**7.1 Diaphragmatic lesions**

The diaphragmatic lesions usually located at the centrum tendineum and can be single or multiple. They usually settle adjacent to nodules. They can be outlined as perforations, fenestrations, holes, stomata, and pores [24, 30, 49] (**Figure 1a** and **b**).

They can be tiny holes measuring 1–3 millimeters in diameter [7, 50], or larger defects measuring up to 10 mm [4, 18] or more than 10 mm [8] or represent as undetected holes proven only by diagnostic pneumoperitoneum [42].

Diaphragmatic defects are usually found close to coexisting nodules or spots, and endometrial tissue is sporadically found at the edges of the defects [4, 9, 11, 22]. This situation supports the theory claiming that the diaphragmatic defects represent the breakdown of endometrial implants during menstrual cycle [22, 24].

There are also case reports of larger lacerations that accompany with intrathoracic liver protrusion, but these presentations are very rare.

A patient with catamenial pneumothorax on the right hemithorax was reported by Pryshchepau et al. Liver of the patient was protruded through a large diaphragmatic defect [44].

### **Figure 1.**

*(a) and (b) Thoracoscopic view of diaphragmatic endometriosis. Fenestrations can be seen on the surface of the diaphragm (arrows). (c) The liver is visible after surgical resection. (d) Sutured diaphragm after endometriosis resection. Images are used with the permission of Demetrio Larrain [49].*

Visouli et al. also reported five cases of catamenial pneumothorax [24], which contains a case very similar regarding liver protrusion, and they have recommended that these findings should be included in the characteristic findings of catamenial and thoracic endometriosis-related pneumothorax, although this presentation is very rare [24].

Catamenial pneumothorax with a huge diaphragmatic laceration and partial intrathoracic liver herniation was reported by Bobbio et al. [43], and Makhija et al. [51] reported a patient with multiple diaphragmatic fenestrations. The largest lesion was reported to have a diameter of 10 cm.

Spontaneous rupture of the right hemidiaphragm and intrathoracic liver herniation was also reported in the literature [41]. Pneumothorax and pneumoperitoneum was detected in a patient with a history of premenstrual periscapular pain. At the edge of the diaphragmatic defect, a nodule looking like an endometrial implant was found in that patient. Histological examination of the nodule revealed endometriosis with hemosiderin-loaded macrophages. This case is considered as endometriosisrelated, but the histological criteria set by the authors was not appropriate [9, 11]. Additionally, previously mentioned cases of large diaphragmatic defects were considered to be limited diaphragmatic ruptures and stated that endometriosis was responsible for these ruptures [43, 44].

## **7.2 Thoracic lesions**

Endometrial tissue is usually detected on histopathological examination of the spots or nodules accompanying catamenial pneumothorax so these lesions are considered to be endometrial implants. Diaphragm, visceral, and parietal pleura are the common sites for location. Pericardial implants were also reported by Fonseca et al. [52]. The lesions may be single or multiple and may have varying size. They may have different presentations in color as brown, purple, red, violet, blueberry, black, white, grayish, and grayish-purple [1–20, 51].

**47**

pleurodesis [6].

*Catamenial Pneumothorax*

*DOI: http://dx.doi.org/10.5772/intechopen.82564*

and longer-term variation [22, 24, 30, 42].

visualization of diaphragm as well [23].

reoperations [4–28, 30].

in terms of spots and nodules.

elimination of intrathoracic lesions [4].

[7, 12, 23, 24, 30, 49] (**Figure 1c** and **d**).

Diaphragmatic and thoracic lesions may be present in all cases, but on the other

Detection of characteristic lesions during thoracotomy or thoracoscopy depends on thorough and deliberate examination of the thorax, including the diaphragm. This also depends on the stage of the disease and catamenial behavior of the disease

In some cases of catamenial pneumothorax, characteristic findings may be absent and blebs and bullae may be the only pathological findings. In some cases, no

Surgical treatment is the gold standard in treatment of catamenial pneumothorax, not only for its better results but less recurrences after treatment as well.

Video-assisted thoracoscopic surgery (VATS) has been mainly in use since 2000 in the treatment of thoracic diseases with several advantages over conventional thoracotomy. Incision may be extended when extensive diaphragmatic repair is required, and also a muscle-sparing thoracotomy may offer better access in such cases. Thoracotomy may be an option especially in recurrent interventions or in

The lung examination for bullae, bleb, and air leakage is very important, but the diaphragm should also be carefully examined for fenestrations and spots or nodules. In addition, it is critical to examine the parietal pleura, lung, and pericardium

Bagan et al. recommended the use of surgical treatment during menstruation. Thus, they stated that endometriotic lesions may be better visualized during menstrual period [22]. Slasky et al. used the pneumoperitoneum method to reveal unseen diaphragmatic fenestrations [42]. Identification of the lesions within the thorax is made easier by the magnification provided by VATS [4–28, 30]. The tissue samples from these lesions make it easy to diagnose thoracic endometriosis [10]. Resection of all visible lesions such as bullae or bleb and also resection of endometriosis-induced thoracic lesions have been recommended by Alifano et al. Limited wedge resection of the diseased lung tissue, limited parietal pleurectomy, and partial diaphragmatic resection were suggested surgical techniques for the

Excision and wedge resection of bullae and blebs [7, 12, 23, 30], along with pleurodesis or pleurectomy, has been mainly performed in the literature [7, 8, 12, 23, 30, 47]. Pleurodesis was found to be the most common intervention [29]. The majority of pleurodesis performed was mechanical pleurodesis (abrasion or pleurectomy), which has been found to be more successful in comparison to chemical

Addressing the diaphragmatic pathology is of paramount importance. Diaphragmatic plication and/or resection of the diseased area have been reported

Korom et al. [7] reviewed 195 cases of CPX among 229 cases and reported that 154 cases (78%) were treated surgically. Among surgically treated patients, diaphragmatic repair (38%), pleurodesis (81%), and lung wedge resection (20%) were performed. There is common consensus in the literature that the appropriate approach to CPX has to be minimally invasive so video-assisted thoracoscopic surgery (VATS) is the choice of treatment. VATS not only provides magnification but complete

hand, only one or more of them can be seen either [1–21, 39, 53, 54].

characteristic thoracic findings may be detected [7, 12, 20, 22–24].

**8. Surgical treatment of catamenial pneumothorax**

Surgery has better results compared with medical treatment [1–20].
