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[Rare late complications following thorotrast arteriographs (author's transl)].

Hematemesis in a thorotrastosis patient with severe liver dystrophy led to a tentative diagnosis of portal hypertension. The possibility of portal hypertension was eliminated via angiography. The cause of the hematoemesis was multiple bleeding stomach ulcers. In spite of severe damage to the liver parenchyma, portal hypertension with thorotrastosis does not usually occur. This has been confirmed in the literature and by histologic investigations. In second thorotrastosis patient, the cause of pain and swelling was a sterile abscess formation in the area of the thorotrastoma.

Aged↗

Leukemia and other related hematological disorders among Danish patients exposed to Thorotrast.

At least 60 case studies of leukemia among people exposed to chronic low-dose alpha-particle radiation from injections with the radiographic contrast medium Thorotrast and 115 cases from follow-up studies have been described in the literature. In the present study, malignant hematological diseases among 1003 Danish patients injected during 1935-1947 and followed to 1992 accruing 20,433 person-years were assessed and available histopathological specimens revised. The mean cumulative bone marrow alpha-particle radiation dose (1.34 Gy) was estimated from records of the amount of Thorotrast injected (mean 18.7 ml). Sixteen cases of acute myelogenous leukemia (AML) and seven cases of myelodysplastic syndrome (MDS) were diagnosed 8-40 years after injection, the cumulative frequency reaching 7.6%. No significant relationship was seen between the cumulative frequency of AML + MDS and the age at injection, gender, or amount of Thorotrast injected, but a multivariate analysis described data best by a model with the bone marrow dose and the power of the attained age. The risk estimate for AML + MDS was 173 cases/10(4) persons per Gy. If also considering cases of acute lymphocytic leukemia (1), chronic myelogenous leukemia (3), non-Hodgkins lymphoma (4), and multiple myeloma (2), the risk estimate became 248 cases/10(4) persons per Gy. It is suggested that RBE of alpha particles from thorium may be lower than 20.

Adolescent↗

Long-term haematological complications of thorotrast.

Six cases representing the spectrum of haematological complications due to systemic administration of Thorotrast are reposted. Two patients suffered from acute leukaemia, one patient had marrow failure and three patients presented with haematological features of hyposplenism; two of these also had solid tumours. The literature is reviewed.

Acute Disease↗

Mutations in the tumor suppressor gene p53 in human liver cancer induced by alpha-particles.

The p53 tumor suppressor gene is mutated in varying fractions of almost all tumor types studied. The rate of mutations and the mutational spectrum in some tumors are specific for environmental mutagens assumed to be involved in the carcinogenic process. Thus, hepatocellular carcinomas supposedly induced by aflatoxin exposure often contain a specific point mutation in codon 249, and in lung cancers of miners with heavy radon exposure, another specific point mutation in codon 249 suggestive of an alpha-particle-specific mutation has been shown. The interpretation of studies linking the mutational spectrum with specific environmental exposures is complicated by the multifactorial or unknown genesis of most tumors. However, people given injections of the X-ray contrast medium Thorotrast (Th) in the past have experienced an enormous risk of liver tumors, and virtually all of these are supposedly induced by alpha-particles from the decay of 232Th. The examination of these tumors may provide evidence as to whether specific p53 point mutations are relevant in alpha-particle carcinogenesis. Therefore, we collected paraffin-embedded, formalin-fixed archival tissues from 18 hepatocellular carcinomas, 9 cholangiocarcinomas, and 9 hepatic angiosarcomas from Thorotrast-exposed patients. The tissues were analyzed for p53 protein expression by immunohistochemical staining by using the mAb DO-7 and for mutations of exons 5-8 by PCR and constant denaturant gel electrophoresis. G --> T transversions of the third base of codon 249 of the p53 gene were specifically screened for by restriction enzymes. No high score for p53 protein expression (i.e., positive staining of >20% of examined cells) was observed; lower scores were seen in 5 of 18 (28%) hepatocellular carcinomas, 1 of 9 (11%) cholangiocarcinomas, and 0 of 8 (0%) hepatic angiosarcomas. Only one p53 mutation, a heterozygous T --> G transversion of the first base codon 176, occurred in a hepatocellular carcinoma. The rate of p53 point mutations in alpha-particle-induced liver tumors seems to be lower than in European hepatocellular carcinomas in general. The study does not exclude the possibility that alpha-particle carcinogenesis may involve inactivation of p53 by gross deletions of the gene, but it speaks against the proposed specificity of point mutations of codon 249 in cancer supposedly induced by alpha-particles from radon progeny.

Adolescent↗

The epidemiology of hepatocellular carcinoma.

Documentation of the wide geographical variation in the incidence of hepatocellular carcinoma has led to the clear identification of several risk factors. These include chronic infection with hepatitis B and/or hepatitis C and exposure to aflotoxin. All these agents may cause hepatocellular carcinoma but how they interact and how they are related to cirrhosis, which underlies most cases, remains an area of active research. Intervention programmes, most notably immunization against hepatitis B, are now under way and a marked decrease in incidence of hepatocellular carcinoma can be anticipated in the early part of the next century.

Aflatoxins↗

Sporadic and Thorotrast-induced angiosarcomas of the liver manifest frequent and multiple point mutations in K-ras-2.

Hepatic angiosarcoma (HA) is an uncommon neoplasm associated with known etiologic factors in 25% to 42% of cases. It is, however, one of the most common sarcomas found in the liver. The aim of this study was to find was to find mutations in the K-ras-2 oncogene in sporadic and Thorotrast (TT)-induced HA. Point mutations in K-ras-2 were sought in archival, formalin-fixed tissue blocks from 24 patients with angiosarcoma. Of these, 19 cases were sporadic and 5 were TT-induced. Mutational analysis was performed by topographic microdissection with PCR amplification followed by genotyping. Specific mutations were determined by two independent methods: (a) direct sequencing of the PCR product confirmed by rePCR and by using a different sequencing primer, and (b) PCR-based selective enrichment of mutant DNA by endonuclease digestion followed by heteroduplex DNA analysis using denaturing gradient gel electrophoresis. Eleven K-ras-2 point mutations were detected in 7 of 24 (29%) tumors, including 5 of 19 (26%) sporadic HA and 2 of 5 (40%) TT-induced HA. There were seven G:C > A:T and four G:C > T:A mutations. All seven mutated tumors contained a codon 12-aspartate amino acid substitution. In addition, a second codon 12-cysteine mutant cell population was present in one of two codon 12-aspartate mutated TT-induced HA and in three of five codon 12-aspartate sporadic tumors. Of these four tumors, three contained both aspartate and cysteine mutations and were composed of multiple nodules; the fourth was a single mass. Seventeen tumors had multiple nodules; whereas 5 had a K-ras-2 mutation, 12 were wild-type. The molecular pathology of both sporadic and TT-induced HA is characterized by a high rate of K-ras-2 mutations characteristic of oxidative damage (ie, G:C > A:T and G:C > T:A mutations) resulting in two mutated population sets: codon 12 GGT > GAT and GGT > TGT (glycine to aspartic acid and cysteine). This is, to date, the first study to characterize the K-ras-2 gene mutations within human sporadic and TT-induced HA by direct sequence analysis and denaturing gradient gel electrophoresis. These data further support the hypothesis linking adduct-forming vinyl chloride exposure to HA containing a much higher frequency of K-ras-2 mutations and a mutational spectrum characteristic of chloroethylene oxide, a carcinogenic metabolite of vinyl chloride.

Adult↗

[Osteomyelofibrosis syndrome 33 years after thorotrast angiography].

33 years after carotid arteriography with thorotrast a 69-year-old patient died from osteomyelofibrosis with severe hematopoietic hypoplasia and myeloid metaplasia detected in liver, lymph nodes, kidney and epicardium. Twenty years before death he underwent "prophylactic" splenectomy; histologically the spleen merely showed hypoplasia, fibrosis and deposits of thorotrast. It is assumed that the osteomyelofibrosis syndrome is a specific complication of thorotrast application which has only rarely been described in the past. This suggestion is supported by observations suggesting that osteomyelofibrosis syndrome may be induced by radiation and by the fact that thorotrast gives rise to foreign body reactions associated with subsequent severe fibrosis. The development of myeloid metaplasia is assumed to be secondary to chronic hematopoietic insufficiency.

Adult↗

Ingestion of colloid in a keratinized epithelium and its localization in membrane-coating granules.

An electron-dense tracer (Thorotrast) was injected into the lamina propria of the keratinized epithelium of the buccal mucosa of rats. Electron microscopy showed that it crossed the basal lamina and penetrated the intercellular spaces of the epithelium up to the proximal layers of the stratum granulosum. Thorotrast was ingested by the epithelial cells in the stratum basale and stratum spinosum and localized in large vesicles and eventually in the membrane-coating granules. The latter, already known to contain lysosomal enzymes, are therefore to be regarded as secondary lysosomes formed in part as a sequel of endocytosis in deeper cell layers. The postulated origin of MCGs directly from the Golgi apparatus is rendered less likely by this observation. Thorotrast remaining in the cells when keratinization is completed is either dispersed into the cytoplasm or else incorporated into keratohyalin granules.

Animals↗