Treatment Strategy for Catamenial and Endometriosis-Related Recurrent Spontaneous Pneumothorax

RELEVANCE. The problem of treating thoracic endometriosis complicated by recurrent spontaneous catamenial pneumothorax is associated with the widespread prevalence of endometriosis, the complexity of its treatment and unsatisfactory long-term outcomes. The diagnosis of catamenial pneumothorax can only be established with a carefully collected history and confirmation of its recurrent nature. Favorable results are achieved with complex therapy carried out by the thoracic surgeon and gynecologist, consisting of an adequate volume of surgical intervention and hormonal therapy with gonadotropin releasing hormone agonists.

AIM OF STUDY. To improve the diagnosis of thoracic endometriosis and recurrent catamenial and endometriosis-related spontaneous pneumothorax. To optimize the currently available treatment tactics by reducing the incidence of early relapses of catamenial pneumothorax and creating favorable conditions for the formation of reliable pleurodesis.

MATERIAL AND METHODS. We studied the immediate outcomes of complex treatment of 30 patients (14.7%) with right-sided recurrent catamenial (28) and endometriosis-related spontaneous pneumothorax (2), with a median age of 41 (37;44) years, for the period from 2011 to the first half of 2023. Surgical treatment via video-assisted thoracoscopic access was performed in 26 patients (86.7%). After surgery, all the patients were recommended a six-month course of hormonal therapy with gonadotropin releasing hormone agonists.

RESULTS. Various types of mechanical pleurodesis were performed in 25 patients (96.1%), resection of the diaphragm — in 17 (65.4%), alloplastic reconstruction with a synthetic mesh implant — in 12 patients (46.1%), pulmonary resection — in 9 (34.6%). In 12 of 26 patients (46.1%) in the early postoperative period, 6 (3; 6.75) days after surgery, a recurrence of catamenial pneumothorax developed, which subsequently required repeated interventions. In 5 patients, the relapse clearly coincided with the menstrual cycle. Early recurrence of pneumothorax required repeated drainage of the pleural cavity in all the patients, chemical pleurodesis in 2, and prolonged drainage of the pleural cavity in 1.

CONCLUSION. Surgeries involving resection and reconstruction of the diaphragm with a mesh implant, pleurectomy, lung resection do not ensure the removal of all endometrioid heterotopias of the diaphragm and lung, therefore, during the first mensis after surgery, in the early postoperative period, 46.1% of the patients had a recurrence of catamenial pneumothorax, with no formed pleurodesis, which contributes to the possibility of further recurrences of pneumothorax. Improving the immediate outcomes of complex treatment of catamenial pneumothorax is possible with the preventive administration of hormonal therapy 1.5–2 months before the planned surgical intervention, which requires a multidisciplinary approach of the thoracic surgeon and gynecologist.

1. Endometrioz – 2020 (02.11.2020). Klinicheskie rekomendatsii. Moscow, 2020. Available at: http://disuria.ru/_ld/10/1002_kr20N80mz.pdf?ysclid=lmt188qxlh336010287 [Accessed Sep 21, 2023]

2. Rousset-Jablonski C, Alifano M, Plu-Bureau G, Camilleri-Broet S, Rousset P, Regnard JF, et al. Catamenial pneumothorax and endometriosis-related pneumothorax: clinical features and risk factors. Hum Reprod. 2011;26(9):2322–2329. PMID: 21685141 https://doi.org/10.1093/humrep/der189

3. Joseph J, Sahn SA. Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med. 1996;100(2):164–170. PMID: 8629650 https://doi.org/10.1016/s0002-9343(97)89454-5

4. Marshall MB, Ahmed Z, Kucharczuk JC, Kaiser LR, Shrager JB. Catamenial pneumothorax: optimal hormonal and surgical management. Ann R Coll Surg Engl. 2005;27(4):662–666. PMID: 17626909 https://doi.org/10.1016/j.ejcts.2004.12.047 PMID: 15784370

5. Alifano M, Jablonski C, Kadiri H, Falcoz P, Gompel A, Camilleri-Broet S, et al. Catamenial and noncatamenial, endometriosis-related or nonendometriosis-related pneumothorax referred for surgery. Am J Respir Crit Care Med. 2007;176(10):1048–1053. https://doi.org/10.1164/rccm.200704-587OC

6. Ciriaco P, Negri G, Libretti L, Carretta A, Melloni G, Casiraghi M, et al. Surgical treatment of catamenial pneumothorax: a single centre experience. Interact Cardiovasc Thorac Surg. 2009;8(3):349–352. PMID: 19088096 https://doi.org/10.1510/icvts.2008.190975

7. Korom S, Canyurt H, Missbach A, Schneiter D, Kurrer MO, Haller U, et al. Catamenial pneumothorax revisited: clinical approach and systematic review of the literature. J Thorac Cardiovasc Surg. 2004;128(4):502–508. PMID: 15457149 https://doi.org/10.1016/j.jtcvs.2004.04.039

8. Voskresensky OV, Smoliar AN, Damirov MM, Galankina IE, Zhelev IG. Thoracic endometriosis and catamenial pneumothorax. Pirogov Russian Journal of Surgery. 2014;(10):4–9. (In Russ.)

9. Voskresensky OV, Damirov MM, Tarabrin EA, Galankina IE, Sharifullin FA. Catamenial (menstrual) pneumothorax is a complication of extragenital endometriosis. Ginecology. 2015;17(2):36–40. (In Russ.)

10. Hallifax RJ, Yousuf A, Jones HE, Corcoran JP, Psallidas I, Rahman NM. Effectiveness of chemical pleurodesis in spontaneous pneumothorax recurrence prevention: a systematic review. Thorax. 2017;72(12):1121–1131. PMID: 27803156 https://doi.org/10.1136/thoraxjnl-2015-207967

11. Alfageme I, Moreno L, Huertas C, Vargas A, Hernandez J, Beiztegui A. Spontaneous Pneumothorax: Long-term Results with Tetracycline Pleurodesis. Chest. 1994;106(2):347–350. PMID: 7774300 https://doi.org/10.1378/chest.106.2.347

12. Haga T, Kurihara M, Kataoka H, Ebana H. Clinical-pathological findings of catamenial pneumothorax: comparison between recurrent cases and non-recurrent cases. Ann Thorac Cardiovasc. 2014;20(3):202–206. PMID: 23698374 https://doi.org/10.5761/atcs.oa.12.02227

13. Haga T, Kataoka H, Ebana H, Otsuji M, Seyama K, Tatsumi K, et al. Thoracic endometriosis-related pneumothorax distinguished from primary spontaneous pneumothorax in females. Lung. 2014;192(4):583–587. PMID: 24831784 https://doi.org/10.1007/s00408-014-9598-1

14. Ziedalski TM, Sankaranarayanan V, Chitkara RK. Thoracic endometriosis: a case report and literature review. J Thorac Cardiovasc Surg. 2004;127(5):1513-1514. PMID: 15116017 https://doi.org/10.1016/j.jtcvs.2003.12.016

15. Fukuoka M, Kurihara M, Haga T, Ebana H, Kataoka H, Mizobuchi T, et al. Clinical characteristics of catamenial and non-catamenial thoracic endometriosis-related pneumothorax. Respirology. 2015;20(8):1272–1276. PMID: 26306694 https://doi.org/10.1111/resp.12610

16. Ochi T, Kurihara M, Tsuboshima K, Nonaka Y, Kumasaka T. Dynamics of thoracic endometriosis in the pleural cavity. PLoS One. 2022;17(5):e0268299. PMID: 35544515 https://doi.org/10.1371/journal.pone.0268299 eCollection 2022.

17. Pishchik VG, Obornev AD, Atyukov MA, Petrov AS, Kovalenko AI. Experience of treatment of endometriosisrelated pneumothorax. Grekov’s Bulletin of Surgery. 2017;176(3):56–60. (In Russ.) https://doi.org/10.24884/0042-4625-2017-176-3-56-60

18. Pechenikova VA, Kostyuchek DF. Extragenital Endometriosis: Clinicopathologic and Immunohistochemical Analysis of 45 Observations With Diverse Organ Localization. Journal of Obstetrics and Women’s Diseases. 2010;51(2):69–77. (In Russ.)

19. Bagan P, Le Pimpec Barthes F, Assouad J, Souilamas R, Riquet M. Catamenial pneumothorax: retrospective study of surgical treatment. Ann Thorac Surg. 2003;75(2):378–381. PMID: 12607643 https://doi.org/10.1016/s0003-4975(02)04320-5

20. Visouli AN, Zarogoulidis K, Kougioumtzi I, Huang H, Li Q, Dryllis G, et al. Catamenial pneumothorax. J Thorac Dis. 2014;6(Suppl 4):S448–S460. PMID: 25337402 https://doi.org/10.3978/j.issn.2072-1439.2014.08.49

21. Yukumi S, Suzuki H, Morimoto M, Shigematsu H, Sugimoto R, Sakao N, et al. Two Young Women with Left-sided Pneumothorax Due to Thoracic Endometriosis. Intern Med. 2016;55(23):3491–3493. https://doi.org/10.2169/internalmedicine.55.7187 PMID: 27904115

22. Nezhat C, Lindheim SR, Backhus L, Vu M, Vang N, Nezhat A, et al. Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management. JSLS. 2019;23(3):e2019.00029. PMID: 31427853 https://doi.org/10.4293/JSLS.2019.00029

23. Bobbio A, Canny E, Mansuet Lupo A, Lococo F, Legras A, Magdeleinat P, et al. Thoracic Endometriosis Syndrome Other Than Pneumothorax: Clinical and Pathological Findings. Ann Thorac Surg. 2017;104(6):1865–1871. PMID: 29054304 https://doi.org/10.1016/j.athoracsur.2017.06.049

24. Alifano M, Roth T, Broët SC, Schussler O, Magdeleinat P, Regnard JF. Catamenial pneumothorax: a prospective study. Chest. 2003;124(3):1004–1008. PMID: 12970030 https://doi.org/10.1378/chest.124.3.1004

25. Leong А.C., Coonar A.S, Lang-Lazdunski L. Catamenial pneumothorax: surgical repair of the diaphragm and hormone treatment. Ann R Coll Surg Engl. 2006;88:547–549. https://doi.org/10.1308/003588406X130732

26. Cieslik L, Haider SS, Fisal L, Rahman JAA, Sachithanandan A. Minimally Invasive Thoracoscopic Mesh Repair of Diaphragmatic Fenestrations for Catamenial Pneumothorax Due to Likely Thoracic Endometriosis: A Case Report. Med J Malaysi. 2013;68(4):366-7.

27. Gavrilov SG, Son DA, Churikov DA, Efremova OI, Shuljak GD. Ultrasonic geometry of synthetic endoprostheses after transabdominal preperitoneal hernioplasty of inguinal hernias. Pirogov Russian Journal of Surgery. 2020;(1):53–60. (In Russ.). https://doi.org/10.17116/hirurgia202001153

28. Cai H, Mao R, Zhou Y. Video-assisted subtotal parietal pleurectomy: an effective procedure for recurrent refractory pneumothorax. BMC Surgery. 2022;22(1):204–209. PMID: 35619102 https://doi.org/10.1186/s12893-022-01653-5

29. Alifano M, Legras A, Rousset-Jablonski C, Bobbio A, Magdeleinat P, Damotte D, et al. Pneumothorax recurrence after surgery in women: clinicopathologic characteristics and management. Ann Thorac Surg. 2011;92(1):322–326. PMID: 21718864 https://doi.org/10.1016/j.athoracsur.2011.03.083

30. West JB. Respiratory Physiology—The Essentials. 3rd ed. Williams & Wilkins, 1985. (Russ. Ed.: Uest Dzh. Fiziologiya dykhaniya. Osnovy. Moscow: Mir Publ.; 1988)

31. Dżeljilji A, Karuś K, Kierach A, Kazanecka B, Rokicki W, Tomkowski W. Efficacy and safety of pleurectomy and wedge resection versus simple pleurectomy in patients with primary spontaneous pneumothorax. J Thorac Dis. 2019;11(12):5502–5508. PMID: 32030269 https://doi.org/10.21037/jtd.2019.11.28