|Year : 2022 | Volume
| Issue : 2 | Page : 67-69
Histopathologic findings following hemostasis with Gelfoam
Jose A Cervantes1, Kavina Patel2, Wendi Wohltmann3, Joshua Wisell4
1 Department of Dermatology, Baylor College of Medicine, Houston, Texas, USA
2 Department of Dermatology, The Univeristy of Texas Health Science Center at Houston, Houston, Texas, USA
3 Department of Dermatology, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas, USA
4 Department of Pathology, University of Colorado-Denver, Aurora Colorado, Colorado, USA
|Date of Submission||08-Nov-2021|
|Date of Decision||02-Aug-2022|
|Date of Acceptance||13-Dec-2021|
|Date of Web Publication||27-Oct-2022|
Department of Dermatology, The Univeristy of Texas Health Science Center at Houston, 6655 Travis Street, Houston, Texas 77030
Source of Support: None, Conflict of Interest: None
Gelfoam, an absorbable gelatin material that can carry thrombin and provide a matrix for the clotting cascade, is commonly used in dermatologic surgery to obtain hemostasis. Gelfoam application is often well tolerated, with minimal surgical site reaction. Gelfoam may be an incidental histopathologic finding following cutaneous surgery, typically without any clinical sequelae. Both dermatologic surgeons and pathologists should be familiar with this histopathologic finding to eliminate confusion and to avoid additional intervention. We present a case of a 76-year-old man with an interesting histopathologic finding of basophilic material predominantly overlying and among keratinocytes in an epithelializing surgical defect that was covered with Gelfoam.
Keywords: Basophilic, Gelfoam, histopathology, surgical defect
|How to cite this article:|
Cervantes JA, Patel K, Wohltmann W, Wisell J. Histopathologic findings following hemostasis with Gelfoam. Indian J Dermatopathol Diagn Dermatol 2022;9:67-9
|How to cite this URL:|
Cervantes JA, Patel K, Wohltmann W, Wisell J. Histopathologic findings following hemostasis with Gelfoam. Indian J Dermatopathol Diagn Dermatol [serial online] 2022 [cited 2022 Dec 9];9:67-9. Available from: https://www.ijdpdd.com/text.asp?2022/9/2/67/359776
| Introduction|| |
In 1944, two chemists Correll and Wise began searching for a substitute material to replace fibrin foam, a product used to achieve hemostasis during World War II. They found a worthy replacement in gelatin, a universal protein devoid of antigenicity, which they further developed into Gelfoam, a sponge-like insoluble, absorbable material that could carry thrombin, capable of providing a matrix for the clotting cascade. Correll et al. studied the histologic reaction and described it as having been no more a cellular reaction than that which takes place with the resorption of a blood clot. In 1950, Taylor and Kaplan highlighted four cases to illustrate the features of the cutaneous histopathological reactions to Gelfoam. The four cases noted were: (1) Gelfoam accumulating in purulent material, (2) a sterile scarifying reaction to Gelfoam, (3) a nonspecific inflammatory reaction to Gelfoam, and (4) deposition of acellular fibrous connective tissue at the site of Gelfoam deposits. He noted that the histological picture of the sponge in its various stages of absorption presented an interesting microscopic observation, which to the uninitiated may prove to be a baffling situation.
| Case Report|| |
A 76-year-old Caucasian man presented for excision of a lentigo maligna melanoma located on the right cheek. Original pathology showed malignant melanoma, lentigo maligna type, at least 0.31 mm in thickness, focally ulcerated with 1/mitosis/mm2, extending to the deep and lateral margins. The lesion was surgically removed and the inferior section was closed in a layered fashion. The superior aspect of the excision was left open pending pathology results and filled with Gelfoam [Figure 1]. Upon repair of the superior defect 1 week later the standing cutaneous tissue cones were sent to the pathology department for permanent sections. Histopathologic examination showed irregular epidermal acanthosis and evidence of a basophilic foreign material consistent with Gelfoam percolating through the epidermis [Figure 2] and [Figure 3]. The intraepidermal foreign material was surrounded by a mixed inflammatory infiltrate composed of lymphocytes and neutrophils.
|Figure 1: Initial closure of the lentigo maligna melanoma excision was left open at superior portion pending pathology results and filled with Gelfoam|
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|Figure 2: Irregular epidermal acanthosis and evidence of a basophilic foreign material consistent with Gelfoam percolating through the epidermis (10× magnification)|
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|Figure 3: On higher magnification (20×), intraepidermal foreign material surrounded by a mixed inflammatory infiltrate composed of lymphocytes and neutrophils|
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| Discussion|| |
Gelfoam is a light, opaque, nonabsorbable, tough sponge-like material able to be molded into any shape or form. It is regularly used to obtain hemostasis following surgical procedures. The application of Gelfoam is well tolerated, typically without tissue reaction or clinical sequelae. Several studies have shown that Gelfoam is normally absorbed within 4–6 weeks without promoting excessive scar tissue. Histopathologically, Gelfoam appears uniformly homogenous, staining in a range of pale to navy blue within anuclear fibrillar bands of pink collagen. Characteristically, cells including lymphocytes, histiocytes, eosinophils, and plasma cells surround the Gelfoam. In addition, loose aggregates of fibroblasts and endotheliocytes forming capillary channels can be appreciated along Gelfoam strands. Because Gelfoam is made up of gelatin, it infiltrates well with paraffin and usually does not pose an issue when sections are being prepared.
Extrusion of Gelfoam can histologically mimic transepithelial elimination (TEE), a process by which foreign material or altered dermal materials undergo cutaneous expulsion. During this process, the overlying epidermis becomes hyperplastic or pseudoepitheliomatous and envelops the dermal foreign material, subsequently eradicating it via a channel or canal within the epidermis., The exact mechanism of TEE is unknown, although it has been postulated that the initial event may involve recognition of foreign material, followed by the production of a dermal substance (possibly partially prostaglandin dependent) that induces epidermal hyperplasia. Experiments have also shown that if an offending material is either too strong of an irritant (which would cause epidermal necrosis) or completely non-irritative (no dermal reaction), TEE will not occur. The hallmark of TEE is the extrusion of altered dermal substances through epidermal channels without disruption of the surrounding structures, which could appear histologically similar to the extrusion of Gelfoam, potentially leading to misdiagnosis and unnecessary medical or surgical intervention.
| Conclusion|| |
To date, there appears to be a paucity of published literature on the specific histopathologic findings of Gelfoam. Given the regularity of its application in setting of dermatologic surgery, Gelfoam is likely to be encountered by both dermatologists and reading pathologists, thus making its recognition critical to rendering the appropriate diagnosis.
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Conflicts of interest
There are no conflicts of interest.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| References|| |
Taylor DR, Kaplan L Histopathologic response of the skin to Gelfoam. AMA Arch Derm Syphilol 1950;62:548-55.
Goette DK Transepithelial elimination in botryomycosis. Int J Dermatol 1981;20:198-200.
Ismail A, Beckum K, McKay K Transepithelial elimination in sarcoidosis: A frequent finding. J Cutan Pathol 2014;41:22-7.
Woo TY, Rasmussen JE Disorders of transepidermal elimination. Part 2. Int J Dermatol 1985;24:337-48.
[Figure 1], [Figure 2], [Figure 3]