Long-term hazards of Thorotrast.
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The accuracy of peritoneoscopy and liver biopsy in the diagnosis of hepatic cirrhosis was compared in 473 consecutive patients submitted to both procedures. One hundred and fifty-two of them had cirrhosis diagnosed by one or both methods. There was 73% agreement between the two procedures. ;Apparent' false-negative results were 17.7% for peritoneoscopy and 9.3% for liver biopsy. The incidence of false-negative results in the diagnosis of cirrhosis can be reduced by combining both procedures.
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Four cases of thyrotoxicosis are reported among 35 patients who had been given Thorotrast during the investigation of intracranial haemorrhage. For the group as a whole Thorotrast had been given between 11 and 31 years (mean 23.4 years) before this study. Thyrotoxicosis occurred in four patients between six and 17 years (mean 11.8 years) after the injection of Thorotrast. The fact that thyrotoxicosis did not occur in a small control group of patients who had had a subarachnoid haemorrhage and in whom Thorotrast had not been used at angiography suggests that Thorotrast may be of aetiological significance. In view of the known association between thyrotoxicosis and changes in the lymphoreticular system it is possible that the irradiation of this system by retained thorium has resulted in an abnormality of function which renders these patients more liable to the development of thyrotoxicosis.A fifth patient developed non-toxic thyroid enlargement 16 years after Thorotrast angiography.
A case of thorotrastosis occurred 25 years after thorotrast angiography, with the previously unrecorded association of myeloma type paraproteinaemia. The relationship between haemangioendothelioma due to thorotrast and other vascular sarcomas of the liver is briefly reviewed.
An example of a Thorotrast granuloma (thorotrastoma) occurred in the neck of a patient 44 years after a carotid angiogram in which Thorotrast was used as radiological contrast medium. The lesion had produced a "cold" abscess and the patient was undergoing treatment for retropharyngeal tuberculosis. Thorotrast leakage can produce unusual clinical symptoms and signs which are frequently misdiagnosed.
A case of nodular regenerative hyperplasia (NRH) of the liver is described in association with exposure to the radiographic contrast medium Thorotrast. This is the first case in which the pathological findings have been fully documented. It is suggested that NRH may have developed through Thorotrast induced damage to portal vein radicles.
A case of myelofibrosis related to thorotrast administration is described. Current concepts of acute myelofibrosis are discussed, as are the varied complications of thorotrast.
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The history of myelography and reactions to various contrast media is reviewed. Air is completely absorbed without producing long-term side effects. Lipiodol and Pantopaque are not absorbed and residual medium in the spinal canal can cause arachnoiditis. Other agents as Diodrast and Thorotrast never gained widespread acceptance. The water-soluble Dimer-X and Conray 60 have come into prominence but they are not totally without reactions. Recently a new water-soluble nonionic contrast medium has been developed in Norway. Metrizamide (Amipaque) has the same overall density as other water-soluble media but produces fewer reactions.
The characteristic roentgenologic features of Thorotrast deposition in the perihepatic and parapancreatic lymphatics are described. Minimal deposits of Thorotrast were seen in the liver and spleen on the abdominal radiograph in 6 patients who had no clinical symptoms. Inquiry into the patient's history invariably disclosed angiography for vascular surgery several years earlier. The typical configuration of the affected lymph node is an oval, heavy density with a long tail, resembling a tadpole or teardrop. Other irregular radiopacities in the same area, including linear ones, probably represent colloid deposition along the lymphatics. Roentgenologic differentiation of Thorotrast deposits from pancreas stones and calcified lymph nodes is discussed.
In 2 adults who had received thorotrast intravenously at ages 2 and 3 years, respectively, radiopaque outlines of their infantile vertebrae were seen in the adult vertebrae. Similar "ghosts" of the hemipelves were present in the pelvis of 1 patient. Autopsy findings and autoradiographs in 1 patient strongly suggest that persisting thorotrast deposits in the infantile vertebrae and pelvis have produced a chronic radiation osteitis and dense thickened bone trabeculae, which are more radiopaque than the surrounding adult bone.
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