Bronchoscopic and angiographic findings in tracheobronchial endometriosis

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.

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.

Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management

Background:

Endometriosis is characterized by the presence of endometrial-like glands and stroma outside the uterine cavity and is believed to affect 6%–10% of reproductive-age women. Endometriosis within the lung parenchyma or on the diaphragm and pleural surfaces produces a range of clinical and radiological manifestations. This includes catamenial pneumothorax, hemothorax, hemoptysis, and pulmonary nodules, resulting in an entity known as thoracic endometriosis syndrome (TES).

Database:

Computerized searches of MEDLINE and PubMed were conducted using the key words “thoracic endometriosis,” “catamenial pneumothorax,” “catamenial hemothorax,” and “catamenial hemoptysis.” References from identified sources were manually searched to allow for a thorough review.

Conclusion:

TES can produce incapacitating symptoms for some patients. Symptoms of TES are nonspecific, so a high degree of clinical suspicion is warranted. Medical management represents the first-line treatment approach. When this fails or is contraindicated, definitive surgical treatment for cases of suspected TES uses a combined video laparoscopy performed by a gynecologic surgeon and video-assisted thoracoscopic surgery performed by a thoracic surgeon. Postoperative hormonal suppression may further reduce disease recurrence.

Surgical treatment of catamenial pneumothorax: Report of three cases

Catamenial pneumothorax (CP) is a rare entity of spontaneous, recurring pneumothorax in females. Although it has been known to be associated with thoracic endometriosis, varying clinical course and the lack of consistent intraoperative findings have led to conflicting etiological theories. We herein discuss the etiology, clinical course, and surgical treatment of three patients with CP. Three females (aged 40 years, 28 years, and 34 years) had recurrent right-sided spontaneous pneumothoraces that coincided with their menses. They had undergone video-assisted thoracoscopic surgery (VATS) previously. Blueberry spots in the right diaphragm were detected in all three cases. Two patients had recurrence, postoperatively. The other patient, who received luteinizing hormone-releasing hormone analog therapy for an abdominal endometriosis in the perioperative period and postoperative chemical pleurodesis to prevent recurrence, has been free of recurrence for 15 months, postoperatively. However, pelvic endometriosis was detected in this patient only. Therefore, CP should be suspected in ovulating females with spontaneous pneumothorax, even in the absence of any symptoms associated with pelvic endometriosis. In addition, while performing VATS, careful inspection of the diaphragmatic surface is important. In complicated cases, hormonal suppression therapy and chemical pleurodesis might also be helpful adjunct modalities.

Endobronchial endometriosis presenting as central-type lung cancer: a case report

Abstract

A 45-year-old female patient was referred to our hospital for complaining of dyspnea and coughing in the past four months. The computed tomography scanning demonstrated a central lesion in the upper lobe of the left lung close to the hilar, and the subsequent bronchoscopy revealed a polypoid lesion of the distal of the left main bronchus. This patient was diagnosed clinically as “possibly central-type lung cancer”. However, the pathologic result of the surgically excised polypoid lesion was endobronchial endometriosis.

Virtual Slides

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[Thoracic endometriosis: A difficult diagnosis]

Thoracic endometriosis is a rare disease, which presents in women at a mean age of 35 years, later than for pelvic endometriosis. There are no known predisposing factors for the condition and its pathogenesis is not yet clearly established. The symptoms always appear in connection with the periods of the person affected by the condition, occurring within 24-48 h after the start of menstruation. Catamenial pneumothorax is the most common clinical entity. It is associated with pelvic endometriosis in 30-50% of cases. Thoracoscopy, preferably performed during menstruation, allows full inspection of the diaphragm and the pleural cavity for defects in the diaphragm, endometrial nodules and bullae. The level of CA 125 is often elevated but this is not a reliable or specific marker. Medical treatment is aimed at blocking the action of estrogen on the endometrium and ectopic endometrial implants. GnRH analogues or danazol are the preferred treatments. Surgery to repair and strengthen the diaphragm and/or resect nodules or bullae also has a role, supplemented by pleurodesis to prevent further pneumothorax or effusions. The main risk is recurrence, and thus the current usual practice is to combine surgery, immediately followed by hormone therapy focusing on GnRH analogues.

[Pneumothorax in women and thoracic endometriosis]

Thoracic endometriosis has been considered a rare clinical condition but it is probably underestimated in the literature. Various clinical symptoms may occur but the most frequent are catamenial pneumothoraces. Four main clinical conditions may reveal thoracic endometriosis: catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and endometrial nodules in the lung. Catamenial pneumothoraces are the most frequent manifestation, characterized, in the majority of the cases, by right side localization and diaphragmatic abnormalities (perforations and/or nodules). The resection of suspected areas of visceral or parietal pleural endometriosis, as well as partial resection of the diaphragm in the case of nodules and/or perforations, allows the histological diagnosis of endometriosis. Because of the high recurrence rate, treatment of catamenial pneumothoraces should combine surgery and hormonal therapy.

[Catamenial hemoptysis during hormone replacement treatment]

INTRODUCTION

Catamenial haemoptysis is a rare clinical entity resulting from the presence of ectopic intra pulmonary endometrial tissue, either parenchymatous or endobronchial. The main diagnostic criterion is the periodic character of the haemoptysis which is synchronous with menstruation.

CASE REPORT

The authors report a case of catamenial haemoptysis due to endobronchial endometriosis in a 46 year old menopausal woman receiving hormone replacement treatment (HRT). She presented with 3 episodes of haemoptysis synchronous with the first days of her menstrual cycle. A thoracic CT scan showed ground glass lesions with micronodulation. Bronchoscopy showed violacious lesions bleeding on contact. The endobronchial and CT abnormalities had disappeared by day 5. After withdrawal of the HRT the haemoptysis did not recur during a follow-up of 2 years.

CONCLUSION

Endobronchial endometrioisis remains a rare occurrence. This is the first case reported in a menopausal woman with artificial cycles receiving hormone replacement therapy.

Catamenial hemoptysis from endobronchial endometriosis in a child with type 1 von Willebrand disease

Catamenial hemoptysis is a rare condition characterized by cyclic pulmonary hemorrhage, synchronous with menses and associated with the presence of intrapulmonary or endobronchial endometrial tissue. Because of the paucity of cases reported in the literature, information regarding the natural history is limited and also the optimal diagnostic workup and management of these patients are not well defined. In this report, we present a case of endobronchial endometriosis in a 12-year-old female diagnosed by bronchoscopy and immunocytochemical assay, associated with type 1 von Willebrand disease.

Pulmonary endometriosis resected by video-assisted thoracoscopic surgery

Catamenial haemoptysis is a rare condition caused by thoracic endometriosis that presents as tracheobronchial or pulmonary endometriosis. The authors report a 31-year-old woman with a 1-year history of catamenial haemoptysis, which was diagnosed by chest CT scan during menses and treated successfully by means of video-assisted thoracoscopic surgery of the solitary pulmonary lesion. There was no evidence of recurrence 6 months after the operation. The authors suggest that video-assisted thoracoscopic surgery is an effective therapy for catamenial haemoptysis caused by localized peripheral pulmonary endometriosis.

Thoracic Endometriosis: Current Knowledge

Thoracic endometriosis syndrome includes four well-recognized clinical entities, namely catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis and lung nodules, as well as some exceptional presentations. The etiological mechanisms of this syndrome are not well understood, and different theories have been proposed. Controversies exist about optimal management, as experience has been drawn from case reports and small clinical series. Surgery, hormonal treatments and combined approaches have all been proposed, with variable results in terms of short and long term outcome.

Computed tomography findings of pathologically confirmed pulmonary parenchymal endometriosis

OBJECTIVE

To evaluate the usefulness of computed tomography (CT) in the localization of parenchymal pulmonary endometriosis and to correlate the CT findings with fiberoptic bronchoscopic and pathologic findings.

METHODS

A prospective study of 5 patients presenting with catamenial hemoptysis was conducted. The CT scans and fiberoptic bronchoscopy were performed twice during and 2 weeks after menstruation. After the localization of the presumed bleeding focus, surgical resection was performed.

RESULTS

The CT scans obtained during menstruation revealed a well-demarcated area of consolidation (n = 4) and ground-glass opacity (n = 5), whereas CT scans obtained after menstruation demonstrated ground-glass opacity (n = 4) or complete resolution of the previously noted lesion (n = 1). Fiberoptic bronchoscopy exhibited trails of blood clot at the orifice of the involved bronchi unilaterally (n = 4) or a thin bloody secretion in the bronchi bilaterally. Histopathologic examination of the resected specimens showed typical findings of pulmonary endometriosis.

CONCLUSION

Computed tomography scans during and after menstruation were useful for the precise preoperative localization of parenchymal pulmonary endometriosis.

Catamenial pneumothorax and other thoracic manifestations of endometriosis

Thoracic endometriosis syndrome is an uncommon entity with varied clinical manifestations. Its pathogenesis is not understood completely. Recurrent unilateral right-sided pneumothorax that occurs within days of the onset of menstruation is the most common presentation. Clinical suspicion and recognition of the temporal relationship of the patient's symptoms with menses are essential to establish the diagnosis. Radiographic studies, bronchoscopy, and thoracoscopy may support the diagnosis. Pathologic evidence of thoracic endometrial tissue is not present universally. Therapeutic interventions, which include medical and surgical options, must be individualized for each patient.

Video-assisted thoracoscopic surgery for catamenial hemoptysis

Catamenial hemoptysis is a rare condition, and only 36 cases have been reported since the first published case. We describe a woman with catamenial hemoptysis recurring over 8 years. The lesion was diagnosed using chest CT scan during menses and was also visualized clearly via thoracoscopy. The patient was treated successfully with a partial resection of the lung using video-assisted thoracic surgery (VATS) and has been asymptomatic for 14 months since the operation. We suggest that VATS for catamenial hemoptysis is a more effective treatment than medical therapy.

Catamenial hemoptysis from tracheobronchial endometriosis: reappraisal of diagnostic value of bronchoscopy and bronchial brush cytology

OBJECTIVES

To analyze the clinical data of four patients with a diagnosis of tracheobronchial endometriosis, and to reappraise the diagnostic value of bronchoscopy and bronchial brush cytology in these patients.

METHODS

We conducted a retrospective study of four patients with documented tracheobronchial endometriosis treated at National Taiwan University Hospital from 1994 to 1998. The complete histories, diagnostic time interval, results of physical examinations, laboratory data, bronchoscopic findings, cytologic results, chest radiographs, and chest CT of these patients were analyzed.

RESULTS

These patients tend to be younger and nonmultiparous as compared to other patients with thoracic endometriosis. Bronchoscopic examination performed within 1 day or 2 days of menses disclosed multiple purplish-red submucosal patches bilaterally that bled easily when touched. Cytologic evaluation of the brushing specimens demonstrated clusters of small cuboid cells consistent with an endometrial origin. Follow-up bronchoscopic examination in the middle of the menstrual cycle showed disappearance of the previous tracheobronchial lesions. The mean diagnostic interval was 3.25 months. All four patients were successfully treated with danazol therapy.

CONCLUSIONS

Tracheobronchial endometriosis consists of a special subgroup of patients with thoracic endometriosis. Proper timing of bronchoscopic examination plays an important diagnostic role in these patients. Cytologic features as well as cyclic changes in bronchoscopic findings are sufficient to warrant the diagnosis. The results of treatment with danazol in these patients seemed favorable.

A case of endobronchial endometriosis treated by subsegmentectomy

We present a case of endobronchial endometriosis with catamenial hemoptysis. The lesion was diagnosed as endobronchial endometriosis using helical CT, and the patient underwent a subsegmentectomy of the upper part of the lateral basal segment. A histopathologic examination of the resected specimen revealed findings typical of endobronchial endometriosis with intimal hyperplasia within the bronchus. Since the operation, the patient has been asymptomatic for 11 months with no recurrence of hemoptysis.