Intrathoracic gossypiboma presenting 47 years later as a purulent fistula: a case report

Background

Intrathoracic gossypiboma is a consequence of retained sponge/swap, gauzoma, muslinoma, textiloma, or cottonoid in the thoracic cavity during surgery. The thoracic cavity is of the rarest place for gossypiboma as these entities most occur after abdominal surgery.

Case presentation

We report a case of intrathoracic gossypiboma that was missed for an extended period of time with no symptoms and was successfully treated with surgical intervention.

Conclusions

The rarity of gossypiboma necessitates a high index of suspicion for correct diagnosis. Gossypiboma is often difficult to diagnose, leading to misdiagnosis and unnecessary interventions. It is important to consider this entity as a diagnosis in any case with an unexplained or unusual presentation during the postoperative period.

What type of imaging work-up will help to confirm the diagnosis of gossypiboma in the limb? Review of literature

Gossypiboma imaging features are not well known and are often confused with soft tissue tumours. Publications on this topic mainly consist of case reports and small cohorts. Its appearance on various imaging modalities is not well defined. This led us to carry out a review of literature to determine specifically: (1) which imaging modalities should be used in cases of suspected gossypiboma, (2) what are the most common imaging findings that contribute to the diagnosis of gossypiboma. An exhaustive review of literature was carried out in June 2015 in the Medline, PubMed and Cochrane databases using the keywords "gossypiboma/textiloma/foreign body". We found 205 articles describing one or multiple cases of gossypiboma in various locations. Of these, the 32 articles that had imaging data were chosen - 16 for the limbs and 16 for other locations. The type of imaging carried out, description of the gossypiboma and circumstances of the discovery and occurrence were recorded. Descriptive statistics were generated to define the type of imaging used and the various findings. Imaging consisted of X-rays in 21/32 cases (66%), computed tomography (CT) in 14/32 cases (43%), magnetic resonance imaging (MRI) in 21/32 cases (65%) and ultrasonography in 14/32 cases (43%). On X-rays, bone involvement was found in 9/15 cases (60%); there was peripheral contrast product uptake on the CT scans in 9/14 cases (64%), a hypointense signal on T1-weighted sequences on MRI in 6/13 cases (46%) and lack of vascularisation in 8/13 cases (62%) and a acoustic shadow on ultrasonography in 9/14 cases (64%). In a patient presenting with a soft tissue lump and history of surgery, an imaging work-up including X-rays, ultrasonography and MRI must be performed. Bone involvement on X-rays, acoustic shadowing on ultrasonography and hypointense signal on T1-weighted MRI sequences with lack of vascularisation in combination with a history of surgery can bring up the possibility of gossypiboma. If there is a possibility of soft tissue tumour, the case should be discussed in a multidisciplinary meeting and a biopsy should be performed first.

LEVEL OF EVIDENCE

IV - systematic analysis of published retrospective studies.

F-18 FDG PET of foreign body granuloma: pathologic correlation with imaging features in 3 cases

PURPOSE

Retained textiles with foreign body granulomatous reaction can form mass-mimicking soft tissue tumors, which may cause diagnostic, clinical, and medicolegal problems. In this study, we present 3 cases of foreign body granuloma by retained textiles, and demonstrate FDG PET findings with detailed pathologic correlation. We also provide a review of previous literatures.

MATERIALS AND METHODS

Three patients (all females; age range, 48-61 years) with histopathologic diagnosis of mass-forming foreign body granuloma caused by retained textiles were retrospectively studied. They underwent an FDG PET scan in our institute. The mass was located in the abdominopelvic cavity in all cases. The time interval between the prior surgery and the PET acquisition was 11 months, 15 or 19 years, and 26 years, respectively.

RESULTS

Intense FDG uptake with a ring-shaped pattern was observed in 2 cases, while no uptake in 1 case. Microscopically, 2 with ring-shaped FDG uptake showed a cellular foreign body reaction peripherally, and artificial textile fibers and acellular eosinophilic amorphous materials in the central portion. In the one without FDG uptake, the mass was composed of mainly necrotic debris surrounding by a thick layer of well-formed collagen fibers. In previous case reports describing the accumulation of FDG in foreign body granulomas, 9 of 10 cases showed intense FDG uptake with a ring-shaped pattern.

CONCLUSIONS

The ring-shaped pattern of FDG uptake seems to well characterize pseudotumor with foreign body granulomas. However, the pattern of FDG accumulation in retained textile with foreign body granulomas may vary due to histologic features.

Imaging of gossypibomas: pictorial review

OBJECTIVE

Textiloma and gossypiboma are terms used to describe a mass of cotton matrix that is left behind in a body cavity during an operation. This is an uncommon surgical complication. Gossypibomas are most frequently discovered in the abdomen. Such foreign bodies can often mimic tumors or abscesses clinically or radiologically; however, they are rarely reported because of the medicolegal implications. The manifestations and complications of gossypibomas are so variable that diagnosis is difficult and patient morbidity is significant.

CONCLUSION

This article discusses the clinical manifestations, pathophysiologic aspects, and most important complications related to gossypibomas; presents the classic imaging features of gossypibomas using a multitechnique approach; and shows some of the typical and atypical sites of gossypibomas.