Imaging Features of Chest Wall Gossypiboma

Case Report Imaging Features of Chest Wall Gossypiboma Huy B. Q. Le, MD, FRCPC, Steven Lee, MBBS, FRANZCR, David Malfair, MD, FRCPC, Peter L. Munk, MD, FRCPC G ossypibomas, or “textilomas,” are retained surgical sponges or swabs that are uncommon complications of any surgical procedure. Gossypiboma is derived from Latin (gossypium, cotton) and Swahili (boma, place of concealment). Most cases have been reported in the abdomen or pelvis, and fewer intrathoracic parenchymal and pleural gossypibomas have been described.1–7 To our knowledge, only 1 case of a chest wall gossypiboma has been previously discussed,3 and we present the findings of an additional case in a young female patient. Case Report Abbreviations AVM, arteriovenous malformation; CT, computed tomography Received February 9, 2009, from Vancouver General Hospital, Vancouver, British Columbia, Canada. Revision requested February 27, 2009. Revised manuscript accepted for publication March 19, 2009. We thank Michael Mudri for help with manuscript and image preparation. Address correspondence to Peter L. Munk, MD, FRCPC, Vancouver General Hospital, 899 12th Ave W, Vancouver, BC V5Z 1M9, Canada. E-mail: [email protected] A 21-year-old female patient with no medical history had a resection for a right-sided anterior chest wall arteriovenous malformation (AVM) at an outside institution. The procedure performed was described as “complicated,” requiring more than usual bandaging for hemorrhage control. Ten days after the procedure, the nonabsorbable sutures were removed, and the patient complained of threads coming out of her wound. At the time, it was thought that these threads represented absorbable sutures. Three months postoperatively, the patient had persistent drainage at the surgical site with “spitting of threads,” prompting a sonographic examination. Sonography revealed 2 masses. One mass was described as calcified because of the presence of linear hyperechogenicity with posterior acoustic shadowing (Figure 1). This was thought to represent an old hematoma. A second mass was seen containing tubular hypoechoic structures with the presence of arterial and venous waveforms on pulsed Doppler imaging (Figure 2). The findings were interpreted as a residual AVM. Two months after the sonographic examination, the patient was referred to a surgeon, and on examination, the surgical wound was partly healed with a central area of pouting containing questionable material that could not be removed because of pain. A second anteroinferior firm mass was described, © 2009 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 2009; 28:1265–1268 • 0278-4297/09/$3.50 Imaging Features of Chest Wall Gossypiboma which was suspected to represent a residual AVM. The patient was afebrile, and there was no drainage of pus or signs of inflammation within or around the wound. No antibiotics were prescribed, and chest computed tomography (CT) was requested. Non–contrast-enhanced chest CT revealed 2 well-defined soft tissue masses in the lower right chest wall. The most superior mass, measuring 2.4 × 1.6 cm, was round and hypoattenuating relative to muscle (Figure 3A). The more inferior mass, measuring 4.1 × 1.3 cm, was isoattenuating and oblong (Figure 3B). Both masses were noncalcified and did not show any local infiltration. No vascular structures were seen entering or abutting either mass. These masses were interpreted as inflammatory in nature in view of the drainage at the surgical site. One week after the CT, the patient was brought to the operating room for resection. Intraoperatively, the masses represented a surgical sponge with no pus or residual AVM. The surgical sponge was grossly confirmed by pathologic examination. mass of different densities surrounding central hyperdensity. Others have reported hypoattenuating cystic masses with calcification3 or a wellencapsulated mass containing a “spongiform” center.4 None of the masses previously described Figure 2. Sonograms of the second anterior chest wall mass. A, Spongiform appearance of the second mass, containing wavy layers of isoechoic structures intertwined with hypoechogenicity. B and C, Venous and arterial waveforms within the mass. A B Discussion The CT imaging features of thoracic gossypibomas have been described and are variable. Cheng et al1 reported that most of their 3 chest gossypibomas appeared as hyperattenuating whirling masses, whereas Sheehan et al2 noted 1 of their gossypibomas manifesting as a lamellated Figure 1. Sonogram of the anterior chest wall showing sharply demarcated curvilinear hyperechogenicity with acoustic shadowing. C 1266 J Ultrasound Med 2009; 28:1265–1268 Le et al had any central enhancement; only mural enhancement was seen at most.4 However, the masses we described here on CT (1 hypoattenuating mass and a second isoattenuating mass relative to muscle) did not correlate with any of the features previously documented, once again emphasizing their variable CT appearances . El Khoury et al5 described the sonographic finding of a breast gossypiboma as having a hyperechoic linear structure with sharply defined acoustic shadowing. This exactly matched the Figure 3. Axial non–contrast-enhanced chest CT. A, Superior rounded hypoattenuating mass. B, Anteroinferior second mass, which is isoattenuated relative to muscle. No calcification is present within either mass. A B J Ultrasound Med 2009; 28:1265–1268 features of 1 of the 2 masses seen on sonography in our young female patient (Figure 1). The second mass we described on sonography as containing tubular hypoechogenicity with arteriovenous waveforms likely represented the isoattenuating anteroinferior mass seen on CT (Figure 3B). In view of no residual AVM seen intraoperatively, the sonograms were reviewed again. In retrospect, the second mass had a spongiform appearance with what appeared to be wavy layers of isoechoic structures interspersed with the tubular hypoechogenicity initially described (Figure 2). To our knowledge, this had not been described previously and could have represented the sonographic equivalent of the spongiform appearance on CT.4 Sheehan et al2 discussed the histologic presence of neovascularity of adjacent pleura in an intrapleural gossypiboma that had been present for 4 years. We think that the second mass may have incited granulation tissue or parasitization of small vessels, accounting for the flow and vascular waveforms seen on sonography. Although flow was present centrally within the second mass, this is somewhat unusual for granulation tissue alone because flow would be expected to be limited to the periphery of the lesion, which is where granulation tissue or a chronic inflammatory response is usually present.2,4,6 Parasitization of vessels centrally might have explained the flow, although to our knowledge, this has yet to be described. Alternatively, there may have been a residual AVM, which may have been missed intraoperatively, but unfortunately, the patient was lost to follow-up, and review of clinical charts did not provide any more information. Despite the clinical presentation of our patient, a gossypiboma was not initially entertained in the clinical or radiologic differential diagnoses. The imaging features of thoracic gossypibomas are variable, making them difficult to diagnose confidently. Our case highlights the multiple appearances of a chest wall gossypiboma on sonography and CT, manifesting as 2 discrete masses with completely different imaging features. In the context of previous surgery and the presence of a nonspecific mass on imaging, a gossypiboma should always be considered in the differential diagnosis and would be the most important step in making a diagnosis.6 1267 Imaging Features of Chest Wall Gossypiboma References 1268 1. Cheng TC, Chou ASB, Jeng CM, Chang PY, Lee CC. Computed tomography findings of gossypiboma. J Chin Med Assoc 2007; 70:565–569. 2. Sheehan RE, Sheppard MN, Hansell DM. Retained intrathoracic surgical swab: CT appearances. J Thorac Imaging 2000; 15:61–64. 3. Madan R, Trotman-Dickenson B, Hunsaker AR. Intrathoracic gossypiboma. AJR Am J Roentgenol 2007; 189:W90–W91. 4. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P. Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol 2005; 78:851–853. 5. El Khoury M, Mignon F, Tardivon A, Mesurolle B, Rochard F, Mathieu MC. Retained surgical sponge or gossypiboma of the breast. Eur J Radiol 2002; 42:58–61. 6. Coskun M, Boyvat F, Agildere AM. CT features of a pericardial gossypiboma. Eur Radiol 1999; 9:728–730. 7. Topal U, Gebitekin C, Tuncel E. Intrathoracic gossypiboma. AJR Am J Roentgenol 2001; 177:1485–1486. J Ultrasound Med 2009; 28:1265–1268