Hepatic Endometriosis With Diaphragmatic and Pulmonary Invasion Treated by En Bloc Resection: A Case Report.

BACKGROUND: Hepatic endometriosis is rare, and transdiaphragmatic extension into the lung has not previously been described. CASE: A 54-year-old postmenopausal woman presented with refractory right upper quadrant and right shoulder pain, requiring opioids for pain control. Imaging revealed a multiloculated, blood-filled lesion in the liver breaching the diaphragm and possible extension into the lower lobe of the right lung. Percutaneous biopsy revealed endometrial stroma and glands. Multidisciplinary assessment recommended en bloc resection given progressive pain and suspected diaphragmatic and pulmonary invasion, indicating possible malignant transformation. The patient underwent en bloc resection of the right hemiliver, part of the diaphragm, and part of the lower lobe of the right lung. The diaphragmatic defect was reconstructed with a biologic mesh. Final pathology demonstrated endometriosis infiltrating liver, diaphragm, and lung parenchyma. There were no histologic signs of malignancy, and resection margins were clear. Postoperative recovery was uneventful apart from a transient sterile pleural effusion managed with drainage and a short course of antibiotics. All drains were removed by day 7, and the patient was discharged on day 8. Follow-up computed tomography at 4 months showed no recurrence and intact mesh repair, and the patient had resumed normal activities without opioid analgesia. CONCLUSION: The present case provides a first description of hepatic endometriosis invading the diaphragm and lung, successfully managed by a combined team of hepatobiliary-thoracic surgeons. Hepatic endometriosis should be considered in the differential diagnosis of a cystic hepatic mass, and aggressive yet organ-sparing surgery can achieve excellent outcomes when extrahepatic extension is present.