{"paper_id":"5a4a4ff0-339a-4405-8eb0-6eb3b14cbbe1","body_text":"WOMEN'S HEALTH AND LUNG DISEASE (A KUMAR, SECTION EDITOR)\nThoracic Endometriosis: a Clinical Review and Update of Current\nand Evolving Diagnostic and Therapeutic Techniques\nRavi Kanth Velagapudi1 & John P. Egan III 2\nAccepted: 13 January 2021\n# The Author(s) 2021\nAbstract\nPurpose of Review The goal of this review is to provide a comprehensive understanding of the pathophysiology, clinical\npresentation, diagnostic workup, and clinical management of thoracic endometriosis (TE), as well as highlight our personal\nexperience with TE workup and management.\nRecent Findings TE can present in a wide range of clinical manifestations. Without high clinical suspicion, diagnosis can be\ndelayed. Since no specific laboratory testing is available, diagnosis is often based on careful history taking, imaging, and direct\nvisualization of endometrial lesions through video-assisted thoracoscopic surgery (VATS). Medical thoracoscopy (MT) may also\nbe a useful tool in the diagnostic workup of TE.\nSummary The diagnosis and management of TE require a multidisciplinary approach and a high index of clinical suspicion.\nWhile VATS remains the gold standard for diagnosis, we share our experience using MT to diagnose and manage a case of TE-\nrelated hemothorax.\nKeywords Thoracic endometriosis . Pleural endometriosis . Catamenial pneumothorax . Catamenial hemothorax . Medical\nthoracoscopy . Pleuroscopy . Catamenial hemoptysis\nIntroduction\nEndometriosis is defined as the presence of endometrial-like\ntissue (stroma and glands) outside of the uterine cavity [1, 2].\nIt is estimated that 10% of women of reproductive age have\nendometriosis [1]. The incidence is noted to be as high as 49%\nin women with chronic pelvic pain [ 1]. The thoracic cavity is\nthe most common location for extra abdominopelvic\nendometriosis [3]. The presence of endometrial tissue in the\nthoracic cavity is called thoracic endometriosis (TE).\nCatamenial pneumothorax (CP) is the most common\nmanifestation of TE and accounts for up to one-third of\nspontaneous pneumothorax occurring in women of re-\nproductive age [ 4]. Other less common manifestations\ninclude hemoptysis, hemothorax, catamenial chest pain, and\nlung nodules.\nPathophysiology\nSeveral hypotheses have been proposed for TE. One of the\nearliest and well-accepted theories is retrograde menstruation,\nwhich is defined as the spillage of viable endometrial tissue\nfrom the uterus into the pelvic cavity [ 2]. Anatomical asym-\nmetry in the abdominopelvic cavity and the existence of peri-\ntoneal currents are some of the other likely explanations for\nthe preponderance of right-sided thoracic endometriosis [2, 5].\nLymphovascular spread and transdiaphragmatic spread\nthrough congenital or acquired diaphragmatic defects are\nsome of the other hypothesized mechanisms by which endo-\nmetrial tissue could spread to the thoracic cavity [ 6, 7].\nThis article is part of the Topical Collection onWomen’s Health and Lung\nDisease\n* Ravi Kanth Velagapudi\nravikanth.velagapudi@spectrumhealth.org\nJohn P. Egan, III\njohn.egan@spectrumhealth.org\n1 Pulmonary and Critical Care Fellow, Division of Pulmonary and\nCritical Care Medicine, Spectrum Health/Michigan State University\nCollege of Human Medicine, Grand Rapids, MI, USA\n2 Interventional Pulmonology, Division of Pulmonary and Critical\nCare Medicine, Spectrum Health/Michigan State University College\nof Human Medicine, Grand Rapids, MI, USA\nhttps://doi.org/10.1007/s13665-021-00269-z\n/ Published online: 9 February 2021\nCurrent Pulmonology Reports (2021) 10:22–29\n\nAnother proposed theory is microembolization after trauma or\nuterine procedures [8, 9].\nImplanted endometrium may or may not undergo cyclic\nhormonal changes as does normal endometrial tissue [ 6].\nHowever, as learned from in vitro studies, certain growth fac-\ntors like epidermal growth factor, insulin-like growth factor,\nand macrophage-derived growth factor may be playing a\nrole in the proliferation of ectopic endometrial tissue, in\naddition to estrogen [ 1, 6]. Therefore, the ectopic endo-\nmetrial lesions in the presence of a complex hormonal and\nproinflammatory environment tend to continue proliferation\nand angiogenesis [1].\nClinical Presentation of Thoracic\nEndometriosis\nThe clinical manifestations of TE encompass a wide spectrum\nof disease and patients can present with more than one clinical\nentity. An increasing amount of literature demonstrates non-\npneumothorax-related manifestations of thoracic endometri-\nosis (Table 1). Manifestations of TE may or may not be cata-\nmenial. The term catamenial refers to a clinical manifestation\noccurring around the time of menses, typically 24 h before and\n72 h after the onset of menses [ 10].\nPneumothorax\nPneumothorax is the most common clinical manifestation of\nTE accounting for 70% of cases [13]. Catamenial pneumotho-\nrax (CP) is defined as pneumothorax occurring between 1 day\nprior to the onset of menses and up to 3 days after the onset\n[4]. Less commonly, it can occur in the intermenstrual period\nas well [ 8]. Roussett-Jablosnki et al. studied pneumothorax\nand its temporal relationship with the menstrual cycle and\ndescribed four different categories (Table 2)[ 8].\nSymptoms of patients presenting with spontaneous pneu-\nmothorax include cough, chest pain, and shortness of breath.\nJoseph et al. reported that 97.5% of cases of CP occur on the\nright side [9]. Roussett-Jablosnki et al. reported that up to one\nin every four women who presented with CP reported having\na history of recurrent thoracic or scapular pain during their\nmenstrual periods and about half of the patients reported a\nhistory of having an obstetric or gynecologic procedure [ 8].\nHistory of obstetric or gynecologic procedures could add\nweight to the theory of microembolization leading to the vas-\ncular spread of endometriosis [8]. Ottolina et al. reported that\nCP is associated with pelvic endometriosis but not with infer-\ntility [14].\nCatamenial Hemothorax/Hemorrhagic Pleural\nEffusion\nThough a rare cause of pleural effusion, catamenial hemotho-\nrax composes up to 15% of all thoracic endometriosis syn-\ndromes [9]. Like CP, catamenial hemothorax also predomi-\nnantly involves the right hemithorax in up to 70% of the cases\nwith 20% occurring bilaterally [ 11]. However, a case series\nreported no laterality in catamenial hemothorax [ 15]. The\npleural fluid analysis itself was not sufficient for establishing\nthe diagnosis of TE in patients presenting with hemothorax or\nhemorrhagic effusion [16]. Joseph et al. reported the presence\nof pleural endometriosis and diaphragmatic defects in five out\nof seven patients with catamenial hemothorax who underwent\nVATS [9]. Recurrence rates are lower in catamenial hemotho-\nrax compared to CP [ 15].\nFor recurrent hemothorax or pleural effusion related to TE,\nVATS-guided wedge resection, pleurectomy, and chemical\npleurodesis were reported in the literature [ 16, 17]. Another\nless invasive approach that can be considered is MT followed\nby diagnostic biopsies and indwelling pleural catheter place-\nment or chemical pleurodesis.\nCatamenial Hemoptysis\nCatamenial hemoptysis is described as hemoptysis occurring\nduring the menses resulting from the presence of\nendobronchial or parenchymal endometrial tissue [ 18].\nCatamenial hemoptysis was noted to occur in relatively youn-\nger patients compared to the other clinical manifestations of\nTable 1 Clinical manifestations\nof thoracic endometriosis.\nIncidences of some of the\ncommon clinical manifestations\nare reported in the following\ntable. Incidence of other rare\nclinical manifestations of TE not\navailable (N/A) [11]\nClinical manifestation Percentage of cases contributing to overall TE cases\nPneumothorax 72%\nHemoptysis 14%\nHemothorax/hemorrhagic pleural effusion 12%\nLung nodules/mass 2%\nCatamenial chest pain N/A\nHydropneumothorax N/A\nDiaphragmatic hernia N/A\nPneumopericardium [12]N /A\n23Curr Pulmonol Rep  (2021) 10:22–29\n\nTE [ 18]. Kim et al. reported that 84% of the patients with\ncatamenial hemoptysis underwent a gynecologic procedure\nprior to the onset of symptoms. Imaging showed ground-\nglass opacities predominantly in the lower lobes further\nconfirming the theory of microembolization of endometrial\ntissue [18].\nDiaphragmatic Rupture\nDiaphragmatic rupture can be primarily due to diaphragmatic\nlesions in TE or secondarily as a consequence of diaphragmat-\nic repair for TE [ 10]. Bobbio et al. reported that two-thirds of\nwomen of reproductive age presenting with diaphrag-\nmatic rupture who underwent VATS were found to have\nendometriosis [ 10]. The occurrence of diaphragmatic\nrupture greater than 6 months after undergoing VATS\nfor CP could be attributed to TE rather than a compli-\ncation of surgery [ 19].\nLung Nodules\nLung nodules are not a common presentation of TE [11]. They\ncan be present asymptomatically or identified in patients with\ncatamenial hemoptysis [11, 18]. Lung nodules on chest com-\nputerized tomography (CT) scan can change in size and ap-\npearance depending on the temporal relation with the menstru-\nal cycle [20].\nDiagnosis of Thoracic Endometriosis\nHigh clinical suspicion and isolation of endometrial tissue\nplay a key role in the diagnosis of TE. The choice of clinical\nmodality for diagnosis predominantly depends on the patient’s\nclinical presentation.\nRadiologic Studies\nRadiologic studies help determine the next step in many cases.\nWhile chest X-ray can easily detect pneumothorax and hemo-\nthorax, chest CT can be helpful in further characterizing the\nparenchymal lesions and presence of diaphragmatic implants\nwhich appear as hypo-attenuating areas [ 21 ]. The\nposterosuperior diaphragm is the most common location for\nthe diaphragmatic implants because endometrial cells travel\nthrough the paracolic gutter and implant on the right hemi-\ndiaphragm [21]. In contrast, the presence of phrenocolic and\nfalciform ligaments prevent the endometrial cells from com-\ning into contact with the left hemi-diaphragm [ 22 ].\nParenchymal endometriosis can present as single or multiple\nlung nodules which vary in size and characteristics in tempo-\nral relation with the menstrual cycle [20, 21]. The formation of\nthin-walled cavities and bullae has also been described in the\nliterature [21].\nChest magnetic resonance imaging (MRI) may be a useful\nimaging modality particularly in individuals with isolated cat-\namenial chest pain who are being considered for VATS.\nWhen performed during menses, MRI of the chest can help\nin identifying diaphragmatic and pleural implants when CT\nchest had been nondiagnostic [23, 24].\nLaboratory Testing\nThere is no specific laboratory test to diagnose TE.\nSignificantly higher levels of cancer antigen (CA) 125 were\nfound in females with TE compared to those who are disease\nfree [ 25]. Also, measurement of CA-125 levels can predict\nrecurrence with high specificity and poor sensitivity [ 25]. A\nhigh level of CA-125 in a woman presenting with spontane-\nous pneumothorax could raise the suspicion of TE in the right\nclinical context [25].\nVideo-Assisted Thoracoscopic Surgery\nVATS can serve as both a diagnostic and therapeutic proce-\ndure. Various findings during VATS have been described in\nthe literature including diaphragmatic defects, diaphragmatic\nimplants, visceral and parietal pleural implants, parenchymal\nimplants, blebs, and bullae [11]. Although roughly half of the\npatients with CP who underwent VATS were found to have\ndiaphragmatic defects, no statistical association was found\nbetween the presence of a diaphragmatic defect and the devel-\nopment of CP [ 11]. It was also noted that the odds ratio of\nhaving a hemothorax is five times higher in patients who were\nfound to have visceral and parietal pleural implants during\nVATS [ 11]. In one case series, roughly half of the patients\nwith CP were found to have TE [ 26]. The presence of the\nendometrial implants predominantly in the posterosuperior\ndiaphragm might limit the ability to visualize some TE lesions\nduring VATS [3, 21].\nTable 2 Categories of spontaneous pneumothorax in women of reproductive age\n1. Catamenial and TE-related pneumothorax Pneumothorax occurring in temporal relation with the menses and with evidence of TE\n2. Catamenial but non-TE-related pneumothorax Pneumothorax occurring in temporal relation with the menses but without evidence of TE.\n3. Non-catamenial but TE-related pneumothorax No temporal relation of pneumothorax with menses but with evidence of TE\n4. Idiopathic pneumothorax Predominant group, with neither temporal relation with menses nor evidence of TE\n24 Curr Pulmonol Rep  (2021) 10:22–29\n\nMedical Thoracoscopy\nThe utility of MT for TE is not well described in the literature.\nMedical thoracoscopy, or pleuroscopy, was first performed by\nSwedish internist, Hans-Christian Jacobaeus, over 100 years\nago to help induce pneumothorax as a treatment for tubercu-\nlosis (TB) [27]. The procedure was no longer needed for TB\nafter the advent of effective pharmacologic TB therapies in the\nmid-twentieth century. However, it was still practiced by\npulmonologists to aid in the diagnosis of idiopathic pleural\neffusions [27]. MT is currently undergoing a resurgence as\nthe field of interventional pulmonology continues to grow.\nThe reasons for this include the procedures ’ safety profile,\naccuracy in diagnosing malignant pleural effusions, and\ncost-effectiveness [28, 29]. MT differs from VATS in that it\nis performed by an interventional pulmonologist in a bron-\nchoscopy suite as opposed to requiring a thoracic surgeon in\nthe operating theater. In contrast to VATS, which requires\ngeneral anesthesia with a double-lumen endotracheal tube,\nMT is performed through a single port with conscious seda-\ntion or monitored anesthesia care with the patient spontane-\nously breathing.\nDuring the procedure, a safe location to access the pleural\neffusion is identified by ultrasound. Anesthesia and local an-\nesthetic are given. The pleural space is then accessed by mak-\ning a 1-cm incision followed by blunt dissection. Next, a 7-\nmm trocar and cannula are inserted, and the pleural fluid is\naspirated and sent for analysis. With the effusion evacuated,\nand the patient spontaneously breathing, a pneumothorax de-\nvelops. This occurs by negative pressure ventilation entraining\nair through the cannula into the pleural space. This allows for\nexcellent visualization of the pleural cavity with either a rigid\nor semi-rigid video telescope (Fig. 1). MT allows for inspec-\ntion of the parietal pleura, visceral pleura, and diaphragm. The\nprocedure also allows the interventional pulmonologist to as-\nsess whether the lung can freely expand into the chest space\nversus a trapped lung or pneumothorax ex vacuo. After in-\nspection, a separate telescope with biopsy forceps attached\ncan be used to biopsy the parietal pleura and the diaphragm.\nBiopsy of the visceral pleura is deferred to avoid air leaks.\nFollowing the diagnostic portion of the procedure, a chest tube\nis placed to evacuate the pneumothorax. Patients are generally\nsent home the same day except for those patients who undergo\na simultaneous talc poudrage as they require continuous chest\ntube drainage to achieve pleurodesis. Tunneled pleural cathe-\nters (TPCs) may also be placed during an MT to palliate\nsuspected or known malignant pleural effusions. Overall, the\nMT offers the ability to diagnose, stage, and palliate malignant\npleural effusions in a single outpatient procedure. However,\nthe utility of MT in the diagnosis and treatment of TE is yet to\nbe established.\nFig. 2 Chest CT showing large\nright pleural effusion\nFig. 1 Rigid medical thoracoscopy equipment\n25Curr Pulmonol Rep  (2021) 10:22–29\n\nAt our institution, we performed adiagnostic and therapeutic\nMT on a patient with known abdominopelvic endometriosis and\nrecurrent hemothorax (fig.2) suspected of having pleural endo-\nmetriosis. This was performed as the patient requested a less\ninvasive alternative to VATS. During the MT procedure, multi-\nple pleural adhesions (Fig. 3) were taken down using biopsy\nforceps resulting in a partial decortication (Fig. 4). The dia-\nphragm was inspected and free of any gross defects. The parietal\npleura was biopsied confirming the presence of pleural endome-\ntriosis (Fig.5). During the procedure, the lung was found to be\ntrapped and not fully expanding. Therefore, a tunneled pleural\ncatheter (TPC) was placed for the palliation of symptomatic he-\nmothorax with trapped lung. The TPC was drained at home\nevery other day with excellent control in symptoms.\nSpontaneous pleurodesis was achieved 90 days after the proce-\ndure and initiation of hormonal therapy and the TPC was re-\nmoved (fig.6). While MT with the placement of a TPC in con-\njunct with leuprolide hormonal therapy resulted in a good out-\ncome, the gold standard for diagnosis and management of TE\nremains VATS. However, further studies on the utility of MT in\nthe diagnosis and management of TE are probably warranted.\nBronchoscopy\nThe role of bronchoscopy in TE is limited and specific. In a\ncase of catamenial hemoptysis, bronchoscopy with airway\nexamination can help identify the anatomical region that is\nbleeding which can be followed by VATS wedge resection\nor endobronchial laser ablation [ 30–32]. Performing bron-\nchoscopy during menses increases the likelihood of success-\nfully identifying endobronchial endometrial tissue [33].\nHistopathologic and Immunohistochemical Analysis\nThe tissue samples can be obtained by various methods as\nmentioned above, which includes VATS, endobronchial\nbiopsies with bronchoscopy, and in our case pleural biop-\nsies obtained by MT. Classic histopathologic features in-\ncluding the presence of endometrial glands, stroma, and\nhemosiderin-laden macrophages are not always present in\nTE making the diagnosis challenging [ 34]. The absence of\nthese histopathologic findings does not rule out TE [ 35].\nAn immunohistochemical analys is positive for estrogen\nFig. 4 Inspection of visceral and\nparietal pleura during medical\nthoracoscopy showing trapped\nlung following partial\ndecortication\nFig. 3 Pleural adhesions noted\nduring medical thoracoscopy\nwhich were taken down resulting\nin a partial decortication\n26 Curr Pulmonol Rep  (2021) 10:22–29\n\nand progestin receptors is not always suggestive of TE as\nalmost 60% of men with spontaneous pneumothorax were\nalso found to be estrogen and progestin receptor positive\non resected VATS specimens [ 34]. However, positive es-\ntrogen and progestin receptor in an aggregated pattern\nalong with positive CD-10 could aid in the diagnosis of\nTE and indicate a high risk of recurrence [ 34].\nManagement of Thoracic Endometriosis\nMedical Management\nAnti-gonadotropic agents work by decreasing endogenous es-\ntrogen production and therefore promoting atrophy of\nendometrial tissue [36, 37]. Hormonal therapy alone is asso-\nciated with higher recurrence after discontinuation; therefore,\nanti-gonadotropin agents are frequently prescribed both pre-\nand post-operatively [ 37]. Recommended duration for an\nanti-gonadotropin agent is at least 6 to 12 months with\nmultidisciplinary approach and timely reassessments [ 4].\nSome of the anti-gonadotrophic agents include cyclic or\ncontinuous oral contraceptives, dienogest, danazol, cy-\nproterone acetate, and GnRH agonist like leuprolide\n[15, 38]. While there are no head to head comparison\nstudies, one study showed that cyclic oral contraceptives\nhad higher recurrence rates compared with continuous\noral contraceptives and GnRH agonists [ 15]. Compared\nto surgical pleurodesis, hormonal treatment has higher\nrecurrence [ 9].\nFig. 6 Chest CT a week prior to\nthe removal of the tunneled\npleural catheter showing\nachievement of pleurodesis\nFig. 5 H&E-stained section of a\npleural biopsy with a focus of\nendometrial-type glands and\nstroma, diagnostic of\nendometriosis\n27Curr Pulmonol Rep  (2021) 10:22–29\n\nSurgical Management\nVATS remains the first line of diagnostic and therapeutic pro-\ncedure for TE, especially in CP. VATS allows the surgeon to\ninspect and identify blebs or bullae, air leaks, signs of TE on\nvisceral and parietal pleura, and defects in the diaphragm.\nTherefore, it helps in performing resection of blebs or bullae,\npulmonary wedge resection, pleurectomy for lesions on pari-\netal pleura, and diaphragmatic resection [ 39]. Depending on\nthe size and location of the endometrial infiltrates, a wedge\nresection or segmental versus subsegmental resection or a lo-\nbectomy can be performed [ 40, 41]. High rates of recurrence\n(32% to 55%) were reported in patients with CP related to TE\ndespite undergoing surgery followed by hormonal therapy\n[15, 36]. VATS performed in women with catamenial chest\npain refractory to conservative management showed symp-\ntomatic improvement [10]. Pleurodesis can also be achieved\nby chemical pleurodesis, pleural abrasion, or parietal\npleurectomy. However, patients who underwent talc\npleurodesis had lower rates of recurrence compared to pleural\nabrasion [36].\nNezhat et al. studied four patients who had pelvic pain,\nchest/shoulder pain, CP, catamenial hemothorax, and history\nof endometriosis in varying combinations, and underwent a\ncombination of laparoscopy for treatment of abdominopelvic\nendometriosis and thoracoscopy for treatment of TE [42]. This\napproach could potentially reduce the number of times a pa-\ntient needs to undergo a procedure and provide diagnostic and\ntherapeutic value to both abdominopelvic and thoracic endo-\nmetriosis at once.\nConclusion\nThe clinical presentation of TE is broad and diagnosis\ncan be challenging. High clinical suspicion and thorough\ngynecological history are paramount to establishing a di-\nagnosis. VATS remains the gold standard for diagnosis\nand treatment. Hormonal treatment can be used as an\nadjuvant to surgical treatmen t. However, treating solely\nwith anti-gonadotropic agents has higher likelihood of\nrecurrence. Though not well described in the literature,\nMT could be helpful in diagnosis and management of\nTE-related hemothorax. We describe our experience in\nwhich MT with placement of a TPC followed by\nleuprolide therapy not only helped in diagnosis of TE\nand but also achieved spontaneous pleurodesis therefore\npreventing the recurrence of a hemorrhagic effusion. A\nmultidisciplinary approach involving gynecologist, tho-\nracic surgeon, radiologist, pulmonologist, and interven-\ntional pulmonologist is crucial to properly navigating\nworkup and management of this complex disease\nprocess.\nCompliance with Ethical Standards\nConflict of Interest Ravi Velagapudi declares no conflict of interest.\nJohn Egan reports personal fees from Auris Health, outside the submitted\nwork.\nHuman and Animal Rights and Informed Consent This article does not\ncontain any studies with human or animal subjects performed by any of\nthe authors.\nOpen Access This article is licensed under a Creative Commons\nAttribution 4.0 International License, which permits use, sharing, adap-\ntation, distribution and reproduction in any medium or format, as long as\nyou give appropriate credit to the original author(s) and the source, pro-\nvide a link to the Creative Commons licence, and indicate if changes were\nmade. The images or other third party material in this article are included\nin the article's Creative Commons licence, unless indicated otherwise in a\ncredit line to the material. If material is not included in the article's\nCreative Commons licence and your intended use is not permitted by\nstatutory regulation or exceeds the permitted use, you will need to obtain\npermission directly from the copyright holder. To view a copy of this\nlicence, visit http://creativecommons.org/licenses/by/4.0/.\nReferences\n1. Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J\nMed. 2020;382:1244–56.\n2. Chapron C, Marcellin L, Borghese B, Santulli P. Rethinking mech-\nanisms, diagnosis and management of endometriosis. Nat Rev\nEndocrinol. 2019;15:666–82.\n3. Nezhat C, Lindheim SR, Backhus L, Vu M, Vang N, Nezhat A,\net al. Thoracic endometriosis syndrome: a review of diagnosis and\nmanagement. JSLS J Soc Laparoendosc Surg. 2019;23:\ne2019.00029.\n4. Fournel L, Bobbio A, Robin E, Canny-Hamelin E, Alifano M,\nRegnard J-F. Clinical presentation and treatment of catameinal\npneumothorax and endometriosis-related pneumothorax. Expert\nRev Respir Med. 2018;12:1031–6.\n5. Bricou A, Batt RE, Chapron C. Peritoneal fluid flow influences\nanatomical distribution of endometriotic lesions: why Sampson\nseems to be right. Eur J Obstet Gynecol Reprod Biol. 2008;138:\n127–34.\n6. Olive DL, Schwartz LB. Endometriosis. N Engl J Med. 1993;328:\n1759–69.\n7. Alifano M, Trisolini R, Cancellieri A, Regnard JF. Thoracic endo-\nmetriosis: current knowledge. Ann Thorac Surg. 2006;81:761–9.\n8. Rousset-Jablonski C, Alifano M, Plu-Bureau G, Camilleri-Broet S,\nRousset P, Regnard J-F, et al. Catamenial pneumothorax and\nendometriosis-related pneumothorax: clinical features and risk fac-\ntors. Hum Reprod. 2011;26:2322–9.\n9. Joseph J, Sahn SA. Thoracic endometriosis syndrome: new obser-\nvations from an analysis of 110 cases. Am J Med. 1996;100:164 –\n70.\n10. Bobbio A, Canny E, Mansuet Lupo A, Lococo F, Legras A,\nMagdeleinat P, et al. Thoracic endometriosis syndrome other than\npneumothorax: clinical and pathological findings. Ann Thorac\nSurg. 2017;104:1865–71.\n11. Channabasavaiah AD, Joseph JV. Thoracic endometriosis.\nMedicine (Baltimore). 2010;89:183–8.\n12. Kienlen A, Fernandez C, Henni-Laleg Z, Andre M, Gazaille V,\nCoolen-Allou N. Endométriose thoracique compliquée de\n28 Curr Pulmonol Rep  (2021) 10:22–29\n\npneumopéricarde et pneumothorax itératifs sur dystrophie bulleuse.\nRev Pneumol Clin. 2018;74:104–8.\n13. Andres MP, Arcoverde FVL, Souza CCC, Fernandes LFC, Abrão\nMS, Kho RM. Extrapelvic endometriosis: a systematic review. J\nMinim Invasive Gynecol. 2020;27:373–89.\n14. Ottolina J, De Stefano F, Viganò P, Ciriaco P, Zannini P, Candiani\nM. Thoracic endometriosis syndrome: association with pelvic en-\ndometriosis and fertility statu s. J Minim Invasive Gynecol.\n2017;24:461–5.\n15. Fukuda S, Hirata T, Neriishi K, Nakazawa A, Takamura M, Izumi\nG, et al. Thoracic endometriosis syndrome: comparison between\ncatamenial pneumothorax or endometriosis-related pneumothorax\nand catamenial hemoptysis. Eur J Obstet Gynecol Reprod Biol.\n2018;225:118–23.\n16. Nair SS. Thoracic endometriosis syndrome: a veritable Pandora ’s\nbox. J Clin Diagn Res. 2016. https://doi.org/10.7860/JCDR/2016/\n17668.7700.\n17. Sharma N, Todhe P, Ochieng P, Ramakrishna S. Refractory thorac-\nic endometriosis. BMJ Case Rep. 2020;13:e235965.\n18. Kim C-J, Nam H-S, Lee C-Y, Yum HK, Yang SH, Seo KH, et al.\nCatamenial hemoptysis: a Nationwide analysis in Korea.\nRespiration. 2010;79:296–301.\n19. Larraín D, Suárez F, Braun H, Chapochnick J, Diaz L, Rojas I.\nThoracic and diaphragmatic endometriosis: single-institution expe-\nrience using novel, broadened diagnostic criteria. J Turk Ger\nGynecol Assoc. 2018;19:116–21.\n20. Chung SY, Kim SJ, Kim TH, Ryu WG, Park SJ, Lee DY, et al.\nComputed tomography findings of pathologically confirmed pul-\nmonary parenchymal endometriosis. J Comput Assist Tomogr.\n2005;29:815–8.\n21. Rousset P, Rousset-Jablonski C, Alifano M, Mansuet-Lupo A, Buy\nJ-N, Revel M-P. Thoracic endometriosis syndrome: CT and MRI\nfeatures. Clin Radiol. 2014;69:323–30.\n22. Gui B, Valentini AL, Ninivaggi V, Micco M, Zecchi V, Grimaldi\nPP, et al. Shining light in a dark landscape: MRI evaluation of\nunusual localization of endometriosis. Diagn Interv Radiol.\n2017;23:272–81.\n23. Marchiori E, Hochhegger B, Zanetti G. Thoracic endometriosis: the\nrole of imaging. Arch Bronconeumol (English Ed). 2015;51:202.\n24. Marchiori E, Zanetti G, Rafful PP, Hochhegger B. Pleural endome-\ntriosis and recurrent pneumothorax: the role of magnetic resonance\nimaging. Ann Thorac Surg. 2012;93:696–7.\n25. Bagan P, Berna P, Assouad J, Hupertan V, Le Pimpec BF, Riquet\nM. Value of cancer antigen 125 for diagnosis of pleural endometri-\nosis in females with recurrent pneumothorax. Eur Respir J.\n2008;31:140–2.\n26. Korom S, Canyurt H, Missbach A, Schneiter D, Kurrer MO, Haller\nU, et al. Catamenial pneumothorax revisited: clinical approach and\nsystematic review of the literature. J Thorac Cardiovasc Surg.\n2004;128:502–8.\n27. Loddenkemper R, Mathur PN, Lee P, Noppen M. History and clin-\nical use of thoracoscopy/pleuroscopy in respiratory medicine.\nBreathe. 2011;8:144–55.\n28. Wan Y-Y, Zhai C-C, Lin X-S, Yao Z-H, Liu Q-H, Zhu L, et al.\nSafety and complications of medical thoracoscopy in the manage-\nment of pleural diseases. BMC Pulm Med. 2019;19:125.\n29. McDonald CM, Pierre C, de Perrot M, Darling G, Cypel M, Pierre\nA, et al. Efficacy and cost of awake thoracoscopy and video-\nassisted thoracoscopic surgery in the undiagnosed pleural effusion.\nAnn Thorac Surg. 2018;106:361–7.\n30. Marques VD, de Mattos LA, Pimenta AM, Pelloso SM, Peralta\nBandeira CO, Lemos MM, et al. Resection of pulmonary endome-\ntriosis by VATS using bronchoscopy as a preoperative strategy.\nAnn Thorac Surg. 2020;110:e391 –3. https://doi.org/10.1016/j.\nathoracsur.2020.03.074.\n31. Huang H, Li C, Zarogoulidis P, Darwiche K, Machairiotis N, Yang\nL, et al. Endometriosis of the lung: report of a case and literature\nreview. Eur J Med Res. 2013;18:13.\n32. Gates J, Sharma A, Kumar A. Rare case of thoracic endometriosis\npresenting with lung nodules and pneumothorax. Case Reports\n2018;2018:bcr-2018-224181.\n33. Wang H-C, Kuo P-H, Kuo S-H, Luh K-T. Catamenial hemoptysis\nfrom tracheobronchial endometriosis. Chest. 2000;118:1205–8.\n34. Kawaguchi Y, Hanaoka J, Ohshio Y, Igarashi T, Okamoto K, Kaku\nR, et al. Diagnosis of thoracic endometriosis with immunohisto-\nchemistry. J Thorac Dis. 2018;10:3468–72.\n35. Scarnecchia E, Inzirillo F, Declich P, Della Pona C. Thoracic\nendometriosis-related non-catamenial pneumothorax with peculiar\nhistological findings. Gen Thorac Cardiovasc Surg. 2019;1:3.\n36. Alifano M, Jablonski C, Kadiri H, Falcoz P, Gompel A, Camilleri-\nBroet S, et al. Catamenial and noncatamenial, endometriosis-related\nor nonendometriosis-related pneumothorax referred for surgery.\nAm J Respir Crit Care Med. 2007;176:1048–53.\n37. Azizad-Pinto P, Clarke D. Thoracic endometriosis syndrome: case\nreport and review of the literature. Perm J. 2014 Summer 18(3):61–\n5. https://doi.org/10.7812/TPP/13-154.\n38. Vercellini P, De Giorgi O, Mosconi P, Stellato G, Vicentini S,\nCrosignani PG. Cyproterone acetate versus a continuous\nmonophasic oral contraceptive in the treatment of recurrent pelvic\npain after conservative surgery for symptomatic endometriosis.\nFertil Steril. 2002;77:52–61.\n39. Alifano M, Roth T, Broët SC, Schussler O, Magdeleinat P, Regnard\nJ-F. Catamenial pneumothorax. Chest. 2003;124:1004–8.\n40. Terada Y, Chen F, Shoji T, Itoh H, Wada H, Hitomi S. A case of\nendobronchial endometriosis treated by subsegmentectomy. Chest.\n1999;115:1475–8.\n41. Kristiansen K, Fjeld NB. Pulmonary endometriosis causing\nhaemoptysis: report of a case treated with lobectomy. Scand J\nThorac Cardiovasc Surg. 1993;27:113–5.\n42. Nezhat C, Nicoll LM, Bhagan L, Huang JQ, Bosev D, Hajhosseini\nB, et al. Endometriosis of the diaphragm: four cases treated with a\ncombination of laparoscopy and thoracoscopy. J Minim Invasive\nGynecol. 2009;16:573–80.\nPublisher’sN o t eSpringer Nature remains neutral with regard to jurisdic-\ntional claims in published maps and institutional affiliations.\n29Curr Pulmonol Rep  (2021) 10:22–29","source_license":"CC0","license_restricted":false}