Looking at the tip of the iceberg: a case report discussing the diagnosis and management of coexistent diaphragmatic and thoracic endometriosis.

Introduction: Diaphragmatic endometriosis is considered the most common extrapelvic localization of endometriosis. Thoracic endometriosis syndrome (TES) involves endometriotic deposits in the pleura and lungs. Diaphragmatic endometriosis and TES are often discussed as separate entities, although emerging evidence suggests a possible correlation. This case report highlights a patient with concurrent diaphragmatic and thoracic endometriosis. Case presentation: A 31-year-old nulligravid patient presented with dyspnea and acute right-sided chest pain. The patient's symptoms had a spontaneous onset and started in the week preceding her presentation. Six months earlier, the patient received an uncomplicated robotic-assisted excisional surgery for pelvic endometriosis, during which diaphragmatic endometriosis was spotted [#Enzian P0, O1/1, T3/3, A3, B2/2, C3, FI (sigmoid colon), F (diaphragm)]. Computed tomography scan revealed right-sided pneumothorax. Given her history, TES was suspected. A multidisciplinary surgical plan was implemented. Intraoperatively, the extension of thoracic endometriosis was much more than that of the disease observed on the peritoneal part of the diaphragm. Surgical excision of diaphragmatic lesions and apical pleurectomy were performed, followed by talc pleurodesis. The patient had a favorable postoperative recovery and remained symptom-free after 6 months. Clinical discussion: This case highlights the potential association between diaphragmatic endometriosis and TES, necessitating a high index of suspicion. Given the limitations of non-invasive imaging, surgical exploration remains crucial for the diagnosis and treatment. Studies suggest that diaphragmatic resection and postoperative hormonal therapy reduce recurrence rates. This case reinforces the need for a combined abdominothoracic approach in severly symptomatic patients. Conclusions: This report demonstrates the safety and efficacy of video-assisted thoracoscopy and laparoscopic surgery in treating coexistent diaphragmatic and thoracic endometriosis. A multidisciplinary approach is crucial for optimizing outcomes, and a high degree of clinical suspicion is necessary to ensure accurate diagnosis and treatment, especially given the limitations of non-invasive diagnostic modalities.