Radiological findings of PE:
Chest radiograph (CR):
-
Pneumothorax;
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Pleural effusions; and
-
Hemopneumothorax.
Computed tomography (CT):
-
Helpful in mapping the lesions and very useful in discarding other diagnoses.
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Usually depicts implants as hypoattenuating nodules sometimes associated with an iso-attenuated component,
depending on the size and blood content.
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Other findings include:
- Pneumothorax;
- Pleural effusions;
- Pleural adhesions; and
- Indirect signs of chronic pleural inflammation.
Magnetic resonance imaging (MRI):
- High contrast resolution;
- Better characterization of hemorrhagic lesions; and
- Better differentiation between pleural and parenchymal implants.
- Acute and subacute bleeding: high signal intensity on T1-weighted images and relatively low signal intensity on T2-weighted images.
- Chronic endometriosis (fibrotic endometrial lesions): irregular spiculated contour and low signal intensity on T2-weighted images.
Five cases will be used to illustrate radiological findings of pleural endometriosis in different exams,
including CR,
CT,
and MRI.
Case 1: Catamenial pneumothorax (Figures 3-4)
A 30-years-old woman with ovarian endometrioma presented with dyspnea and a catamenial right sided pneumothorax. CR and CT demonstrate right-sided pneumothorax.
The patient was managed with video-assisted thoracoscopic surgery (VATS) and pleural biopsy showed fibrotic tissue,
hemosiderin filled macrophages and inflammatory cells.
Fig. 3: Case 1: Catamenial pneumothorax. CR (A) and coronal chest CT scan (B) demonstrate a right sided pneumothorax.
Fig. 4: Case 1: Catamenial pneumothorax. Axial chest CT scan demonstrates a right sided pneumothorax and pleural adhesions.
Case 2: Nodular pleural thickening and intrapulmonary nodule (Figures 5-8)
A 48-years-old woman asymptomatic and bilateral mastectomy for atypical papillomas performed a routine chest CT.
CT demonstrates two areas of nodular pleural thickening and one intrapulmonary nodule.
The patient was managed with a CT – guided percutaneous biopsy of left lung nodule.
She also performed a pleural biopsy guided by VATS.
Both biopsies confirmed endometrial tissue.
Fig. 5: Case 2: Nodular pleural thickening implant adjacent to the diaphragm. Axial chest CT scan demonstrates an iso-attenuated implant with hypoattenuating component.
References: Hospital Sírio Libanês - São Paulo/Brazil
Fig. 6: Case 2: Nodular pleural thickening implant adjacent to the mediastinum. Axial chest CT scan demonstrates an hypoattenuating implant with an iso-attenuated component.
References: Hospital Sírio Libanês - São Paulo/ Brazil
Fig. 7: Case 2: Axial CT images show an intrapulmonary nodule (arrow).
References: Hospital Sírio Libanês - São Paulo/ Brazil
Fig. 8: Case 2: CT – guided percutaneous biopsy of left lung nodule.
References: Hospital Sírio Libanês - São Paulo/ Brazil
Case 3: Catamenial pneumothorax (Figures 9-10)
A 41-years-old woman asymptomatic with tubal endometriosis performed a preoperative evaluation.
CR and CT show right-sided pneumothorax and pleural adhesions.
The patient was managed with VATS converted into an open thoracotomy.
Anatomopathological confirmed pleural endometriosis.
Fig. 9: Case 3: Catamenial pneumothorax. CR(A) and coronal chest CT scan (B) demonstrate a partial pulmonary collapse and right sided pneumothorax.
Fig. 10: Case 3: Catamenial pneumothorax. Axial (A) and sagittal (B) CT images show right-sided pneumothorax and pleural adhesion (arrows).
Case 4: Catamenial hemothorax (Figures 11-13)
A 51-years-old woman diagnosed with pelvic endometriosis presented with dyspnea and ventilator-dependent chest pain associated with recurrent episodes of catamenial right-sided hemothorax and an episode of catamenial left sided hemothorax.
CR and CT images demonstrate bilateral pleural effusion,
nonspecific nodular pleural thickening,
and extrapleural chronicity signs.
The patient was managed with VATS and pleural biopsy showed endometrial tissue.
Fig. 11: Case 4: Catamenial hemomothorax. CR images demonstrate bilateral pleural effusion.
Fig. 12: Case 4: Catamenial hemomothorax. Coronal CT image demonstrates bilateral pleural effusion (A). Axial CT image shows a nonspecific nodular pleural thickening (B).
Fig. 13: Case 4: Catamenial hemomothorax. Axial CT images show an extrapleural fat hypertrophy (A) and inner cortical thickening of of adjacent rib (B), suggesting chronicity.
Case 5: Catamenial hemopneumothorax (Figures 14-19)
A 32-years-old woman with pelvic endometriosis presented with dyspnea and ventilator-dependent chest pain. Axial and coronal T1WI shows a hemopneumothorax and a nodule on the pleural surface,
suggestive of hemorrhagic content.
Pelvic MRI presents an ovarian endometrioma and a retrocervical fibrotic lesions.
Diagnosis of pleural endometriosis was confirmed with pleural biopsy guided by VATS.
Fig. 14: Case 5: Catamenial hemopneumothorax. CR images demonstrate right-sided hemopneumothorax.
Fig. 15: Case 5: Catamenial hemopneumothorax. Axial (A) and coronal (B) T1WI show high signal-intensity nodule (arrows) attached to the parietal pleura surface.
Fig. 16: Case 5: Catamenial hemopneumothorax. Axial T1WI shows high signal-intensity nodule (arrows) attached to the right parietal pleura surface.
Fig. 17: Case 5: Catamenial hemopneumothorax. Axial T1WI shows a small hyperintense right-sided hemopneumothorax (arrows), suggestive of hemorrhagic content.
Fig. 18: Case 5: Catamenial hemopneumothorax. Axial T2 image shows a irregular spiculated contour with low signal intensity, suggesting fibrotic endometrial lesion (A). There also is a left ovarian endometrioma with high signal intensity on T1WI (B) and relatively low signal intensity on T2 image (A).
Fig. 19: Case 5: Catamenial hemopneumothorax. Sagittal T2 images show a retroverted uterus (A) and a retrocervical spiculated margins lesion (B). There also is deep endometriosis infiltrating sigmoid colon/ rectum.