| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Guest Access | Sign In via User Name/Password
|
|
|
|||||||
Guest Access | Sign In via User Name/Password |
|||||||||
* From the Division of Thoracic Surgery (Drs. Puma, Casucci, Urbani, and Porcaro), University of Perugia, Ospedale Civile S. Maria, Terni, Perugia, Italy; and the Department of Radiology (Drs. Carloni and Puligheddu), Ospedale di Città di Castello, Castello, Italy.
Correspondence to: Francesco Puma, MD, Chirurgia Toracica, Ospedale Civile S. Maria, 05100 Terni, Italy; e-mail: francescopuma{at}aospterni.it
 |
Abstract |
|---|
 TOP Abstract IntroductionCase ReportDiscussionReferences |
|---|
Key Words: endometriosis • female genital disease • hemoptysis • laser surgery • lung diseases • respiratory tract diseases
|
Introduction |
|---|
|
TOPAbstractIntroductionCase ReportDiscussionReferences |
|---|
Diagnosis of and therapy for this condition are still a matter of debate. The precise source of bleeding is generally not easy to localize because the chest radiograph, CT scan, and bronchoscopy often show normal findings after menses. Histopathologic confirmation of pulmonary endometriosis is also difficult since both biopsy and resected specimens should be obtained just before the onset of the menses.4 The main criterion for the diagnosis is the finding of periodic hemoptysis that is synchronous with menstruation, and most of the reported cases were diagnosed on the basis of the patient’s clinical history, without a supportive histologic demonstration.5
In this report, we present a case of bronchial endometriosis diagnosed by spiral CT scan with virtual bronchoscopy and cured by endoscopic Nd-YAG laser treatment.
|
Case Report |
|---|
|
TOPAbstractIntroductionCase ReportDiscussionReferences |
|---|
The findings of a physical examination and laboratory study were normal. The patient underwent, after and during menses, high-resolution CT scans of the chest, and a conventional enhanced, single-breathhold, spiral CT scan supplemented with multiplanar reconstructions and virtual bronchoscopy. The CT scan performed after menses did not reveal any bronchopulmonary abnormality. The second examination, obtained at the onset of menses, demonstrated some ground-glass opacifications with a patchy distribution at the level of the left lower lobe that was related to the presence of blood in the alveoli (Fig 1 ). Furthermore, a small area of bronchial mucosal thickening was observed at the origin of the left upper bronchus by virtual bronchoscopy (Fig 2 ). These findings were not visible with the first CT scan (Fig 3 ). A pelvic CT scan and gynecologic examination did not reveal pelvic endometriosis. At the onset of the next menses, the patient underwent flexible fiberoptic bronchoscopy that showed a tiny submucosal red spot at the origin of the left upper bronchus with signs of recent bleeding. No further abnormalities were noticeable. Cytologic examination of the brushing specimens showed clusters of nonmucinous cylindrical cells without a glandular pattern.
|
|
|
Discussion |
|---|
|
TOPAbstractIntroductionCase ReportDiscussionReferences |
|---|
The role of bronchoscopy and CT scanning in the diagnosis of catamenial hemoptysis remains undefined. For some authors, bronchoscopy is not indicated in the diagnostic workup when clinical and CT scan findings are present.7 8 On the other hand, a low diagnostic yield from the CT scan has been reported in tracheobronchial endometriosis without parenchymal involvement.2 CT scans obtained during menses can demonstrate only small ground-glass opacifications representing the areas of bleeding or nodular lesions, thin-walled cavities, and bullous formations.9 In the interval between menses, the CT scan findings may be normal, or a change in the size of the described lesions may be observed. In patients with central airway endometriosis, a CT scan may show only mild thickening of the bronchial wall.2 In our case, such findings were clearly evident with the virtual bronchoscopy.
Flexible fiberoptic bronchoscopy can be normal even if performed within 24 h of the hemoptysis. Multiple normal bronchoscopy findings do not prevent the achievement of a correct diagnosis after serial examinations.1 In other patients, fiberoptic bronchoscopy can clearly localize bleeding without producing a tissue diagnosis because the lesion lay too distal in the bronchial tree.10 In central airway endometriosis, endoscopic findings at the onset of menses vary from single or scattered purplish-red submucosal patches to white cystic lesions.2 The lesions disappear after menses, and a crypt can be observed, as a sign of the cyst’s healing.1
The use of both CT scanning and flexible fiberoptic bronchoscopy are mandatory in the diagnosis of catamenial hemoptysis. The proper timing of such examinations plays the most important role for the diagnosis, and serial diagnostic procedures may be required. Even though central airway endometriosis is a much rarer phenomenon than parenchymal lesions, flexible fiberoptic bronchoscopy within the first day of menses should be performed in every patient with catamenial hemoptysis. In our patient, both the findings of the first CT scan and flexible bronchoscopy performed after menses were normal, but both were important for the diagnosis. The second CT scan conducted during menses showed a small area of bronchial mucosa thickening, particularly evident with the virtual bronchoscopy and not visible during the first examination. Comparisons between the two CT scans led to the correct diagnosis. On the basis of such findings, flexible fiberoptic bronchoscopy, performed on the first day of menses, disclosed a tiny submucosal red spot in the left upper bronchus with signs of recent bleeding.
Medical therapy has been recommended as the first choice in pulmonary endometriosis. It consists of the suppression of endometrial tissue with progesterone (ie, pseudopregnancy) or danazol (ie, pseudomenopause). Danazol is a synthetic steroid with antiestrogenic and light androgenic effects that affects ovarian hormone synthesis.11 It has proved to be effective in curing or controlling symptoms, even in patients who are nonresponsive to ovulation suppression,12 but a variable recurrence rate after the cessation of therapy has been reported.1 13 Furthermore, heavy side effects of the hormonal therapy often are observed, including climacteric symptoms, virilization, weight gain, and sterility.4 Surgery should be the preferred method if the patient wishes to become pregnant, if the side effects of hormonal therapy are intolerable, or in case of recurrence when the drug therapy is discontinued. Pulmonary resection is indicated when a single point of bleeding has been located definitively. For peripheral lesions, thoracoscopic wedge resections have been successfully performed.4 14 In patients with centrally located bronchial endometriosis, subsegmentectomy, segmentectomy, or lobectomy are required.3 15 16 17 Treatment with oophorectomy has been reported in the literature,18 but it seems to be an extreme solution and should be avoided.
The precise endoscopic identification of the tracheobronchial lesions brings new therapeutic options. With the combination of CT scanning and flexible fiberoptic bronchoscopy, the source of bleeding should be located in every tracheobronchial endometriosis.
In our patient, we decided to proceed to laser treatment because the lesion had been precisely located in a bronchus, which is easily reachable by the bronchoscope. We preferred the ventilating rigid bronchoscopy mainly for our extensive experience in the use of this procedure. Nevertheless, a successful laser ablation of the lesion also could have been performed through the flexible fiberoptic bronchoscope.
No previous endoscopic treatments of this condition have been reported in the literature. Endoscopic Nd-YAG laser can eliminate mucosal and submucosal lesions with a minimally invasive procedure, without significant operative risk. Such treatment could be the first line of therapy for central airway endometriosis, provided that the source of bleeding has been conclusively located and the lesions can be reached with the bronchoscope. Endoscopic ablation potentially can achieve good and probably long-term outcomes without the adverse effects of pharmacologic therapy and surgical therapy.
|
|
References |
|---|
|
TOPAbstractIntroductionCase ReportDiscussionReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  J.-P. L'Huillier and F. Puma Endobronchial Endometriosis Nd-YAG Therapy vs Drug Therapy Chest, February 1, 2005; 127(2): 684 - 685. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
