Abstracts
OBJECTIVE:
The aim of this study was to analyze chest CT scans of patients with thoracic textiloma.
METHODS:
This was a retrospective study of 16 patients (11 men and 5 women) with surgically confirmed thoracic textiloma. The chest CT scans of those patients were evaluated by two independent observers, and discordant results were resolved by consensus.
RESULTS:
The majority (62.5%) of the textilomas were caused by previous heart surgery. The most common symptoms were chest pain (in 68.75%) and cough (in 56.25%). In all cases, the main tomographic finding was a mass with regular contours and borders that were well-defined or partially defined. Half of the textilomas occurred in the right hemithorax and half occurred in the left. The majority (56.25%) were located in the lower third of the lung. The diameter of the mass was ≤ 10 cm in 10 cases (62.5%) and > 10 cm in the remaining 6 cases (37.5%). Most (81.25%) of the textilomas were heterogeneous in density, with signs of calcification, gas, radiopaque marker, or sponge-like material. Peripheral expansion of the mass was observed in 12 (92.3%) of the 13 patients in whom a contrast agent was used. Intraoperatively, pleural involvement was observed in 14 cases (87.5%) and pericardial involvement was observed in 2 (12.5%).
CONCLUSIONS:
It is important to recognize the main tomographic aspects of thoracic textilomas in order to include this possibility in the differential diagnosis of chest pain and cough in patients with a history of heart or thoracic surgery, thus promoting the early identification and treatment of this postoperative complication.
Foreign-body reaction; Tomography; spiral computed; Thoracic surgery
OBJETIVO:
Analisar retrospectivamente os aspectos encontrados em TCs de tórax com textiloma torácico.
MÉTODOS:
Estudo retrospectivo de 16 pacientes (11 homens e 5 mulheres) com diagnóstico de textiloma torácico confirmado cirurgicamente. As TCs de tórax foram avaliadas, de modo independente, por dois observadores, e os casos discordantes foram resolvidos por consenso.
RESULTADOS:
Na maioria dos casos (62,5%), o fator causal foi a cirurgia cardíaca prévia. Os sintomas mais frequentes foram dor torácica (em 68,75%) e tosse (em 56,25%). Em todos os casos, o principal achado tomográfico foi de massa com contornos regulares e limites bem definidos ou parcialmente definidos. A localização dos textilomas ocorreu na mesma proporção no hemitórax direito e esquerdo, mas foi mais comum no terço inferior (em 56,25%). O tamanho das massas foi ≤ 10 cm e > 10 cm, respectivamente, em 10 (62,5%) e em 6 pacientes (37,5%). A maioria dos textilomas apresentou densidade heterogênea (81,25%), observando-se no seu interior calcificações, gás, marcador radiopaco ou material da compressa. A impregnação periférica da lesão foi observada em 12 (92,3%) dos 13 pacientes que receberam o meio de contraste. A cirurgia demonstrou acometimento do espaço pleural e pericárdico, respectivamente, em 14 (87,5%) e em 2 pacientes (12,5%).
CONCLUSÕES:
É importante reconhecer os principais aspectos tomográficos dos textilomas intratorácicos a fim de incluir essa possibilidade no diagnóstico diferencial em pacientes com dor torácica e tosse e história de cirurgia cardíaca ou torácica, contribuindo assim para o tratamento precoce dessa complicação cirúrgica.
Reação a corpo estranho; Tomografia computadorizada espiral; Cirurgia torácica
Introduction
Textiloma (also known as gossypiboma) is a term used to describe the presence of a mass
within a patient's body consisting of a cotton matrix, which usually corresponds to
retained surgical gauze or sponge, surrounded by foreign body reaction.(
11. Martins MC, Amaral RP, Andrade CS, Lucato LT, Leite CC.
Características de imagem na ressonância magnética de gossipiboma intracraniano:
relato de caso e revisão da literatura. Radiol Bras. 2009;42(6):407-9.
http://dx.doi.org/10.1590/S0100-39842009000600016
https://doi.org/10.1590/S0100-3984200900...
2. Poncelet AJ, Watremez C, Tack D, Noirhomme P. Paracardiac opacity
following inferior- and middle-lobe resection for bronchogenic carcinoma: unsuspected
diagnosis. Chest. 2005;128(1):439-41.
http://dx.doi.org/10.1378/chest.128.1.439
https://doi.org/10.1378/chest.128.1.439...
-
33. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol.
2005;78(933):851-3. http://dx.doi.org/10.1259/bjr/61657645
https://doi.org/10.1259/bjr/61657645...
) A textiloma is the most common retained surgical foreign body.(
44. O'Connor A, Coakley F, Meng M, Eberhardt S. Imaging of retained
surgical sponges in the abdomen and pelvis. AJR Am J Roentgenol. 2003;180(2):481-9.
http://dx.doi.org/10.2214/ajr.180.2.1800481
10.2214/ajr.180.2.1800481...
) It can occur in any part of the body and after any type of surgery, but
most cases reported in the literature are linked to abdominal surgery.(
55. Fouelifack FY, Fouogue JT, Fouedjio JH, Sando Z. A case of abdominal
textiloma following gynecologic surgery at the Yaounde Central Hospital, Cameroon.
Pan Afr Med J. 2013;16:147.
http://dx.doi.org/10.11604/pamj.2013.16.147.3201
https://doi.org/10.11604/pamj.2013.16.14...
) Few cases are related to thoracic surgery.(
66. Topal U, Gebitekin C, Tuncel E. Intrathoracic gossypiboma. AJR Am J
Roentgeno.l 2001;177(6):1485-6.
http://dx.doi.org/10.2214/ajr.177.6.1771485
https://doi.org/10.2214/ajr.177.6.177148...
,
77. Vayre F, Richard P, Ollivier JP. Intrathoracic gossypiboma: magnetic
resonance features. Int J Cardiol. 1999;70(2):199-200.
http://dx.doi.org/10.1016/S0167-5273(99)00003-0
https://doi.org/10.1016/S0167-5273(99)00...
) Because it is a relatively uncommon condition, with serious medical-legal
consequences and nonspecific clinical manifestations that can, however, be accompanied
by severe complications (such as hemoptysis, fistulas, and abscesses), which are
sometimes fatal,(
88. Ariz C, Horton KM, Fishman EK. 3D CT evaluation of retained foreign
bodies. Emerg Radiol. 2004;11(2):95-9.
http://dx.doi.org/10.1007/s10140-004-0373-0
https://doi.org/10.1007/s10140-004-0373-...
9. Biswas RS, Ganguly S, Saha ML, Saha S, Mukherjee S, Ayaz A.
Gossypiboma and surgeon - current medicolegal aspect - a review. Indian J Surg.
2012;74(4):318-22. http://dx.doi.org/10.1007/s12262-012-0446-3
https://doi.org/10.1007/s12262-012-0446-...
-
1010. Williams RG, Bragg DG, Nelson JA. Gossypiboma--the problem of the
retained surgical sponge. Radiology. 1978;129(2):323-6.
http://dx.doi.org/10.1148/129.2.323
https://doi.org/10.1148/129.2.323...
) it is necessary that clinicians, surgeons, and radiologists always consider
this diagnostic possibility and its radiological presentations so that early diagnosis
and correct definitive treatment can be established in a timely manner.
In general, performing an X-ray is the first step, since X-ray is the cheapest and most
readily available method and, in the presence of a visible radiopaque marker, it can be
conclusive. Transthoracic or transesophageal ultrasound can be important in the
assessment of a textiloma and its relationship with adjacent structures. Usually, CT is
the most effective method to establish the diagnosis and to analyze possible associated
complications.(
1111. Manzella A, Filho PB, Albuquerque E, Farias F, Kaercher J. Imaging
of gossypibomas: pictorial review. AJR Am J Roentgenol. 2009;193(6 Suppl):S94-101.
http://dx.doi.org/10.2214/AJR.07.7132
https://doi.org/10.2214/AJR.07.7132...
) In cases of a textiloma in the pericardial cavity, magnetic resonance
imaging allows a more appropriate and reliable assessment of the relationship between
the mass under study and the heart wall, facilitating surgical planning.(
1212. Coşkun M, Boyvat F, Ağildere AM. CT features of a pericardial
gossypiboma. Eur Radiol. 1999;9(4):728-30.
http://dx.doi.org/10.1007/s003300050743
https://doi.org/10.1007/s003300050743...
13. Madan R, Trotman-Dickenson B, Hunsaker AR. Intrathoracic
gossypiboma. AJR Am J Roentgenol. 2007;189(2):W90-1.
http://dx.doi.org/10.2214/AJR.07.2250
https://doi.org/10.2214/AJR.07.2250...
-
1414. Szarf G, Mussi de Andrade TC, Nakano E, Szjenfeld D, Costa AS Jr,
Rymkiewicz E, et al. Forty-year-old Intrathoracic gossypiboma after cardiac valve
surgery. Circulation. 2009;119(24):3142-3.
http://dx.doi.org/10.1161/CIRCULATIONAHA.109.849794
https://doi.org/10.1161/CIRCULATIONAHA.1...
)
Since this is a benign condition, it is important that the correct diagnosis be
established in the preoperative phase, because it allows surgical planning to be
conducted more carefully, unlike what occurs in cases of acute lesions. It also allows
surgeons to be more aware of possible associated complications that should be resolved
during the same operation. In addition, because it behaves as a mass and mimics a
neoplasm, patient anxiety and stress caused by an incorrect or inconclusive diagnosis
should be taken into consideration. Although some cases of textiloma are clinically
silent and are only discovered on routine radiological examination, surgical treatment
is indicated in almost all cases,(
1515. Hajj-Chahine J, Jayle C, Tomasi J, Corbi P. eComment. Late
presentation of thoracic textiloma. Interact Cardiovasc Thorac Surg. 2012;15(4):785.
http://dx.doi.org/10.1093/icvts/ivs362
https://doi.org/10.1093/icvts/ivs362...
) given that most patients have a frequent history of cough, chest pain, and
hemoptysis. These complications generally resolve completely after resection of the
lesion.
The objective of the present study was to investigate the main morphological characteristics and the most common CT findings of textilomas, as well as to analyze some epidemiological aspects of textilomas, such as clinical manifestations, gender and age distribution, and causal procedure.
Methods
This was a retrospective, descriptive observational study of CT scans of 16 patients with a confirmed diagnosis of textiloma. The CT scans were randomly obtained from radiologists and thoracic surgeons at various medical institutions in six Brazilian states, between January of 2005 and October of 2013. In addition, we collected clinical and epidemiological data about those patients, including age, gender, signs and symptoms, causal procedure, and surgical location of the lesion.
We included patients (n = 16) in whom the diagnosis of textiloma was confirmed by surgical excision of the mass, the analysis of which revealed fragments of surgical sponge. Two of the patients had previously undergone transthoracic biopsy, but in only one of them were small filaments, described as foreign bodies, identified by histopathology. The study was approved by the Research Ethics Committee of the Antonio Pedro University Hospital of the Fluminense Federal University. Because this was a retrospective study, using existing clinical data with no change in patient monitoring or treatment, written informed consent from patients was not required.
No standardization existed in the CT studies because multiple institutions were involved and multiple CT scanners were used. However, all scans were acquired with slice thicknesses ranging from 1 to 10 mm, at 5- to 10-min intervals, from the apices to the hemidiaphragms or until the entire mass was included, for masses extending to the abdomen, with the patient in the supine position, and at end-inhalation. The images were acquired and reconstructed in a 512 × 512 matrix and photographed, for assessment of the lung fields, at a window width of 1,200 to 2,000 HU and a level of −300 to −700 UH. For assessment of the mediastinum, the images were photographed at a window width of 350 to 500 HU and a center of 10 to 50 HU. The scans were evaluated by two independent radiologists. Discordant results were resolved by consensus.
The masses on each of the scans were analyzed for the following characteristics:
contour; borders; diameter; homogeneity; content; contrast enhancement; location (right
or left hemithorax; lower, middle, or upper third of the hemithorax); origin (parietal,
mediastinal, or pulmonary); and presence or absence of associated findings (pleural
thickening, atelectasis, pleural effusion, and consolidation). The criteria used to
define the CT findings were those reported in a Brazilian consensus.(
1616. Silva CI, Marchiori E, Souza Júnior AS, Müller NL; Comissão de
Imagem da Sociedade Brasileira de Pneumologia e Tisiologia. Illustrated Brazilian
consensus of terms and fundamental patterns in chest CT scans. J Bras Pneumol.
2010;36(1):99-123. http://dx.doi.org/10.1590/S1806-37132010000100016
https://doi.org/10.1590/S1806-3713201000...
) A mass was defined as any expansive pulmonary, pleural, mediastinal, or
chest wall lesion with soft tissue, adipose tissue, or bony tissue density, greater than
3 cm in diameter, with at least partially defined contours, outside the fissural area,
regardless of the characteristics of its contours or the heterogeneity of its content.
Consolidation was defined as increased lung parenchymal attenuation that precludes the
visualization of the vessels and outer contours of the bronchial walls. Atelectasis was
defined as decreased lung volume due to lower aeration of part or all of the lung.
Results
Clinical and epidemiological aspects
The clinical manifestations of the 16 patients included chest pain, in 11 patients (68.75%); cough, in 9 (56.25%); dyspnea, in 4 (25.00%); pain in the right shoulder, in 2 (12.50%); and low-grade fever, in 2 (12.50%). One patient (6.25%) was asymptomatic. The patient group consisted of 11 men (68.75%) and 5 women (31.25%). Patient ages ranged from 29 to 85 years, with a mean of 52 years and 2 months. Regarding the original surgery, 10 patients (62.50%) had undergone heart surgery, 3 (18.75%) had undergone lung surgery, and 3 (18.75%) had undergone other procedures (repair of a diaphragmatic laceration, in 2; and mediastinal tumor resection, in 1). The interval between the original surgery and the diagnosis of textiloma ranged from 1 to 120 months, with a mean of 30.6 months (2.5 years).
CT aspects
All 16 patients underwent CT. Iodinated contrast material was used in 13 patients (81.25%). The contrast material was not used in 3 patients (18.75%), because they had a history of allergy to iodine.
All cases presented as a (round or ovoid) mass with regular contours and borders that were well-defined or partially defined. In 7 cases (43.76%), the mass measured no more than 5 cm in diameter; in 4 (25.00%), it measured 10-15 cm; in 3 (18.75%), it measured 5-10 cm; in 1 (6.25%), it measured 15-20 cm; and in 1 (6.25%), it measured 20-25 cm. Three (18.75%) of the 16 masses were homogeneous, and 13 (81.2%) were heterogeneous. It was possible to identify images consistent with sponge-like material in 6 (46.1%; Figure 1); radiopaque marker, in 3 (23.1%; Figure 2); gas permeating the foreign body, in 2 (15.4%; Figure 3); calcification, in 1 (7.7%); and other findings (high and low attenuation areas), in 6 (46.1%). Some masses had two or more simultaneous changes. We found peripheral enhancement of the mass (Figure 4) in 12 (92.3%) of the 13 patients in whom the contrast agent was used. No other type of enhancement was identified. A folded pattern was identified in 3 patients (18.7%), and a spongiform pattern was identified in 2 (12.5%).
Intravenous contrast-enhanced chest CT scan with mediastinal window settings. Presence of a bulky cystic mass (arrows) with regular contours and well-defined borders, occupying and bulging the entire lower third of the right hemithorax and crossing the midline. Note peripheral contrast enhancement and typical folds (arrowheads) within the cystic mass, corresponding to the retained surgical sponge.
Non-contrast-enhanced chest CT scan with mediastinal window settings. Presence of an ovoid mass in the lower third of the right hemithorax, with soft tissue density, containing a dense linear image that corresponds to the retained surgical sponge marker (arrows). The lesion has regular contours and maintains, in most of its extent, close contact with the pleural surface.
Axial intravenous contrast-enhanced chest CT scan with mediastinal window settings. Presence of a mass (arrows) with regular contours and welldefined borders at the base of the right hemithorax, compressing the liver and showing a typical spongiform pattern due to the presence of gas within it.
Axial intravenous contrast-enhanced chest CT scan with mediastinal window settings. Presence of a mass with regular contours, well-defined borders, and peripheral contrast enhancement, in close contact with the pleural surface and located posteriorly in the middle third of the left hemithorax.
Half (50.0%) of the textilomas occurred in the right hemithorax and half (50.0%) occurred in the left. The textilomas were located in the lower third of the chest in 9 patients (56.3%), in the middle third in 5 (31.2%), and in the upper third in 2 (12.5%). In addition to the mass, 13 patients (81.2%) had other CT findings, which included pleural thickening, in 6 patients (46.15%); atelectasis, in 5 (38.50%); pleural effusion, in 3 (23.10%); and parenchymal consolidation, in 1 (7.70%). No patients were identified with fistula.
Surgical and pathological aspects
CT-guided transthoracic fine needle aspiration biopsy was performed in only 2 patients (12.5%). No neoplastic cells were identified in either of the biopsy samples. For only 1 of those 2 patients did the pathologist detect the presence of small filaments on the slide, described as foreign bodies. The 16 patients underwent surgery, and, in all of them, the presence of a foreign body containing cotton fibers was confirmed.
Sponge fragments, fibrous wall, and giant cell foreign body reaction were observed in all masses. In addition, areas of necrosis and calcification were identified in some of them. Regarding the space (pleural, pericardial, or mediastinal space) within which the mass was found intraoperatively, there was a significant predominance of the pleural space, in 14 (87.5%) of the 16 patients, followed by the pericardial space, in only 2 (12.5%).
Discussion
In the present study, which deals with thoracic textilomas exclusively, we found a
predominance of males, which corresponded to 68.75% of the cases. Because the vast
majority of published papers on thoracic textilomas consist of isolated case reports,
few describe the incidence of textilomas by gender. According to one group of
authors,(
1717. Kiernan F, Joyce M, Byrnes CK, O'Grady H, Keane FB, Neary P.
Gossypiboma: a case report and review of the literature. Ir J Med Sci.
2008;177(4):389-91. http://dx.doi.org/10.1007/s11845-008-0197-0
https://doi.org/10.1007/s11845-008-0197-...
) referring to textilomas in general, there is a slight predominance in
females (63%), which is related to the fact that pelvic surgery is more common in this
group than in males. However, in the case of thoracic textilomas, we found no reports of
prevalence by gender in the literature.
As to prevalence by age, in our sample, the age group affected was the 29- to 85-year
age group. We found no reports of prevalence by age in the literature. This is probably
due to the fact that, unlike many diseases, textilomas can affect any age group, being
not directly related to age, but rather directly related to the surgical procedures
undergone by patients, which can occur at any age. An analysis of literature case
reports involving adult patients showed that age at diagnosis of gossypiboma ranged from
22 years(
33. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol.
2005;78(933):851-3. http://dx.doi.org/10.1259/bjr/61657645
https://doi.org/10.1259/bjr/61657645...
) to 87 years.(
1818. Whang G, Mogel GT, Tsai J, Palmer SL. Left behind: unintentionally
retained surgically placed foreign bodies and how to reduce their
incidence--pictorial review. AJR Am J Roentgenol. 2009;193(6 Suppl):S79-89.
http://dx.doi.org/10.2214/AJR.09.7153
https://doi.org/10.2214/AJR.09.7153...
) In the vast majority of cases, age at diagnosis does not correspond to age
at onset of the mass, because although the diagnosis in some cases is established in a
young patient, the surgery that caused the textiloma often was performed many years
earlier, whereas in an elderly patient, the original surgery often was performed
recently. In fact, in the above two references, we found that, despite being much
younger, the 22-year-old patient had undergone the original surgery at 3 years of age,
i.e., 19 years earlier, to treat a penetrating wound to the left hemithorax, whereas the
patient who was diagnosed at 87 years of age had undergone the original surgery (aortic
valve replacement) only 7 days prior. In addition, on the basis of these two cases, we
note that the age range is very similar to that found in our study, as well as to that
reported in most studies.
The most common complaints in our sample were chest pain, cough, and dyspnea. According
to the literature, the most common clinical manifestations are cough, expectoration,
chest pain, hemoptysis, and dyspnea.(
33. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol.
2005;78(933):851-3. http://dx.doi.org/10.1259/bjr/61657645
https://doi.org/10.1259/bjr/61657645...
,
1919. Boutayeb A, Marmade L, Laaroussi M, Bensouda A, Moughil S. Textiloma
mimicking a pericardial hydatid cyst: a case report. Heart Lung Circ.
2012;21(5):278-80. http://dx.doi.org/10.1016/j.hlc.2012.01.005
https://doi.org/10.1016/j.hlc.2012.01.00...
,
2020. Nobre LF, Marchiori E, May F, Carrão AD Jr, Zanetti G, Machado DM.
Thoracic textilomas after myocardial revascularisation: typical CT findings. Br J
Radiol. 2010;83(985):4-7. http://dx.doi.org/10.1259/bjr/68800282
https://doi.org/10.1259/bjr/68800282...
) Regarding the surgery that caused the textiloma, heart surgery
predominated, having been performed in 10 patients (62.5%), followed by lung surgery, in
3 (18.75%), and by other procedures (repair of a diaphragmatic laceration and
mediastinal tumor resection), also in 3 (18.75%). In almost all published studies
focused specifically on thoracic textilomas that we consulted,(
22. Poncelet AJ, Watremez C, Tack D, Noirhomme P. Paracardiac opacity
following inferior- and middle-lobe resection for bronchogenic carcinoma: unsuspected
diagnosis. Chest. 2005;128(1):439-41.
http://dx.doi.org/10.1378/chest.128.1.439
https://doi.org/10.1378/chest.128.1.439...
,
33. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol.
2005;78(933):851-3. http://dx.doi.org/10.1259/bjr/61657645
https://doi.org/10.1259/bjr/61657645...
,
1212. Coşkun M, Boyvat F, Ağildere AM. CT features of a pericardial
gossypiboma. Eur Radiol. 1999;9(4):728-30.
http://dx.doi.org/10.1007/s003300050743
https://doi.org/10.1007/s003300050743...
13. Madan R, Trotman-Dickenson B, Hunsaker AR. Intrathoracic
gossypiboma. AJR Am J Roentgenol. 2007;189(2):W90-1.
http://dx.doi.org/10.2214/AJR.07.2250
https://doi.org/10.2214/AJR.07.2250...
-
1414. Szarf G, Mussi de Andrade TC, Nakano E, Szjenfeld D, Costa AS Jr,
Rymkiewicz E, et al. Forty-year-old Intrathoracic gossypiboma after cardiac valve
surgery. Circulation. 2009;119(24):3142-3.
http://dx.doi.org/10.1161/CIRCULATIONAHA.109.849794
https://doi.org/10.1161/CIRCULATIONAHA.1...
,
2020. Nobre LF, Marchiori E, May F, Carrão AD Jr, Zanetti G, Machado DM.
Thoracic textilomas after myocardial revascularisation: typical CT findings. Br J
Radiol. 2010;83(985):4-7. http://dx.doi.org/10.1259/bjr/68800282
https://doi.org/10.1259/bjr/68800282...
21. Park HJ, Im SA, Chun HJ, Park SH, O JH, Lee KY. Changes in CT
appearance of intrathoracic gossypiboma over 10 years. Br J Radiol.
2008;81(962):e61-3. http://dx.doi.org/10.1259/bjr/27014111
https://doi.org/10.1259/bjr/27014111...
22. Rijken MJ, van Overbeeke AJ, Staaks GH. Gossypiboma in a man with
persistent cough. Thorax. 2005;60(8):708.
http://dx.doi.org/10.1136/thx.2004.035659
https://doi.org/10.1136/thx.2004.035659...
23. Scott WW, Beall DP, Wheeler PS. The retained intrapericardial
sponge: value of the lateral chest radiograph. AJR Am J Roentgenol.
1998;171(3):595-7. http://dx.doi.org/10.2214/ajr.171.3.9725280
https://doi.org/10.2214/ajr.171.3.972528...
24. Sheehan RE, Sheppard MN, Hansell DM. Retained intrathoracic surgical
swab: CT appearances. J Thorac Imaging. 2000;15(1):61-4.
http://dx.doi.org/10.1097/00005382-200001000-00012
https://doi.org/10.1097/00005382-2000010...
25. Hochhegger B, Zanetti G, Garcia TS, Marchiori E. Retained surgical
sponge presenting as a cardiac mass. Eur J Cardiothorac Surg. 2012;41(5):e129.
http://dx.doi.org/10.1093/ejcts/ezs072
https://doi.org/10.1093/ejcts/ezs072...
-
2626. Hameed A, Naeem A, Azhar M, Fatimi SH. Intrathoracic gossypiboma.
BMJ Case Rep. 2014;2014.
) heart surgery predominated as the original surgery, followed by lung
surgery.
In the present study, the interval between the original surgery and the diagnosis of
textiloma ranged from 1 to 120 months, with a mean of 30.6 months. Because the condition
can occur after any surgical procedure and because some patients are asymptomatic, we
deduce that this interval can vary greatly. Therefore, on the basis once again of
published research focusing exclusively on thoracic textilomas, by means of a
report-by-report analysis, we could confirm this variability. There are patients in whom
the diagnosis was established shortly after the original surgery, as in the report by
Whang et al.,(
1818. Whang G, Mogel GT, Tsai J, Palmer SL. Left behind: unintentionally
retained surgically placed foreign bodies and how to reduce their
incidence--pictorial review. AJR Am J Roentgenol. 2009;193(6 Suppl):S79-89.
http://dx.doi.org/10.2214/AJR.09.7153
https://doi.org/10.2214/AJR.09.7153...
) in which the interval was 7 days. In other patients, the diagnosis was made
long after the original surgery, as in the report by Madan et al.,(
1313. Madan R, Trotman-Dickenson B, Hunsaker AR. Intrathoracic
gossypiboma. AJR Am J Roentgenol. 2007;189(2):W90-1.
http://dx.doi.org/10.2214/AJR.07.2250
https://doi.org/10.2214/AJR.07.2250...
) in which the interval between the original surgery and the diagnosis was 46
years. Even considering these details, it is not always possible to determine exactly
how long the surgical sponge has been in the patient's body. Some patients cannot
accurately tell the date of the original surgery or how old they were at the time. Other
patients underwent more than one surgical procedure, which makes it difficult to
determine the exact time of the onset of the condition. One group of authors(
33. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol.
2005;78(933):851-3. http://dx.doi.org/10.1259/bjr/61657645
https://doi.org/10.1259/bjr/61657645...
) reported the case of a female patient who had undergone at least two
thoracic procedures, making it impossible to determine which intervention had caused the
textiloma.
CT scan analysis showed that, in all of our 16 cases, the mass had a similar shape, as
well as regular contours and borders that were mostly well defined. In most of the
papers consulted,(
33. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol.
2005;78(933):851-3. http://dx.doi.org/10.1259/bjr/61657645
https://doi.org/10.1259/bjr/61657645...
,
1414. Szarf G, Mussi de Andrade TC, Nakano E, Szjenfeld D, Costa AS Jr,
Rymkiewicz E, et al. Forty-year-old Intrathoracic gossypiboma after cardiac valve
surgery. Circulation. 2009;119(24):3142-3.
http://dx.doi.org/10.1161/CIRCULATIONAHA.109.849794
https://doi.org/10.1161/CIRCULATIONAHA.1...
,
2020. Nobre LF, Marchiori E, May F, Carrão AD Jr, Zanetti G, Machado DM.
Thoracic textilomas after myocardial revascularisation: typical CT findings. Br J
Radiol. 2010;83(985):4-7. http://dx.doi.org/10.1259/bjr/68800282
https://doi.org/10.1259/bjr/68800282...
,
2323. Scott WW, Beall DP, Wheeler PS. The retained intrapericardial
sponge: value of the lateral chest radiograph. AJR Am J Roentgenol.
1998;171(3):595-7. http://dx.doi.org/10.2214/ajr.171.3.9725280
https://doi.org/10.2214/ajr.171.3.972528...
) textilomas were described as masses, and no other morphological aspects
were identified. In addition, it is of note that the lesions are almost always regular
and well defined.(
33. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol.
2005;78(933):851-3. http://dx.doi.org/10.1259/bjr/61657645
https://doi.org/10.1259/bjr/61657645...
,
77. Vayre F, Richard P, Ollivier JP. Intrathoracic gossypiboma: magnetic
resonance features. Int J Cardiol. 1999;70(2):199-200.
http://dx.doi.org/10.1016/S0167-5273(99)00003-0
https://doi.org/10.1016/S0167-5273(99)00...
,
2020. Nobre LF, Marchiori E, May F, Carrão AD Jr, Zanetti G, Machado DM.
Thoracic textilomas after myocardial revascularisation: typical CT findings. Br J
Radiol. 2010;83(985):4-7. http://dx.doi.org/10.1259/bjr/68800282
https://doi.org/10.1259/bjr/68800282...
,
2525. Hochhegger B, Zanetti G, Garcia TS, Marchiori E. Retained surgical
sponge presenting as a cardiac mass. Eur J Cardiothorac Surg. 2012;41(5):e129.
http://dx.doi.org/10.1093/ejcts/ezs072
https://doi.org/10.1093/ejcts/ezs072...
)
In most cases in our sample (87.5%), the mass measured 4 to 15 cm in diameter. As was
the case with gender and age, we found no statistically significant values for mean
diameter of thoracic textilomas in the literature. Analysis was made even more difficult
by the fact that many authors(
33. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol.
2005;78(933):851-3. http://dx.doi.org/10.1259/bjr/61657645
https://doi.org/10.1259/bjr/61657645...
,
1212. Coşkun M, Boyvat F, Ağildere AM. CT features of a pericardial
gossypiboma. Eur Radiol. 1999;9(4):728-30.
http://dx.doi.org/10.1007/s003300050743
https://doi.org/10.1007/s003300050743...
,
2323. Scott WW, Beall DP, Wheeler PS. The retained intrapericardial
sponge: value of the lateral chest radiograph. AJR Am J Roentgenol.
1998;171(3):595-7. http://dx.doi.org/10.2214/ajr.171.3.9725280
https://doi.org/10.2214/ajr.171.3.972528...
) have emphasized several radiological characteristics of the lesion
(homogeneity, as well as presence of gas, calcifications, and markers) in their papers,
but without mentioning its diameter. In the studies in which the diameter of the mass
was reported,(
22. Poncelet AJ, Watremez C, Tack D, Noirhomme P. Paracardiac opacity
following inferior- and middle-lobe resection for bronchogenic carcinoma: unsuspected
diagnosis. Chest. 2005;128(1):439-41.
http://dx.doi.org/10.1378/chest.128.1.439
https://doi.org/10.1378/chest.128.1.439...
,
77. Vayre F, Richard P, Ollivier JP. Intrathoracic gossypiboma: magnetic
resonance features. Int J Cardiol. 1999;70(2):199-200.
http://dx.doi.org/10.1016/S0167-5273(99)00003-0
https://doi.org/10.1016/S0167-5273(99)00...
,
1313. Madan R, Trotman-Dickenson B, Hunsaker AR. Intrathoracic
gossypiboma. AJR Am J Roentgenol. 2007;189(2):W90-1.
http://dx.doi.org/10.2214/AJR.07.2250
https://doi.org/10.2214/AJR.07.2250...
,
2020. Nobre LF, Marchiori E, May F, Carrão AD Jr, Zanetti G, Machado DM.
Thoracic textilomas after myocardial revascularisation: typical CT findings. Br J
Radiol. 2010;83(985):4-7. http://dx.doi.org/10.1259/bjr/68800282
https://doi.org/10.1259/bjr/68800282...
21. Park HJ, Im SA, Chun HJ, Park SH, O JH, Lee KY. Changes in CT
appearance of intrathoracic gossypiboma over 10 years. Br J Radiol.
2008;81(962):e61-3. http://dx.doi.org/10.1259/bjr/27014111
https://doi.org/10.1259/bjr/27014111...
-
2222. Rijken MJ, van Overbeeke AJ, Staaks GH. Gossypiboma in a man with
persistent cough. Thorax. 2005;60(8):708.
http://dx.doi.org/10.1136/thx.2004.035659
https://doi.org/10.1136/thx.2004.035659...
,
2424. Sheehan RE, Sheppard MN, Hansell DM. Retained intrathoracic surgical
swab: CT appearances. J Thorac Imaging. 2000;15(1):61-4.
http://dx.doi.org/10.1097/00005382-200001000-00012
https://doi.org/10.1097/00005382-2000010...
) the vast majority of the masses measured 4 to 9 cm, although one was
reported to measure 14 cm.(
1414. Szarf G, Mussi de Andrade TC, Nakano E, Szjenfeld D, Costa AS Jr,
Rymkiewicz E, et al. Forty-year-old Intrathoracic gossypiboma after cardiac valve
surgery. Circulation. 2009;119(24):3142-3.
http://dx.doi.org/10.1161/CIRCULATIONAHA.109.849794
https://doi.org/10.1161/CIRCULATIONAHA.1...
) These data are very similar to our findings.
Significant CT characteristics in our sample included heterogeneity, in 13 (81.2%) of
the 16 cases, and peripheral enhancement, in 12 (92.3%) of the 13 cases in which
intravenous contrast material was used. There is a consensus among authors, especially
among those who have published papers highlighting CT findings of thoracic textilomas,
that chief among the predominant characteristics of these lesions are heterogeneity and
peripheral enhancement.(
33. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol.
2005;78(933):851-3. http://dx.doi.org/10.1259/bjr/61657645
https://doi.org/10.1259/bjr/61657645...
,
77. Vayre F, Richard P, Ollivier JP. Intrathoracic gossypiboma: magnetic
resonance features. Int J Cardiol. 1999;70(2):199-200.
http://dx.doi.org/10.1016/S0167-5273(99)00003-0
https://doi.org/10.1016/S0167-5273(99)00...
,
2727. Marchiori E, Zanetti G, Hochhegger B, Machado D. Hydatid disease
versus textiloma: a diagnostic challenge. Thorax. 2011;66(7):635; author reply 635.
http://dx.doi.org/10.1136/thx.2010.156935
https://doi.org/10.1136/thx.2010.156935...
)
The lesions that were heterogeneous in density showed findings consistent with
sponge-like material, gas, calcification, or radiopaque marker. Of those aspects, the
one most commonly found in the cases of the present study was sponge-like material,
which was seen in 6 of the 16 masses. Gas bubbles were found within 2 lesions only. Some
authors have shown that, despite being typical, the finding of air bubbles trapped in
the fibers of the surgical sponge can be absent. (
33. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol.
2005;78(933):851-3. http://dx.doi.org/10.1259/bjr/61657645
https://doi.org/10.1259/bjr/61657645...
,
2828. Kopka L, Fisher U, Gross AJ, Funke M, Oestmann JO, Grabbe E. CT of
retained surgical sponges (textilomas): pitfalls in detection and evaluation. J
Comput Assist Tomogr. 1996;20(6):919-23.
http://dx.doi.org/10.1097/00004728-199611000-00009
https://doi.org/10.1097/00004728-1996110...
,
2929. Sakorafas GH, Sampanis D, Lappas C, Papantoni E, Christodoulou S,
Mastoraki A, et al. Retained surgical sponges: what the practicing clinician should
know. Langenbecks Arch Surg. 2010;395(8):1001-7.
http://dx.doi.org/10.1007/s00423-010-0684-4
https://doi.org/10.1007/s00423-010-0684-...
) A surgical sponge left in the pleural space, which corresponded to 87.5% of
the cases in our sample, does not typically result in images of gas because of the
reabsorption of air by the pleura,(
77. Vayre F, Richard P, Ollivier JP. Intrathoracic gossypiboma: magnetic
resonance features. Int J Cardiol. 1999;70(2):199-200.
http://dx.doi.org/10.1016/S0167-5273(99)00003-0
https://doi.org/10.1016/S0167-5273(99)00...
,
1212. Coşkun M, Boyvat F, Ağildere AM. CT features of a pericardial
gossypiboma. Eur Radiol. 1999;9(4):728-30.
http://dx.doi.org/10.1007/s003300050743
https://doi.org/10.1007/s003300050743...
,
1313. Madan R, Trotman-Dickenson B, Hunsaker AR. Intrathoracic
gossypiboma. AJR Am J Roentgenol. 2007;189(2):W90-1.
http://dx.doi.org/10.2214/AJR.07.2250
https://doi.org/10.2214/AJR.07.2250...
) which usually occurs within the first 30 days after surgery.(
3030. Karabulut N, Herek D, Kiroglu Y. CT features of intrathoracic
gossypiboma (textiloma). Diagn Interv Radiol. 2011;17(2):122-4
) Therefore, bubbles may not be a prominent finding in retained intrathoracic
surgical sponges, as is the case of those in the abdominal cavity. In the consulted
literature, there were no specifications as to the frequency at which sponge-like
material, gas, calcifications, or radiopaque markers are identified within
textilomas.
A folded pattern was identified in 3 of the 16 cases in our sample, and a spongiform
pattern was identified in 2. The air crescent sign, described on rare
occasions,(
2121. Park HJ, Im SA, Chun HJ, Park SH, O JH, Lee KY. Changes in CT
appearance of intrathoracic gossypiboma over 10 years. Br J Radiol.
2008;81(962):e61-3. http://dx.doi.org/10.1259/bjr/27014111
https://doi.org/10.1259/bjr/27014111...
) was not seen in any of the cases in our sample. There also have been no
reports in the literature of the frequency of spongiform or folded patterns.
It is important to note that some authors, in a retrospective analysis, found that
certain characteristics of the mass changed over the years, while the diagnosis was not
confirmed. This refers not only to characteristics such as homogeneity, given that an
initially homogeneous textiloma can become heterogeneous after calcifications or gas
develop within it, but also to others, since there may be changes in size and even
location when it comes to pleural masses.(
1919. Boutayeb A, Marmade L, Laaroussi M, Bensouda A, Moughil S. Textiloma
mimicking a pericardial hydatid cyst: a case report. Heart Lung Circ.
2012;21(5):278-80. http://dx.doi.org/10.1016/j.hlc.2012.01.005
https://doi.org/10.1016/j.hlc.2012.01.00...
,
2121. Park HJ, Im SA, Chun HJ, Park SH, O JH, Lee KY. Changes in CT
appearance of intrathoracic gossypiboma over 10 years. Br J Radiol.
2008;81(962):e61-3. http://dx.doi.org/10.1259/bjr/27014111
https://doi.org/10.1259/bjr/27014111...
)
Neither hemithorax was predominantly affected, but the lower third was involved in most cases (56.25%). No frequency rates for these data were available in the articles studied. Associated findings were present in 13 patients (81.2%). Pleural thickening, atelectasis, and pleural effusion were found in 6 (37.5%), 5 (31.2%), and 3 (18.8%) of the patients, respectively.
It was possible to establish that, on the basis of case reports in the literature, in
the vast majority of cases, the diagnosis of thoracic textiloma is confirmed only after
surgical resection.(
33. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol.
2005;78(933):851-3. http://dx.doi.org/10.1259/bjr/61657645
https://doi.org/10.1259/bjr/61657645...
,
1919. Boutayeb A, Marmade L, Laaroussi M, Bensouda A, Moughil S. Textiloma
mimicking a pericardial hydatid cyst: a case report. Heart Lung Circ.
2012;21(5):278-80. http://dx.doi.org/10.1016/j.hlc.2012.01.005
https://doi.org/10.1016/j.hlc.2012.01.00...
,
2121. Park HJ, Im SA, Chun HJ, Park SH, O JH, Lee KY. Changes in CT
appearance of intrathoracic gossypiboma over 10 years. Br J Radiol.
2008;81(962):e61-3. http://dx.doi.org/10.1259/bjr/27014111
https://doi.org/10.1259/bjr/27014111...
) This finding is in agreement with ours, since in only 1 of the 16 patients
studied was the diagnosis confirmed by transthoracic biopsy before resection.
The most common site of occurrence of textilomas was the pleural space (in 14 of the 16
cases; 87.5%). The pericardial space was involved in only 2 cases (12.5%), with the
lesion being located posteriorly. These data corroborate those reported in the
literature. Some authors have shown that the thoracic site where retained surgical
sponges are most commonly found is the pleural space, followed by the pericardial
space.(
22. Poncelet AJ, Watremez C, Tack D, Noirhomme P. Paracardiac opacity
following inferior- and middle-lobe resection for bronchogenic carcinoma: unsuspected
diagnosis. Chest. 2005;128(1):439-41.
http://dx.doi.org/10.1378/chest.128.1.439
https://doi.org/10.1378/chest.128.1.439...
,
77. Vayre F, Richard P, Ollivier JP. Intrathoracic gossypiboma: magnetic
resonance features. Int J Cardiol. 1999;70(2):199-200.
http://dx.doi.org/10.1016/S0167-5273(99)00003-0
https://doi.org/10.1016/S0167-5273(99)00...
,
1212. Coşkun M, Boyvat F, Ağildere AM. CT features of a pericardial
gossypiboma. Eur Radiol. 1999;9(4):728-30.
http://dx.doi.org/10.1007/s003300050743
https://doi.org/10.1007/s003300050743...
) Even in studies in which the initiating surgical procedure was heart
surgery, the pleural space was the most commonly affected site.(
2020. Nobre LF, Marchiori E, May F, Carrão AD Jr, Zanetti G, Machado DM.
Thoracic textilomas after myocardial revascularisation: typical CT findings. Br J
Radiol. 2010;83(985):4-7. http://dx.doi.org/10.1259/bjr/68800282
https://doi.org/10.1259/bjr/68800282...
) When the pericardial space is involved, the mass tends to be located
posteriorly,(
33. Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol.
2005;78(933):851-3. http://dx.doi.org/10.1259/bjr/61657645
https://doi.org/10.1259/bjr/61657645...
,
2323. Scott WW, Beall DP, Wheeler PS. The retained intrapericardial
sponge: value of the lateral chest radiograph. AJR Am J Roentgenol.
1998;171(3):595-7. http://dx.doi.org/10.2214/ajr.171.3.9725280
https://doi.org/10.2214/ajr.171.3.972528...
) which also occurred in our sample.
In conclusion, in this study, the cases of thoracic textiloma presented as masses, mostly heterogeneous, with peripheral contrast enhancement, and neither hemithorax was predominantly affected. The most common clinical manifestations were chest pain and cough. In the majority of the cases, the initiating surgical procedure was heart surgery, and most textilomas were found intraoperatively in the pleural space.
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» https://doi.org/10.1016/j.hlc.2012.01.005 -
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» https://doi.org/10.1259/bjr/68800282 -
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» https://doi.org/10.1259/bjr/27014111 -
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» https://doi.org/10.1136/thx.2004.035659 -
23Scott WW, Beall DP, Wheeler PS. The retained intrapericardial sponge: value of the lateral chest radiograph. AJR Am J Roentgenol. 1998;171(3):595-7. http://dx.doi.org/10.2214/ajr.171.3.9725280
» https://doi.org/10.2214/ajr.171.3.9725280 -
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27Marchiori E, Zanetti G, Hochhegger B, Machado D. Hydatid disease versus textiloma: a diagnostic challenge. Thorax. 2011;66(7):635; author reply 635. http://dx.doi.org/10.1136/thx.2010.156935
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Financial support: None
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*
Study carried out at the Fluminense Federal University, Niterói, Brazil
Publication Dates
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Publication in this collection
Sep-Oct 2014
History
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Received
31 July 2014 -
Accepted
29 Aug 2014