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Introduction : Catamenial pneumothorax (CP) is defined as a recurrent spontaneous pneumothorax occurring in females of reproductive age. In the 'perimenstrual period,' it is still considered relatively rare although accounting for 20-35% of spontaneous pneumothoraces occurring in premenopausal women. It is the most frequent manifestation of thoracic endometriosis, which can also cause pneumothorax during the intermenstrual period (TER non-CP). Areas covered : In this article, we review and comment the clinical presentation, etiopathogenesis, diagnostic criteria, and therapeutic management of CP and TER non-CP. We particularly emphasize on the surgical optimal treatment and associated multidisciplinary care and follow-up. Electronic databases, mostly PubMed, were used for searching terms including 'catamenial pneumothorax' and 'thoracic endometriosis.' Expert commentary : Clinical presentation and imaging of CP and TER non-CP are often unspecific except for possible visualization of endometriosis foci or diaphragmatic lesions at computed tomography-scan or magnetic resonance imaging. Thus, we recommend careful interrogatory and intraoperative inspection for appropriate diagnosis and treatment of pneumothorax in women. Despite better awareness of surgical teams, CP and TER-non CP are still associated with high rates of postoperative recurrence (around 30%). We strongly advocate for a multidisciplinary management including early surgical and chemical pleurodesis, resection of all visible endometriosis-related lesions, hormonal blockade, and prolonged follow-up.

Rationale: Hereditary multiple exostoses (HME) is a genetic musculoskeletal condition causing multiple exostoses. Rib location of exostosis can be complicated by thoracic injuries., Patient Concerns and Diagnoses: We report a case of pneumothorax in a 32-year-old man with a partial left-sided pneumothorax caused by an exostosis of the fourth and fifth ribs., Interventions and Outcomes: Clinical and radiological presentations allowed a conservative management. A video-assisted thoracoscopic surgery was performed a few weeks later to avoid any recurrence., Lessons: Rib exostosis represents an unusual cause of pneumothorax. Any local modification of symptoms or size of the exostosis should lead to investigations in regard to chondrosarcoma transformation.

Objective: The objective of this study was to determine the efficacy of alginate staple-line reinforcement of fissure openings as compared with stapling alone, with or without tissue sealant or glue, in reducing the incidence and duration of air leakage after pulmonary lobectomy for malignancy., Summary Background Data: No randomized trial evaluating alginate staple-line reinforcement has been performed to date., Methods: The Staple-line Reinforcement for Prevention of Pulmonary Air Leakage study was a multicenter randomized trial, with blinded evaluation of endpoints. Patients over 18 years of age scheduled for elective open lobectomy or bilobectomy for malignancy were eligible for enrollment. At thoracotomy, patients were deemed ineligible if an unanticipated pneumonectomy was indicated, or if air leakage occurred after the liberation of pleural adhesions. Otherwise, if the fissure was incomplete or the lung had an emphysematous appearance, patients were randomized to either standard management or interventional procedure consisting of fissure opening with linear cutting staplers buttressed with paired alginate sleeves (FOREseal). The number of eligible patients necessary in each randomization arm was estimated to be 190, and an outcomes analysis was performed on an intention-to-treat basis., Results: Of the 611 patients consented to study enrollment, 380 met the inclusion criteria and were randomized. Based on an intention-to-treat analysis, the primary endpoint of air leak duration was not different between the 2 groups: 1 day (range: 0-2 d) in the FOREseal group and 1 day (range: 0-3 d) in the control group (P = 0.8357). In addition, the 2 groups were similar in terms of the proportion of patients presenting with prolonged air leakage (7.8% in the FOREseal group vs 11.3% in the control group, P = 0.264) and the average duration of chest drainage (P = 0.107). Procedure costs were comparable for both groups., Conclusions: FOREseal did not demonstrate a significant advantage over standard treatment alone.

Background: Epidemiology of spontaneous pneumothorax has been scantily studied. We aimed to assess the incidence of spontaneous pneumothorax and describe patients' characteristics with respect to age, sex, seasonal occurrence, primary or secondary character, surgical management and rehospitalisations on a large-scale database., Methods: Data from all patients aged ≥14 years and hospitalised with a diagnosis of non-traumatic pneumothorax in France from 2008 to 2011 were retrieved from the National Hospitalisation Database., Results: There were 59 637 hospital stays corresponding to 42 595 patients. Twenty-eight per cent of patients were rehospitalised at least once during the 4-year period. Annual rate of pneumothorax could be estimated at 22.7 (95% CI 22.4 to 23.0) cases for 100 000 habitants. The women to men ratio was 1:3.3. Mean age was significantly higher in women than in men (41±19 vs 37±19 years, p<0.0001). No seasonal variation was observed. A surgical procedure was performed in 14 352 hospital stays (24%). In the group of patients aged <30 years, there was no statistical difference between men and women with regard to type of pneumothorax (primary or secondary), type of hospitalisation unit (surgery vs medicine), treatment modality (surgery or not), intensive care unit (ICU) admission and hospital stay duration. Rehospitalisation was more frequent in women than in men (56% vs 52%, p<0.0001). In the 30-49 years age group, surgery and rehospitalisation were more frequent in women than in men (each, p<0.001). In the 50-64 years age group, surgical procedures and rehospitalisations were more frequent in men than in women (p=0.002 and p<0.0001, respectively)., Conclusions: Sex and age are determinant factors in the course of spontaneous pneumothorax., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: A significant percentage of pneumothorax in women is due to thoracic endometriosis. Pathophysiologic mechanisms continue to be debated, and pathologic aspects are poorly known., Methods: Clinical and pathologic records of all consecutive women of reproductive age operated on for pneumothorax between 2000 and 2011 were retrospectively reviewed., Results: Two hundred twenty-nine women (mean age, 33 years) underwent surgery. One hundred forty-four cases (63%) were right-sided, and pneumothoraces were catamenial for 80 women (35%). Diagnosed pelvic endometriosis was associated in 29 cases. At pathology, thoracic endometriosis was diagnosed in 54 cases (24%). Endometrial glands were observed in 33 of 54 cases and were often cystic (16 of 33). Stroma was observed in 51 of 54 cases and endometrial stroma without glands in 21 cases. Hemosiderin-laden macrophages were observed in 27 of 54 cases. All cases of thoracic endometriosis were positive for progesterone and/or estrogen receptors (intense and nuclear). Catamenial pneumothoraces (n = 80, 34.9%) were endometriosis related in 50% of cases (n = 40, 17% of the whole population). Pneumothoraces were noncatamenial but endometriosis related in 6% of cases (n = 14) and merely idiopathic in 60% of patients (n = 135). Multivariate analysis showed that right side, presence of diaphragmatic abnormalities, relapse after unilateral surgery, and presence of hemosiderin-laden macrophages were independent variables associated with thoracic endometriosis (all, P &lt; .02). Apical emphysema-like changes were found in 184 of the 213 patients (86%) with apical resection and were significantly associated with the absence of thoracic endometriosis (P &lt; .001)., Conclusions: In women with surgically treated pneumothorax, prevalence of catamenial/endometriosis-related pneumothorax is high. Clinicians and pathologists must be aware to recognize such a difficult diagnosis.

Background: Catamenial pneumothorax and thoracic endometriosis (TE) are still under diagnosed. The purpose of this study is to increase the diagnostic accuracy for these conditions in patients with spontaneous pneumothorax and to identify their risk factors., Methods: We conducted a retrospective study on all consecutive women of reproductive age referred to our Centre for surgical treatment of spontaneous pneumothorax between July 2000 and January 2009., Results: The study population comprised 156 premenopausal women of whom 49 (31.4%) had catamenial and/or TE-related pneumothorax. Over a quarter of these 49 patients had a previous history of recurrent thoracic or scapular catamenial pain. They experienced their first pneumothorax episode at an older age (mean ± SD) (34.0 years ± 6.7) than women with idiopathic pneumothorax (28.7 ± 6.1 years, P < 0.001). Pelvic endometriosis was found in 51% of women with catamenial and/or TE-related pneumothorax. After adjustment for confounding factors by multiple logistic regression analysis, the results show that, infertility [odd ratio (OR) = 4.21, 95% confidence interval (CI) = 1.28-13.88] and a history of pelvic surgery with a uterine procedure and/or uterine scraping (OR = 2.85, 95% CI = 1.12-7.26) were the strongest predictors of catamenial and/or TE-related pneumothorax., Conclusions: Infertility and uterine procedures are significantly associated with catamenial and/or TE-related pneumothorax. Scapular or thoracic pain during menses often precedes the occurrence of pneumothorax and is highly specific for the diagnosis of TE. Our results suggest that in women with pelvic endometriosis, these symptoms should be systematically investigated for an earlier diagnosis of TE.

Background: Our aim was to study the clinical, surgical, and pathological characteristic of women with homolateral recurrence of pneumothorax despite previous surgery., Methods: This study is a retrospective analysis of the clinical and pathological records of all consecutive women of reproductive age hospitalized in a thoracic surgery department for surgical treatment of pneumothorax recurrence despite previous surgery between 2000 and 2009., Results: During the study period, 35 women were operated on. Their mean age was 37 years. Twenty-nine pneumothoraces (83%) were right sided. In 20 women, the recurrence occurred during the menstrual period. At initial surgery, 5 cases had been catamenial with evidence of thoracic endometriosis, 12 were catamenial with no evidence of endometriosis, 5 were noncatamenial with thoracic endometriosis, and 13 were idiopathic. At repeat surgery the figures were 18, 4, 5, and 8 cases, respectively. Repeat operation was carried out by video-assisted thoracoscopy in 13 cases, video-assisted minithoracotomy in 10, and standard thoracotomy in 12. Partial diaphragmatic resection was performed at repeat surgery in 16 patients (45.7%). Talc pleurodesis and pleural abrasion were carried out in 20 (57.1%) and 15 patients (42.9%), respectively. No major morbidity was observed. After repeat surgery, hormonal treatment was prescribed in 24 cases. Median follow-up was 40 months (range, 1.5 to 138 months). In 6 women, further homolateral recurrence of pneumothorax occurred (17.1%) and required surgery in 3 cases., Conclusions: Repeat surgery can be safely performed in women with recurrence of pneumothorax despite previous surgery, and frequently shows initially missed endometriosis., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Although known for several decades, catamenial pneumothorax has been considered until recently as an extremely rare entity. The condition is now more easily recognized and several studies have been published, with somewhat relevant discrepancies with respect to etiologic, epidemiologic, and management features. In the present review, I will provide a synthesis of available knowledge on the subject., Recent Findings: Catamenial pneumothorax accounts for approximately one third of cases of spontaneous pneumothoraces in women referred for surgery. At video-assisted thoracic surgery, diaphragmatic defects and nodules are the most frequent findings. Pathology shows endometriosis in most instances. Endometrial implants in visceral pleura are also found, although less frequently. Findings of surgical explorations support the theory of transabdominal-transdiaphragmatic passage of air to explain the pathogenesis of catamenial pneumothorax., Summary: Management of patients with catamenial pneumothorax implies surgery, if possible by video-assisted technology, to obtain samples for pathologic confirmation of endometriosis and to treat the main pathogenic mechanisms of pneumothorax. Partial diaphragmatic resection and/or exeresis of visceral pleural implants, as well as talc pleurodesis, are nowadays frequently carried out. Medical therapy to achieve ovarian rest is mandatory in the postoperative period, the multimodality management being the key to treatment success in this condition.

Objective: To elucidate the pathophysiology of catamenial pneumothorax (CP) due to thoracic endometriosis and support the theory of the transdiaphragmatic passage of air from the genital tract through diaphragmatic perforations caused by endometrial implants., Design: Three case reports., Setting: Academic hospital., Patient(s): Three women with pneumoperitoneum concomitant to CP., Intervention(s): Thoracic/abdominal computed tomography scans and chest x-rays., Main Outcome Measure(s): Presence of pneumoperitoneum coexisting with CP., Result(s): The observation of pneumoperitoneum associated with CP supports the theory of the transdiaphragmatic passage of air, which implies the occurrence of a pneumoperitoneum as an intermediate step., Conclusion(s): Our three cases strongly support the theory of the transdiaphragmatic passage of air in the pathogenesis of CP.

Rationale: Catamenial and endometriosis-related pneumothorax are considered relatively rare entities. Their clinical characteristics and outcome are incompletely known., Objectives: To evaluate the frequencies, clinical characteristics, and outcomes of catamenial and endometriosis-related pneumothoraces occurring in women with no underlying lung disease referred for surgical treatment., Methods: Clinical files of all the women of reproductive age referred to our center during a 6-year period for surgical treatment of spontaneous pneumothorax were retrospectively reviewed. Catamenial pneumothorax (CP) was defined as recurrent pneumothorax occurring between the day before and within 72 hours after the onset of menses. All histologic slides were reviewed to confirm initial diagnoses., Measurements and Main Results: A total of 114 women underwent video-assisted thoracic surgery; 28 women (24.6%) had CP (right-sided in all but one), and diaphragmatic abnormalities (perforations and/or nodules) were observed in 22 of them. Diaphragmatic abnormalities were seen in 21 of 86 patients with non-CP. Histologic examination found endometriosis, mainly diaphragmatic, in 18 of 28 CPs and 11 of 86 non-CPs. A 6-month antigonadotropic treatment was prescribed postoperatively to women with either CP or endometriosis-related pneumothorax. Mean follow-up was 32.7 (+/-18.5) months. Recurrence rates in CP, non-CP but endometriosis-related, and non-CP non-endometriosis-related pneumothoraces were 32, 27, and 5.3%, respectively., Conclusions: Our experience shows that (1) CP and/or endometriosis-related pneumothoraces account for an important percentage of spontaneous pneumothoraces referred for surgery, (2) diaphragmatic abnormalities seem to play a fundamental role in their pathogenesis, and (3) management is difficult because of the high recurrence rate.

Background: Idiopathic spontaneous pneumothorax (ISP) results from rupture of blebs, bullas, or diseased alveolar walls. Initiating mechanisms may relate to increased transpulmonary pressure. The possible impact of changes in atmospheric pressure (Patm) on the occurrence of ISP remains uncertain., Methods: We studied the relationship between the occurrence of ISP and meteorological conditions during a 4-year period in the urban area of Bologna, Italy, in which all cases of pneumothorax can be exhaustively identified. For each day of the study period, Patm and ambient temperature were obtained from the local meteorological institute. A cluster was defined as the admission of at least two patients with pneumothorax within 3 days of each other., Results: There were 294 episodes of ISP; 247 (84%) occurred in 76 clusters. Clusters were significantly associated with wider differences in Patm between the index day (ie, the first day of the cluster) and the previous day (ie, the difference in mean [+/- SEM] Patm, -1.23 +/- 0.45 vs + 0.04 +/- 0.12 mm Hg, respectively; p = 0.01[analysis of variance]). Similarly, pneumothorax and storms (but not temperature) were significantly associated (p < 0.0001 [chi(2) test])., Conclusions: This large-scale study shows that patients with ISP are hospitalized in clusters and suggests that important variations in Patm may be involved. The knowledge of this relationship may help to understand the pathophysiology of the disease.

Catamenial pneumothorax is an uncommon disease whose management is not consensual. We report the case of a patient who experienced several episodes of pneumothorax. She was initially treated by repair of diaphragmatic defects and hormonal treatment. During the therapeutic amenorrhea, no recurrence occurred. However, each cessation of medical therapy was followed by recurrence. Finally, talc pleurodesis and tubal ligature were performed without any recurrence in the subsequent 12 months. This report outlines the great difficulties that can be encountered in the management of patients with catamenial pneumothorax.

Objectives: To evaluate the incidence of catamenial pneumothorax (CP) among women who have been referred for the surgical treatment of spontaneous pneumothorax (SP) and to study its pathogenic mechanisms., Design: A prospective study of women of reproductive age who have been referred to our center for the surgical treatment of SP. Patients with pneumothorax secondary to a known lung disease were excluded., Setting: A university hospital., Methods: At the preoperative evaluation, special attention was given to the investigation of a possible temporal relationship between pneumothorax and menses. Video-assisted thoracoscopy constituted the operative technique of choice. The lung was inspected to identify blebs or bullae and the origin of possible air leaks. Signs of thoracic endometriosis were also carefully searched for. The diaphragm was systematically inspected to search for holes and/or endometrial implants. When limited diaphragmatic abnormalities were found, a partial diaphragmatic resection was carried out using an endoscopic stapler. In case of lesions that were not accessible by a purely endoscopic approach, a utility minithoracotomy was used., Results: In an 18-month period, 32 women with SP were referred for surgery. In eight cases, the catamenial character of the pneumothorax was recognized by clinical history. In all these patients, the following diaphragmatic abnormalities were found at surgery: holes (one patient); endometrial implants (three patients); and both (four patients). Visceral pleural endometriosis was found in one patient. During pathologic examination, diaphragmatic endometriosis was confirmed in seven of the eight cases. In one patient, it was associated with pulmonary and pleural endometriosis. In only one patient (with multiple diaphragmatic holes and a pulmonary nodular brown lesion), endometriosis could not be confirmed at histology, but signs of parenchymal focal hemorrhages were found., Conclusions: Our experience shows that (1) CP is more frequent than expected and (2) diaphragmatic abnormalities seem to play a fundamental role in its pathogenesis.

We report the case of a 25-year-old woman with recurrent right-sided catamenial pneumothorax. At thoracoscopy, the diaphragm presented several violet implants with holes. The presence of diaphragmatic endometrial implants was confirmed at pathologic examination. Re-review of the preoperative chest x-ray film showed 8 x 5 and 1 x 1 mm bubbles at the level of the right diaphragm associated with the homolateral pneumothorax, thus suggesting that passage of air from the genital tract through the diaphragm was responsible for the pneumothorax. This may further clarify the pathogenesis of catamenial pneumothorax which remains controversial in the literature.

Thoracic endometriosis syndrome includes four well-recognized clinical entities, namely catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis and lung nodules, as well as some exceptional presentations. The etiological mechanisms of this syndrome are not well understood, and different theories have been proposed. Controversies exist about optimal management, as experience has been drawn from case reports and small clinical series. Surgery, hormonal treatments and combined approaches have all been proposed, with variable results in terms of short and long term outcome. [Copyright &y& Elsevier]

Evaluates the incidence of catamenial pneumothorax among women referred for the surgical treatment of spontaneous pneumothorax. Investigation of possible temporal relationship between pneumothorax and menses; Identification of blebs and origin of possible air leaks; Signs of thoracic endometriosis.