{"paper_id":"1c3bfde7-38f1-416d-8271-2b9960c4cb5b","body_text":"Copyright@ Atsushi  Imai | Biomed J Sci & Tech Res | BJSTR. MS.ID.006467.\n32365\nMini Review\nISSN: 2574 -1241       DOI: 10.26717/BJSTR.2021.40.006467\nPneumothorax Associated with Thoracic \nEndometriosis: Current Knowledge\nShiomi Usida1, Satoshi Ichigo 1, Hiroshi Takagi1, Kazutoshi Matsunami1, Toshio Kasugai2 and \nAtsushi  Imai1*\n1Department of Obstetrics and Gynecology, Matsunami General Hospital, Japan\n2Department of Thoracic Surgery, Matsunami General Hospital, Japan\n*Corresponding author:  Atsushi Imai, Department of Obstetrics and Gynecology, Matsunami General Hospital, 185-1 Dendai, \nKasamatsu, Gifu 501-6062, Japan\nIntroduction \nEndometriosis is a condition in which endometrial-like glands \nand stroma are located outside of the uterine cavity. The ectopic \nendometrium is encountered most commonly pelvic structures \nsuch as ovary, uterine ligaments, pelvic peritoneum, and genital \nstructures [1-4]. The usual site of endometriosis outside of the \nabdominopelvic cavity is in or around the lung (intrathoracic cavity) \n(Figure 1). Although endometriosis in general can affect up to 15% \nof women of reproductive age, thoracic endometriosis remains \na very rare condition [5-9]. Thoracic endometriosis produces a \nbroad range of clinical and radiological manifestations, including \ncatamenial pneumothorax (80%), catamenial hemothorax (15%), \nhemoptysis (5%), and rarely pulmonary nodules [5-9]. The age \nof onset in patients with thoracic endometriosis (a mean of 35 \nyears) is higher compared to a mean age at presentation of 25 to \n30 years in patients with only pelvic endometriosis [5-9]. The exact  \nmechanism of catamenial pneumothorax associated with thoracic  \n \nendometriosis remains unclear, but several hypotheses have \ndeveloped to explain this condition.\nFigure 1: Endometriosis involving the pleural surface of \ndiaphragm (arrows). The clinical and laboratory findings \nhave been reported previously [32].\nARTICLE INFO ABSTRACT\nReceived: \n  November 30, 2021\nPublished: \n  December 14, 2021\nCitation: Shiomi Usida, Satoshi Ichigo, Hi-\nroshi Takagi, Kazutoshi Matsunami, Tosh-\nio Kasugai, Atsushi  Imai. Pneumothorax \nAssociated with Thoracic Endometriosis: \nCurrent Knowledge. Biomed J Sci & Tech \nRes 40(3)-2021. BJSTR. MS.ID.006467.\nThoracic endometriosis is characterized by the presence of endometrial-like \nglands and stroma within the lung parenchyma or on the diaphragm and pleural \nsurfaces. It remains unclear how endometrial tissue migrates into the thoracic \ncavity and produces pneumothorax. Currently proposed hypotheses include \nretrograde menstruation through diaphragmatic fenestrations, coelomic metaplasia, \nprostaglandin, hematogenous or lymphatic metastases. None of the theories proposed \nalone can elucidate all clinical manifestations of this condition, so the etiology of \nthe development of thoracic endometriosis is likely to be multifactorial and closely \nintertwined with each other hypothesis.\n\nCopyright@ Atsushi  Imai | Biomed J Sci & Tech Res | BJSTR. MS.ID.006467.\nVolume 40- Issue 3\nDOI: 10.26717/BJSTR.2021.40.006467\n32366\nRetrograde Menstruation through Diaphragmatic \nFenestrations\nThe endometrial tissue is thought to move through the fallopian \ntubes to the peritoneal cavity by retrograde menstruation backflow \n[4]. The endometrial cells in peritoneal fluid may follow clockwise \nperitoneal circulation and pass through the right paracolic gutter \ntowards the right sub-diaphragmatic region. The phrenicocolic \nligament on the left side and falciform ligament form barriers that \nprevent cells and fluids from reaching the left sub-diaphragmatic \narea [10,11]. Implantation of endometrial cell leads to the formation \nof endometriotic nodules on the ventral side of the diaphragm [10]. \nThe nodules cause cyclical necrosis and induce diaphragmatic \nfragility, leading to the formation of the usual diaphragmatic \nfenestrations. After endometrial tissue enters the pleural space, it \nmay form colonies in other part of the diaphragm or in the pleural \nspace. Air leaks from vagina may occur during the menstrual cycle \nwhen the cervical mucus plug is deleted [10-14]. This hypothesis \nmay be in good agreement with the observation that endometriosis \noccurs nine times frequently on the right hemidiaphragm than on \nthe left [4,6,14,15].\nCoelomic Metaplasia\nThe second proposes the coelomic metaplasia mechanism that \ncauses endometriosis by metaplasia of mesothelial cells lining \nthe pleura and peritoneal surfaces into endometrial stroma and \ngland [9,16,17]. Transformation of these cells may be affected \nby physiological stimuli such as estrogen [18]. Support for this \nhypothesis is observed in endometriosis patients with Mayer-\nRokitansky-Küster-Hauser syndrome who lack a functional \nendometrium [19,20]. Rare cases of endometriosis can also occur \nin men receiving high-dose estrogen. The coelomic metaplasia \nhypothesis provides an explanation for pleural cases of thoracic \nendometriosis. However, this fails to explain the right-sided \npredominance seen in patients with thoracic endometriosis.\nProstaglandin\nThe third is a bioactive substance-mediated mechanism in \nwhich high levels of prostaglandins, in particular prostaglandin \nF2α. Prostaglandins are detectable in the plasma of women \nduring menstruation. Circulating prostaglandins increase with \nmenstruation [21,22-25] and causes vascular and bronchiolar \nvasoconstriction, leading to the vasospasm and associated ischemia \nwithin the lung [23,25,26]. This may result in alveolar rupture of \npreviously formed subpleural blebs and bullae, and subsequent air \nleaks [23,25-27]. \nHematogenous or Lymphatic Metastasis\nAn interesting hypothesis of metastasis suggests that \nendometrial transplantation occurs through lymphatic or \nhematogenous dissemination of endometrial cells, explaining \nboth the thoracic and other sites of implantation, in an analogous \nmanner to cancer metastasis [7,28,29]. Review of autopsy data \nof humans with thoracic endometriosis shows that patients with \nbronchopulmonary endometriosis usually have bilateral lesions, \nwhereas diaphragmatic and pleural diseases are predominantly \nright sides [17]. Perhaps the most compelling evidence for the \nbenign metastasis hypothesis is derived from the investigations of \nectopic endometriosis lesions occurring in remote parts of the body \nincluding the bone or brain [8,21,30-32].\nComment\nThoracic endometriosis is characterized by the presence of \nendometrial-like glands and stroma within the lung parenchyma \nor on the diaphragm and pleural surfaces. It remains unclear how \nendometrial tissue migrates to the thoracic cavity, but it is often \nassociated with abdominal endometriosis. As none of the theories \nproposed alone can account for all clinical manifestations of this \ncondition, so the etiology of thoracic endometriosis development \nis likely multifactorial and closely intertwined with each other \nhypothesis.\nDisclosure Statement\nThe authors declare no conflict of interests regarding the \npublication of this report.\nReferences\n1. 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Biomed J Sci Tech Res.\nSubmission Link: https://biomedres.us/submit-manuscript.php\nAssets of Publishing with us\n• Global archiving of articles\n• Immediate, unrestricted online access\n• Rigorous Peer Review Process\n• Authors Retain Copyrights\n• Unique DOI for all articles\nhttps://biomedres.us/\nThis work is licensed under Creative\nCommons Attribution 4.0 License\nISSN: 2574-1241\nDOI: 10.26717/BJSTR.2021.40.006467\nAtsushi  Imai. Biomed J Sci & Tech Res","source_license":"CC0","license_restricted":false}