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A rare case of retroperitoneal gossypiboma mimicking renal tumor
European Journal of Radiology Extra 61 (2007) 31–32
A rare case of retroperitoneal gossypiboma mimicking renal tumor Georgios P. Dimitriadis ∗ , Ioannis Prousalidis, Anastasios Tahmatzopoulos, Demetrios C. Radopoulos 1st Department of Urology and Department of Surgery, Aristotle University of Thessaloniki, Ethn. Aminis 41, GR-546 35 Thessaloniki, Greece Received 23 July 2006; received in revised form 10 October 2006; accepted 16 October 2006
Abstract An unusual case of gossypiboma, a foreign cotton body, in a 75-year-old male patient, who underwent staging studies for colon adenocarcinoma, is presented. A lower pole mass on his right kidney appeared on the preoperative workup, which was revealed to be a retained gauze, during the surgical exploration. A history of renal stone surgery, 32 years before was the possible reason of this situation. There are relatively few reports in the literature concerning gossypibomas, however, their true incidence might be underestimated due to underreporting because of legal implications. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Retroperitoneal gossypiboma; Renal tumor; Surgical sponge
1. Introduction Gossypibomas are iatrogeneously introduced foreign bodies, which are frequently composed of retained sponges or surgical instruments accidentally left during an operative procedure. The term derives from the Latin word gossypium (cotton) and the Kiswahili word boma (place of concealment) [1]. Their incidence is reported to be 1 in 1000–1500 operations [2], however, not many cases are reported in the literature, probably due to legal consequences. In the case presented, the diagnosis of a gossypiboma, appearing as a right lower pole renal mass lesion in a patient with adenocarcinoma of the colon, is been described.
2. Case report A 75-year-old male patient complaining of fatigue and lower intestinal bleeding for almost 3 months, was diagnosed suffering from right colon adenocarcinoma on colonoscopy. The patient had been subjected to an open procedure for nephrolithiasis 32 years ago. His laboratory ∗
Corresponding author. Tel.: +30 2310 825775; fax: +30 2310 992520. E-mail address: [email protected] (G.P. Dimitriadis).
1571-4675/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2006.10.011
tests, including renal function tests, were normal except for mild anaemia (Hb = 11 mg/dl) and microscopic haematuria (20–25 RBCs/hpf). On preoperative staging with CT scan, a well circumscribed right lower pole enhancing renal mass lesion was demonstrated. There was evidence of a tumor pseudocapsule with similar uptake to that of the normal renal parenchyma and a central part showing inhomogeneously diminished contrast uptake (Fig. 1). At subsequent MR imaging an encapsulated thick walled cystic mass was demonstrated, consistent with a centrally degenerated solid tumor (Fig. 2). A right hemicolectomy, with simultaneous right nephrectomy via transabdominal access, was performed. Macroscopically, the size of the well circumscribed lower pole mass was 8 cm × 6 cm × 7.5 cm and the cut surface appeared partly cystic, containing gauze material (Fig. 3). Microscopically, the mass was composed mainly of blood clots and necrobiotic material with areas of fibrous connective tissue. On its peripheral part the mass was surrounded by a thick fibrous pseudocapsule with inflammatory infiltration by lymphocytes, plasma cells, polymorhonuclear cells and histiocytes. Evidence of foreign-body giant cell reaction was noted in some areas. The right hemicolectomy specimen was classified as a pT3pN0 colon adenocarcinoma. The patient had an uneventful recovery with no evidence of
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G.P. Dimitriadis et al. / European Journal of Radiology Extra 61 (2007) 31–32
tumor recurrence or metastatic disease at 6- and 12 months postoperative follow-up.
3. Discussion
Fig. 1. Contrast-enhanced CT scan showing an enhancing solid right lower pole mass, well circumscribed, with inhomogeneous internal structure (arrow).
Fig. 2. Contrast-enhanced T1 MRI film (coronal plane, Gadolinium, 1.5T, TR 723, TE 12) demonstrating a cystic retroperitoneal mass arising from the lower pole of the right kidney (arrow).
There are two main ways of tissue response to a foreign body: the most commonly described is an aseptic fibrous inflammatory reaction with capsule formation and a foreign body granuloma development. The second is an exudative response that can lead to abscess formation with or without secondary bacterial contamination [3]. The fibrous reaction can remain clinically silent for many years in the majority of cases, until it is accidentally discovered during evaluation for another medical problem, as in the present case, or until it grows to a clinically palpable size. The exudative response is usually easier to diagnose due to early acute manifestations of infection, abscess formation or sepsis. The presence of a radiopaque marker in a mass lesion can be very helpful in the differential diagnosis. Computed tomography image may vary, including cases of a calcified mass with capsule formation or hypodense mass with peripheral enhancement or even a spongiform configuration with entrapment of small air bubbles. The latter one or a history of previous operations is strongly suggestive of a gossypiboma [4]. Differential diagnosis usually includes tumor, abscess, hematoma or pseudocyst formation. In the case presented the CT findings were highly indicative of renal tumor while the MR imaging could be retrospectively compatible with a well encapsulated foreign body, possibly related to the previous kidney operation. Clinically silent cases can often remain asymptomatic for the rest of the patient’s life, however, meticulous attention to sponge and instrument count and improvement in the quality of communication between team members are mandatory to avoid this complication. Frustratingly, in most cases of a missed sponge, the sponge count is apparently correct [3]. Therefore, attention to detail, inspection of the operative field before closure as well as intraoperative radiologic examination in equivocal cases could contribute to the reduction of the incidence of gossypibomas.
References
Fig. 3. Macroscopic appearance of the nephrectomy specimen. Tumor-like appearance of the mass, which is in part cystic, with a brown cut surface containing gauze.
[1] Jain M, Jain R, Sawhney S. Gossypiboma: ultrasound-guided removal. J Clin Ultrasound 1995;23:321–3. [2] Sugano S, Suzuki T, Iinuma M, et al. Gossypiboma: diagnosis with ultrasonography. J Clin Ultrasound 1993;21:289–92. [3] Moyle H, Hines OJ, McFadden DW. Gossypiboma of the abdomen. Arch Surg 1996;131:566–8. [4] Liessi G, Semisa M, Sandini F, et al. Retained surgical gauzes: acute and chronic CT and US findings. Eur J Radiol 1989;9:182–6.
A rare case of retroperitoneal gossypiboma mimicking renal tumor Georgios P. Dimitriadis ∗ , Ioannis Prousalidis, Anastasios Tahmatzopoulos, Demetrios C. Radopoulos 1st Department of Urology and Department of Surgery, Aristotle University of Thessaloniki, Ethn. Aminis 41, GR-546 35 Thessaloniki, Greece Received 23 July 2006; received in revised form 10 October 2006; accepted 16 October 2006
Abstract An unusual case of gossypiboma, a foreign cotton body, in a 75-year-old male patient, who underwent staging studies for colon adenocarcinoma, is presented. A lower pole mass on his right kidney appeared on the preoperative workup, which was revealed to be a retained gauze, during the surgical exploration. A history of renal stone surgery, 32 years before was the possible reason of this situation. There are relatively few reports in the literature concerning gossypibomas, however, their true incidence might be underestimated due to underreporting because of legal implications. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Retroperitoneal gossypiboma; Renal tumor; Surgical sponge
1. Introduction Gossypibomas are iatrogeneously introduced foreign bodies, which are frequently composed of retained sponges or surgical instruments accidentally left during an operative procedure. The term derives from the Latin word gossypium (cotton) and the Kiswahili word boma (place of concealment) [1]. Their incidence is reported to be 1 in 1000–1500 operations [2], however, not many cases are reported in the literature, probably due to legal consequences. In the case presented, the diagnosis of a gossypiboma, appearing as a right lower pole renal mass lesion in a patient with adenocarcinoma of the colon, is been described.
2. Case report A 75-year-old male patient complaining of fatigue and lower intestinal bleeding for almost 3 months, was diagnosed suffering from right colon adenocarcinoma on colonoscopy. The patient had been subjected to an open procedure for nephrolithiasis 32 years ago. His laboratory ∗
Corresponding author. Tel.: +30 2310 825775; fax: +30 2310 992520. E-mail address: [email protected] (G.P. Dimitriadis).
1571-4675/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2006.10.011
tests, including renal function tests, were normal except for mild anaemia (Hb = 11 mg/dl) and microscopic haematuria (20–25 RBCs/hpf). On preoperative staging with CT scan, a well circumscribed right lower pole enhancing renal mass lesion was demonstrated. There was evidence of a tumor pseudocapsule with similar uptake to that of the normal renal parenchyma and a central part showing inhomogeneously diminished contrast uptake (Fig. 1). At subsequent MR imaging an encapsulated thick walled cystic mass was demonstrated, consistent with a centrally degenerated solid tumor (Fig. 2). A right hemicolectomy, with simultaneous right nephrectomy via transabdominal access, was performed. Macroscopically, the size of the well circumscribed lower pole mass was 8 cm × 6 cm × 7.5 cm and the cut surface appeared partly cystic, containing gauze material (Fig. 3). Microscopically, the mass was composed mainly of blood clots and necrobiotic material with areas of fibrous connective tissue. On its peripheral part the mass was surrounded by a thick fibrous pseudocapsule with inflammatory infiltration by lymphocytes, plasma cells, polymorhonuclear cells and histiocytes. Evidence of foreign-body giant cell reaction was noted in some areas. The right hemicolectomy specimen was classified as a pT3pN0 colon adenocarcinoma. The patient had an uneventful recovery with no evidence of
32
G.P. Dimitriadis et al. / European Journal of Radiology Extra 61 (2007) 31–32
tumor recurrence or metastatic disease at 6- and 12 months postoperative follow-up.
3. Discussion
Fig. 1. Contrast-enhanced CT scan showing an enhancing solid right lower pole mass, well circumscribed, with inhomogeneous internal structure (arrow).
Fig. 2. Contrast-enhanced T1 MRI film (coronal plane, Gadolinium, 1.5T, TR 723, TE 12) demonstrating a cystic retroperitoneal mass arising from the lower pole of the right kidney (arrow).
There are two main ways of tissue response to a foreign body: the most commonly described is an aseptic fibrous inflammatory reaction with capsule formation and a foreign body granuloma development. The second is an exudative response that can lead to abscess formation with or without secondary bacterial contamination [3]. The fibrous reaction can remain clinically silent for many years in the majority of cases, until it is accidentally discovered during evaluation for another medical problem, as in the present case, or until it grows to a clinically palpable size. The exudative response is usually easier to diagnose due to early acute manifestations of infection, abscess formation or sepsis. The presence of a radiopaque marker in a mass lesion can be very helpful in the differential diagnosis. Computed tomography image may vary, including cases of a calcified mass with capsule formation or hypodense mass with peripheral enhancement or even a spongiform configuration with entrapment of small air bubbles. The latter one or a history of previous operations is strongly suggestive of a gossypiboma [4]. Differential diagnosis usually includes tumor, abscess, hematoma or pseudocyst formation. In the case presented the CT findings were highly indicative of renal tumor while the MR imaging could be retrospectively compatible with a well encapsulated foreign body, possibly related to the previous kidney operation. Clinically silent cases can often remain asymptomatic for the rest of the patient’s life, however, meticulous attention to sponge and instrument count and improvement in the quality of communication between team members are mandatory to avoid this complication. Frustratingly, in most cases of a missed sponge, the sponge count is apparently correct [3]. Therefore, attention to detail, inspection of the operative field before closure as well as intraoperative radiologic examination in equivocal cases could contribute to the reduction of the incidence of gossypibomas.
References
Fig. 3. Macroscopic appearance of the nephrectomy specimen. Tumor-like appearance of the mass, which is in part cystic, with a brown cut surface containing gauze.
[1] Jain M, Jain R, Sawhney S. Gossypiboma: ultrasound-guided removal. J Clin Ultrasound 1995;23:321–3. [2] Sugano S, Suzuki T, Iinuma M, et al. Gossypiboma: diagnosis with ultrasonography. J Clin Ultrasound 1993;21:289–92. [3] Moyle H, Hines OJ, McFadden DW. Gossypiboma of the abdomen. Arch Surg 1996;131:566–8. [4] Liessi G, Semisa M, Sandini F, et al. Retained surgical gauzes: acute and chronic CT and US findings. Eur J Radiol 1989;9:182–6.