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Communications to the Editor |

Endobronchial Endometriosis Nd-YAG Therapy vs Drug Therapy FREE TO VIEW

Jean-Pierre L’Huillier, MD
Author and Funding Information

Affiliations: Cabinet de Pneumologie, La Varenne Saint-Hilaire, France,  University of Perugia Medical School, Terni, Italy

Correspondence to: Jean-Pierre L’Huillier MD, Cabinet de Pneumologie, F-94210 La Varenne Saint-Hilaire, France; e-mail: lhuillier.jean-pierre@wanadoo.fr



Chest. 2005;127(2):684-685. doi:10.1378/chest.127.2.684
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To the Editor:

I read with great interest the selected report by Puma et al1in a recent issue of CHEST (September 2003). They described a case of endobronchial endometriosis that was successfully treated by Nd-YAG laser therapy. However, I would like to suggest that pulmonary endometriosis is probably less rare than is commonly thought, as I have counted 104 cases of tracheobronchial or pulmonary endometriosis as a result of searches of the medical literature (including 23 cases published in languages other than English). Some of these cases presented evidence such as a pattern of lung opacities or necropsy findings and not catamenial hemoptysis. I also think that Nd-YAG laser therapy could be useful for the treatment of endobronchial endometriosis only when drug therapy is not effective, or when the adverse effects of this drug therapy are intolerable, as this procedure is associated with a certain morbidity. Although the risk of general anesthesia is considered to be low, hypoxemia, hypercapnia, and acidosis secondary to apneas, and the reduction of ventilation are presumed to be the major causes of intraoperative and postoperative complications.2 Cardiac arrest due to ventricular fibrillation may occur during rigid bronchoscopic laser therapy even in young patients with benign bronchial lesions.3The authors maintained that “Medical therapy has been recommended as the first choice in pulmonary endometriosis. It consists of the suppression of endometrial tissue with progesterone (ie, pseudopregnancy) or danazol (ie, pseudomenopause).” I only partly agree with this statement, as the authors failed to mention that gonadotropin-releasing hormone agonists have been prescribed for > 10 years and are effective in the treatment of this disease, as in our published case.5 Finally, I think that the follow-up period was not sufficiently long enough to ensure that the treatment was permanently effective. Unfortunately, the authors did not mention whether follow-up fiberoptic bronchoscopy was performed during menses.

Puma, F, Carloni, A, Casucci, G, et al (2003) Successful endoscopic Nd-YAG laser treatment of endobronchial endometriosis.Chest124,1168-1170. [CrossRef] [PubMed]
 
Vitacca, M, Natalini, G, Cavaliere, S, et al Breathing pattern and arterial blood gases during Nd-YAG laser photoresection of endobronchial lesions under general anesthesia: use of negative pressure ventilation: a preliminary study.Chest1997;112,1466-1473. [CrossRef] [PubMed]
 
D’Aloia, A, Faggiano, P, Fiorina, C, et al Cardiac arrest due to ventricular fibrillation as a complication occurring during rigid bronchoscopic laser therapy.Monaldi Arch Chest Dis2003;59,88-90. [PubMed]
 
L’Huillier, JP, Salat-Baroux, J Une observation d’endométriose pulmonaire.Rev Pneumol Clin2002;58,233-236. [PubMed]
 
Espaulella, J, Armengol, J, Bella, F, et al Pulmonary endometriosis: conservative treatment with GnRH.Obstet Gynecol1991;78,535-537. [PubMed]
 
To the Editor:

We read with interest the letter by Dr. L’Huillier regarding our article, “Successful Endoscopic Nd-YAG Laser Treatment of Endobronchial Endometriosis,” published in CHEST (September 2003).1 The rarity of central airway endometriosis and the difficulty of a clear demonstration of the bronchial lesion, until now, has hampered local therapy for this condition. In our patient, the bronchial lesion was conclusively located by spiral CT scan and fiberoptic bronchoscopy, which were obtained at the onset of menses. In such a fortunate case, the simple endoscopic Nd-YAG laser vaporization of the previously recognized target led to the patient’s immediate and stable recovery. The patient is still asymptomatic after a follow-up period of 34 months, which we consider to be a good long-term outcome. The patient’s condition was controlled at the onset of menses with fiberoptic bronchoscopy 3 months after treatment, with normal endoscopic findings.

Dr. L’Huillier emphasizes the risk of general anesthesia and rigid bronchoscopic laser therapy. Worldwide, thousands of such procedures have been carried out with low risk, even in desperate situations such as in patients with critical tracheal stenoses. We have extensive experience in rigid bronchoscopic laser therapy of tracheobronchial obstructions in > 1,200 consecutive cases with a mortality rate < 0.1% (in an emergency procedure for impending asphyxia). For this reason, in the reported case, we preferred to use the ventilating rigid bronchoscope under general anesthesia, mainly to obtain a steady target and to more precisely deliver the laser beam. Nevertheless, we clearly stated that the procedure “could have been performed through the flexible bronchoscope” with local anesthesia in an outpatient setting. Hormonal therapy is effective in curing or controlling symptoms, however:

  1. It needs to be maintained for a long period of time;

  2. There is a variable recurrence rate after drug therapy is discontinued23; and

  3. Heavy side effects can be observed.

We respect our colleague’s opinions, but we think that some concepts in Dr. L’Huillier’s letter overlook an obvious point. Unquestionably, a single course or even multiple courses of bronchoscopic laser therapy are preferable to prolonged hormonal therapy with its possibly heavy side effects and uncertain results. The problem of local therapy for this condition is related to the difficulty of conclusively locating the bleeding source in the tracheobronchial mucosa.

Finally, a clear-cut distinction should be maintained between pulmonary endometriosis with distal parenchymal lesions and the less common endobronchial endometriosis. Only patients with the latter condition can take advantage of endoscopic laser therapy.

References
Puma, F, Carloni, A, Casucci, G, et al Successful endoscopic Nd-YAG laser treatment of endobronchial endometriosis.Chest2003;124,1168-1170. [CrossRef] [PubMed]
 
Bateman, ED, Morrison, SC Catamenial hemoptysis from endobronchial endometriosis: a case report and review of previously reported cases.Respir Med1990;84,157-161. [CrossRef] [PubMed]
 
Lawrence, HC Pulmonary endometriosis in pregnancy.Am J Obstet Gynecol1988;159,733-734. [PubMed]
 

Figures

Tables

References

Puma, F, Carloni, A, Casucci, G, et al (2003) Successful endoscopic Nd-YAG laser treatment of endobronchial endometriosis.Chest124,1168-1170. [CrossRef] [PubMed]
 
Vitacca, M, Natalini, G, Cavaliere, S, et al Breathing pattern and arterial blood gases during Nd-YAG laser photoresection of endobronchial lesions under general anesthesia: use of negative pressure ventilation: a preliminary study.Chest1997;112,1466-1473. [CrossRef] [PubMed]
 
D’Aloia, A, Faggiano, P, Fiorina, C, et al Cardiac arrest due to ventricular fibrillation as a complication occurring during rigid bronchoscopic laser therapy.Monaldi Arch Chest Dis2003;59,88-90. [PubMed]
 
L’Huillier, JP, Salat-Baroux, J Une observation d’endométriose pulmonaire.Rev Pneumol Clin2002;58,233-236. [PubMed]
 
Espaulella, J, Armengol, J, Bella, F, et al Pulmonary endometriosis: conservative treatment with GnRH.Obstet Gynecol1991;78,535-537. [PubMed]
 
Puma, F, Carloni, A, Casucci, G, et al Successful endoscopic Nd-YAG laser treatment of endobronchial endometriosis.Chest2003;124,1168-1170. [CrossRef] [PubMed]
 
Bateman, ED, Morrison, SC Catamenial hemoptysis from endobronchial endometriosis: a case report and review of previously reported cases.Respir Med1990;84,157-161. [CrossRef] [PubMed]
 
Lawrence, HC Pulmonary endometriosis in pregnancy.Am J Obstet Gynecol1988;159,733-734. [PubMed]
 
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