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Narrow Band Imaging for Thoracic Endometriosis Takehiro Yamamoto*, Ryo Fujikawa, Yoshifumi Arai and Toru Nakamura

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Narrow Band Imaging for Thoracic Endometriosis Takehiro Yamamoto*, Ryo Fujikawa, Yoshifumi Arai and Toru Nakamura Yamamoto et al. surg case rep (2020) 6:242 https://doi.org/10.1186/s40792-020-01000-x CASE REPORT Open Access Narrow band imaging for thoracic endometriosis Takehiro Yamamoto*, Ryo Fujikawa, Yoshifumi Arai and Toru Nakamura Abstract Background: The thoracic cavity is the most frequent site of extrapelvic endometriosis. It exhibits a wide variety of clinical manifestations, such as chest pain, cough, and respiratory distress, and is frequently associated with pelvic endometriosis. Although histological confrmation is the gold standard for a defnitive diagnosis, endoscopic iden- tifcation of the afected area is often difcult. Narrow band imaging (NBI) is an imaging technique that emphasizes vascular structures and is reported to be useful in the diagnosis of pelvic endometriosis. Case presentations: A 31-year-old woman and 39-year-old woman developed a recurrent right pneumothorax during their menstruation cycles. They both had no medical history suggesting pelvic endometriosis. We planned an elective video-assisted thoracoscopic surgery for the suspicion of thoracic endometriosis. In addition to white light alone, an NBI observation enhanced the microvasculature of the suspected lesions and allowed us to identify the afected area more clearly. Partial resections of the diaphragm were performed. Histopathological and immunohisto- chemical studies of each specimen confrmed the diagnosis of extrapelvic endometriosis. Conclusions: NBI may improve the diagnostic accuracy for thoracic endometriosis, especially in clinically suspected patients but without a history of pelvic endometriosis. Keywords: Thoracic endometriosis, Catamenial pneumothorax, Narrow band imaging (NBI) Background endometriosis exhibiting a catamenial pneumothorax Extrapelvic endometriosis is caused by ectopic endome- successfully diagnosed by NBI. trial tissue outside the abdominopelvic cavity [1]. Te thoracic cavity is the most frequent site with a wide vari- Case presentations ety of clinical manifestations such as chest pain, cough- Case 1 ing, and respiratory distress [2, 3]. Although histological A 31-year-old woman (Gravida 0, Para 0) presented confrmation is the gold standard for a defnitive diagno- with a recurrent right spontaneous pneumothorax that sis, endoscopic identifcation of the afected area is often occurred 4 days after the onset of menstruation. She had difcult similar to that of pelvic endometriosis [4]. Nar- a history of an ipsilateral pneumothorax treated by chest row band imaging (NBI) is an imaging technique that tube drainage 2 months prior. Her other past history emphasizes vascular structures and has been reported to was negative for dysmenorrhea, pelvic pain, or any other be useful for the laparoscopic diagnosis of pelvic endo- symptoms suggestive of pelvic endometriosis. Given the metriosis [5]. Here, we report two cases of thoracic recurrent pneumothorax without any underlying disease such as a lung cyst on chest computed tomography, we planned an elective video-assisted thoracoscopic surgery (VATS) to rule out thoracic endometriosis during her *Correspondence: [email protected] next menstrual cycle. Under thoracoscopic imaging with Departments of General Thoracic Surgery and Pathology, Seirei an endoscope system (Olympus Endoeye video telescope Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, Shizuoka 430-8558, Japan model LTF-S190-5CE, Olympus Medical Systems Corp., © The Author(s) 2020. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://crea- tivecommons.org/licenses/by/4.0/. Yamamoto et al. surg case rep (2020) 6:242 Page 2 of 4 Tokyo, Japan), brownish pleural spots over the centrum consistent with thoracic endometriosis and a gonadotro- tendineum of the diaphragm were observed with stand- pin-releasing hormone agonist was administered in both ard white light (Fig. 1a). Some of those changes were cases. Tey are currently disease free at 11 months after emphasized and more clearly visualized with dark green the surgery. in the NBI (Fig. 1b). Tese morphological changes were judged signifcant based on a subjective visual inspection. Conclusions A partial resection of the diaphragm was performed. Endometriosis is caused by ectopic endometrial tissue in areas other than the uterine cavity, which can lead to a Case 2 variety of symptoms, such as dysmenorrhea and infertil- A 39-year-old woman (Gravida 0, Para 0) presented ity, and a histological confrmation is the gold standard with a recurrent right spontaneous pneumothorax that for a defnitive diagnosis [6, 7]. However, the accuracy of occurred a day after the onset of menstruation. She had a the visual identifcation using laparoscopy is vulnerable history of an ipsilateral pneumothorax that resolved with depending on the surgeon’s expertise and morphological conservative management 6 months prior. Despite lack- change in the target lesion during the menstruation cycle ing any other history suggesting pelvic endometriosis, we [7, 8]. Tose factors may lead to a diagnostic delay and planned an elective VATS for the suspicion of thoracic poor surgical outcome [9, 10]. endometriosis during her next menstrual cycle. Several Te thoracic cavity is the most frequent site of brownish spots over the lung surface (Fig. 2a) and dia- extrapelvic endometriosis [11]. A wide variety of clini- phragm were observed with standard white light. Tose cal manifestations are seen such as chest pain, coughing, changes were visualized as dark green indicating hyper- and respiratory distress, and may not necessarily coincide vascularity in the NBI (Fig. 2b). A partial resection of the with the menstrual cycle [12]. Tat may result in diagnos- diaphragm was performed. tic difculty even by VATS [1, 13–15]. As with a laparo- scopic biopsy for pelvic endometriosis, cyclic changes in Pathological fndings and postoperative course the lesion and the skill of the attending surgeon might In the histopathological examinations of cases 1 and 2, also infuence the outcome [12]. ectopic endometrial lesions were found on the surface NBI is an imaging technique that emphasizes vascular of the pleura and diaphragm and were accompanied by structures and improves the detection of microvessels infammatory granulation with hemosiderin-laden mac- not clearly identifed under only conventional white light rophages (Fig. 3a, b). Immunohistochemically, each [5]. It is widely used in the gastrointestinal diseases and ectopic endometrial tissue sample was positive for estro- not costly to perform [16]. Recent studies have reported gen receptors and CD10 (Fig. 3c, d). Tose results were promising results of NBI for the diagnostic utility of Fig. 1 Representative images of the diaphragm in case 1. Some brownish spots were more clearly visualized as dark green with NBI (arrows) Yamamoto et al. surg case rep (2020) 6:242 Page 3 of 4 Fig. 2 Representative images of the lung surface in case 2. Brownish spots were visualized as dark green with NBI Fig. 3 Pathological specimens from both cases showing ectopic endometrial lesions on the surface of the diaphragm, accompanied by infammatory granulation with hemosiderin-laden macrophages (a: Case 1/b: Case 2). Immunohistochemical staining of CD10 (c: Case 1) and estrogen receptors (d: Case 2) with a positive expression that confrms the histological nature of endometriosis diagnosing pelvic endometriosis by detecting hyper- have been no reports of NBI having been used for tho- vascularity, which is a specifc disease pathology [8, 15]. racic endometriosis. However, to the best of our knowledge, to date, there Yamamoto et al. surg case rep (2020) 6:242 Page 4 of 4 Although most patients with thoracic endometrio- 2. Bagan P, Berna P, Assouad J, Hupertan V, Le Pimpec BF, Riquet M. Value of cancer antigen 125 for diagnosis of pleural endometriosis in females with sis have been associated with pelvic endometriosis [17], recurrent pneumothorax. Eur Respir J. 2008;31(1):140–2. the present cases had no suspicious history before the 3. Rousset-Jablonski C, Alifano M, Plu-Bureau G, Camilleri-Broet S, Rousset surgery. Terefore, we applied NBI to improve the diag- P, Regnard JF, et al. Catamenial pneumothorax and endometriosis- related pneumothorax: clinical features and risk factors. Hum Reprod. nostic accuracy at the time of their menstruation cycle. 2011;26(9):2322–9. Te NBI observation enhanced the microvasculature of 4. Wykes CB, Clark TJ, Khan KS. REVIEW: Accuracy of laparoscopy in the the suspected lesions, which was not clearly identifed diagnosis of endometriosis: a systematic quantitative review. BJOG. 2004;111(11):1204–12. by white light alone, and enabled a histological diagno- 5. Gono K, Obi T, Yamaguchi M, Ohyama N, Machida H, Sano Y, et al. Appear- sis of extrapelvic endometriosis with excellent clinical ance of enhanced tissue features in
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