Article

Catamenial Pneumothorax: A Heterogeneous Syndrome

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  • Hospitales Angeles. Minimal Invasive Thoracic Surgery Institute.
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Article
Background: Catamenial pneumothorax is an uncommon form of spontaneous pneumothorax in women. The exact epidemiology and pathogenesis remain elusive. Video-assisted thoracoscopic surgery is used for diagnostic and therapeutic purposes. Objective: The aim of this review was to analyze the demographic features, intraoperative findings, treatment methods and outcome in catamenial pneumothorax patients. In addition, we assessed the relationship between catamenial pneumothorax and pelvic endometriosis. Search strategy: A PubMed search of medical literature, published from January 1993 (video-assisted thoracoscopic surgery first described in literature) to January 2015, using the keywords "catamenial pneumothorax" was performed. Our study complied with the preferred reporting of items for systematic reviews and meta-analysis principles. A total of 182 patients were included in the analysis, including 4 patients treated at our institution. Selection criteria: The inclusion criteria of were recurrent (at least two) episodes of spontaneous pneumothorax in relation to onset of menses. Data selection and analysis: Age at time of diagnosis, side affected, diagnosis of pulmonary endometriosis, intraoperative findings, histological confirmation of thoracic endometriosis, methods of treatment and outcome were recorded. Main results: In 2.9% of the patients no pathological lesions were found; however, 59.3% had endometrial implants and 57.0% diaphragmatic perforations. Pelvic endometriosis was reported in 39.5% patients. Patients with diagnosed pelvic endometriosis showed a significantly higher rate of endometrial implants and histologically confirmed endometriosis lesions than patients without pelvic endometriosis. In 26.9% of patients, recurrence was observed after treatment. Conclusion: Video-assisted thoracoscopic surgery provides good diagnostic and therapeutic results; however, 25% of patients experienced recurrence despite adequate treatment. A strong association exists between thoracic and pelvic endometriosis in catamenial pneumothorax patients.
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Article
We report the case of a 25-year-old woman with recurrent right-sided catamenial pneumothorax. At thoracoscopy, the diaphragm presented several violet implants with holes. The presence of diaphragmatic endometrial implants was confirmed at pathologic examination. Re-review of the preoperative chest x-ray film showed 8 x 5 and 1 x 1 mm bubbles at the level of the right diaphragm associated with the homolateral pneumothorax, thus suggesting that passage of air from the genital tract through the diaphragm was responsible for the pneumothorax. This may further clarify the pathogenesis of catamenial pneumothorax which remains controversial in the literature.
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Article
Menstruation-related spontaneous pneumothorax (MSP), also termed catamenial pneumothorax, is a syndrome of spontaneous pneumothorax during menstruation due to endometriotic lesions in the diaphragm and thoracic cavity. Previously MSP was considered rare, and to cause only 3-6% of all spontaneous pneumothoraces in otherwise healthy women. Current data suggest that the incidence is substantially higher and MSP might be the reason for spontaneous pneumothoraces in up to 25-33% of all cases in women of reproductive age. The typical characteristics are a high recurrence rate and diaphragmatic spread of endometriotic lesions. We report six patients who had been diagnosed to have diaphragmatic endometriosis and four of them had developed MSP. Optimal management requires flexible collaboration between thoracic surgeons and gynecologists. Although treatment is primarily surgical, long-lasting and successful management requires that amenorrhea is induced with hormonal therapy, either by continuous contraceptives, progestins, the levonorgestrel-releasing intrauterine device or GnRH-agonists.
Article
Although known for several decades, catamenial pneumothorax has been considered until recently as an extremely rare entity. The condition is now more easily recognized and several studies have been published, with somewhat relevant discrepancies with respect to etiologic, epidemiologic, and management features. In the present review, I will provide a synthesis of available knowledge on the subject. Catamenial pneumothorax accounts for approximately one third of cases of spontaneous pneumothoraces in women referred for surgery. At video-assisted thoracic surgery, diaphragmatic defects and nodules are the most frequent findings. Pathology shows endometriosis in most instances. Endometrial implants in visceral pleura are also found, although less frequently. Findings of surgical explorations support the theory of transabdominal-transdiaphragmatic passage of air to explain the pathogenesis of catamenial pneumothorax. Management of patients with catamenial pneumothorax implies surgery, if possible by video-assisted technology, to obtain samples for pathologic confirmation of endometriosis and to treat the main pathogenic mechanisms of pneumothorax. Partial diaphragmatic resection and/or exeresis of visceral pleural implants, as well as talc pleurodesis, are nowadays frequently carried out. Medical therapy to achieve ovarian rest is mandatory in the postoperative period, the multimodality management being the key to treatment success in this condition.
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Catamenial pneumothorax (CPT) is a rare complication of systemic endometriosis, as shown by this classic case. A nonsteroidal antiinflammatory prostaglandin synthetase inhibitor was used to treat the patient.
Article
An epidemiologic study was done on spontaneous pneumothorax in women. Six hundred sixty-four patients with spontaneous pneumothorax comprising 409 with idiopathic pneumothorax (61.6 percent), and 255 with secondary pneumothorax (38.4 percent) were studied. By age, idiopathic pneumothorax had its peak incidence in the 20s and secondary pneumothorax the 30s. Secondary pneumothorax included iatrogenic pneumothorax resulting from acupuncture treatment. The female patients were not so thin and tall as the male patients. The percentage of positive family history among the female patients was 4.42 percent in the idiopathic type and 0.45 percent in the secondary type. The percentage in the male idiopathic type of pneumothorax was 2.29 percent. Catamenial pneumothorax and pneumothorax with pulmonary hamartoangiomyomatosis are well known as specific in female subjects, but the cases are rare. Nonetheless, attention should be paid to female-specific rare types, for the etiology of idiopathic pneumothorax.
Article
Two new cases of catamenial pneumothorax are described and the clinical features of 20 previously reported cases reviewed. In 1 patient catamenial pneumothorax involved the left hemithorax. This is the only left-sided involvement in the 22 known cases. The pathogenesis and treatment are discussed in relation to thoracic endometriosis. © 1974 The American College of Obstetricians and Gynecologists.
Article
In 1958, Maurer described the syndrome of recurring catamenial pneumothorax associated with pelvic and diaphragmatic endometriosis. Since then, similar cases have been reported, indicating that pelvic endometriosis and pleural or diaphragmatic endometrial implants may be present. On the basis of experience with six patients of our own, and in a review of the literature, we find no support for the explanations so far proposed, eg, that the uterine cavity is the source of air that passes through congenital diaphragmatic defects. Our experience confirms that the syndrome occurs in ovulating women and that symptoms are relieved by hormonal suppression of ovulation; that endometriosis may not be present; and that usually no specific pulmonary process is found. Awareness of this entity will lead to more frequent case findings, thus permitting the determination of its true incidence and the testing of current theories.
Article
To determine the demographics, clinical presentations, pathological findings, and the effectiveness of treatment in 110 patients with thoracic endometriosis syndrome (TES). Retrospective analysis based on data published in the English medical literature. The mean age at presentation of TES was 35 +/- 0.6 years (+/- standard error of the mean) with a range from 15 to 54. The trends of age-specific incidence for pelvic endometriosis and TES were similar. The peak incidence for pelvic endometriosis occurred between 24 and 29 years, whereas the peak incidence for TES was between 30 and 34 years. Pneumothorax was the most common presentation, occurring in 80 of 110 (73%), followed by hemothorax in 15 (14%), hemoptysis in 8 (7%), and lung nodules in 7 (6%). The right hemithorax was involved in more than 90% of all manifestations except for nodules. Hemothorax was more often associated with presence of pleural and pelvic endometriosis compared with other manifestations (P < 0.003, P < 0.02). Compared with hormonal treatment, surgical pleurodesis resulted in low recurrence rate for pneumothorax or hemothorax among patients treated with danazol or oral contraceptives. There is a significant association between the presence of pelvic endometriosis and TES, with the latter occurring approximately 5 years later. Pneumothorax is the most common manifestation. The most plausible explanation for pathogenesis involves peritoneal-pleural movement of endometrial tissue through diaphragmatic defects and microembolization through pelvic veins. Diagnosis is established on clinical grounds in most cases. Surgical pleural abrasion is superior to hormonal treatment in the long-term management of pneumothorax. Earlier diagnosis and effective therapy of TES can decrease the morbidity of this disease in women during their reproductive period.
Article
Chronic recurring spontaneous pneumothorax is a relatively common disorder which usually results from rupture of subpleural blebs. Endometriosis of the diaphragm, on the other hand, is an exceedingly rare lesion and, as nearly as can be determined, has never been reported in association with, or as a cause of, unilateral recurring pneumothorax. The following case report is presented because of the extreme rarity of the lesion involved and the unusual association of pneumothorax with the menstrual cycle. It is the first recorded instance of successful surgical treatment of chronic recurring pneumothorax by excision of a defect in the diaphragm that has resulted from endometriosis. Report of a Case A 35-year-old woman was first seen in consultation on March 13, 1953, because of pain and dyspnea resulting from a spontaneous pneumothorax on the right side. The patient had had two previous spontaneous pneumothoraces on the right, the first having occurred on
Article
Catamenial pneumothorax is a rare entity of spontaneous, recurring pneumothorax in women. It has been associated with thoracic endometriosis, yet varying clinical courses and the lack of consistent intraoperative findings have led to conflicting etiologic theories. We discuss etiology, clinical course, and surgical treatment of 3 women with catamenial pneumothorax. In addition, the world literature since the first description is reviewed. Three women (31, 32, and 39 years old) had recurrent, menses-associated, right-sided spontaneous pneumothoraces. They had undergone video-assisted thoracoscopic surgery previously, with various unsuccessful procedures. Finally, with video-assisted thoracoscopic surgery multiple small perforations in the tendinous part of the right diaphragm with adjacent endometrial implants were detected. After plication of the involved area, 2 patients have been free of recurrence for 22 and 13 months, respectively. Laparoscopic evaluation in 1 woman with a further recurrence revealed asymptomatic pelvic endometriosis. This patient has been free of recurrence since initiation of luteinizing hormone-releasing hormone analog therapy for 17 months. In a review of 229 cases of catamenial pneumothorax in the literature, adequate information was given for 195 patients (85.2%). One hundred fifty-four (79%) were treated surgically, with detailed findings reported for 140 (91%). Thoracic endometriosis was diagnosed in 73 patients (52.1%), and 54 (38.8%) showed diaphragmatic lesions. Pleurodesis, with or without diaphragmatic repair or wedge resection, was performed in 81.7% of the cases. Catamenial pneumothorax may be suspected in ovulating women with spontaneous pneumothorax, even in the absence of symptoms associated with pelvic endometriosis. During video-assisted thoracoscopic surgery, inspection of the diaphragmatic surface is paramount. Plication of the involved area alone can be successful. In complicated cases, hormonal suppression therapy is a helpful adjunct.
Article
Catamenial pneumothorax is defined as spontaneous pneumothorax occurring within 72 hours before or after onset of menstruation. Although catamenial pneumothorax is the most common clinical manifestation of intrathoracic endometriosis, this latter condition is not universally identified in women with catamenial pneumothorax and cannot fully explain the recurrent and cyclical episodes of pneumothorax. Therefore, the etiology of this syndrome is unknown, although many theories have been proposed to explain it. We describe a 37-year-old woman with recurrent episodes of spontaneous right-sided pneumothorax and chest pain that occurred close to her menstrual periods. The patient's condition did not abate after initial surgical exploration with abrasive mechanical pleurodesis or after hormonal suppressive therapy at an institution elsewhere. The patient was referred to our institution for further evaluation. A second surgical inspection of the pleural cavity and diaphragm disclosed the presence of multiple diaphragmatic fenestrations that were closed surgically at that time. Postoperatively, the patient discontinued hormonal suppressive therapy, and menstrual cycles became regular. Six months after surgery, the patient remains asymptomatic with no evidence of recurrence of pneumothorax. This case supports recent reports that diaphragmatic defects are often present in patients with catamenial pneumothorax. Surgical exploration to inspect the diaphragm and to close all Identified defects should be performed in patients who continue to experience pneumothorax despite effective hormonal suppression.