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DOI:10.2214/AJR.07.2250
AJR 2007; 189:W90-W91
© American Roentgen Ray Society

Radiologic-Pathologic Conferences of Brigham and Women's Hospital

Intrathoracic Gossypiboma

Rachna Madan1, Beatrice Trotman-Dickenson and Andetta R. Hunsaker

1 All authors: Department of Radiology, Thoracic Radiology Division, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.

Received January 11, 2007; accepted after revision March 22, 2007.

Address correspondence to R. Madan (rmadan{at}partners.org).

WEB This is a Web exclusive article.

Keywords: cardiac imaging • chest imaging • CT • gossypiboma • heart surgery • malpractice • medicolegal issues • surgical complications

A53-year-old woman with a history of cardiac surgery at the age of 7 years for repair of an atrial septal defect presented for evaluation of recent-onset atrial fibrillation. An echocardiogram and chest radiograph showed a left paracardiac mass. Subsequently, a contrast-enhanced CT examination of the chest showed a well-defined cystic mass along the posterolateral aspect of the left ventricle (Fig. 1A). The mass showed complex variable density with peripheral rim calcification as well as central chunks of calcification. Large areas of low density (15 H) and soft-tissue density (40 H) were seen in the dependent portions of the mass, none of which showed contrast enhancement. The mass appeared to be extraparenchymal and densely adherent to the left pericardial surface (Fig. 1B). There was no evidence of lymphadenopathy or of pleural or pericardial effusions. A cardiac MRI examination revealed minimal mass effect on the left ventricle and no apparent invasion of the myocardium. Diagnostic cardiac catheterization revealed no feeding vessel arising from the coronary circulation.


Figure 1
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  		Fig. 1A —53-year-old woman with history of cardiac surgery. Axial image from contrast-enhanced CT of chest shows cystic left paracardiac mass adjacent to left ventricle. Thin rim of peripheral calcification is noted at periphery of mass; mass has cystic contents interspersed with more dense soft tissue seen in its lateral portion.

 

Figure 2
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  		Fig. 1B —53-year-old woman with history of cardiac surgery. Coronal reformatted image from contrast-enhanced CT of chest shows large left paracardiac mass posterior to left ventricle has thin rim of peripheral calcification and contains large coarse chunks of calcification in center of mass. Calcifications are interspersed with cystic and soft-tissue contents. No enhancement is evident. Mass appears to adhere to left pericardial surface.

 
Based on the imaging findings and the patient's history of cardiac surgery, differential diagnoses included a gossypiboma and a calcified hematoma. A malignant tumor was less likely given the lack of solid enhancing elements. Also, the appearance of the mass was not suggestive of an echinococcal cyst or of a granulomatous disease, such as tuberculosis. The patient subsequently underwent left thoracotomy and en bloc resection of the left paracardiac mass with partial pericardiectomy.

On sectioning of the 9 x 7 x 4 cm cystic mass, whitish tan-yellow toothpastelike debris, embedded meshlike material, and two pieces of retained gauze were identified in the center of the mass (Fig. 1C). Histologic examination revealed dense hyalinized tissue with foreign-body giant cell reaction, necrosis, calcification, and fragments of gauze. These findings confirmed the diagnosis of retained surgical swab (gossypiboma).


Figure 3
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  		Fig. 1C —53-year-old woman with history of cardiac surgery. Photograph of excised mass shows complex cystic lesion measuring 9 x 7 x 4 cm. Two pieces of retained gauze (arrows) are shown on left.

 
The term "gossypiboma" is derived from the Latin word "gossypium," which means cotton, and the Swahili word "boma," which means place of concealment and refers to retained sponge in the surgical bed. Gossypiboma (textiloma or cottonoid) is an important complication of surgery, with an estimated incidence of one case per 1,500 surgeries [1]. Although gossypibomas are most frequently reported after laparotomy, gossypibomas can occur as a complication of almost any surgical procedure. Pathologically, either an aseptic fibrous response resulting in adhesion, encapsulation, and granuloma formation is seen, as noted in this case, or an exudative reaction leading to abscess formation is seen [1].

Characteristic CT features of abdominal gossypibomas include a spongiform appearance with gas bubbles [2, 3]; a low-density mass with a thin enhancing capsule [2, 4]; and calcifications deposited along the network architecture of a surgical sponge, which has been described as the "calcified reticulate rind" sign [5]. On the other hand, a sponge left within the pleural space, which appears to be the most common location within the thorax [4], shows no gas lucencies due to resorption of the air by the pleura. This lack of gas lucencies was also noted in the case we describe here.

The medicolegal consequences of gossypiboma are significant because the patient may experience chronic pain or chronic infection or may undergo surgery or other treatments for malignancy on the basis of a misdiagnosis.

In conclusion, gossypibomas are often a diagnostic dilemma because of their inconsistent radiologic appearances, which are determined by the amount of time the material has been in situ, the type of material, and the anatomic location of the material. Gossypiboma should be included in the differential diagnosis of an atypical chest mass in any patient who has undergone an operative procedure.

References

  1. Rappaport W, Haynes K. The retained surgical sponge following intra-abdominal surgery: a continuing problem. Arch Surg 1990; 125:405 -407[Abstract/Free Full Text]
  2. Kopka L, Fischer U, Gross AJ, Funke M, Oestmann JW, Grabbe E. CT of retained surgical sponges (textilomas): pitfalls in detection and evaluation. J Comput Assist Tomogr 1996;20 : 919-923[CrossRef][Medline]
  3. Yamato M, Ido K, Izutsu M, Narimatsu Y, Hiramatsu K. CT and ultrasound findings of surgically retained sponges and towels. J Comput Assist Tomogr 1987;11 : 1003-1006[Medline]
  4. Sheehan RE, Sheppard MN, Hansell DM. Retained intrathoracic surgical swab: CT appearances. J Thorac Imaging2000; 15:61 -64[CrossRef][Medline]
  5. Lu YY, Cheung YC, Ko SF, Ng SH. Calcified reticulate rind sign: a characteristic feature of gossypiboma on computed tomography. World J Gastroenterol 2005; 11:4927 -4929[Medline]

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