C. Mehta1, B. Stanifer1, S. Fore-Kosterski1, A. Yeldandi1, C. Gillespie1, S. Meyerson1, D. Odell1, M. DeCamp1, A. Bharat1 1Northwestern Memorial Hospital,Chicago, IL, USA
Introduction: The etiology of primary spontaneous pneumothorax (PSP) in healthy normal-statured women differs from tall, thin men. Nevertheless, PSP is managed similarly in both men and women. We investigated the natural history of PSP in females and determined the incidence of clinical, morphological, and histological features of catamenial pneumothorax (CP).
Methods: Between 5/2009 – 6/2015, all healthy normal-statured, menstruating women without tobacco or marijuana smoking, lung disease, trauma or pregnancy were included in this study. Clinico-demographic variables were studied using a prospective database. Kaplan-Meier curves were constructed to determine PSP recurrence and analyzed using log-rank test.
Results:The mean age of the study cohort (n=33) was 33.4+/- 14.4 years. Nine (27%) had left-sided and 24 (73%) had right-sided PSP. Tube thoracostomy in all led to successful initial treatment. Overall recurrence rate during follow up (median 14 mo) was 64%. Right PSP had higher and earlier recurrence (70%; median follow up 7 mo) compared to left (56%; 16 mo, p=0.02). Four patients (12%) presented with a large recurrent tension pneumothorax within the first 6 months of the initial episode. Two patients refused further treatment after ipsilateral recurrence. The remaining 19 patients (58%) underwent surgery including apical wedge resection with mechanical pleurodesis (12/19, 63%) or subtotal pleurectomy (7/19, 37%). One patient had ipsilateral recurrence after surgery which was treated with talc poudrage. Histology showed apical blebs/fibrosis in 11 patients with mesothelial hyperplasia and reactive changes but no endometrial glands or stroma.
Eight (24%) patients had symptoms within 72 hours of onset of menses. Of these, 3 patients had known pelvic endometriosis. All 8 patients were placed on oral contraception, however all had ipsilateral recurrence within the first year of the initial episode. Six (75%) were right and 2 (25%) were left pneumothorax. All 8 patients underwent surgery at the second episode. Thoracoscopy revealed diaphragmatic fenestrations in 4 (50%) and nodular deposits in 3 patients (38%). No endometrial glands/stroma were seen in any specimens. Three (38%) patients had hemosiderin-laden macrophages at the site of fenestrations.
Conclusion:PSP in healthy, normal-statured menstruating women has high recurrence and can be life threatening. This may warrant surgical intervention at the initial episode. Further, the diagnosis of CP should be made clinically as pathologic findings of endometrial glands or stroma are rare. Women with clinical CP also have high recurrence despite hormonal suppression and thus should be considered for pleural symphysis at initial presentation.
