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Case of the Month
Case of the Month
Gossypiboma mimicking a solitary fibrous tumor of the retroperitoneum
Gossypiboma mimicking a solitary fibrous tumor of the retroperitoneum
Contributed by: Zubin Driver
Contributed by: Zubin Driver
Introduction:
Introduction:
The name "gossypiboma" is derived from two Latin words, Gossypium- cotton and boma- a place to hide. Gossypiboma are retained surgical sponges in the body. The most common site is in the abdominal cavity. The chest, brain, extremities, and breasts are rare sites [1]. Due to fear of medicolegal consequences, the actual incidence remains underrated. The fibrotic reaction around the gauze piece can mimic an aggressive fibrous neoplasm like a solitary fibrous tumor. Solitary fibrous tumors are neoplasms of mesenchymal origin. They show lobulated enhancing fibrous mass with central areas of necrosis. Here we present a case of a well-encapsulated enhancing soft tissue mass in a 69-year-old man.
The name "gossypiboma" is derived from two Latin words, Gossypium- cotton and boma- a place to hide. Gossypiboma are retained surgical sponges in the body. The most common site is in the abdominal cavity. The chest, brain, extremities, and breasts are rare sites [1]. Due to fear of medicolegal consequences, the actual incidence remains underrated. The fibrotic reaction around the gauze piece can mimic an aggressive fibrous neoplasm like a solitary fibrous tumor. Solitary fibrous tumors are neoplasms of mesenchymal origin. They show lobulated enhancing fibrous mass with central areas of necrosis. Here we present a case of a well-encapsulated enhancing soft tissue mass in a 69-year-old man.
Clinical Profile:
Clinical Profile:
A 69-year-old man came with complaints of low backache for six months. He had a history of live donor renal transplant in 2003 for chronic kidney disease. He had no history of trauma, weight loss, or fever. On examination, there was a scar in the right iliac fossa. There was no palpable lump.
A 69-year-old man came with complaints of low backache for six months. He had a history of live donor renal transplant in 2003 for chronic kidney disease. He had no history of trauma, weight loss, or fever. On examination, there was a scar in the right iliac fossa. There was no palpable lump.
His current serum creatinine levels were in the normal range. He was on triple immunosuppressants (low-dose corticosteroids + azathioprine + cyclosporine).
His current serum creatinine levels were in the normal range. He was on triple immunosuppressants (low-dose corticosteroids + azathioprine + cyclosporine).
Radiological investigations:
Radiological investigations:
A curvilinear ultrasound probe placed transversely in the hypogastric region(Figure 1 A) showed a lobulated heterogeneously isoechoic lesion with a central anechoic area and post acoustic shadowing, adjacent to the right common iliac vessel. On colour Doppler, vascularity was not demonstrated in the lesion (Figure 1 B).
A curvilinear ultrasound probe placed transversely in the hypogastric region(Figure 1 A) showed a lobulated heterogeneously isoechoic lesion with a central anechoic area and post acoustic shadowing, adjacent to the right common iliac vessel. On colour Doppler, vascularity was not demonstrated in the lesion (Figure 1 B).
Figure 1 A, B: Ultrasonogram shows a well-defined lobulated heterogeneously isoechoic lesion with central anechoic area and post acoustic shadowing. The periphery of lesion shows no vascularity on the colour Doppler.
On the CT scan (Figure 2 A), the lesion is hypodense (average attenuation of 35 HU), measuring 8 x 8 x 9.5 cm ' located medial to the transplanted kidney in the hypogastrium and arising from the endopelvic fascia. It abuts the transplanted renal artery without any significant mass effect or loss of fat planes. There were a few discrete foci of calcification in the lesion. The lesion showed heterogeneous peripheral enhancement in the arterial phase with progressive peripheral enhancement in the venous (Figure 2B) and delayed phases (Figure 2 C). The transplanted kidney was normal.
On the CT scan (Figure 2 A), the lesion is hypodense (average attenuation of 35 HU), measuring 8 x 8 x 9.5 cm ' located medial to the transplanted kidney in the hypogastrium and arising from the endopelvic fascia. It abuts the transplanted renal artery without any significant mass effect or loss of fat planes. There were a few discrete foci of calcification in the lesion. The lesion showed heterogeneous peripheral enhancement in the arterial phase with progressive peripheral enhancement in the venous (Figure 2B) and delayed phases (Figure 2 C). The transplanted kidney was normal.
Figure 2 A, B, C: Plain, venous, and excretory phase axial CT scans of the abdomen show a well-defined hypodense lesion medial to the transplanted kidney with no mass effect or loss of fat planes. It shows heterogeneous peripheral enhancement in the venous phase with progressive peripheral enhancement in the delayed phase.
On MRI, the lesion showed a T2 hyperintense (Figure 3 A) /T1 hypointense (Figure 3 B) center with a thick lobulated T2/T1 isointense capsule. The peripheral capsule had a few foci of diffusion restriction (Figure 3 C) with corresponding drop on ADC map (Figure 3 D). These features pointed towards a fibrous lesion with a necrotic center.
On MRI, the lesion showed a T2 hyperintense (Figure 3 A) /T1 hypointense (Figure 3 B) center with a thick lobulated T2/T1 isointense capsule. The peripheral capsule had a few foci of diffusion restriction (Figure 3 C) with corresponding drop on ADC map (Figure 3 D). These features pointed towards a fibrous lesion with a necrotic center.
Figure 3 A, B: MRI shows T2 hyperintense/T1 hypointense center with a thick lobulated isointense capsule.
Figure 3 C, D: The capsule shows few foci of diffusion restriction and corresponding hypointensity on the ADC map.
A whole-body PET CT was done to rule out lymph nodal or hematogenous metastasis(Figure 4). PET CT showed low metabolic FDG uptake (SUV max of 5.27) along the periphery of the mass lesion. There was no uptake in the center.
A whole-body PET CT was done to rule out lymph nodal or hematogenous metastasis(Figure 4). PET CT showed low metabolic FDG uptake (SUV max of 5.27) along the periphery of the mass lesion. There was no uptake in the center.
Radiological diagnosis:
Radiological diagnosis:
Based on imaging features, the differentials considered were:
Based on imaging features, the differentials considered were:
1. Solitary fibrous tumor
1. Solitary fibrous tumor
2. Retroperitoneal sarcoma
2. Retroperitoneal sarcoma
3. Malignant peripheral nerve sheath tumor
3. Malignant peripheral nerve sheath tumor
Treatment:
Treatment:
The patient underwent laparotomy with the excision of mass under general anaesthesia.
The patient underwent laparotomy with the excision of mass under general anaesthesia.
Pathological diagnosis:
Pathological diagnosis:
The gross morphology of the cut specimen showed a central cavity with old gauze and necrotic material with a surrounding thick whitish capsule.
The gross morphology of the cut specimen showed a central cavity with old gauze and necrotic material with a surrounding thick whitish capsule.
Microscopy showed a thick encapsulated mass composed of fibrotic material surrounding an old gauze and suture material. There were multiple multinucleated giant cells with surrounding fibrosis. There was no evidence of tuberculosis or malignancy.
Microscopy showed a thick encapsulated mass composed of fibrotic material surrounding an old gauze and suture material. There were multiple multinucleated giant cells with surrounding fibrosis. There was no evidence of tuberculosis or malignancy.
Fig. 5 : Excised operative specimen
Final diagnosis:
Final diagnosis:
Gossypiboma
Gossypiboma
Timeline :
Timeline :
Discussion:
Discussion:
Gossypibomas might manifest immediately following surgery or decades after the first operation [2]. Foreign body reactions elicited in the body in response to retained gauze pieces fall into two broad categories: exudative and aseptic fibrous [1]. Cotton, the material used to make surgical sponges, does not trigger any biochemical activity other than adhesion and granuloma formation. The aseptic fibrous type of reaction can develop encapsulation, adhesions, and granuloma development. The former, however, typically takes place early in the healing process and may entail secondary bacterial contamination, leading to fistulas [3]. The clinical manifestations in patients with retained gauze pieces could be subacute or acute. In the immediate postoperative period, vague abdominal pain, a nonspecific abdominal lump, abdominal distension, nausea, and vomiting may be present[4]. Patients may be asymptomatic for prolonged periods, and this lesion may be seen as an incidental finding during imaging done for other purposes, as in our case [5].
Gossypibomas might manifest immediately following surgery or decades after the first operation [2]. Foreign body reactions elicited in the body in response to retained gauze pieces fall into two broad categories: exudative and aseptic fibrous [1]. Cotton, the material used to make surgical sponges, does not trigger any biochemical activity other than adhesion and granuloma formation. The aseptic fibrous type of reaction can develop encapsulation, adhesions, and granuloma development. The former, however, typically takes place early in the healing process and may entail secondary bacterial contamination, leading to fistulas [3]. The clinical manifestations in patients with retained gauze pieces could be subacute or acute. In the immediate postoperative period, vague abdominal pain, a nonspecific abdominal lump, abdominal distension, nausea, and vomiting may be present[4]. Patients may be asymptomatic for prolonged periods, and this lesion may be seen as an incidental finding during imaging done for other purposes, as in our case [5].
The diagnosis can likely be when a distinctive whorl-like pattern is evident on plain radiographs [6]. An area of opacity and a few spotted, small air densities superimposed on the abdomen can be seen on radiographs [7]. Plain radiographs may not show findings in many of the patients with gossypiboma, while features of intestinal obstruction arise in the acute setting.
The diagnosis can likely be when a distinctive whorl-like pattern is evident on plain radiographs [6]. An area of opacity and a few spotted, small air densities superimposed on the abdomen can be seen on radiographs [7]. Plain radiographs may not show findings in many of the patients with gossypiboma, while features of intestinal obstruction arise in the acute setting.
On ultrasonogram, the mass is well-defined and has a wavy hyperechoic area and predominant acoustic shadowing [8].
On ultrasonogram, the mass is well-defined and has a wavy hyperechoic area and predominant acoustic shadowing [8].
The preferred method for finding gossypiboma and potential problems is computed tomography (CT). A retained sponge on CT is a well-defined low-density heterogeneous soft-tissue mass that may have a whorled texture or a spongiform pattern with trapped gas bubbles [9]. It may have a high-density enhancing wall. The wall may show calcifications. The bulk of the mass may have high-density, wavy-striped regions that resemble sponges [1]. Gradual calcification may build up along its wavy fiber network to give a reticulate pattern of calcification. On the other hand, solitary fibrous tumors on CT can be either hyperdense or hypodense compared to the muscle due to variability in the collagen content. They show central areas of cystic degeneration and heterogeneous contrast enhancement [10]
The preferred method for finding gossypiboma and potential problems is computed tomography (CT). A retained sponge on CT is a well-defined low-density heterogeneous soft-tissue mass that may have a whorled texture or a spongiform pattern with trapped gas bubbles [9]. It may have a high-density enhancing wall. The wall may show calcifications. The bulk of the mass may have high-density, wavy-striped regions that resemble sponges [1]. Gradual calcification may build up along its wavy fiber network to give a reticulate pattern of calcification. On the other hand, solitary fibrous tumors on CT can be either hyperdense or hypodense compared to the muscle due to variability in the collagen content. They show central areas of cystic degeneration and heterogeneous contrast enhancement [10]
MRI findings of gossypiboma include a well-defined mass with thick peripheral walls of low signal intensity at T1- and T2-weighted imaging and modest to moderate post-contrast enhancement [11]. Serrations may be present in the thick enhancing walls. T2-weighted imaging typically shows low signal whorled stripes within the central portion consistent with gauze fibers[3]. Solitary fibrous tumor on MRI shows iso intensity on T1-weighted images and heterogenous high or low intensity on T2-weighted images. The collagen appears hypointense on T1- and T2-weighted imaging [10].
MRI findings of gossypiboma include a well-defined mass with thick peripheral walls of low signal intensity at T1- and T2-weighted imaging and modest to moderate post-contrast enhancement [11]. Serrations may be present in the thick enhancing walls. T2-weighted imaging typically shows low signal whorled stripes within the central portion consistent with gauze fibers[3]. Solitary fibrous tumor on MRI shows iso intensity on T1-weighted images and heterogenous high or low intensity on T2-weighted images. The collagen appears hypointense on T1- and T2-weighted imaging [10].
A gossypiboma may be visible on PET and PET/CT as a mass with poor central uptake because of necrotic material around the site of the retained gauze piece and an exterior capsule with significant FDG activity as a result of the fibroblastic composition. High SUV uptake values make it difficult to differentiate a gossypiboma with a fibrotic capsule from a malignant tumor such as a sarcoma on PET CT.
A gossypiboma may be visible on PET and PET/CT as a mass with poor central uptake because of necrotic material around the site of the retained gauze piece and an exterior capsule with significant FDG activity as a result of the fibroblastic composition. High SUV uptake values make it difficult to differentiate a gossypiboma with a fibrotic capsule from a malignant tumor such as a sarcoma on PET CT.
Conclusion:
Conclusion:
Gossypiboma should be one of the differentials in patients with a history of recent or remote surgery presenting with asymptomatic intra-abdominal lesions. Fibrotic reaction around the gauze piece may show delayed peripheral enhancement with central necrosis mimicking an aggressive fibrous neoplasm.
Gossypiboma should be one of the differentials in patients with a history of recent or remote surgery presenting with asymptomatic intra-abdominal lesions. Fibrotic reaction around the gauze piece may show delayed peripheral enhancement with central necrosis mimicking an aggressive fibrous neoplasm.
References:
References:
1. Manzella A, Filho PB, Albuquerque E, Farias F, Kaercher J. Imaging of gossypibomas: pictorial review. American journal of roentgenology. 2009 Dec;193(6_supplement):S94-101
1. Manzella A, Filho PB, Albuquerque E, Farias F, Kaercher J. Imaging of gossypibomas: pictorial review. American journal of roentgenology. 2009 Dec;193(6_supplement):S94-101
2. Ribalta T, McCutcheon IE, Neto AG, Gupta D, Kumar AJ, Biddle DA, Langford LA, Bruner JM, Leeds NE, Fuller GN. Textiloma (gossypiboma) mimicking recurrent intracranial tumor. Archives of pathology & laboratory medicine. 2004 Jul;128(7):749-58
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3. Kim CK, Park BK, Ha H. Gossypiboma in abdomen and pelvis: MRI findings in four patients. American Journal of Roentgenology. 2007 Oct;189(4):814-7
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Acknowledgement :
Acknowledgement :
We are grateful to the Department of Surgery at our institution for providing us the photograph of the operative specimen.
We are grateful to the Department of Surgery at our institution for providing us the photograph of the operative specimen.