Catamenial hemothorax in a patient with multiple sclerosis

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.

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.

Thoracic Endometriosis Syndrome Other Than Pneumothorax: Clinical and Pathological Findings

BACKGROUND

Thoracic endometriosis syndrome refers to a broad spectrum of clinical manifestations related to the presence of ectopic intrathoracic endometrial tissue. Few studies have reported on manifestations other than pneumothorax.

METHODS

Clinical, surgical, and pathology records of all consecutive women of reproductive age referred to our institution from September 2001 to August 2016 for clinically suspected thoracic endometriosis syndrome were retrospectively reviewed. After excluding women with pneumothorax, we enrolled 31 patients, divided into three subgroups: catamenial chest pain (n = 20), endometriosis-related diaphragmatic hernia (n = 6), and endometriosis-related pleural effusion (n = 5).

RESULTS

Surgery was performed in 11 patients with catamenial thoracic pain (median age, 30 years; range, 23 to 42). Median pain intensity assessed on the 0 to 10 Visual Analogue Scale was 8 (range, 8 to 9) before surgery. At surgery, 8 patients had diaphragmatic endometriosis implants, which were resected with direct suture of diaphragm. At follow-up, median pain score was 3 (range, 0 to 8). In the group presenting with diaphragmatic hernia (median age, 36 years; range, 29 to 50), diaphragm was repaired by direct suture or placement of prosthesis in 4 and 2 cases, respectively. At follow-up, no sign of recurrent hernia was observed. Finally, among women with endometriosis-related pleural effusion (median age, 30 years; range, 25 to 42), surgical treatment was represented by evacuation of the pleural effusion and biopsy (n = 4) or removal (n = 1) of visible endometrial foci.

CONCLUSIONS

Thoracic endometriosis syndrome is a poorly recognized entity responsible for various manifestations other than pneumothorax. In case of catamenial thoracic pain, diaphragmatic hernia and catamenial pleural effusion surgery should be advised in a multidisciplinary setting.