Hormonal therapy after the operation for catamenial pneumothorax - is it always necessary?

[Catamenial pneumothorax with persistent air leak]

Catamenial pneumothorax is a spontaneous recurrent pneumothorax that occurs in women of reproductive age and in temporal relationship with the menses. It usually occurs within 24 hours before or 72 hours after the start of the menstrual cycle; however, multiple variations have been described in terms of the temporal relationship. To date, it is considered a rare condition; this may be justified by the limited available knowledge on this disease leading to misdiagnosis. Often, making a diagnosis of catamenial pneumothorax is complicated; it mainly depends on the medical history; also, it may be a surgical or histopathological diagnosis. Management strategies for catamenial pneumothorax may include combinations of hormonal therapy, pleurodesis, lung parenchyma resection, and diaphragm resection/repair. The aim of reporting this atypical case of catamenial pneumothorax is to highlight the relevance of having the adequate knowledge on this entity so it does not go unnoticed despite its apparent low incidence.

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

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.

The Importance of Stromal Endometriosis in Thoracic Endometriosis

Thoracic endometriosis (TE) is a rare type of endometriosis, where endometrial tissue is found in or around the lungs and is frequent among extra-pelvic endometriosis patients. Catamenial pneumothorax (CP) is the most common form of TE and is characterized by recurrent lung collapses around menstruation. In addition to histology, immunohistochemical evaluation of endometrial implants is used more frequently. In this review, we compared immunohistochemical (CPE) with histological (CPH) characterizations of TE/CP and reevaluated arguments in favor of the implantation theory of Sampson. A summary since the first immunohistochemical description in 1998 until 2019 is provided. The emphasis was on classification of endometrial implants into glands, stroma, and both together. The most remarkable finding is the very high percentage of stromal endometriosis of 52.7% (CPE) compared to 10.2% (CPH). Chest pain, dyspnea, right-sided preference, and diaphragmatic endometrial implants showed the highest percentages in both groups. No significant association was found between the recurrence rate and the various appearances of endometriosis. Sometimes in CPE (6.8%) and CPH (30.6%) no endometrial implants were identified underlining the importance of sensitive detection of endometriosis during and after surgery. We suggest that immunohistochemical evaluation should become mandatory and will improve diagnosis and classification of the disease.

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

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

Should surgical treatment of catamenial pneumothorax include diaphragmatic repair?

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Thoracic and diaphragmatic endometriosis: Single-institution experience using novel, broadened diagnostic criteria

Objective:

To describe our experience with the multidisciplinary management of both thoracic/diaphragmatic endometriosis (TED), applying a broadened definition of the “Thoracic endometriosis syndrome (TES)” to define cases.

Material and Methods:

We present a retrospective series of consecutive patients affected by pathology-proven TED, treated at our institution, during a period of 7 years.

Results:

Five women were included. Two patients were referred due to catamenial chest/shoulder pain, one due to recurrent catamenial pneumothorax, and one due to new-onset diaphragmatic hernia. One patient had no thoracic symptoms, but diaphragmatic endometriosis was found during gynecologic laparoscopy for pelvic endometriosis. Endometriosis was histologically confirmed in all cases. After follow-up, all patients remain asymptomatic.

Conclusion:

Broadened TES criteria could increase the incidence of TED and determine better knowledge of this condition. Multidisciplinary, minimally invasive surgery is effective and safe, but should be reserved for tertiary referral centers.

[Endometriosis medical treatment: Hormonal treatment for the management of pain and endometriotic lesions recurrence. CNGOF-HAS Endometriosis Guidelines]

The available literature, from 2006 to 2017, on hormonal treatment has been analysed as a contribution to the HAS-CNGOF task force for the treatment of endometriosis. Available data are heterogeneous and the general level of evidence is moderate. Hormonal treatment is usually offered as the primary option to women suffering from endometriosis. It cannot be used in women willing to conceive. In women who have not been operated, the first line of hormonal treatment includes combined oral contraceptives (COC) and the levonorgestrel-releasing intra uterine system (52mg LNG-IUS). As a second line, desogestrel progestin only pills, etonogestrel implants, GnRH analogs (GnRHa) with add back therapy and dienogest can be offered. Add back therapy should include estrogens to prevent bone loss and improve quality of life, it can be introduced before the third month of treatment to prevent side effects. The literature does not support preoperative hormonal treatment for the sole purpose of reducing complications or recurrence, or facilitating surgical procedures. After surgical treatment, hormonal treatment is recommended to prevent pain recurrence and improve quality of life. COCs or LNG IUS are recommended as a first line. To prevent recurrence of endometriomas COC is advised and maintained as long as tolerance is good in the absence of pregnancy plans. In case of dysmenorrhea, postoperative COC should be used in a continuous scheme. GnRHa are not recommended in the sole purpose of reducing endometrioma recurrence risk.

[Medical treatment of endometriosis: Hormonal treatment of pain, impact on evolution and future perspectives]

CONTEXT

Endometriosis is a chronic painful disease, for which hormone therapy is usually offered as a first line option to women not willing to conceive.

OBJECTIVES

To analyse and synthesize the literature, from 2006 onwards, on pain control, and disease evolution in oemn using combined hormonal contraceptives, progestins and GnRH analogs. Data on other current and future treatment perspectives is included as well.

SOURCES

Medline (Pubmed), the Cochrane Library, and endometriosis treatment recommendations published by European Society of Human Reproduction and Embryology (ESHRE), National Institute for health and Care Excellence (NICE), American College of Obstetricians and Gynecologists (ACOG), Royal College of Obstetricians and Gynaecologists (RCOG) and Société des Obstétriciens et Gynécologues du Canada (SOGC).

STUDY SELECTION

Meta-analysis and clinical trials are included.

RESULTS

Study quality is heterogeneous in general. Hormone therapy inconstantly allows pain relief and prevention of endometrioma and rectovaginal wall nodules recurrence. Available molecules and routes of administration as well as risk benefit balance are evaluated. Data on future perspectives are limited to date and do not allow use in routine.

CONCLUSION

Hormonal treatment of endometriosis relies on combined hormonal contraceptives (using different routes of administration), progestins and particularly the levonorgestrel-releasing IUS, and GnRH analogs as a last option, in combination with an add-back therapy. Promising alternatives are currently under preclinical and clinical evaluation.