—  SPECIALTY CONFERENCE  —

Surgical Pathology

Case 5 - Textiloma (Gossypiboma), Microfibrillar Collagen (Avitene®)-Associated,
with Eosinophilic Inflammatory Response

Gregory N. Fuller
MD Anderson Cancer Center
Houston, TX


Click on each slide thumbnail image for an enlarged view
Clinical History
A 56-year-old man presented with a history of a left parietal lobe glioblastoma that was surgically resected three months previously at a referring hospital, followed by radiation therapy. He reported increasing frequency of severe headaches and progressive motor and sensory changes on the right side of his body. A subsequent MRI scan revealed a new contrast-enhancing mass in the left parietal lobe at the site of his prior tumor, which was associated with extensive edema in the surrounding brain. The clinico-radiologic differential diagnosis included recurrent glioma, radiation necrosis, abscess, hemorrhage into the tumor bed, and venous infarction. Re-operation was performed for resection of the lesion to relieve the mass effect and provide tissue for a definitive diagnosis so that appropriate treatment could be instituted.


Case 5 - Figure 1 - Textiloma. Low power view of lesion reveals a heterogeneous mass with both hypocellular and hypercellular areas. (H&E, x20)
Case 5 - Figure 2 - Textiloma. At higher power, amorphous eosinophilic material is seen in association with an inflammatory cell infiltrate. (H&E, x100)
Case 5 - Figure 3 - Textiloma. In some fields, the eosinophilic material is seen to consist of smaller strands or cords. (H&E, x100)


Case 5 - Figure 4 - Textiloma. At high power, the inflammatory cell infiltrate is found to be dominated by eosinophils. Such a pronounced eosinophilic response is not seen in every case but when present is strongly suggestive of microfibrillar collagen (Avitene®) as the instigating hemostatic agent. (H&E, x400)
Case 5 - Figure 5 - Textiloma. Nodules of epithelioid cells (macrophages) may suggest granulomatous disease if the hemostatic agent is not identifiable. (H&E, x400)
Case 5 - Figure 6 - Textiloma. Foci of hemostat in an advanced stage of degeneration can resemble necrosis and, when surrounded by a hypercellular cuff of macrophages, might suggest necrosis with pseudopalisading, particularly in patients with a clinical history of glioblastoma. (H&E, x400)

Diagnosis
Textiloma (Gossypiboma), Microfibrillar Collagen (Avitene®)-Associated, with Eosinophilic Inflammatory Response

Discussion

Histology
Tissue sections show necrosing brain parenchyma associated with reactive vascular changes and a marked mixed acute and chronic inflammatory cell response in which an eosinophilic component is particularly prominent. Fragments of an amorphous eosinophilic substance are present, some of which are surrounded by hypercellular cuffs of epithelioid cells and occasional multinucleated giant cells.

Differential Diagnosis
Clinical Differential Diagnosis
The clinical differential diagnosis of a newly arising contrast-enhancing mass in a brain tumor patient following surgical resection and radiation therapy includes three principal entities: recurrent tumor, radiation necrosis and textiloma [1, 2] .

Histologic Differential Diagnosis
The presence of foreign material in the surgical specimen immediately suggests hemostat-related textiloma as either the sole cause or contributing factor to the mass effect and clinical symptoms. The additional presence of a prominent eosinophilic infiltrate strongly suggests microfibrillar collagen (Avitene®) as the instigating hemostatic agent [1, 2, 3, 4] . To those unfamiliar with the range of host reactions to microfibrillar collagen, the prominent eosinophilic response may suggest parasitic or other infection, drug reaction, or other pathologic processes that are associated with systemic eosinophilia. The acute inflammatory response in general might give the misleading impression of an abscess. Finally, as seen in this case, small fragments of degenerating hemostatic agent can mimic foci of necrosis, which, together with the surrounding hypercellular cuff of macrophages, can simulate either caseating granulomas or tumor necrosis with pseudopalisading such as that seen in glioblastoma. The latter is a particularly enticing pitfall when seen in the setting of a patient with a known clinical history of glioblastoma [1].

Historical Background
Textilomas (Gossypibomas) in general surgical pathology
The term "gossypiboma" is derived from the Latin word for cotton, gossypium, together with the Kiswahili term, boma, meaning "place of concealment." The term "textiloma" is derived from the Latin textilis, meaning "woven" (same derivation as textile, texture, etc.) plus the suffix -oma ("swelling, tumor"). The etymology of both terms refers to the ubiquitous cotton pledgets used as hemostats in general surgery (in addition to cotton, a range of newer synthetic agents are currently available), and historically have been used as euphemistic synonyms for "retained surgical sponge" (which itself is a euphemism). Two closely related terms are "muslinoma" (after muslin, a cotton fabric, used to wrap aneurysms) and "gauzoma" (after cotton gauze, used as a hemostat). There is an important medico-legal distinction between gossypibomas/textilomas and muslinomas. In general surgical practice, the former are iatrogenic mistakes in which non-resorbable hemostats are inadvertently left behind and have subsequently served as the basis for litigation, whereas in the latter situation, the foreign material (surgical muslin) is deliberately left in place and, in fact, constitutes the treatment for the disease. The occasional marked inflammatory reaction that results in a clinically symptomatic "muslinoma" is most appropriately viewed as a side effect of the treatment, analogous to adverse drug reactions.

The incidence of textiloma is highest following abdominal surgery, followed by orthopedic procedures. This iatrogenic lesion, however, has been reported in all major anatomic compartments (e.g., chest, retroperitoneum, extremities, head and neck), and following a wide range of surgical procedures, with case reports noting adverse effects in association with virtually every major body organ, including bowel, breast, heart, kidney, bladder, urethra, uterus, and ovary [5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19] . The time interval to clinical presentation ranges from the immediate postoperative period to decades after surgery [20, 21, 22, 23] .

The risk factors and incidence of "retained" sponges and other operating instruments have been recently reviewed [24] and have received coverage in the popular press [25]. Gawande and colleagues [24] identified three statistically significant risk factors: emergency surgery, unplanned changes in a surgical procedure, and high body-mass index. Because of legal liability considerations, it has been speculated that the incidence of textiloma as reported in hospital series is significantly underestimated. One result of under-reporting may be a decreased level of awareness.

As stated by Rafique [26]:

"Gossypiboma (retained sponge) is an iatrogenic complication. It is infrequently reported in literature because of legal implications setting up a vicious cycle of non-anticipation and misdiagnosis."
Hemostatic agents used in current neurosurgical practice. Contemporary hemostatic agents used in neurosurgical practice are divided into non-resorbable and resorbable categories [1]. Non-resorbable hemostats include several types of cotton and rayon-based pledgets, cottonoids and kites. These are used for intraoperative hemostasis only and are not designed to be left in place after surgery. Similar to the non-resorbable hemostats that are used in general surgery, they typically contain embedded radio-opaque markers and string tags that hang outside of the craniotomy for identification and retrieval. Instances of "retained surgical sponge" (i.e., non-resorbable hemostats inadvertently left in place) in craniotomy procedures are exceptionally rare.

In contrast, resorbable hemostatic agents may be left in place when necessary to help prevent post-operative hemorrhage. In a majority of instances these agents are degraded over time by the host without adverse effects. In some individuals, however, the degree of the inflammatory response is of sufficient magnitude to create a clinically symptomatic mass effect. Using the language of general surgery, the resulting lesion is termed a "textiloma" or "gossypiboma" even though the vast majority of neurosurgical textilomas do not result from physician error, but rather, as noted above, constitute a relatively rare side effect of a therapeutic device that has been used as intended and in accordance with accepted standards of care.

There are three major types of resorbable hemostatic agents in current neurosurgical use that differ based on chemical composition: gelatin foam (Gelfoam®); oxidized cellulose (Surgicel®, Oxycel® ); and microfibrillar collagen (Avitene® ). All three agents may elicit textiloma formation in the central nervous system [1, 2, 27, 28, 29, 30, 31, 32, 33] .

Unique features of microfibrillar collagen (Avitene®) textilomas
Two unique morphologic features separate microfibrillar collagen textilomas from those arising secondary to other hemostatic agents. One is ultrastructure, discussed below. The second is a propensity to elicit an eosinophilic response in some patients [1, 2, 3, 4] .

Special studies
Compared to all other hemostatic agents, microfibrillar collagen has the most distinctive ultrastructural morphology. Electron microscopic examination shows the characteristic periodic banding pattern of collagen [1].

Tics and fleas
Mixed textilomas, i.e., textilomas in which more than one type of hemostatic agent is present in the mass have also been reported [1].

Regional neuroanatomic considerations
Textilomas associated with two specific neuroanatomic sites warrant brief comment.

Spine surgery
Textilomas located within or adjacent to the vertebral column constitute a rare complication of spinal surgery [34, 35] .

Optic neuropathy associated with "muslinoma" One form of treatment for those rare central nervous system aneurysms that cannot be treated by other modalities such as clipping, coiling or balloon occlusion is wrapping with muslin cloth. The most common sites of origin of intracranial aneurysms are from the internal carotid, anterior cerebral and anterior communicating arteries, which are located in close anatomic juxtaposition to the optic nerves, chiasm and tracts. An inflammatory reaction (adhesive arachnoiditis) and subsequent textiloma formation ("muslinoma") are rare but well documented complications of muslin wrapping [36, 37, 38, 39, 40, 41] . Patients typically present with progressive visual loss, sometimes years after the aneurysm surgery.

Molecular Biology of Textilomas
At first blush, a discussion of the molecular biology of textilomas might seem absurd; however, in one recent study, Peyrottes and colleagues reported a clonal chromosomal abnormality, t(9;17)(q21;p13.3), which was detected in the reactive cellular component of a textiloma [42]. The authors postulate that the translocation might provide a selective advantage supporting the inflammatory reaction and cite other reports of clonal cytogenetic aberrations in reactive non-neoplastic lesions such as Dupuytren's contracture and osteoarthritis.

References

  1. Ribalta T, McCutcheon IE, AG Neto, Gupta D, Kumar, AJ, Biddle DA, Langford LA, Bruner JM, Leeds NE, Fuller GN. Textiloma (Gossypiboma) Mimicking Recurrent Intracranial Tumor. Arch Path Lab Med, 2004 (in press).
  2. Fuller GN, McCutcheon IE, Kumar AJ, Langford LA, Bruner JM, DeMonte F, Hassenbusch SJ, Moser RP, Leeds NE: Textiloma (gossypiboma) mimicking recurrent brain tumor: Evaluation of a series. Modern Pathology 10:150A, 1997; Laboratory Investigation 76:150A, 1997 [abstracts]
  3. Kitamura K, Yasuoka R, Ohara M, et al. How safe are the xenogeneic hemostats? Report of a case of severe systemic allergic reaction. Surg Today 1995;25:433-435.
  4. McGregor DH, McArthur RI, Carter T. Avitene granulomas of colonic serosa. Annals Clin Lab Sci 1986;16:296-302.
  5. Topal U et al. Intrathoracic gossypiboma. AM J Roentgenol 2001;177:1485-1486.
  6. Solaini L et al. Intrathoracic gossypiboma: a movable body within a pseudocystic mass. Eur J Cardiothorac Surg 2003;24:300.
  7. Malempre D et al. Retroperitoneal textiloma. J Belge Radiol 1989;72:522-523.
  8. Lo CP et al. Gossypiboma of the leg:MR imaging characteristics. Korean J Radiol 2003;4:191-193.
  9. Mboti B et al. Textiloma of the thigh presenting as a sarcoma. Acta Orthop Belg 2001;67:513-518.
  10. Kalbermatten et al. Cotton-induced pseudotumor of the femur. Skeletal Radiol 2001;30:415-417.
  11. Gencosmanoglu R, Inceoglu R. An unusual cause of small bowel obstruction: gossypiboma – case report. BMC Surg 2003;3:article 6 [e-publication]
  12. El Koury M et al. Retained surgical sponge or gossypiboma of the breast. Eur J Radiol 2002;42:58-61.
  13. Bhat HS et al. "Gossypiboma": an unusual cause of perinephric abscess. J R Coll Surg Edinb 1997;42:277-278.
  14. Heffernan JP et al. Gossypiboma (retained surgical sponge) and recurrent bladder neck contracture after radical retropubic prostatectomy and bilateral pelvic lymph node dissection. J Urol 1997;157:1356-1357.
  15. Lin TY et al. Gossypiboma: migration of retained surgical gauze and spontaneous transurethral protrusion. BJU Int 1999;84:879-880.
  16. Lerner CA, Dang HP. MR imaging of a pericardial gossypiboma. Am J Roentgenol 1997;169:314.
  17. Coskun M et al. CT features of a pericardial gossypiboma. Eur Radiol 1999;9:728-730.
  18. Fadiora SO et al. Gossypiboma simulating huge ovarian mass: a case report. Niger J Med 2003;12:52-56.
  19. Deger RB, LiVolsi VA, Noumoff JS. Foreign body reaction (gossypiboma) masking as recurrent ovarian cancer. Gynecol Oncol 1995;56:94-96.
  20. Apter S et al. Gossypiboma in the early post-operative period: diagnostic problem. Clin Radiol 1990;42:128-129.
  21. Hadrami J et al. Pulmonary textiloma revealed by hemoptysis 12 years after thoracotomy. Rev Med Interne 1998;19:826-829 [article in French]
  22. Roumen RM, Weerdenburg HP. MR features of a 24-year-old gossypiboma. Acta Radiol 1998;39:176-178.
  23. Rajput A et al. Diagnostic challenges in patients with tumors: case 1. Gossypiboma (foreign body) manifesting 30 years after laparotomy. J Clin Oncol 2003 21:3700-3701.
  24. Gawande AA et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348:229-235.
  25. Grady D. Forgotten surgical tools "uncommon but dangerous." New York Times Online, Health & Fitness, January 21, 2003 [internet publication]
  26. Rafique M. Vesical gossypiboma. J Coll Physicians Surg Pak 2003;13:293-295.
  27. Gondo G, Yamashita T, Ishiwata Y, Hirata K. Peculiar computed tomographic images after intracranial use of microfibrillar collagen hemostat: report of three cases. No Shinkei Geka 1989;17:1067-1071.
  28. Knowlson GTG. Gel-foam granuloma in the brain. J Neurol Neurosurg Psychiatry 1974;37:971-973.
  29. Guerin C, Heffez DS. Inflammatory intracranial mass lesion: an unusual complication resulting from the use of gelfoam. Neurosurgery 1990;26:856-859.
  30. Ito H,Onishi H, Shoin K, Nagatani H . Granuloma caused by oxidized cellulose following craniotomy. Acta Neurochir (Wien) 1989;100:70-73.
  31. Buckley SC, Broome JC. A foreign body reaction to Surgicel mimicking an abscess or tumor recurrence. Br J Neurosurg 1995;9:561-563.
  32. Sandhu GS, Elexpuru-Camiruaga JA, Buckley S. Oxidized cellulose (Surgicel) granulomata mimicking tumour recurrence. Br J Neurosurg 1996;10:617-619.
  33. Kothbauer KF, Jallo GI, Siffert J, Jimenez E, Allen JC, Epstein FJ. Foreign body reaction to hemostatic materials mimicking recurrent brain tumor. Report of three cases. J Neurosurg 2001;95:503-506.
  34. Van Goethem JWM, Parizel PM, Perdieus D, Hermans P, de Moor J. MR and CT imaging of paraspinal textiloma (gossypiboma). J Comput Assist Tomogr 1991;15:1000-1003.
  35. Ebner F, Tolly E, Tritthart H. Uncommon intraspinal space occupying lesion (foreign body granuloma) in the lumbosacral region. Neuroradiology 1985;27:354-356.
  36. Chambi I, Tasker RR, Gentili F, et al. Gauze-induced granuloma ("gauzoma"): an uncommon complication of gauze reinforcement of berry aneurysms. J Neurosurg 1990;72:163-170.
  37. Felsberg GJ, Tien RD, Haplea S, Osumi AK. Muslin-induced optic arachnoiditis ("gauzoma"): findings on CT and MR. J Comput Assist Tomogr 1993;17:485-487.
  38. Brady KM, Font RL, Lee AG. Muslin-induced intracranial sterile abscess. A cause of visual loss after aneurysm repair. Surg Neurol 1999;51:566-567.
  39. Prabhu SS, Keogh AJ, Parekh HC, Perera S. Optochiasmal arachnoiditis induced by muslin wrapping of intracranial aneurysms. A report of two cases and a review of the literature. Br J Neurosurg 1994;8:471-476.
  40. Bhatti MT, Holder CA, Newman NJ, Hudgins PA. MR characteristics of muslin-induced optic neuropathy: report of two cases and review the literature. AJNR 2000;21:346-352.
  41. Berger C, Hartmann M, Wildemann B. Progressive visual loss due to a muslinoma – report of a case and review of the literature. Eur J Neurol 10:153-158, 2003.
  42. Peyrottes I, Thyss A, Maire G, Machiavello JC, Angelozzi A, Pedeutour F. Clonal chromosomal abnormality induced by surgically retained foreign bodies: t(9;17) (q21;p13.3) in a textiloma. Virchows Arch. 442:507-508, 2003 [letter].