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Catamenial Pneumothorax
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Catamenial Pneumothorax Can All Cases Be Explained by the Pore Hypothesis? To the Editor: I read the reply of Dr. Kirschner (November 2002).1 Certainly, some of these cases seem possibly to be explained by the transphrenic passage of gas, inasmuch as there was one patient who had been cured by a tubal ligation.2 However, since diaphragmatic defects/fenestrations have been found in only 19 to 33% of cases,3 and since some patients continued to show recurrent pneumothoraces after undergoing hysterectomies,4 I do not think that all cases can be explained by the pore hypothesis. Furthermore, according to this hypothesis, pneumothoraces also may occur in the nonmenstrual period since spontaneous pneumoperitoneum can be seen after intercourse or exercise, for example.5 My hypothesis is that intrathoracic free-air leaks from the lung due to focal defect(s) caused by a breakdown of the pleural endometrial tissue that has been absorbed from the stomata. Kazuhiro Funatsu, MD Funatsu Clinic Fukuoka, Japan Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: Kazuhiro Funatsu, MD, Funatsu Clinic, Akama 963, Munakata, Fukuoka 811-4146, Japan
References 1 Funatsu K, Kirschner PA. Catamenial pneumothorax: an example of porous diaphragm syndromes? [letter and response]. Chest 2002; 122:1865 2 Slasky BS, Siewers RD, Lecky JW, et al. Catamenial pneumothorax: the roles of diaphragmatic defects and endometriosis. AJR Am J Roentgenol 1982; 138:639 – 643 766
3 Carter EJ, Ettensohn DB. Catamenial pneumothorax. Chest 1990; 98:713–716 4 Soderberg CH, Dahlquist EH. Catamenial pneumothorax. Surgery 1976; 79:236 –239 5 Da¨hnert W. Pneumoperitoneum. In: Da¨hnert W, ed. Radiology review manual. 3rd ed. Baltimore, MD: Williams & Wilkins, 1996; 541
To the Editor: I welcome the opportunity to continue the discussion of catamenial pneumothorax and the role of the diaphragmatic defects. Again, I would like to emphasize that catamenial pneumothorax is only one of a varied host of disparate conditions in which the common denominator is a “porous diaphragm.”1 Catamenial pneumothorax is definitely linked to one aspect of endometriosis. But there are two distinct routes of spread of endometrial tissue to the thorax. The first, by far the most common, is the transperitoneal route from the pelvis to the diaphragm, which accounts for diaphragmatic pores and catamenial pneumothorax. The other, quite rare, is the hematogenous route, by which uterine endometrial tissue and/or decidua literally “metastasize” to the lung via the venous system, which drains the uterus. In this latter instance, the result is the appearance of pulmonary nodules or deposits, which are clinically manifested by hemoptysis, not by pneumothorax or hemothorax. The pathologic examination of resected specimens proves them to be endometrial or decidual tissue metastatic to the pulmonary parenchyma. The monthly periodicity of catamenial hemoptysis, sometimes referred to as vicarious menstruation, is due to the cyclic hormonal activity of the metastatic endometrial nodule in the lung parenchyma.2,3 It does not cause catamenial pneumothorax. Paul A. Kirschner, MD, FCCP Mount Sinai Medical Center New York, NY Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: Paul A. Kirschner, MD, FCCP, Mount Sinai Medical Center, Box 1028, One Gustave L. Levy Pl, New York, NY 10029
References 1 Kirschner PA. Porous diaphragm syndromes. Chest Surg Clin N Am 1998; 8:449 – 473 2 Lattes R, Shepard F, Tovell H, et al. A clinical and pathological study of endometriosis of the lung. Surg Gynecol Obstet 1956; 103:552–556 3 Yeh TJ. Endometriosis within the thorax: metaplasia, implantation or metastasis? J Thorac Cardiovasc Surg 1967; 53: 201–205 Communications to the Editor
Catamenial Pneumothorax Can All Cases Be Explained by the Pore Hypothesis? To the Editor: I read the reply of Dr. Kirschner (November 2002).1 Certainly, some of these cases seem possibly to be explained by the transphrenic passage of gas, inasmuch as there was one patient who had been cured by a tubal ligation.2 However, since diaphragmatic defects/fenestrations have been found in only 19 to 33% of cases,3 and since some patients continued to show recurrent pneumothoraces after undergoing hysterectomies,4 I do not think that all cases can be explained by the pore hypothesis. Furthermore, according to this hypothesis, pneumothoraces also may occur in the nonmenstrual period since spontaneous pneumoperitoneum can be seen after intercourse or exercise, for example.5 My hypothesis is that intrathoracic free-air leaks from the lung due to focal defect(s) caused by a breakdown of the pleural endometrial tissue that has been absorbed from the stomata. Kazuhiro Funatsu, MD Funatsu Clinic Fukuoka, Japan Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: Kazuhiro Funatsu, MD, Funatsu Clinic, Akama 963, Munakata, Fukuoka 811-4146, Japan
References 1 Funatsu K, Kirschner PA. Catamenial pneumothorax: an example of porous diaphragm syndromes? [letter and response]. Chest 2002; 122:1865 2 Slasky BS, Siewers RD, Lecky JW, et al. Catamenial pneumothorax: the roles of diaphragmatic defects and endometriosis. AJR Am J Roentgenol 1982; 138:639 – 643 766
3 Carter EJ, Ettensohn DB. Catamenial pneumothorax. Chest 1990; 98:713–716 4 Soderberg CH, Dahlquist EH. Catamenial pneumothorax. Surgery 1976; 79:236 –239 5 Da¨hnert W. Pneumoperitoneum. In: Da¨hnert W, ed. Radiology review manual. 3rd ed. Baltimore, MD: Williams & Wilkins, 1996; 541
To the Editor: I welcome the opportunity to continue the discussion of catamenial pneumothorax and the role of the diaphragmatic defects. Again, I would like to emphasize that catamenial pneumothorax is only one of a varied host of disparate conditions in which the common denominator is a “porous diaphragm.”1 Catamenial pneumothorax is definitely linked to one aspect of endometriosis. But there are two distinct routes of spread of endometrial tissue to the thorax. The first, by far the most common, is the transperitoneal route from the pelvis to the diaphragm, which accounts for diaphragmatic pores and catamenial pneumothorax. The other, quite rare, is the hematogenous route, by which uterine endometrial tissue and/or decidua literally “metastasize” to the lung via the venous system, which drains the uterus. In this latter instance, the result is the appearance of pulmonary nodules or deposits, which are clinically manifested by hemoptysis, not by pneumothorax or hemothorax. The pathologic examination of resected specimens proves them to be endometrial or decidual tissue metastatic to the pulmonary parenchyma. The monthly periodicity of catamenial hemoptysis, sometimes referred to as vicarious menstruation, is due to the cyclic hormonal activity of the metastatic endometrial nodule in the lung parenchyma.2,3 It does not cause catamenial pneumothorax. Paul A. Kirschner, MD, FCCP Mount Sinai Medical Center New York, NY Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: Paul A. Kirschner, MD, FCCP, Mount Sinai Medical Center, Box 1028, One Gustave L. Levy Pl, New York, NY 10029
References 1 Kirschner PA. Porous diaphragm syndromes. Chest Surg Clin N Am 1998; 8:449 – 473 2 Lattes R, Shepard F, Tovell H, et al. A clinical and pathological study of endometriosis of the lung. Surg Gynecol Obstet 1956; 103:552–556 3 Yeh TJ. Endometriosis within the thorax: metaplasia, implantation or metastasis? J Thorac Cardiovasc Surg 1967; 53: 201–205 Communications to the Editor