Keywords
foreign body - astrocytoma - neoplasm recurrence - local - textiloma
Introduction
Textiloma (Txm) is a nonmedical term that has been given to foreign body-related inflammatory
pseudotumor arising from retained nonabsorbable cotton matrix that is either inadvertently
or deliberately left behind during surgery, which may trigger an inflammatory reaction.
In current neurosurgical practice, Txm often refers to a resorbable hemostatic agent
that is intentionally left in place to prevent the potentially disastrous consequences
of postoperative intracranial hemorrhage. The vast majority of neurosurgical patients
in whom resorbable hemostatic agents are left in place remain asymptomatic.[1]
Txms in the field of neurosurgery have been found mostly in patients with subdural
lesions postcraniotomy. This report describes a case of Txm mimicking a recurrent
high-grade astrocytoma, highlighting the importance of recognizing this entity in
the setting of tumoral recurrence.
Case Report
A 69-year-old right-handed female presented to our facility with a 6-month history
of progressive left-sided weakness. She was initially managed by an outside facility
as a stroke but she continued clinically deteriorating. After neuroimaging was obtained,
a biopsy was performed on a large, nonenhancing mass in the right frontoparietal lobe.
Pathology reported a diffuse astrocytoma, World Health Organization grade II with
wild type isocitrate dehydrogenase 1 by immunohistochemistry, epidermal growth factor
receptor amplification, and phosphatase and tensin homolog negative results by fluorescent
in situ hybridization analysis. She received external beam radiation to the areas
of residual tumor with a total dose of 54 Gy.
During a routine evaluation, 4 months after completion of radiation therapy, a magnetic
resonance imaging (MRI) revealed a nodular area of contrast enhancement dorsal and
inferior to the margin of the biopsy tract, growing between interval scans ([Fig. 1]). Advanced MRI techniques using dynamic susceptibility contrast perfusion-weighted
imaging (PWI) reported elevated relative cerebral blood volume (rCBV) up to 3:1 when
compared with the contralateral white matter, supporting hyperperfusion and tumor
recurrence. Of note, she was clinically asymptomatic.
Fig. 1 Advanced magnetic resonance imaging of the case. (A) Contrasting axial image in T1 with gadolinium, (B) perfusion map rCBV, (C) image fusion rCBV/MRI. Nodular area of contrast enhancement in the dorsal margin
of the biopsy tract, with elevated rCBV, suggesting hyperperfusion (arrows). MRI,
magnetic resonance imaging; rCBV, relative cerebral blood volume.
After the biopsy, she underwent a complete resection of this area. The pathology returned
as a Txm with Surgicel fibers ([Fig. 2]). Reactive changes were also seen consistent with radiation effect and areas of
atypical cells consistent with residual tumor but not significantly mitotically active.
She did not require any further treatments and continued MRI surveillance for 14 months
until another area of progression was seen.
Fig. 2 Low power (×40 original magnification) micrograph of Txm showing optically clear
bundles of foreign material (*) with morphology consistent with oxidized cellulose that is used for hemostasis.
The left portion of the micrograph shows fibrosis, hemosiderin-laden macrophages,
and chronic inflammation (H & E). H & E, hematoxylin and eosin.
Discussion
Intracranial and spinal Txm sometimes can manifest with early severe symptoms, neurological
deficits, pain, or seizures but, generally, they are nonspecific or asymptomatic,
like in our case. This inflammatory reaction is commonly misdiagnosed as an abscess,
tumor reoccurrence, radiation necrosis, infarction, or primary neoplasm.[2] Our case shows a clinical scenario similar to a pseudoprogression phenomenon in
which radiographic changes from treatments are not easy to distinguish from recurrent
tumor. Pseudoprogression characterizes a well-described phenomenon in patients with
high-grade gliomas (HGG) treated with radiation and chemotherapy in which radiographic
changes, such as new areas of contrast enhancement and edema occur early after treatments.[3]
Foreign-body reactions encountered in neurosurgical practice; however, they are very
rare and they are usually due to hemostatic agents that are deliberately left behind
during craniotomies. Surgicel, or oxidized cellulose polymer, is composed of polyanhydroglucuronic
acid that is woven into surgical gauze fibers and primarily used to coagulate bleeding
vessels. Txm composed of oxidized regenerated cellulose (Surgicel; Ethicon, Inc. and
Johnson & Johnson, Inc.) have been previously reported.[1]
For evaluation of Txm, a computed tomography (CT) scan is the imaging technique of
choice. Suggested CT findings are low-density heterogeneous masses with a hyperdense
rim with enhancement after contrast injection. In MRI, a heterogeneous structure with
a low-signal intensity, wavy pattern at T1 and a high-signal intensity at T2 has been
reported. Txm cannot be easily distinguished from a recurrent tumor or abscess due
to their nonspecific characteristics.[4] Therefore, careful history taking about previous operations and being aware of Txm
are very important for imaging diagnosis.
In regards to advanced neuroimaging, only a few reports have included diffusion imaging
and apparent diffusion coefficient mapping in Txm, mainly as a tool for distinguish
them from brain abscess.[5] The lack of low apparent diffusion coefficient centrally within the lesion favors
against abscess and could push toward the other diagnoses including Txm. MRI spectroscopy
has the potential to differentiate between tumor and infection/inflammation, thus
it helps in selecting cases to identify a recurrent tumor from other lesions.[2] In our case, the use of advanced neuroimaging with dynamic susceptibility contrast
PWI suggested transformation to a HGG but the corresponding high-grade features were
not visible on the pathology specimen.
Ribalta et al[1] conducted a study in which five patients with Txm were identified, all of which
based on the clinical and neuroimaging findings, suggested a recurrent tumor or tumor
progression prompting the resection of the mass. In our case, the use of dynamic susceptibility
contrast PWI suggested transformation to a HGG which also prompted surgical excision
of the mass.
Conclusions
After treatment of a neoplasm, if unexpected clinical or imaging evidence of recurrence
is present, a foreign body reaction to hemostatic material used during the initial
surgery should be included in the differential diagnosis which could often spare patients
from unnecessary therapies. Standard conventional neuroimaging and advanced techniques
have limitations. The standardization of advanced MRI is well recognized as a pressing
clinical and research need.
