Textiloma (Gossypiboma) Mimicking Recurrent Intracranial Tumor

Archives of Pathology & Laboratory Medicine,  Jul 2004  by Ribalta, Teresa,  McCutcheon, Ian E,  Neto, Antonio G,  Gupta, Deepali,  Et al

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Context.-Resorbable substances used to achieve hemostasis during neurosurgical procedures comprise 3 principal classes based on chemical composition: (1) gelatin sponge, (2) oxidized cellulose, and (3) microfibrillar collagen. Nonresorbable hemostatic aides include various forms of cotton and rayon-based hemostats (cottonoids and kites). Resorbable and nonresorbable hemostatic agents have been reported to cause symptomatic mass lesions, most commonly following intra-abdominal surgery. Histologic examination typically shows a core of degenerating hemostatic agent surrounded by an inflammatory reaction. Each agent exhibits distinctive morphologic features that often permit specific identification. Hemostat-associated mass lesions have been variously referred to as textilomas, gossypibomas, gauzomas, or muslinomas.

Objectives.-The aims of this study were to (1) identify cases of histologically proven cases of textiloma in neurosurgical operations, (2) characterize the specific hemostatic agent associated with textiloma formation, and (3) characterize the preoperative magnetic resonance imaging appearance of textiloma.

Design.-Cases in which a textiloma constituted the sole finding on repeat surgery for recurrent brain tumor, or was a clinically significant component of a radiologically identified mass lesion together with residual tumor, constituted the study set.

Results.-Five textilomas were identified and evaluated. The primary neoplasm was different in each case and included pituitary adenoma, tanycytic ependymoma, anaplastic astrocytoma, gliosarcoma, and oligodendroglioma. In all cases, preoperative magnetic resonance imaging suggested recurrent tumor. Textilomas included all categories of resorbable hemostatic agent. Other foreign bodies were present in some cases; the origin of these foreign bodies was traced to fibers shed from nonresorbable hemostatic material placed temporarily during surgery and removed before closure (cottonoids and kites). Inflammatory reactions included giant cells, granulomas, and fibroblastic proliferation. Microfibrillar collagen (Avitene) textilomas were associated with a striking eosinophil infiltration that was not seen with any other hemostatic agent.

Conclusions.-Hemostatic agents may produce clinically symptomatic, radiologically apparent mass lesions. When considering a mass lesion arising after intracranial surgery, the differential diagnosis should include textiloma along with recurrent tumor and radiation necrosis.

(Arch Pathol Lab Med. 2004;128:749-758)

A variety of hemostatic agents are routinely used to control intraoperative bleeding in many surgical subspecialties, including neurosurgery. Nonresorbable materials include various forms of cotton pledgets and cloth (such as muslin) and synthetic rayon hemostats (cottonoids and kites); these agents are removed prior to surgical closure, except in the case of muslin, which is used to repair or reinforce intracranial aneurysms. In contrast, although not originally intended as permanent implants, in practice bioabsorbable hemostats are often left in the surgical bed to prevent rebleeding after surgical closure. Three classes of resorbable hemostatic agents are currently in widespread use: gelatin foam (Gelfoam), oxidized cellulose (Surgicel, Oxycel), and microfibrillar collagen (Avitene). These agents and other foreign substances that are deliberately introduced into the central nervous system may induce an excessive inflammatory reaction in the vicinity of the surgical site, which produces a clinically symptomatic and/or radiologically apparent mass lesion that is often indistinguishable from recurrent tumor on clinical and neuroimaging studies.1-35

Textiloma (from Latin textile, a woven fabric, plus the suffix oma, meaning swelling or tumor), gossypiboma (from Latin Gossypium, the genus of cotton plants, plus borna, a Kiswahili term meaning place of concealment), gauzoma (from surgical gauze), and muslinoma (from muslin, a woven cotton fabric) are the historical terms that have been given to foreign body-related inflammatory pseudotumors arising from retained nonabsorbable cotton matrix that is either inadvertently or deliberately (as in the case of muslin wrapping of aneurysms) left behind during surgery, together with the associated inflammatory reaction. All of these terms are still currently in use in the technical literature, but appear infrequently or not at all in most medical dictionaries, pathology textbooks, and neurosurgery textbooks.

The hemostatic agents most widely used in contemporary neurosurgical practice include products in the following categories.

Resorbable Hemostatic Agents

Gelfoam (Figure 1, A through C).-Gelfoam (Ethicon, Somerville, NJ), a gelatin sponge introduced in 1945,36 is derived from an animal source and has an amorphous appearance. It is manufactured by beating and whipping lightly formalinized gelatin solution into a foam of uniform porosity. After drying, the gelatin foam is cut and sterilized. Gelfoam can also be produced in microsphere form for use as an embolie agent. By light microscopy, Gelfoam has a very distinctive branching architecture and stains purple with hematoxylin-eosin (H&E). It shows no birefringence.