Intrathoracic gossypiboma

Abstract

A 65-year-old man presented with left-sided chest pain. He had undergone surgery 6 years earlier for a paravertebral abscess caused by tuberculosis. An unenhanced CT scan showed a pleural mass on the left side (Fig. 1A,1B,1C). A CT-guided transthoracic core biopsy of the lesion yielded whitish cotton fibers. The patient was taken to surgery with the preliminary diagnosis of a retained surgical sponge. At surgery, a mass with extensive fibrosis and adhesions to the pleura was found in the pleural space. Gross examination showed that the mass was a surgical sponge surrounded by purulent material. The condition of lung adjacent to the mass was unremarkable, and the mass was removed.Gossypiboma (also called textiloma or cottonoid) is a term used to describe a mass in the body that is composed of a cotton matrix surrounded by a foreign-body reaction [1, 2]. It is a rare complication of surgery. In most countries, sponges used in surgery have radiopaque markers that can easily be recognized on radiographs [1, 2]. Even with the presence of such a marker, diagnosis of retained surgical material may not be possible if the marker is misinterpreted as a calcification or surgical suture. Various reports in the literature describe radiologic findings of gossypibomas, especially in the abdomen [1, 2]. CT is the method of choice in the evaluation of the gossypibomas [2]. Although the typical spongiform pattern with gas bubbles is the most CT characteristic sign for gossypibomas [1, 2], another sign associated with the condition is an inhomogenous, lowdensity mass with a thin, high-density capsule that shows marked enhancement after administration of contrast material [1,2,3]. The mass may contain wavy, striped, high-density areas that represent the sponge itself.

There are relatively few descriptions of the imaging findings of retained intrathoracic sponges [2, 3]. Of the potential sites in the thorax where a sponge may be left, the pleural space seems to be the most likely one [3]. In our patient, the mass was pleural-based and the margins were very well-defined, which led us to consider the possibility that it was extrapulmonary in origin. However, sometimes gossypibomas appear as intrapulmonary masses [3]. This kind of appearance may be related to the exudative and fibrotic reaction in the pleural space and infolding of the lung adjacent to the lesion [3]. If the material remains at the site for an extended time after the operation, chronic inflammatory changes may develop in the adjacent lung. In our patient, the lung adjacent to the mass was normal. In this case, we were not able to make the diagnosis on the basis of the radiologic findings, nor was the CT appearance of gossypiboma in our patient specific enough for us to make the diagnosis. We did not identify the air bubbles in the mass. Air bubbles may not be as prominent a feature of retained intrathoracic sponges as they are in retained intraabdominal sponges. We think that resorption of the air by the pleura may be a possible explanation for the difference. It was the whitish cotton fibers obtained at biopsy that helped us to make the correct diagnosis before surgery. To our knowledge, such a biopsy finding has not been previously mentioned in the literature. In a patient with the history of surgery, biopsy findings of whitish cotton fibers obviously should alert the physician to the presence of a retained sponge. In summary, because retained intrathoracic sponges do not have the characteristic radiologic appearances found with retained intraabdominal sponges, it may not be easy to recognize them. Even in a patient with a history of surgery, a physician may find it difficult to make a preoperative diagnosis However, the findings of a transthoracic core biopsy may be helpful by showing the characteristic cotton fibers.