British Journal of Radiology (2008) 81, e61-e63
© 2008 British Institute of Radiology
doi: 10.1259/bjr/27014111
Changes in CT appearance of intrathoracic gossypiboma over 10 years
H J PARK
1
S A IM
1
H J CHUN
1
S H PARK
1
J H O
1 and
K-Y LEE
2
Departments of 1 Radiology and 2 Pathology, Kangnam St. Mary's Hospital, The Catholic University of Korea, Banpo-dong Seocho-gu, Seoul
Correspondence: Seog Hee Park, MD, Department of Radiology, Kangnam St. Mary's Hospital, The Catholic University of Korea, 505, Banpo-dong Seocho-gu, Seoul, 137-040, South Korea. E-mail: parksh{at}catholic.ac.kr
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Abstract
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An intrathoracic gossypiboma is a rare condition. Moreover, intrathoracic gossypibomas with intrapulmonary location are extremely rare and only a few cases of intrapulmonary gossypiboma have been published. Usually gossypiboma has the characteristic CT appearance of a soft tissue mass with high attenuation, air bubbles and a whirl-like pattern, but its radiological manifestations may be variable according to the location and chronicity of the sponge. We report a case of intrathoracic gossypiboma initially misdiagnosed as an aspergilloma owing to its intrapulmonary location and air crescent sign on CT. In addition, our case will show morphological changes of the gossypiboma on CT during the 10 year follow-up period and correlate the CT findings with pathological results.
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Introduction
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Intrathoracic gossypiboma is a rare condition with variable CT appearances, depending on the location and chronicity of the sponge. We report a case of intrathoracic gossypiboma and illustrate changes in the CT appearances during a 10 year follow-up period. To our knowledge, this is the first manuscript illustrating the serial radiographic changes of gossypiboma, which may explain the mechanism of atypical CT manifestations of intrathoracic gossypiboma, intrapulmonary location and air crescent sign.
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Case report
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A 59-year-old man presented with a history of long-standing mass in the right lower lobe and recurrent haemoptysis for several decades. He had a right middle lobectomy for treatment of pulmonary tuberculosis 31 years ago.
10 years ago, he visited a different hospital for management of haemoptysis. Chest CT at that time showed an ovoid mass with a central hyperdense nidus and a peripheral thick capsule in the posterior aspect of the right lower lobe (Figure 1a
). The mass had a large contact area with the pleura and displayed an extrapulmonary location. 5 years later, he revisited the hospital for management of haemoptysis and underwent a second chest CT (Figure 1b). Compared with the first CT scan, spongiform air bubbles had appeared within the mass. The area of contact between the mass and the pleura was smaller, whereas the surrounding area of the lung had become larger. The mass was rounder in shape. At the other hospital, the man had undergone transarterial embolization for the treatment of haemoptysis caused by aspergilloma.
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Figure 1. A 59-year-old man with intrapulmonary gossypiboma. (a) Non-enhanced CT scan, obtained 10 years ago, shows a well-defined, ovoid mass about 6 cm in size, broadly based on pleura at the posterior aspect of the right lower lobe. The mass contains a central hyperdense nidus surrounded by a peripheral thick wall. A tiny air bubble (arrow) is seen at the anterior aspect of the mass. Extrapleural fat proliferation is seen adjacent to the mass, indicative of the chronic condition. (b) Non-enhanced CT scan, obtained 5 years ago, shows that the mass became more round with multiple air bubbles within the central nidus. The contacting area of the mass in the pleura decreased compared with the previous examination. (c) Current CT scan reveals an air crescent between the central nidus and the peripheral wall. (d) A photograph of the microscopic examination (H&E, x400) shows the thick fibrous wall lined by striated squamous epithelium. Erosion of the epithelial lining and multifocal clusters of the inflammatory cells are visible in the wall. Two respiratory bronchioles with ciliated columnar epithelium communicate with the cavity via the erosive pits of the wall (arrows).
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5 years later, the patient was admitted to our hospital for surgical removal of the long-standing pulmonary mass in the right lower lobe. He underwent a third chest CT. The CT scan showed a newly present "air crescent" between the central nidus and the capsule (Figure 1c
). The central nidus was still hyperdense.
The mass was removed by wedge resection. Surgical exploration revealed a well-encapsulated surgical gauze in the right lower lobe. On microscopic examination, the cavity wall surrounding the surgical gauze was composed of thick fibrous tissue (Figure 1d). The cavity communicated with adjacent respiratory bronchioles through erosion pits in the cavity wall.
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Discussion
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The term "gossypiboma", derived from the Latin "gossypium" (cotton) and the Swahili "boma" (place of concealment), describes sponges and surrounding foreign body reaction. Although this term describes foreign bodies of a cotton matrix, it usually refers to any kind of retained surgical materials. Foreign bodies are essentially inert in gossypiboma and lead to an aseptic foreign body reaction with fibroblastic reaction and encapsulation. Most patients are therefore asymptomatic [1].
Although there are many reports of intra-abdominal gossypibomas, only rare cases of intrathoracic gossypibomas have been published. Moreover, gossypibomas in intrapulmonary locations are extremely rare because the potential sites of gauzes left after thoracic surgery mostly involve the pleural spaces. The intrapulmonary location of a gossypiboma seems to be improbable, but it may be explained by the enfolding of the lung adjacent to the retained sponge after organization of an accompanying exudative pleural effusion [2]. In our case, the gossypiboma was initially manifested as a pleura-based extrapulmonary mass that changed into an intrapulmonary mass with a decreasing contact area with the pleura over time. This morphological change in our case supports the mechanism of the intrapulmonary location, in which the lung may gradually enfold the central gauze.
Gossypibomas vary in radiological manifestation according to their location and the chronicity of the retained gauze, type of foreign body reaction and the presence of a radiopaque marker. On plain chest radiographs, a gossypiboma is manifested as an unusual opacity or as an atypical mass, which generally does not change over time. CT is the best method for detecting a sponge and for evaluating complications [3]. The typical CT feature of retained gauze is a predominantly high-attenuating central mass with a spongiform pattern of air bubbles and a hyperdense, well-enhancing rim [1–3]. Several hypotheses on the origin of air bubbles have been suggested. The air bubbles had been interpreted as infection or even an abscess [4, 5]. Recently, air bubbles have been believed to be caused by trapped gas within the synthetic fibres of surgical gauze inadvertently left in place during previous surgery and that the air can remain inside or decrease over a period of time [4]. However, our case suggested a different hypothesis for the origin of the air bubbles. Our case showed a gradual increase in the amount of air bubbles within the gossypiboma and the presence of communications between the cavity and the respiratory bronchioles on pathology. Air bubbles may be derived from bronchioles through the communication in our case.
The "air crescent sign" usually results from air filling the space between the devitalized tissue and the surrounding parenchyma [6]. Although the majority of "air crescent signs" may be associated with pulmonary aspergilloma, several cases of intrathoracic gossypibomas with "air crescent sign" have been reported [7–9]. In our case, the air crescent within the gossypiboma may have resulted from communications between the mass and adjacent bronchioles in the same way as in the development of the air bubbles. However, the hyperdense central nidus of the mass can be helpful in the differentiation of gossypiboma from aspergilloma in our case.
In conclusion, gossypiboma can change in location and appearance, as seen in our case. Over time, the retained gauze left in the pleural space is enfolded by lung and seems to be an intrapulmonary mass. Air bubbles and air crescent can newly develop and gradually increase within the mass. The origin of air bubbles and air crescent within a gossypiboma can be from adjacent organs such as bronchioles, rather than from trapped air within the gauze.
Received for publication September 30, 2006.
Revision received November 6, 2006.
Accepted for publication December 6, 2006.
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References
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- Catalano O, Nunziata A. An unusual thoracic opacity. Gossypiboma (retained surgical foreign body). Radiologe 1997;37:763–4.[CrossRef][Medline]
- Sheehan RE, Sheppard MN, Hansell DM. Retained intrathoracic surgical swab: CT appearances. J Thorac Imaging 2000;15:61–4.[CrossRef][Medline]
- Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P. Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol 2005;78:851–3.[Abstract/Free Full Text]
- 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;20:919–23.
- Schmitt R, Helmberger T, Spindler-Thiele S, Loitzsch RM. Sonography and computed tomography in intraperitoneally retained abdominal drapes. Rofo 1992;157:520–2.[Medline]
- Abramson S. The air crescent sign. Radiology 2001;218:230–2.[Free Full Text]
- Nomori H, Horio H, Hasegawa T, Naruke T. Retained sponge after thoracotomy that mimicked aspergilloma. Ann Thorac Surg 1996;61:1535–6.[Abstract/Free Full Text]
- Solaini L, Prusciano F, Bagioni P. Intrathoracic gossypiboma: a movable body within a pseudocystic mass. Eur J Cardiothorac Surg 2003;24:300[Free Full Text]
- Rijken MJ, van Overbeeke AJ, Staaks GH. Gossypiboma in a man with persistent cough. Thorax 2005;60:708[Free Full Text]
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Abstract
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