A RARE CASE OF THORACIC DIAPHRAGMATIC ENDOMETRIOSIS INVADING THE LIVER AND LOWER LOBE OF LUNGS

Introduction:Thoracic endometriosis is a rare manifestation of extra genital endometriosis with important clinical ramifications. Despite growing awareness of thoracic endometriosis, it remains an enigmatic condition with various theories proposed to explain its pathogenesis.Case history:A 47 year old presented to the Fast Track chest clinic with a cough of 10 months duration. She also reported having had right upper quadrant pain and ipsilateral shoulder and arm pain for approximately 15 years. All of the above coincided with her menstruation.She was found to have a 6.5 cm ill-defined lobulated mass invading the right hemi diaphragm, lower lobe of lung and protruding into the right lobe of the liver based on an MRI scan. The differential diagnosis was that of endometriosis or a primary pleural malignancy.A liver biopsy was taken which confirmed hepatic endometriosis. Given the benign nature of the disease, a multidisciplenary team review suggested that a medical therapy approach with GNRH (Gonadotropin- releasing hormone) analogues rather than resectional surgery would be more appropriate in view of her perimenopausal status. Being fully compliant with her medical therapy, there was a complete resolution of symptoms with confirmatory changes on a CT scan.Discussion:Thoracic endometriosis often presents as a delayed diagnosis. The reasons could be partly due to the lack of proper history taking, as multiple symptoms being both cyclical gynaecological and non gynaecolical (dyschezia, dysuria, haematuria, rectal bleeding, shoulder pain) increases the likelihood of having endometriosis or the thoracic component taking a longer time to reveal as the diaphragm undergoes cyclical necrosis and subsequent cycles may lead to the production of fenestrations , as in this particular case .Conclusion:The diagnosis of diaphragmatic endometriosis is challenging and requires a high index of suspicion. Due to the complexity and rarity of this condition, the diagnosis is often delayed or missed and can have a major impact and a detrimental effect on the patient’s overall health and fertility.