A 60-year-old man presented to the emergency department with life-threatening hemoptysis 14 years after thoracotomy and chemoradiation for thoracic plasmacytomas. Early postoperative imaging confirmed the presence of a retained surgical gauze (gossypiboma) in the left hemithorax, but surgical removal was declined by the patient. An emergency contrast-enhanced thoracic CT angiography revealed bilateral ground-glass opacities (consistent with diffuse alveolar hemorrhage) and a heterogeneous left parahilar mass containing a linear high-attenuation structure (consistent with a radiopaque marker) (Fig. 1A, B). Marked hypertrophy of systemic arteries, including bilateral bronchial arteries, left intercostal arteries, and the left inferior phrenic artery was identified (Fig. 1C–F), together with foci of active contrast extravasation (Fig. 1G). Selective embolization of several systemic arteries (bronchial, intercostal, and left inferior phrenic arteries) was performed (Fig. 1H–I), resulting in the clinical stabilization of the patient. Intrathoracic gossypiboma refers to a mass formed by retained surgical material surrounded by an inflammatory or fibrotic reaction that may remain clinically silent for years and mimic thoracic malignancy or chronic infection on imaging [1–3]. Massive hemoptysis is exceptional and may result from chronic inflammatory systemic neovascularization predominantly affecting the bronchial arteries, whereas involvement of other systemic vessels is unusual. CT angiography plays a crucial role in identifying diffuse alveolar hemorrhage, detecting hypertrophied systemic vessels, and guiding embolization planning [4].
(A) Coronal minimum intensity projection (minIP) CT image (lung window) shows a large area of ground-glass attenuation in the right lower lobe, consistent with hemorrhage. Note a large mass in the left hemithorax (asterisk). (B) Axial maximum intensity projection (MIP) CT image (mediastinal window) shows the radiopaque filament (ellipse) of the retained foreign object (a surgical gauze). (C and D) Coronal 3D reconstruction CT images show a hypertrophic left bronchial artery (black arrows) and tortuous intercostal arteries (white arrows). (E) Coronal MIP CT image demonstrated an enlarged left phrenic artery (arrows). (F) Coronal MIP CT image (mediastinal window) shows a focus of contrast extravasation (arrow), consistent with active bleeding; note the radiopaque filament of the retained surgical gauze (ellipse). (G and H) Angiography of the left bronchial (G) and intercostal (H) arteries show hypertrophic arteries (black arrows). Note the presence of a contrast blush in G (white arrow) indicating active bleeding, and the opacification of left lower lobe pulmonary arteries in H (white arrows) indicating the formation of systemic-to-pulmonary artery fistulas. Also note the radiopaque marker of the gossypiboma (ellipse) and the vascular catheters (curved arrows).
All authors contributed equally to the manuscript writing. L.G. selected and edited the radiological images. All authors provided input to the final version of the manuscript.
Ethical considerationsThis article does not involve any studies on human participants conducted by the authors.
Informed consentThe authors certify that they have obtained all appropriate patient consent forms.
Artificial intelligence involvementThe authors declare that they have not used any type of generative artificial intelligence for the writing of this manuscript, nor for the creation of images, graphics, tables, or their corresponding captions.
FundingThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interestThe authors declare not to have any conflicts of interest that may be considered to influence directly or indirectly the content of the manuscript.
