Review
Thoracic Endometriosis: Current Knowledge

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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.

Section snippets

Material and Methods

Literature searches were carried out using Medline for articles published up to December 2004 containing the associations of words “catamenial pneumothorax,” “catamenial hemothorax,” “catamenial hemoptysis,” “pneumothorax endometriosis,” “hemothorax endometriosis,” “hemoptysis endometriosis,” “lung nodule endometriosis,” “thoracic endometriosis,” “diaphragmatic endometriosis,” “pulmonary endometriosis,” “bronchial endometriosis,” and “pleural endometriosis.” We also reviewed the references from

Epidemiology

Endometriosis is thought to affect 5% to 15% of women in reproductive age [1]. Clinical and radiologic manifestations of thoracic endometriosis are generally thought to be extremely rare, but specific figures are scanty and come almost completely from case reports and small retrospective series. The most consistent, albeit retrospective, series on TES included 110 patients and showed that the mean age at presentation was 35 ± 0.6 years, with a range from 15 to 54 years [5]. Interestingly, the

Etiologic Mechanisms

There is general agreement that thoracic endometriosis is the only cause of CHt [11], CH [12, 13], and of the exceedingly rare endometriotic lung nodules [5]. Catamenial pneumothorax, although very frequently associated with thoracic endometriosis, may also have other etiological mechanisms [5, 8]. The clinical manifestations of CHt, CH, and endometriosis-related pneumothorax imply the presence of intrathoracic endometrial tissue undergoing cyclical changes in response to the physiologic

Pathology

Thoracic endometriosis is represented by the presence of morphologically normal endometrial tissue within the thoracic cavity (Fig 3, Fig 4). Regardless of the site, endometriotic foci consist of both stroma and glands in different proportions, often with ectatic glands, mostly lined by pseudostratified cuboidal to cylindrical epithelium. Flieder and colleagues [35] provided a definite description of nine cases of pleuropulmonary endometriosis. They described the presence of proliferative-type

Clinical Presentations

Catamenial pneumothorax is the most frequent presentation of TES, accounting for approximately 80% of cases [5]. Catamenial pneumothorax is generally defined as a recurrent pneumothorax occurring within 72 hours after the onset of menstruation [8], but somewhat different time frames are possible. There are reports of recurrence in relation to the immediate premenstrual period [24, 38] and the ovulatory phase [39]. Furthermore, recurrent endometriosis-related pneumothorax may also be observed in

Diagnosis

In accordance with the preferential peripheral location of endometrial tissue in the lung of patients with CH, bronchoscopy does not show visible lesions in most cases [12, 18, 19, 46, 47], although it frequently allows localization of the bleeding lobe or segment [12, 46, 47]. Descriptions of bronchoscopic findings are, therefore, extremely rare with fewer than 10 cases having been reported [48, 51, 52, 53, 55, 56]. Multiple, bilateral purplish-red submucosal lesions, which ooze easily if

Treatment

In the era of video-assisted surgery, treatment of TES is best achieved by video-assisted thoracoscopy. Once the pathogenic mechanism has been identified by exploration, targeted treatment may be carried out in most instances [8]. Diaphragmatic involvement by either endometrial tissue or perforations is probably best managed by diaphragmatic resection [8]. Simple suturing of the holes has been reported to be followed by recurrence [64], and it does not provide tissue for diagnosis. What is

Outcome

Information about the outcome of manifestations of thoracic endometriosis are scanty and have significant limitations because they are derived from case reports or small series, and refer to short-term follow-up periods. That is especially true for CH and CHt, whereas the outcome of CP is better known. Bagan and colleagues [24] reported the outcome of a retrospective series of 10 patients who were followed up for a mean period of 55.7 months: the recurrence rate among patients treated by simple

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