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Clinical Observations |
1 Department of Radiology and Center for Imaging Science, Samsung Medical
Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-gu,
Seoul, Korea 135-710.
2 Department of Pathology, Samsung Medical Center, Sungkyunkwan University
School of Medicine, Seoul, Korea.
Received March 27, 2007;
accepted after revision May 15, 2007.
Address correspondence to C. K. Kim
(chankyokim{at}smc.samsung.co.kr).
Abstract
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CONCLUSION. On MRI, gossypiboma in the abdomen and pelvis manifested as a well-defined mass that showed a peripheral wall of low signal intensity at T1- and T2-weighted imaging and enhancement at contrast-enhanced T1-weighted imaging. The whorled stripes within the central portion were characteristically shown as low signal at T2-weighted imaging, and the serrated contour in the inner border of the peripheral wall was shown at contrast-enhanced T1-weighted imaging. Histopathologically, the peripheral wall showed granulomatous inflammation with massive fibrosis and foam cell and multinucleated giant cell infiltrations, whereas the whorled stripes within the central portion were gauze fibers. If a patient has a history of a previous operation, the possibility of gossypiboma should be suggested when the central whorled stripes or serrated contour in the inner border of the peripheral wall is present at MRI.
Keywords: abdomen • gossypiboma • MRI • pelvis • surgery complications
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Table 1 presents the clinical features of the four patients. The location of gossypiboma was the pelvic cavity (n = 2), left lower quadrant (n = 1), and left nephrectomy site (n = 1). The time interval between surgery and MRI ranged from 5.5 to 20.0 years (mean, 13.9 years). The causes of previous surgery in the abdomen and pelvis were renal cell carcinoma (n = 1), ovarian endometriosis (n = 1), appendicitis (n = 1), and postpartum bleeding (n = 1).
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MRI was performed on a 1.5-T MR system (Signa, GE Healthcare) in two patients and a 3-T MR system (Intera Achieva, Philips Medical Systems) in the remaining two patients using a phased-array or body coil. A phased-array coil was used for pelvic imaging and a body coil for abdominal imaging. All patients were requested to fast for at least 6 hours before MRI and received 20 mg of intramuscularly administered butyl scopolamine (Buscopan, Boehringer Ingelheim) before MRI (unless contraindicated). No bowel preparation was performed.
The pelvic imaging was performed with axial, sagittal, and coronal fast or turbo spin-echo T2-weighted imaging with a 3- to 5-mm section thickness and a 1- to 2-mm intersection gap. Axial fast or turbo spin-echo T1-weighted imaging with spatial resolution similar to that of the T2-weighted imaging was then performed. T1-weighted imaging was repeated with and without 0.1 mmol/kg of IV gadopentetate dimeglumine (Magnevist, Schering). Axial fatsaturated gradient-echo pelvic images were obtained in each case after administering IV contrast material.
Abdominal imaging was performed using axial, sagittal, and coronal fast or turbo spin-echo T2-weighted imaging and axial T1-weighted gradient-echo or spin-echo imaging. T2-weighted imaging had a 5- to 8-mm section thickness and a 2- to 3-mm intersection gap. Axial and coronal contrast-enhanced T1-weighted gradient-echo images were obtained after the administration of contrast material.
MR images were analyzed retrospectively and jointly by two radiologists with 6 and 4 years of experience, respectively, in MRI of the abdomen and pelvis. The decisions on the MRI findings were reached by consensus. We assessed the morphologic pattern (size, shape, and margin) and MRI features in the center and peripheral wall of the masses (signal intensity, presence or absence of whorled stripes within the central portion, and contour in the inner peripheral wall on contrast-enhanced scans). An experienced pathologist reviewed all of the histopathologic specimens, and MRI features were correlated with pathologic findings.
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In the three masses with a fluid-filled central cavity (Figs. 1A, 1B, 1C and 2A, 2B, 2C), the center portion at T1- and T2-weighted imaging showed heterogeneously high signal intensity compared with muscle signal intensity. At T2-weighted imaging, the whorled stripes of low signal intensity were characteristically shown in the central cavity, and on contrast-enhanced T1-weighted imaging they showed no enhancement. Regarding the peripheral wall, T1- and T2-weighted imaging showed homogeneously low signal intensity with a thickened wall, and contrast-enhanced T1-weighted imaging showed mild to moderate enhancement with the serrated contour in the inner border of the peripheral wall. In surgical specimens, the fluid-filled central cavity contained brownish thick fluid, and cultures remained sterile. On histopathologic examination, cross-sectional specimens revealed the presence of gauze fibers in the central cavity. The peripheral wall of tumors showed granulomatous inflammation with massive fibrosis and foam cell and multinucleated giant cell infiltrations.
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Many radiologic findings are characteristically used to diagnose gossypiboma. If the sponge contains a radiopaque marker, the diagnosis can be made easily by conventional radiography. However, the retained sponge might not be identified at conventional radiography if a radiopaque sponge breaks into pieces or if the marker becomes bound or folded [9]. The sonographic findings are a well-defined mass with a wavy hyperechoic area and dense acoustic shadowing [11]. On CT scans, a retained sponge is typically seen as a well-defined soft-tissue mass and may show a whorled texture or a spongiform pattern with contained gas bubbles [12]. Calcification of the wall of the mass may be observed on CT scans [6, 13].
To date, however, only a few reports on the MR appearance of gossypiboma in the abdomen and pelvis have been published [2–7]. On MRI, the signal intensity may vary according to histologic composition, stage, and fluid content of the tumor. On MRI, a retained sponge is typically seen as a soft-tissue mass with a thick well-defined capsule and as a whorled internal configuration on T2-weighted imaging. One study reported that after radical cystectomy, MRI features of retained absorbable hemostatic sponges in five patients manifested as intermediate T1 and high T2 signal intensity [2]. And complex mixed signal intensity similar to the whorled appearance of other retained surgical sponges may be seen on T2-weighted imaging.
In our study, three cases had the fluid-filled central cavity, and they manifested as well-defined masses at T1- and T2-weighted imaging that showed mild to moderate enhancement of a thick peripheral wall on contrast-enhanced scans. Histopathologically, the peripheral wall showed foreign body reaction with marked fibrosis. The whorled stripes within the central cavity with low signal intensity at T2-weighted imaging were specifically seen and compatible with gauze fibers. On contrast-enhanced scans, the inner border of the thick peripheral wall showed a serrated appearance. In particular, the masses of two cases were located in the pelvic cavity. Because the masses were abutting the gynecologic organs or small-bowel loops, the differential diagnosis from degenerated uterine myoma, ovarian sex cord–stromal tumor, or gastrointestinal stromal tumor was difficult. One case in our study did not have the fluid-filled central cavity within the mass arising from the nephrectomy site. The mass showed heterogeneously high signal at T1- and T2-weighted imaging and strong enhancement on contrast-enhanced scans. These enhancement patterns at MRI were nonspecific and difficult to differentiate from recurrent renal cell carcinoma.
In conclusion, gossypiboma in the abdomen and pelvis is a rare tumor. Its diagnosis is not often easy, and delayed diagnosis can be problematic. MRI is currently widely used for the evaluation of soft-tissue tumors. Therefore, a familiarity with the imaging features of gossypiboma is of utmost importance. On MRI, gossypiboma in the abdomen and pelvis manifested as a well-defined mass that showed a peripheral wall of low signal intensity at T1- and T2-weighted imaging and enhancement at contrast-enhanced T1-weighted imaging. The whorled stripes within the central portion were characteristically shown as low signal at T2-weighted imaging, and the serrated contour in the inner border of the peripheral wall was shown at contrast-enhanced T1-weighted imaging. Histopathologically, the peripheral wall showed fibrosis with granulomatous inflammation and lymphocyte and giant cell infiltration, whereas the whorled stripes within the central portion were gauze fibers. If a patient has a history of a previous operation, the possibility of gossypiboma should be suggested when the central whorled stripes or a serrated contour in the inner border of the peripheral wall is present at MRI.
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