It is not uncommon for surgical material, most often gauze, to remain in the body after surgery. It is usually found inside the patient's abdominal or pelvic cavity. Here we describe a unique case of Gossypiboma found in a patient’s axilla, 14 years after myxosarcoma surgery. A 57-year-old patient, after noticing a change in her left axilla, was referred from primary care to our hospital after. 14 years ago, a patient had a malignant tumor at the same site, which was surgically removed. Examination of the left axillary fossa revealed a solid, painless nodule, which was clinically diagnosed as recurrent malignancy. To our knowledge, this is the first case he describes with gossypiboma in this part of the body.

Gossypiboma or Textiloma is a term used to describe the mass of retained surgical material, most commonly surgical gauze, left inside the body after surgery, followed by the reaction of the surrounding tissue to the foreign body present [1, 2]. It is most commonly found in large body cavities such as the thoracic cavity, abdominal cavity, or pelvis, [3], and is extremely rare in other parts of the body, such as the extremities [4] and mouth [5, 6]. Two common responses lead to the discovery of retained material. The first type is an exudative inflammatory reaction with the formation of an abscess and usually leads to early detection and surgical removal. The second type is aseptic, with a fibrous reaction to cotton material and the development of soft tissue mass [7]. In this in this scientific paper, we describe a case of asymptomatic retained surgical gauze, discovered in the axilla 14 years after Myxosarcoma surgery.

A 57-year-old patient was admitted to our hospital after noticing a change in her left axilla. During the examination, the presence of an immobile, tightly attached, painless nodule in the left armpit was established, which was clinically diagnosed as recurrent malignancy (Tumor axillae lateralis sinistri recurrence). The patient had no other symptoms. Previously, at the same site, she had a tumor that was surgically removed 14 years ago. The pathohistological diagnosis of the tumor was: "Myxosarcoma gradus 1 (low grade) pT2a". Based on the anamnesis and findings, surgical treatment is indicated. During the surgical treatment of the left axillary pit, performed under general anesthesia, a bizarre-looking tumor, the size of a melon, was completely removed (Extripatio tumoris in totto). The sample was sent for pathohistological analysis to our department. On macroscopic examination, the tumor appears to have an intact cystic formation, measuring 115 x 100 mm, with a smooth, partly uneven surface. According to the longitudinal section, the cystic formation is a wall 2 to 10 mm thick (Figures 1 and 2), mostly of a smooth luminal surface, where in one focus a solid, partly dilapidated patchy foreign body, yellowish in color, is observed. The lumen of the cystic formation is filled with a dark, yellowish fluid. A closer inspection of a foreign body established that it was a surgical gauze, forgotten during the surgical treatment 14 years ago. After microscopic examination, the pathohistological diagnosis was: "Granuloma corporis alieni textus mollis et musculi striati precipituae cystica". After postoperative follow-up, four days later the patient was discharged home, in good health.

Figure 1: Cystic formation with patchy foreign body removed from left axillary fossa

It is difficult to determine precisely the incidence of Gossypiboma because there are insufficient reports of these cases due to possible consequent medical-legal problems [7]. Most of the available data refer to abdominal-pelvic Gossypibomes in which the incidence of occurrence varies significantly from 1: 1000 - 1: 1500 [8] to 1: 5027 [9]. Objects left in the extremity are often present in the form of soft tissue, which can be confused with neoplasma [10]. Patients with retained foreign bodies were found to be more likely to have emergency surgery, an unexpected change in surgery, or a higher body mass index [11]. Depending on their nature, they are classified into acute and chronic, and in both cases, the symptoms disappear after the operation. In the acute form, patients usually have early postoperative symptoms such as abscess formation and fistula. In the case of chronic forms of Gossypiboma, they usually appear as encapsulated granulomas that are not detected for a long time, because they are asymptomatic or show some non-specific symptoms [12, 13]. They are accompanied by a slow reaction to a foreign body with the formation of granulomas [14]. In this case, it was an asymptomatic, chronic Gossypiboma, immobile in the axillary pit of the patient, which did not cause a biochemical reaction or inflammation for 14 years.

There are several ways to minimize the possibility of these events. For example, a radiofrequency device may preoperatively mark applied surgical material, which can be detected and removed at the end of surgery by scanning the surgical field [15]. Unfortunately, such a device is not available in our country. Another, much simpler method is a careful surgical counting protocol, in which all the material used during the operation is counted before and after the procedure. The number of materials should be equal preoperatively and postoperatively, otherwise the surgeon approaches a detailed inspection of the operative field [16].

Despite precautions, Gossypiboma persists and should be considered a differential diagnosis in patients with a history of previous surgery. Particular attention should be paid to the occurrence of symptomatic or asymptomatic palpable masses at the site of previously translated surgical treatment of malignancy in order to suppress the replacement of Gossypibom with a recurrent neoplasm. The appearance of Gossypiboma can have unforeseeable consequences on the life and health of the patient, and the professional reputation of the surgeon. It is necessary to continuously seek and implement additional preventive measures, and monitor the progress of foreign body detection technology in order to prevent human error during the operation.