Bilateral Thoracic Endometriosis Affecting the Lung and Diaphragm

Nezhat C, Camran Nezhat, Louise P. King, King LP, Paka C, Chandhana Paka, Odegaard J, Justin I. Odegaard, Justin Odegaard, Ramin E. Beygui, Ramin Beygui, Beygui R
JSLS : Journal of the Society of Laparoendoscopic Surgeons · 2012 · vol. 16(1) , pp. 140–142 · doi:10.4293/108680812x13291597716384 · PMID:22906342 · PMC3407434 · W2089503094
article OA: gold CC0 ⤵ 30 in-corpus citations
📄 Open PDF Full text JSON View on OpenAlex View on PubMed View at publisher
⚙ AI-generated summary by gemini-2.5-flash-lite, 2026-06-07 ⓘ

This case report describes a 43-year-old patient with bilateral pneumothoraces, confirmed to be caused by bilateral lung and diaphragmatic endometriosis.

One-sentence paraphrase of the abstract; not a substitute for reading it. No clinical advice. How this works

⚙ AI-generated deep summary by claude@2026-06, 2026-06-15 · read from full text ⓘ

This paper reports what the authors state is the first pathology-proven case of bilateral pulmonary parenchymal endometriosis, in a 43-year-old woman with prior stage IV endometriosis who developed menstrual-cycle-associated (catamenial) bilateral spontaneous pneumothoraces in 2011. Using combined bilateral VATS and VALS, they visualized and treated right lung hemorrhagic endometriotic areas with adhesiolysis and resection, applied plasma energy to superficial right chest wall and hemi-diaphragm lesions, resected a possible left apical lung lesion, and excised extensive left hemi-diaphragm endometriosis, while histology showed well-circumscribed proliferative-phase endometrial glands in fibrotic stroma with blood and hemosiderin-laden macrophages. A major limitation noted is that in prior work only about one-third of grossly similar foci are histologically proven, and in this case 3 of 6 biopsied foci were definitively endometriosis while others showed hemorrhage and fibrosis despite exhaustive sectioning. This paper is centrally about endometriosis — it details bilateral thoracic (lung parenchymal) and diaphragmatic endometriosis associated with catamenial pneumothorax.

Read from the paper's body, not the abstract. Not a substitute for reading the paper. No clinical advice. How this works

Abstract

INTRODUCTION: Endometriosis of the lung and the diaphragm is rare. Patients may present with symptoms such as shortness of breath, chest pain, and shoulder pain or they may be asymptomatic. Of note, there have been few reports of bilateral catamenial disease, and no reports, to our knowledge, of bilateral pathology proven pulmonary parenchymal endometriosis. CASE: A 43-year-old with stage IV endometriosis and large leiomyoma underwent a laparoscopic hysterectomy and treatment of endometrial lesions in 2005. In March and April of 2011, she presented with bilateral pneumothoraces. She subsequently underwent video-assisted thoracoscopy as well as resection and fulguration of bilateral lung and diaphragmatic endometriosis. Pathology confirmed endometrial implants in the lung parenchyma bilaterally. CONCLUSION: Catamenial pneumothorax is the most common presentation of thoracic endometriosis. However, bilateral catamenial pneumothoraces are rare. To the best of our knowledge, this case reflects the first report of pathology proven bilateral lung and diaphragm endometriosis.
Full text 5,669 characters · extracted from pmc-nxml · 3 sections · click to expand

Case

A 43-year-old Asian American female, with a history of stage IV endometriosis and large leiomyoma, was treated by total laparoscopic hysterectomy and treatment of endometriotic lesions in 2005. 4 Subsequently, in March and April of 2011, she developed bilateral spontaneous pneumothoraces. Both instances were preceded by typical symptoms she associated with her pre-hysterectomy menstrual cycles. The patient underwent a combined bilateral video-assisted thoracoscopic surgery (VATS) and video-assisted laparoscopic surgery (VALS) for treatment of endometriosis. We have previously described our standard approach to thoracic endometriosis. 5 Thoracoscopy revealed multiple hemorrhagic areas on the right lung with adhesions to the chest wall, which were resected. Other superficial areas of endometriosis affecting the right chest wall and right hemi-diaphragm were treated using plasma energy. 6 Mechanical pleurodesis was performed on the right pleura. Examination of the left lung revealed an apical bleb consistent with possible endometriosis that was resected. Endometriosis of the left hemi-diaphragm appeared extensive and was excised with the assist of an Endo-GIA stapler. Chest tubes were inserted bilaterally. Upon completion of the thoracoscopy, a video-assisted laparoscopic bilateral salpingo-oophorectomy with treatment of endometriosis within the pelvis was performed. Further examination of the abdominal portion of the diaphragm revealed no evidence of endometriosis. On postoperative day 2, acute onset chest pain prompted a computed topography scan, which revealed a defect in the left hemi-diaphragm. The patient was taken urgently to the operating room for thoracotomy and repair of a diaphragmatic defect. The patient did well thereafter and was discharged home on hospital day 6 without any further complications. Histologic examination of lesions from both lungs demonstrated well-circumscribed intra-parenchymal foci of proliferative-phase endometrial glands set in a fibrotic stroma. An admixture of blood and hemosiderin-laden macrophages was present within the lesional glands and the surrounding alveolar spaces. In total, 3 of the 6 biopsied foci of grossly similar lesions demonstrated definite endometriosis, while the remaining samples showed only hemorrhage and fibrosis despite exhaustive sectioning, compatible with previous reports (only ∼1/3 of foci are histologically proven). 7 The patient gave consent to publish these features of her case.

Discussion

Thoracic endometriosis is a rare manifestation of extragenital endometriosis. 1 Up to 60% of cases will be associated with pelvic endometriosis. 1 , 8 , 9 Lesions on the diaphragm and visceral pleura are the most commonly described sites (38.8% and 29.6%, respectively). 8 Lesions of the parenchyma are uncommonly encountered. 1 , 9 Bilateral thoracic endometriosis is rare. The exact pathophysiology of catamenial pneumothorax remains unclear. Three main theories have been proposed. 10 The theory of retrograde menstruation suggests endometrial cells enter the peritoneal cavity and then enter the pleural space through lymphatic channels, diaphragmatic fenestrations or hematogenously as with metastatic disease. This theory was first described by Schron and Ruysh over 237 years ago. 11 The hormonal model implicates high prostaglandin F 2 at ovulation, which may result in vasospasm and associated ischemia in the lungs. This, in turn and in combination with prostaglandin-induced bronchospasm, may result in alveolar rupture and subsequent pneumothorax. 12 Finally, the anatomic model suggests that the loss of the cervical mucus plug during menses results in communication between the environment, peritoneal cavity, and subsequently the pleural space. 13 Diagnosis of thoracic endometriosis weighs heavily on clinical suspicion. 9 Most patients will present with symptoms consistent with catamenial pneumothorax: shortness of breath, cough, and pleurisy. Chest radiograph, CT, MRI, thoracentesis, and bronchoscopy have been deemed useful in evaluating thoracic endometriosis. However, video-assisted thoracoscopic surgery (VATS) remains the gold standard for both definitive diagnosis and surgical treatment. 13 Medical treatment is the first step in the management of symptoms; however, it can be expensive and recurrence is high with discontinuation. By contrast, chemical pleurodesis, pleurectomy, and segmental resection have all proven successful in the resolution of symptoms. 14 The introduction of video-assisted endoscopic surgery has revolutionized modern day surgery. 15 In the same vein, the use of VATS allows for direct visualization of implants and nodules throughout the thoracic cavity, and the ability to resect apical blebs, parenchymal, and diaphragmatic implants. Superficial implants can be treated using bipolar, CO 2 laser or plasma energy. Exploratory thoracotomy, previously used regularly for diagnosis and treatment, now is reserved for cases in which minimally invasive techniques fail. In this case, we used a multidisciplinary approach of VATS and VALS, thus optimally addressing pelvic, thoracic cavity, and subdiaphragmatic regions in a single operation. 5 The minimally invasive, combined approach to thoracic endometriosis is gaining momentum as the mainstream surgical option for patients.

Introduction

Endometriosis of the lung parenchyma was first described by Schwarz in 1938. 1 Spontaneous pneumothorax associated with menstrual cycles (catamenial pneumothorax) was described as early as 1958. 2 , 3 To our knowledge, the current case represents the first report of pathology proven bilateral pulmonary parenchymal endometriosis.

Text is read by the "Ask this paper" AI Q&A widget below. Extraction quality varies by source — PMC NXML preserves structure cleanly, OA-HTML may include some navigation residue, and OA-PDF can have broken hyphenation. The publisher copy (via DOI) is the canonical version.

My notes (saved in your browser only)

⚙ Ask this paper AI returns verbatim quotes from the full text · source: pmc-nxml ⓘ

Answers must be backed by verbatim quotes from this paper's full text. Hallucinated quotes are dropped automatically; if no verbatim passage answers the question, we say so. How this works

Condition tags

endometriosisthoracic_endometriosis

MeSH descriptors

Endometriosis Pneumothorax Pneumothorax Thoracic Surgery, Video-Assisted Adult Endometriosis Female Humans Lung Lung Pneumothorax Pneumothorax Pneumothorax

Citation neighborhood

Papers in the corpus that this work cites (lower rings, blue) and that cite this one (upper rings, green). Dot size scales with the paper's in-corpus citation count — bigger dot = more influential within the endo/adeno field. Click a dot to open that paper. [ expand to 2 hops ] — adds papers reached through this work's immediate citers/citees. Heavier; up to 60 extra dots.

References (19)

Cited by (30)

Source provenance

europepmc
last seen: 2026-09-04T06:17:57.233406+00:00
openalex
last seen: 2026-06-10T17:14:06.276822+00:00
pubmed
last seen: 2026-05-13T22:16:04.919516+00:00
License: CC0 · commercial use OK