Case 5 -
Textiloma (Gossypiboma), Microfibrillar Collagen (Avitene®)-Associated,
with Eosinophilic Inflammatory Response
Gregory N. Fuller
MD Anderson Cancer Center
Click on each slide thumbnail image for an enlarged view
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)
Textiloma (Gossypiboma), Microfibrillar Collagen (Avitene®)-Associated, with Eosinophilic Inflammatory Response
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
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
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
. 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 .
Textilomas (Gossypibomas) in general surgical pathology
"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
. The time interval to clinical
presentation ranges from the immediate postoperative period to decades after surgery
The risk factors and incidence of "retained" sponges and other operating instruments have been
recently reviewed  and have received coverage in the popular press . Gawande and colleagues 
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 :
"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
Hemostatic agents used in current neurosurgical practice. Contemporary hemostatic
agents used in neurosurgical practice are divided into non-resorbable and resorbable categories .
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
Unique features of microfibrillar collagen (Avitene®) textilomas
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
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 .
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 .
Regional neuroanatomic considerations
Textilomas associated with two specific neuroanatomic sites warrant brief comment.
Textilomas located within or adjacent to the vertebral
column constitute a rare complication of spinal surgery
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
. 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 . 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.
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