Letrozole for the Treatment of Thoracic Endometriosis: A Case Report [15J]

T Chadwick, Kevin M. Audlin
In: Obstetrics & Gynecology · 2019 · vol. 133(1) , pp. 110S–111S · doi:10.1097/01.aog.0000558831.80021.80 · W2943922561
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This case report demonstrates that letrozole effectively resolved recurrent hemothorax and symptoms in a patient with thoracic endometriosis following surgical sterilization, suggesting its potential as a hormonal suppression therapy for this rare condition.

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This case report examines the use of letrozole, an aromatase inhibitor, to treat thoracic endometriosis syndrome in a 48-year-old patient who experienced recurrent hemothorax and pneumothorax despite prior hysterectomy, bilateral salpingo-oophorectomy, and leuprolide therapy. The authors hypothesized that letrozole would suppress estrogen synthesis via peripheral conversion of androgens, thereby inhibiting the growth of ectopic endometrial tissue within the thoracic cavity. Following a twenty-one-month treatment course with letrozole, the patient remained asymptomatic with no recurrence of hemothorax or other symptoms associated with the condition. This paper is centrally about endometriosis — specifically the management of thoracic endometriosis syndrome using hormonal suppression.

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Abstract

INTRODUCTION: Thoracic endometriosis syndrome describes ectopic endometrial tissue within the thoracic cavity causing significant morbidity including cyclic chest pain, pneumothorax, hemothorax, and hemoptysis. Thoracic endometriosis is a rare condition usually requiring multiple interventions and hormonal suppression of the endometrial implants. Given the overexpression of aromatase P450 within endometrial tissue, off label use of aromatase inhibitors has been proposed as a mechanism for hormonal suppression with successful treatment of symptoms in cases of pelvic endometriosis. METHODS: A case report of a 48 year old with recurrent thoracic endometriosis following hysterectomy with bilateral salpingo-oophorectomy. Her disease was significant, resulting in pneumothorax requiring bleb resection and pleurodesis, as well as subsequent hemothorax requiring chest tube placement. She was maintained on Lupron therapy after surgical sterilization with recurrent hemothorax again requiring thoracentesis. She was subsequently switched to Letrozole with resolution of symptoms and no further episodes of hemothorax. The patient consented to publication of a case report. RESULTS: After 21 months of Letrozole treatment, the patient has remained asymptomatic without recurrence of hemothorax. Following surgical sterilization, the main source of estrogen is peripheral conversion of androgens to estrogen through the aromatization process. Thus, aromatase inhibitors can be used to eliminate this pathway for estrogen synthesis that can stimulate endometriosis. CONCLUSION: While aromatase inhibitors have been demonstrated to reduce the pain associated with pelvic endometriosis, this case report demonstrates its potential efficacy in treating thoracic endometriosis as well. Additional research is needed to determine the potential for aromatase inhibitors to become a mainstay in the treatment of thoracic endometriosis.
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Introduction

Thoracic endometriosis syndrome describes ectopic endometrial tissue within the thoracic cavity causing significant morbidity including cyclic chest pain, pneumothorax, hemothorax, and hemoptysis. Thoracic endometriosis is a rare condition usually requiring multiple interventions and hormonal suppression of the endometrial implants. Given the overexpression of aromatase P450 within endometrial tissue, off label use of aromatase inhibitors has been proposed as a mechanism for hormonal suppression with successful treatment of symptoms in cases of pelvic endometriosis.

Methods

A case report of a 48 year old with recurrent thoracic endometriosis following hysterectomy with bilateral salpingo-oophorectomy. Her disease was significant, resulting in pneumothorax requiring bleb resection and pleurodesis, as well as subsequent hemothorax requiring chest tube placement. She was maintained on Lupron therapy after surgical sterilization with recurrent hemothorax again requiring thoracentesis. She was subsequently switched to Letrozole with resolution of symptoms and no further episodes of hemothorax. The patient consented to publication of a case report.

Results

After 21 months of Letrozole treatment, the patient has remained asymptomatic without recurrence of hemothorax. Following surgical sterilization, the main source of estrogen is peripheral conversion of androgens to estrogen through the aromatization process. Thus, aromatase inhibitors can be used to eliminate this pathway for estrogen synthesis that can stimulate endometriosis.

Conclusion

While aromatase inhibitors have been demonstrated to reduce the pain associated with pelvic endometriosis, this case report demonstrates its potential efficacy in treating thoracic endometriosis as well. Additional research is needed to determine the potential for aromatase inhibitors to become a mainstay in the treatment of thoracic endometriosis.

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