Thoracic Endometriosis

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Thoracic Endometriosis, Endometriosis of the lung 

While endometriosis of the thoracic area is rare, it can occur. Several case reports and studies that are cited below, report symptoms of coughing up blood (hemoptysis), isolated chest pain, and/or shortness of breath with menstrual cycles. At times, a collapsed lung (pneumothorax) has been reported (symptoms such as shortness of breath, chest pain, fast or shallow breathing). One study demonstrates that thoracic endometriosis has been reported since earlier than 1968! There are also links for further information as well as to a facebook group for extra pelvic endometriosis.

Studies:

 “Conclusion: The diagnosis and management of thoracic endometriosis requires a multidisciplinary approach, based upon skillful differential diagnosis, and involving careful gynecologic evaluation and assessment of the cyclicity of pulmonary symptoms. Imaging findings are non-specific, though there may be laterality towards the right lung. Since symptom recurrence is more common in those with presenting with pneumothorax, post-operative adjuvant medical therapy is recommended.

“…Thoracic endometriosis is defined as the presence of ectopic endometrial tissue inside the thoracic cavity [8]. It usually presents with pneumothorax, hemothorax, hemoptysis, lung nodules, isolated chest pain or pneumomediastinum; symptoms are synchronized with the menstrual cycle [5]. A pneumothorax occurring between 24 hours before and 72 hours after the onset of menstruation is described as “catamenial.” Although this may include primary spontaneous pneumothorax, occurring coincidently during the perimenstrual period, the majority of recurrent episodes of catamenial pneumothorax are caused by thoracic endometriosis. It is encountered in 20% to 30% of women with spontaneous pneumothorax [9].”

“Catamenial pneumothorax (CP) is generally caused by intraperitoneal air leaking from the uterus into the thoracic cavity via a defect in the endometrial tissue of the diaphragm and is usually detected in the right thorax. We report a case of left-sided CP caused by endometriosis in the visceral pleura and with no abnormal findings in the diaphragm. A 33-year-old female patient presented at the end of a course of low-dose contraceptive pills for pelvic endometriosis, with spontaneous pneumothorax in the left chest. Chest CT revealed a bulla in the left upper lung lobe.”

“Thoracic endometriosis syndrome is a rare disorder characterised by the presence of functioning endometrial tissue in pleura, lung parenchyma, airways, and/or encompasses mainly four clinical entities–catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and lung nodules. The cases were studied retrospectively by reviewing the records at Amrita Institute of Medical Sciences, for duration of five years i.e., form March 2010-2014 and analysed for the clinical presentation and management of thoracic endometriosis syndrome. Catamenial breathlessness was the main symptom. Pneumothorax and pleural effusion were the findings on investigations. Histopathology report of endometriosis was present in three cases (50%). Conditions with excess oestrogen like endometriosis, fibroid, adenomyosis were diagnosed in these patients by pelvic scan. After the initial supportive treatment with hormones, pleurodesis, hysterectomy and lung decortication were the treatment modalities. Two cases that had multiple recurrences were diagnosed as disseminated TES. They underwent combined treatment of surgery and hormones.”

“A total of 21 patients were retrieved, 15 of which were eligible for inclusion. Of these 15, 8 patients were diagnosed with thoracic endometriosis with hemoptysis as their chief complaint, and 7 patients presented with pneumothorax. The median age was 35 years (range, 23–48 years). All patients displayed some degree of catamenial symptoms, although patterns differed; some patients reported symptoms with every cycle of menstrual bleeding (n=7), whereas others showed only occasional episodes during menstruation (n=8). Patients had experienced between 1 and 7 catamenial episodes before presenting for medical advice. None of the 15 patients were smokers; 1 patient had a history of asthma, and 2 patients presenting with catamenial hemoptysis had histories of empirical tuberculosis medication-use prior to being diagnosed with thoracic endometriosis. Three patients had previously undergone video-assisted thoracoscopic surgery (VATS), undertaken at other centers, following which they had not been diagnosed with thoracic endometriosis. In 1 patient with a history of pneumothorax (P12), the episode occurred on the contralateral side to the presence of endometriotic lesions and the underlying etiology was considered equivocal.”

“A 25-yr-old Caucasian woman was referred by her GP with a 3 yr history of right shoulder pain. The shoulder pain frequently occurred at the start of menses and was responsive to ibuprofen. Clinical examination, shoulder radiographs and blood tests (CRP, rheumatoid factor) were all normal. The MRI of the shoulder and right hemi-diaphragm showed small areas of high signal on T1, T2 and STIR sequences at the lateral right hemi-diaphragm, consistent with areas of recent haemorrhage, suggestive of ectopic endometrial tissue ( Fig. 1 ). Positive identification and ablation of the endometrial tissue by laparoscopy was thought to be a low-yield procedure so the patient commenced the continuous progestogen—only pill which caused amenorrhoea and resolution of her symptoms.”

“A 54-year-old woman, born in Hungary but living in Australia during the past eight years, was found on mass miniature radiography to have a shadow in the right lung and was referred for further investigation. She gave a history of exertional dyspnoea for the past few years, during which she had gained weight….There was no history of cough, haemoptysis, or chest pain. She had had two uncomplicated pregnancies, 35 and 14 years previously, and her menopause had occurred in 1964 with no subsequent bleeding. She gave no history of any operation or serious illness. INVESTIGATION A radiograph of the chest (Fig. I) showed a thin-walled cystic lesion in the right midzone with a little irregularity of the lower wall of the cyst.”

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