Extrapelvic Endometriosis: A Systematic Review

J Minim Invasive Gynecol. 2020 Feb;27(2):373-389. doi: 10.1016/j.jmig.2019.10.004. Epub 2019 Oct 13.

Abstract

Objective: To conduct a systematic review of the literature on patients with extrapelvic deep endometriosis.

Data sources: A thorough search of the PubMed/Medline, Embase, and Cochrane databases was performed.

Methods of study selection: Studies in the last 20 years that reported on primary extrapelvic endometriosis were included (PROSPERO registration number CRD42019125370).

Tabulation, integration, and results: The initial search identified 5465 articles, and 179 articles, mostly case reports and series, were included. A total of 230 parietal (PE), 43 visceral (VE), 628 thoracic (TE), 6 central nerve system, 12 extrapelvic muscle or nerve, and 1 nasal endometriosis articles were identified. Abdominal endometriosis was divided into PE and VE. PE lesions involved primary lesions of the abdominal wall, groin, and perineum. When present, symptoms included a palpable mass (99%), cyclic pain (71%) and cyclic bleeding (48%). Preoperative clinical suspicion was low, the use of tissue diagnosis was indeterminate (25%), and a few (8%) malignancies were suspected. Surgical treatment for PE included wide local excision (97%), with 5% recurrence and no complications. Patients with VE involving abdominal organs - kidneys, liver, pancreas, and biliary tract - were treated surgically (86%) with both conservative (51%) and radical resection (49%), with 15% recurrence and 2 major complications reported. In patients with TE involving the diaphragm, pleura, and lung, isolated and concomitant lesions occurred and favored the right side (80%). Patients with TE presented with the triad of catamenial pain, pneumothorax, and hemoptysis. Thoracoscopy with resection followed by pleurodesis was the most common procedure performed, with 29% recurrence. Adjuvant medical therapy with gonadotropin-releasing hormone was administered in 15% of cases. Preoperative magnetic resonance imaging was performed in all cases of nonthoracic and nonabdominal endometriosis. Common symptoms were paresthesia and cyclic pain with radiation. Surgical resection was reported in 84%, with improvement of symptoms.

Conclusion: Extrapelvic endometriosis, traditionally thought to be rare, has been reported in a considerable number of cases. Heightened awareness and clinical suspicion of the disease and a multidisciplinary approach are recommended to achieve a prompt diagnosis and optimize patient outcomes. Currently, there are no comparative studies to provide recommendations regarding optimal diagnostic methods, treatment options, and outcomes for endometriosis involving extrapelvic sites.

Keywords: Deep endometriosis; Extrapelvic endometriosis; Lung endometriosis; Nerve endometriosis; Parietal endometriosis; Thoracic endometriosis; Visceral endometriosis.

Publication types

  • Systematic Review

MeSH terms

  • Adult
  • Diaphragm / pathology
  • Diaphragm / surgery
  • Endometriosis / diagnosis
  • Endometriosis / epidemiology*
  • Endometriosis / pathology
  • Endometriosis / therapy
  • Female
  • Gastrointestinal Diseases / diagnosis
  • Gastrointestinal Diseases / epidemiology*
  • Gastrointestinal Diseases / pathology
  • Gastrointestinal Diseases / therapy
  • Humans
  • Magnetic Resonance Imaging
  • Muscular Diseases / diagnosis
  • Muscular Diseases / epidemiology*
  • Muscular Diseases / pathology
  • Muscular Diseases / therapy
  • Nervous System Diseases / diagnosis
  • Nervous System Diseases / epidemiology*
  • Nervous System Diseases / pathology
  • Nervous System Diseases / therapy
  • Pneumothorax / diagnosis
  • Pneumothorax / epidemiology
  • Pneumothorax / etiology
  • Pneumothorax / therapy
  • Recurrence
  • Thoracic Diseases / diagnosis
  • Thoracic Diseases / epidemiology*
  • Thoracic Diseases / pathology
  • Thoracic Diseases / therapy
  • Thoracoscopy