndrome in Nigeria: a single-centre experience

OBJECTIVES

Thoracic endometriosis syndrome (TES) is the presence of functional endometrial tissue in or around the lung. There seem to be differences in the clinical presentation of this condition among Nigerian patients. We aim to study the clinical presentation and management outcome of TES in our centre.

METHODS

This is an analysis of consecutive patients with TES treated over a 5-year period and followed up for 6 months to 5 years. Information collected included the gynaecological history, clinical presentation, causes of misdiagnosis, modalities of treatment and outcome.

RESULTS

Twenty-three patients with TES aged between 24 and 45 years (median 32 years) were treated. Severe dysmenorrhoea was a prominent symptom in 91.3% of cases (median dysmenorrhoea score 8) and was uninfluenced by the marital status (P = 0.522). The patients usually presented with massive or recurrent haemothorax associated with massive ascites [16/23 (69.5%) of cases (P = 0.0006)]. The right side alone was involved in 21 cases and 1 patient had catamenial haemoptysis as a part of her symptoms, even though there was bronchial bleed at bronchoscopy in 6 patients. In 40%, tuberculosis was the misdiagnosis. Diagnosis was established histologically in 18/23 (78.3%) of the cases. Treatment was multimodal and multidisciplinary with notable macroscopic lesions in 77.8% of the patients that had surgery.

CONCLUSIONS

TES is not an uncommon lesion. Presentation with massive haemothorax is usually associated with massive ascites. A large percentage of such have pleural and diaphragmatic lesions that require surgical treatment. The ascites may be refractory to treatment requiring repeated paracentesis.

Thoracic Endometriosis: Still a Diagnostic Dilemma

We report a case of thoracic endometriosis syndrome (TES) presenting with a five-week history of progressive shortness of breath, cough, and wheezing. Investigations revealed a large, right-sided pleural effusion that was bloody on aspiration. A diagnosis of TES was one of the diagnoses entertained and eventually confirmed on finding evidence of pelvic endometriosis on laparotomy. The management of TES should include hormonal therapy, surgical management, or a combination of both.

Improving the diagnostic recognition of thoracic endometriosis: Spotlight on a new histo-morphological indicator

The diagnosis of thoracic endometriosis (TE) is challenging, hence resulting in under-diagnosis as well as long delays before arriving at a correct definitive diagnosis. Our aim is to review the histopathological findings in TE, summarise the diagnostic features, identify any major histo-morphological indicator(s) hitherto unrecognised as such, suggest diagnostic criteria; all with the aim of improving the diagnostic capacity and reducing observer error even where the clinical suspicion is low. A case-control study in which a search in the pathology archives of a referral hospital over a 10-year period was conducted. Twenty-six cases of TE were identified, reviewed, and compared with a control population of 48 cases taken from common benign thoracic diseases. Nine notable histological features were identified in varying permutations in the test group, namely: endometrioid glands, lymphoid clusters, ceroid macrophages, siderophages, cholesterol crystals, capillary congestion, multinucleated giant cells, smooth muscle bundles and fibrosis. The first 6 features were frequent; each being present in over 13 (13/26; 50%) test cases. The first 8 features showed significant association with TE by the Chi-squared test (P<0.05). In this group, the strength of association is high for the first 4 features (Cramér's V≥0.5). The presence of ceroid macrophages is shown to be a novel key feature, previously unrecognised as such, for the identification of TE. The presence of any three of four features including endometrioid glands, lymphoid clusters, ceroid macrophages and siderophages is a suggested criterion for the definitive diagnosis of TE.

Surgical management of diaphragmatic and thoracic endometriosis': A French multicentric descriptive study

INTRODUCTION

Surgical management of Diaphragmatic and thoracic endometriosis (DTE) is still controversial, a thoracic or an abdominal approach can be proposed.

METHODS

We conducted a multicentric retrospective study in 8 thoracic, gynecology or digestive surgery units in 5 French university hospitals. The main objective was to review the current management of DTE.

RESULTS

50 patients operated for DTE from 2010 to 2017 were included: 26 with a thoracic approach and 24 with an abdominal approach. Preoperative pelvic endometriosis (PE) concerned 25 patients. In 38 patients, DTE diagnosis was made on clinical symptoms (pneumothorax (n = 19), chronic or catamenial chest pain (n = 18) or hemopneumothorax (n = 1)). Median time from onset of symptoms to diagnosis was 47 months (0-212). PE surgery concurrently occurred in 22 patients. We report diaphragmatic nodules, pleuropulmonary nodules and diaphragmatic perforations in 42, 5 and 22 women respectively. Lesions were right-sided in 45 patients. Nodules were destructed in 12 cases and resected in 38 cases. When a diaphragmatic reconstruction was needed (n = 31), a simple suture was performed in 26 patients, while 5 patients needed a mesh repair. Pleural symphysis was performed for all patients who received a thoracic approach. DTE resection was considered complete in 46 patients. Three patients had severe 30-days complications of DTE surgery. Median follow-up was 20 months (range 1-69). Recurrence occurred in 10 patients.

CONCLUSION

The results emphasize the importance of systematically looking for chest pain in patients suffering from PE and underline the lack of a standardized procedure and treatment in DTE.

Recurrent pleural effusion secondary to endometriosis: a rare malady

Thoracic endometriosis is a rare entity, wherein thoracic endometrial tissue deposition occurs. Recurrent pleural effusion is one of its manifestations. Diagnosis and treatment are often challenging, owing to the rarity of the condition and recurrences. We present an interesting case of a young woman of childbearing age who presented with recurrent haemorrhagic pleural effusion. She was referred to our centre after her initial video-assisted thoracoscopic biopsy was inconclusive. She was re-evaluated, and video-assisted thoracoscopic biopsy confirmed thoracic endometriosis. She underwent pleurodesis two times and currently on hormonal treatment, maintaining well.

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.

Endometriosis-Related Pleural Effusion: A Case Report and a PRISMA-Compliant Systematic Review

Background: Endometriosis-related pleural effusion (PE) is a relatively rare but treatable cause of bloody PE. The clinical characteristics and outcome of patients with endometriosis-related PE remain unknown.

Objectives: We present a case of endometriosis-related PE diagnosed on pleural fluid cytology. A systematic review of all endometriosis-related PE cases in literature was conducted to elucidate the clinical characteristics, explore the diagnostic yield of pathological examinations, and to summarize the outcomes of therapeutic approaches in this disease.

Methods: A case of endometriosis-related PE diagnosed in study hospital was reported. PubMed, Web of Science, and EMBASE were searched for publications pertaining to cases of endometriosis-related PE using predefined search terms. This case and those identified from PubMed, Web of Science, and EMBASE were analyzed.

Results: A total of 67 patients were included. Catamential symptoms were presented in 30 (44.8%) patients. Dyspnea was presented in 50 patients (74.6%), followed by right chest/shoulder pain in 34 (50.7%) and cough in 18 (26.9%). 82.8% of the patients had concomitant pelvic endometriosis and 76.7% was infertile or nulliparous. The diagnostic yield of pleural fluid cytological examination, percutaneous pleural biopsy, and surgical biopsy was 9.0, 45.5, and 78.7%, respectively. The patients who received surgery-based therapy had a significantly longer time to relapse than those who received progestational agents or GnRH analogs alone (P = 0.025) or hysterectomy and bilateral salpingoophorectomy (HBSO) (P = 0.040).

Conclusions: High clinical awareness of pleural endometriosis is essential in all female with hemorrhagic PE, especially in young females who have infertility and/or pelvic endometriosis. Plerual fluid cytology might be a simple minimally invasive and cost-effective modality in the diagnosis of endometriosis-related PE. Treatment is challenging due to high recurrence and the optimal management of endometriosis-related PE needs further evaluation. The combined approach by surgery and hormonal therapy may achieve the best relapse-free survival.

Incomplete pseudo-Meigs' syndrome caused by endometrial ovarian cyst: A case report

A 63-year-old female was admitted to our hospital with history of persistent dyspnea. Right pleural effusion and ovarian tumor were discovered, but here were no significant findings on thoracoscopy under local anesthesia. The pleural effusion was suspected to be secondary to Meigs' syndrome, and a diagnosis of endometriotic ovarian cyst was made. Since the pleural effusion resolved after surgery, the patient was diagnosed with incomplete pseudo-Meigs' syndrome. We consider this to be a valuable case, as there are no previously reported cases of pseudo-Meigs' syndrome derived from an endometriotic ovarian cyst, to the best of our knowledge.

Diagnosis and treatment of diaphragmatic endometriosis: results of an international patient survey

OBJECTIVES

To quantify the delays associated with the diagnosis and treatment of diaphragmatic endometriosis (DE), and to evaluate patient-reported postoperative outcomes.

STUDY DESIGN

An anonymous survey was designed to collect data regarding demographics, duration and nature of DE symptoms, type of surgery and postoperative outcomes. Members of endometriosis patient associations in 14 countries were invited to complete the survey if they had been diagnosed with DE. Factors associated with postoperative outcomes were analyzed using Mann-Whitney U and Fisher's exact tests.

RESULTS

Data was available from 136 respondents (median age 34 years). 98 % of respondents were from Europe, North America or Oceania. The most frequently reported symptoms of DE were moderate-severe pain in the upper abdomen (68 %), chest (64 %) and shoulder (54 %). Pain was right-sided in 54 %, left-sided in 11 % and bilateral in 35 %. Of 122 respondents who initially consulted a primary care physician, a gynaecology referral occurred after a median of five consultations (range 1-100). The median time between first primary care consultation and diagnosis of DE was two years (range 0-23). 31 % were diagnosed >1 year after their first gynaecology consultation (range 1-13 years), and 30 % required two or more laparoscopies before diagnosis. 116 respondents underwent surgical treatment. Postoperative data was available for 113 respondents, and 65 % reported either a significant improvement or complete resolution of symptoms. There was no significant difference in age (P = 0.19), timing of diagnosis (P = 0.59) or type of procedure (excision or ablation) (P = 0.13) between respondents who did and did not experience symptomatic relief after surgery. 61 % reported long-lasting symptomatic relief after a median of 1 year, whilst 39 % reported ongoing moderate-severe pain or have undergone further surgery for recurrent symptoms.

CONCLUSION

The diagnosis and treatment of diaphragmatic endometriosis is often delayed, due to lack of awareness by patients and healthcare professionals. The diagnosis of DE requires a high index of suspicion and involvement of surgeons trained in laparoscopic liver mobilization. Recurrent symptoms are common following surgical treatment, and international collaborative studies are required to determine the long-term outcomes of this condition.

Endometriotic lung cyst causing catamenial hemoptysis; a case report and review of literature

We report a rare case of an endometriotic lung cyst in a 47-year woman with recurrent catamenial hemoptysis. Chest computed tomography (CT) obtained outside the menstruation in October 2019 revealed a cystic lesion (2.5 cm) located in the right inferior lobe near the distal esophagus and the inferior pulmonary vein. Compared to CT abdomen in May 2019, this lesion had increased with a larger volume and a thicker wall. An endometrial lung cyst was suspected as episodes of hemoptysis no longer occurred after initiating hormonal treatment with nomegestrol acetate. Exploratory video-assisted thoracoscopic surgery with wedge resection of the cyst was performed. Histopathologic examination confirmed the diagnosis of an endometriotic cystic lesion. Postoperative course was uneventful with no further symptoms since then.

Diaphragmatic endometriosis and thoracic endometriosis syndrome: a review on diagnosis and treatment

Endometriosis of the diaphragm has been gaining more attention in the practice of gynecologists and thoracic surgeons in recent years. Understanding related symptoms and developing imaging methods have improved their approach. A review of the literature was performed with the aim to report on incidence, diagnosis, treatment and prognosis of diaphragmatic endometriosis. We also cover the issue of the Thoracic Endometriosis Syndrome (TES). Complaints of cyclic chest pain in patients of childbearing age should have as differential diagnosis the presence of thoracic endometriosis. Catamenial pneumothorax is the main manifestation of diaphragmatic endometriosis and Thoracic Endometriosis Syndrome. Other possible manifestations are hemothorax, pulmonary nodules, and diaphragmatic hernia. Despite the possibility of drug treatment, many patients will be submitted to surgical treatment. The minimally invasive approach should be the one of choice. The robotic pathway allows for an easier approach due to its ability to articulate robotic arms, allowing the treatment of lesions in hard-to-reach locations, such as the posterior part of the diaphragm. Multidisciplinary treatment should be used in most cases, as only abdominal approach is not sufficient for the diagnosis and treatment of lesions in the thoracic cavity. The approach of endometriosis of the diaphragm and Thoracic Endometriosis Syndrome should be multidisciplinary, allowing the improvement of quality of life in most patients.

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.