the ovaries are the most common sites affected , but endometriosis can also involve the gastrointestinal tract , urinary tract , chest , and soft tissues .
endometriosis of the chest is uncommon , and the diagnosis is usually established on clinical grounds .
endometrial tissue may involve the pleura by migrating from the peritoneal cavity to the pleural cavity through diaphragmatic defects or via microembolization .
pleuritic chest pain , pneumothorax , pleural effusions , or cyclic haemoptysis can occur with pulmonary involvement [ 35 ] .
a 35-year - old female presented with episodes of a right chest pain approximately 3 - 4 days in a month and resolved spontaneously .
her primary care physician had treated her with antibiotics empirically throughout the four months . during the last episode of chest pain , the patient described having a pain not resolving with analgesics combination .
the patient did not have any exacerbating factors , fevers , dyspnoea , haemoptysis , weight loss , and gastrointestinal complaints .  
the patient 's medical history was unremarkable , and she specifically denied a history of trauma and cardiopulmonary disease .
she had spent 4 months in seaside town and had also worked at a seafood restaurant .
her physical examination was within normal limits , except minimal pain in the right - sided lower chest and tenderness of the left lower abdominal quadrant .
routine laboratory tests and tumor markers ( afp , cea , ca 15 - 3 , ca 19 - 9 ) were within normal limits but increased serum level of ca-125 level ( 53.7  u / ml , normal value : 035  u / ml ) .
her chest radiography showed a closed right - sided costophrenic angle and minimal pleural effusion without evidence of pneumonia ( figure 1(a ) ) .
chest computed , tomography ( ct ) scans were performed 6 days after the onset of menstruation , and these did not demonstrate pleural effusion or any abnormality ( figure 1(b ) ) .
a percutane thoracal punction ( no abnormalities were noted on histopathologic examination ) was done because she denied thoracoscopic examination .
pelvic endometriosis was considered a possible diagnosis according to the results of us and mr of the abdomen .
pelvic us revealed a left adnexal semisolid mass , with a thick wall and septa , measuring 71  61  cm ( figure 1(c ) ) .
mr imaging evaluated a left adnexal mass in 67  57  mm diameter with , high - signalintensity areas on t1- ( figures 2(a ) and 2(b ) ) and t2-weighted ( figures 2(c ) and 2(d ) ) images .
in addition , dynamic signal range was not narrowed with fat - suppressed sequence , and heterogeneous pattern was found on postcontrast series .
therefore , based on imaging characteristics immature teratoma , endothermal sinus tumor , and germ cell tumor must be considered primarily .   at exploratory laparotomy
, a transverse incision was performed , and a 6  cm mass was found just behind the uterus , as well as adhesions between the mass and the adjacent tissues .
the patient needed sharp dissection and underwent adhesiolysis with left - sided salpingo - oophorectomy .
rest of endometriotic focuses on uterus , pouch of douglas , and other peritoneal surfaces were destroyed with electro - coagulation .
macroscopic appearance showed multiple irregular hemorrhagic foci and chocolate cysts ( figure 3 ) .  
the postoperative recovery was uneventful , and the patient was discharged on the third post - operative day .
leuprolide acetate ( lucrin 3.75  mg ; abbott australasia , kurnell , nsw , australia ) was used to achieve endometrial atrophy for six months after surgery .
medical treatment was continued with a cyclic low - dose combined oral contraceptive ( yasmin ; bayer healthcare pharmaceuticals inc . ,
one year of regular followup , there was no evidence of recurrent pleural effusion , chest pain , and abdominal complaints .
the endometrial cells implant on serosal surfaces into the peritoneal cavity and transport to the thorax through diaphragmatic defects and lymphatic or vascular channels .  
thoracal endometriosis , depending on the extent and tissue affected , can produce pleuritic chest pain , pleural effusion , hemothorax , and pneumothorax .
the physical manifestations are variable , with some patients being asymptomatic and others having disabling chest or pelvic pain , adnexal masses , or unusually signs . in our patient ,
periodic episodes of symptoms concurrent with menstruation led to the suspicion of a relationship between these conditions .
the peak incidence for pelvic endometriosis occurred between   24   and 29 years , whereas the peak incidence for thoracal involvement was between 30 and 34 years .   in a series of 110 patients with thoracal endometriosis , pneumothorax , hemothorax , hemoptysis , and pulmonary nodules
the right hemithorax was involved in more than 90% of all manifestations except for nodules .  
regardless of pathophysiology , thoracal endometriosis is generally associated with coexistent pelvic endometriosis and usually occurs 5 years after the diagnosis of pelvic endometriosis .
however , most women with endometriosis have normal or nonspecific results from physical examinations , and laparoscopy is necessary for the definitive diagnosis . for the definite confirmation of presence of endometrial tissue ct - guided percutaneous transthoracic needle biopsy   or thoracoscopic tissue biopsy
we only able to perform thoracal ct and abdominal mr imaging in present case , because our patient denied a thoracoscopic examination .
the us appearance of pelvic endometriosis exhibits diffuse low - level internal echoes , hypoechoic focal lesion , and rarely , may be anechoic , mimicking a functional ovarian cyst .
patel et al . found that wall thickness is not a differentiating feature between endometriomas and other ovarian masses . using ct , endometriosis of the lung parenchyma
mr imaging has been shown to have greater specificity for the diagnosis of abdominal endometriomas .
. lesions with degenerated blood products , including concentrated protein , appear with high - signalintensity areas on t1- and t2-weighted images . in our case ,
t1-weighted mr image showed a multilocular high - signalintensity mass on the left ovary , and highness in signal intensity remained in t2-weighted image .
a common feature of an endometrioma , shading , is present when a cyst that is hyperintense on a t1-weighted image becomes hypointense on a t2-weighted image .
this shading reflects the chronic nature of an endometrioma and helps differentiate it from other blood - containing lesions except hemorrhagic corpus luteum cysts , which do not exhibit shading on t2-weighted images .
other lesions that appear with high - signalintensity on t1-weighted images include dermoids , mucinous cystic tumors , and hemorrhagic masses .  
treatment for thoracal endometriosis can be medical for chest pain and effusion or surgical , depending on the severity of urgent and elective symptoms .
medical treatment is one of the choices of treatment to relieve cyclic pain in endometriosis .
multiple pharmacologic agents in use include combined oral contraceptives , danazol , gn - rh agonists and progestins . in our patient , medical treatment with a gn - rh agonist , which was continued with a cyclic low - dose
definitive surgery includes hysterectomy and oophorectomy and is usually reserved for women with intractable pain .
the conservative surgery , including left - sided oophorectomy , was performed to our patient . in our patient ,
, we did not establish pleural endometriosis cytologically but the monthly chest pain associated with endometrioma of the ovary supported extrapelvic lesion , clinically .
 chest pain is a rare sign of thoracal endometriosis associated with endometrioma of the tubo - ovarian endometrioma . 
 we report the case periodic episodes of chest pain concurrent with menstruation in a 35-year - old female , in which ovarian endometrioma was diagnosed and left - sided oophorectomy was performed . after surgery , 
 patient underwent medical treatment which included a gn - rh agonist and a combined oral contraceptive . in the follow - up period 
 , there was no evidence of chest pain . 
1. Introduction
2. Case Report
3. Discussion