대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Pleural endometriosis

Radiologic Findings

Fig 1. Contrast-enhanced chest CT shows irregular low attenuated pleural nodule at Rt. diaphragmatic pleura
Fig 2 & 3. 18F-FDG PET/CT scan does not show hypermetabolism in the pleural nodule
Fig 4. Contrast-enhanced chest CT a year ago shows small elongated low attenuated lesion in the subpleural area of Rt. diaphragmatic pleura. When compared with CT scan a year later, there is a distinct growth of that lesion.
Fig 5. There is no definite evidence of abnormal pleural lesion on the contrast-enhanced CT scan 2 years before.

Brief Review

Endometriosis is the condition wherein endometrial tissue is present outside of the uterine cavity. It is encountered most commonly in pelvic structures such as the ovary, uterine ligaments, pelvic peritoneum, cervix, labia, and vagina. Although endometriosis in general can affect up to 15% of women in their reproductive years, endometriosis involving pleura or lung is rare, and its prevalence remains unknown because of a paucity of relevant studies.
The most common clinical manifestation of pleural endometriosis is the recurrent shortness of breath due to recurrent pneumothorax. Less frequent presentations include recurrent hemorrhagic pleural effusion, hemoptysis, or catamenial pain. Catamenial hemothorax represents the second-most common manifestation, occurring in 14 % of known cases, and affects the right side in about 80 % of the time.
Chest X-rays in cases of pleural endometriosis usually reveal pneumothorax or occasionally pleural abnormality such as pleural effusion or nodular lesion. Chest CT scan may show pleural or diaphragmatic thickening in involved areas. In the present case, radiologic investigations revealed a right-sided loculated pleural effusion and diaphragmatic thickening. In contrast, chest X-rays in parenchymal endometriosis show nodular infiltrates or opacification.
Pleural endometriosis is almost invariably confined to the right side. The lesions are characteristically multiple, dark red or blue, nodules or cysts, commonly on the diaphragmatic pleura.
Microscopically, endometriosis typically consists of both endometriotic glands and stroma. The glands usually have an endometrioid appearance ranging from inactive to proliferative (or occasionally, secretory) to hyperplastic.
Diagnosis is frequently delayed until several episodes have occurred as patient fails to associate symptoms with menstruation. A pleural fluid cytology is usually not helpful. CA-125 level may be elevated in the serum and body cavity fluid of patients with endometriosis. The concentration of CA-125 correlates with both the severity and the clinical course of the disease.
Therapeutic management for pleural endometriosis includes the suppression of endometrial tissue and the prevention of further pelvic seeding. Medical therapy should be considered as the first line treatment, commonly with oral contraceptives, progesterone agents, danazol, or gonadotropin-releasing hormone agonists, to suppress the ovarian estrogen secretion. Pleurodesis may be considered as a means of preventing the recurrence of hemothorax.
Hysterectomy with bilateral salpingooophorectomy, although effective, results in permanent infertility and does not address dormant endometrial implants that may become active with administration of exogenous estrogen.

References

1. Azizad-Pinto P, Clarke D. Thoracic endometriosis syndrome: case report and review of the literature. The Permanente Journal. 2014;18:61.
2. Bhattacharjee S, Deb J, Saha R, Chakrabarti S, Mukherji J, Tapadar SR. Pleural Endometriosis: An Exceptional Cause of Hemorrhagic Pleural Effusion. The Journal of Obstetrics and Gynecology of India. 2014;64:100-04.
3. Dhanaworavibul K, Hanprasertpong J, Cheewadhanaraks S, Buhachat R. Bilateral pleural endometriosis. Journal of Obstetrics and Gynaecology Research. 2006;32:86-89.
4. Johnson MM. Catamenial pneumothorax and other thoracic manifestations of endometriosis. Clin Chest Med. 2004;25:311-19.
5. Flieder DB, Moran CA, Travis WD, Koss MN, Mark EJ. Pleuro-pulmonary endometriosis and pulmonary ectopic deciduosis: a clinicopathologic and immunohistochemical study of 10 cases with emphasis on diagnostic pitfalls. Hum Pathol. 1998;29:1495-503.
6. Dawood MY, Khan-Dawood FS, Ramos J. Plasma and peritoneal fluid levels of CA 125 in women with endometriosis. American journal of obstetrics and gynecology. 1988;159:1526-31.

Keywords

Pleura, Others,