Nodular hepatocellular carcinoma--treatment with intraarterial injection of I-131 Lipiodol

Twenty four patients with hepatocellular carcinoma who refused surgery or had unresectable tumor ranging 2.5 to 8.0 cm in size were treated with intrahepatic arterial injection of iodine-131-labeled iodized oil (I-131 Lipodol) in an attempt to achieve internal radiation of tumor. 555-2,220 MBq in 3-8 ml of I-131 Lipiodol was injected into the hepatic artery or proximal to the tumor feeding vessel depending on the tumor size. Tumor size reduction was observed in 88.9% of tumor smaller than 4.0 cm in diameter, 65.5% between 4.1 to 6.0 cm, and 25.0% of larger than 6.1cm, respectively. The tumor size reduction was corresponded to the gradual drop of serum AFP levels, decreased uptake on gallium-67 scintigraphy, and devascularization on follow-up angiography. Tumors having significant A-V shunts revealed further tumor growth. Adverse reactions from the treatment include fever, mild abdominal pain, nausea and elevation of transaminases. These have been mild and well-tolerated by the patients. This method was able to provide long term local control without complications related to thyroid, lung, GI tract and bone marrow.

[Changes in the lungs and pleura following chemoembolization of liver tumors with mitomycin-lipiodol]

The authors performed 68 liver embolizations in 51 patients. As selectively as possible, Lipiodol, to block the capillary bed, and a chemotherapeutic agent were injected into the liver tumors. A CT performed 24 hours after treatment showed the distribution of the contrast medium which is also an indicator of the distribution of the chemotherapeutic agents. It was found that the contrast medium had accumulated not only in the liver but also in the lungs. Here, four different degrees of accumulation were found, according to the amount of Lipiodol used. Embolization of the liver thus involves potential hazards for the lungs, such as microembolisms, pneumonia, and toxic effects of the chemotherapeutic agents.

Cerebral embolization and coma after hysterosalpingography with oil-soluble contrast medium

A case of coma due to embolization after HSG, using oil-soluble contrast medium is presented. The patient was in a comatose state 11 days and then spontaneously regained full consciousness. The safety of oil-contrast medium for HSG is questionable.

[Pulmonary complication following intra-arterial infusion of lipiodol-adriamycin emulsion for hepatocellular carcinoma, report of a case]

A case of acute pulmonary complication following intra-arterial infusion of Lipiodol-Adriamycin emulsion for hepatocellular carcinoma was reported. Intra-arterial infusion chemotherapy was performed on a 75-year-old male with Lipiodol-Adriamycin emulsion (Lipiodol 8 ml + Adriamycin 40 mg). Severe dyspnea and cyanosis started about 30 minutes after the infusion, and blood gas analysis revealed hypoxemia and hypocapnia. Chest X-ray revealed diffuse infiltrative shadow throughout the both lungs. He was on positive end-expiratory pressure breathing for 4 days. Clinical symptoms and chest X-ray improved rapidly in the course of two weeks, he became almost asymptomatic. We concluded that the nature of this pulmonary damage was pulmonary edema due to the large amount of Adriamycin that flowed into pulmonary artery via arterio-venous shunt present in the hepatocellular carcinoma.

Dacryocystography: comparison of water-soluble and oil-based contrast agents

Dacryocystography has been widely used in the assessment of the nasolacrimal duct system, particularly in patients with epiphora. Our study was undertaken to evaluate image quality and level of patient discomfort during examinations with water-soluble contrast agents (iohexol [Omnipaque 240], iopamidol [Isovue 200 and 300], and 52.7% diatrizoate meglumine and 26.9% iodipamide meglumine [Sinografin]) compared with the iodized oil-based contrast agent Lipiodol. Fifty-five dacryocystograms were obtained from 41 consecutive patients. The procedure was performed first with a water-soluble contrast agent, then repeated with Lipiodol. A distention technique was used with conventional radiography. Patients were asked to evaluate their level of discomfort (none, mild, moderate, severe). The images were evaluated separately by two radiologists, blinded to which water-soluble agent was employed, and the images were graded on a five-point scale. Images obtained with Lipiodol were significantly better than those with other agents (P less than .02), and image quality deteriorated as iodine concentration decreased. Use of Isovue 300 and Sinografin produced significantly more patient discomfort (P less than .03) than the use of other agents. The authors conclude that, in most instances, Lipiodol is the contrast agent of choice with regard to both highest level of patient comfort and greatest conventional radiographic image quality among the agents compared.

Treatment of liver metastases by arterial injection of adriamycin/mitomycin C lipiodol suspension

Sixty-one patients with liver metastases were treated with hepatic arterial injection of Adriamycin/Mitomycin C oil suspension (ADMOS). The liver metastases originated from the gastrointestinal tract in 41 patients and from other organs in 20 patients. Sixty-nine liver tumors were analyzed in these 61 patients. Computed tomography (CT) after ADMOS injection (Lip-CT) gave more information in 19 cases (31%) than enhanced CT with a water-soluble contrast medium. With Lip-CT, Lipiodol tumor enhancement was observed in 64 of 69 lesions. The patterns of Lipiodol uptake in the tumors were classified into 4 types: Homogeneous accumulation (20%), heterogeneous accumulation (16%); accumulation with a central defect (57%); and no accumulation (7%). A tumor response was achieved in 41 of 69 lesions (59%). Anticancer effects were also shown as a decrease in serum CEA levels. The one year survival rate estimated by the Kaplan-Meier method was 43 per cent and the median survival time was 337 days. The results were better among patients who received multiple doses of ADMOS. Only minimal side effects were associated with ADMOS. The method is considered to be an excellent diagnostic and therapeutic procedure for liver metastases.

[Principle and therapeutic effect of lipophilic anticancer agent [SMANCS/lipiodol]: selective targeting with oily contrast medium]

Lipiodol, an oily contrast medium, is utilized to deliver the anticancer agent SMANCS to the target tumor in which the tumor selective delivery of 2,500 fold more than plasma was confirmed with prolonged retention in the tumor tissue. This unique tumor targeting is accomplished by the arterial injection of the oily formulation of the drug. The method utilizes unique vascular properties of tumor tissue. SMANCS is a derivative of neocarzinostatin conjugated with copolymer of styrene and maleic acid. It has much propronounced lipophilicity, stability against various harsh environments and exerts a potent cytotoxicity. Therapeutic effect of the drug to unresectable primary hepatoma is much better than the conventional method. For Child A category patients with intrahepatic metastasis in no more than three area, a 3 yr survival rate is more than 87%. When the Child's A and B are combined with no distant metastasis, 1-, 2- and 3-year survival rates are 87%, 50%, and 35%, respectively. The side effect of this treatment [SMANCS/Lipiodol, i.p.] is minimal; transitory low grade fever is the commonest one (40-50% of cases) which can be controlled by a routine protocol. No liver or marrow toxicity was observed. Procedural limitations for the lung cancer etc. are discussed.

Clinical trials with a new iodinated lipid emulsion for computed tomography of the liver

A new iodinated lipid emulsion, Intraiodol, for which animal studies have indicated better tolerance than for other iodinated lipid emulsions, was tested in 15 patients with malignant lesions, and in one patient with focal nodular hyperplasia. Repeated CT scans of the liver and spleen and blood tests were performed for 24 hours after intravenous injection of Intraiodol. The uptake of Intraiodol in the liver (peak mean 28.6 HU) was higher than in the spleen (peak mean 21.8 HU). The uptake of Intraiodol in malignant lesions was minimal (peak mean 2.8 HU). The detection rate of hepatic lesions was equal to or better than that achieved by US, CT, and/or CT angiography. However, liver uptake of Intraiodol was low in 2 patients with severe fatty infiltration. Intraiodol produced vascular enhancement up to one hour after injection since it was eliminated slowly from the circulation. The observed adverse reactions consisted of temporary metallic taste in 5 of the patients, fever and exacerbation of back pain in one patient, and transient thrombocytopenia in one patient. Alkaline phosphatase increased (17%, p less than 0.01) only at two hours, and erythrocyte count (6%, p less than 0.05) at 24 hours after injection. Our initial results indicate diagnostic advantages of Intraiodol without serious adverse reactions. Further clinical studies are required to confirm these findings.

A 5-year experience of lipiodolization: selective regional chemotherapy for 200 patients with hepatocellular carcinoma

Between 1982 and 1987, selective regional cancer chemotherapy using Lipiodol plus an anticancer drug (lipiodolization) was prescribed for 200 patients with hepatocellular carcinoma. One hundred forty-nine patients were given lipiodolization alone, and the remaining 51 underwent hepatic resection following lipiodolization. The grades of deposits of the oily contrast medium in the neoplastic tissue seen on the plain X-ray correlated well with the antitumor effect. In the resected specimens of 17 patients treated with lipiodolization prior to surgery, concentrations of adriamycin in the malignant liver tissues were 13.2 +/- 18.2 micrograms per gm, whereas the adjacent liver parenchyma contained 1.4 +/- 2.0 micrograms per gm of adriamycin; the difference was statistically significant (p less than 0.05). In the 149 patients treated with lipiodolization, 1-, 2-, 3- and 4-year survival rates were 56.1, 28.9, 17.3 and 7.4%, respectively. Thus, lipiodolization was considerably more effective, compared to the results achieved by hepatic artery ligation and cannulation into the hepatic artery for patients in Stages I and II. In this sequential nonrandomized study, the survival rates for patients undergoing hepatic resection were superior to those for patients in Stage I and treated with lipiodolization. The significant difference appeared to depend on incomplete killing of tumor cells, which are most often present in the fibrous capsule, by lipiodolization. We conclude from these data that lipiodolization is an effective treatment for hepatocellular carcinoma when the tumor is not curatively resectable. When the clinical status is good, then surgery is warranted.

Effect of intravenously injected iodinated lipid emulsion on the liver. An experimental study correlating computed tomography findings with in vivo microscopy and electron microscopy findings

Iodinated lipid emulsions have been shown to have great potential as site specific contrast media for the liver and spleen. Because of unacceptable adverse reactions none of these emulsions has been adopted for clinical use. In an attempt to find an explanation for these adverse reactions we tested three iodinated lipid emulsions, EOE-13, AG 60.99 and AG 66.18. The following models were used: Computed tomography (CT) of the rabbit liver, in vivo microscopy and electron microscopy of the rat liver. The emulsions contained particles of different sizes and were used in varying doses. We found that the larger the emulsion particles, the more likely they were to be taken up by the Kupffer cells and thereby the higher the opacification of the liver achieved at CT. We also observed changes in the microcirculation of the liver when the emulsions were given in doses required to secure satisfactory opacification of the liver at CT. The main changes were 1) a marked increase in the size of the Kupffer cells, and 2) damage to the sinusoidal endothelium, both contributing to sinusoidal congestion. These changes strongly suggest activation of the macrophages and this in turn probably results in the release of toxic mediators. We suspect that the adverse reactions observed in patients when using iodinated lipid emulsions are due to these toxic mediators.

Acalculous cholecystitis complicating hepatic intraarterial lipiodol: case report

Hepatic intraarterial injection of Lipiodol has been used by various authors to enhance the diagnostic accuracy of computed tomography in hepatic tumors. The technique appears safe and seems free from serious complications when used judiciously. We report a case in which injection of hepatic intraarterial Lipiodol precipitated acalculous cholecystitis requiring urgent laparotomy.

[Does a iatrogenic damage caused by dacryography exist?]

This study was aimed at investigating the changes in corneal epithelium caused by dacryocystography. Such changes can be either chemical--from iodate contrast media (iodized oil and water-soluble non-ionic cm)--or physical--from needle or catheter. Twenty-five patients (50 eyes) were studied using BUT, Schirmer tests, biomicroscopy, and pachymetry. Follow-ups immediately after dacryocystography demonstrated superficial keratitis, which was less severe with water-soluble non-ionic cm. Such lesions were hardly ever observed in patients who had been treated with dacriosol ointment on the cornea just before the X-ray exam. Follow-ups at 24 hours showed the superficial keratitis to have disappeared in all patients, independent of the kind of cm employed and of the ophthalmic ointment applied to the cornea.

[Large-dose intra-arterial injection of lipiodol in liver cancer]

Effects of lipiodol (LPD) on liver functions were examined in 130 patients with primary and metastatic liver cancer who underwent TAE or intraarterial chemotherapy between May 1984 and March 1988 at our department and were available for follow-up studies. Effects of anticancer agents, particularly Adriamycin (ADM), were also evaluated. Large-dose intraarterial infusion of LPD had little effect on the liver functions of patients without liver cirrhosis but often caused a deterioration in liver functions of those with cirrhosis. A combination of this therapy with TAE using Gelfoam sponge caused only a temporary elevation in the transaminase level. The dose of ADM showed little association with the degree of liver disorders, unlike the case of cardiotoxicity or bone marrow suppression. Although the therapeutic effects of intraarterial infusion of ADM-LPD emulsion for advanced cancer (e.g., H4 and Vp3) such as improvements in the Vp factor are remarkable, the dose must be carefully determined, especially when liver cancer is complicated by liver cirrhosis.

Clinical evaluation of hepatic artery embolization: comparison between Gelfoam and Lipiodol with anticancer agent

Transcatheter embolization of the hepatic artery for hepatomas was performed with the use of Gelfoam and Lipiodol-ADM in 98 patients (Gelfoam 63 patients; Lipiodol-ADM 35 patients). The cumulative one-year survival rate was 52.9% for the Gelfoam group and 28% for the Lipiodol-ADM group. Response to hepatic embolization was most remarkable in the nodular type; CR was obtained in five patients and PR in 31 patients (response rate: CR + PR = 57.1%) in the Gelfoam group, with no CR and six PRs (response rate, 17.6%) in the Lipiodol-ADM group. Alfa-feto protein (AFP) decrease of more than 50% was observed in 78.1% of the Gelfoam group and 40% of the Lipiodol-ADM group. The side effects were transient and controlled with conservative treatment. Gelfoam seemed to be more effective in the treatment of hepatoma, but the damage to normal tissue was more severe with this embolic material.

[Pulmonary microlithiasis following iodine lipiodol lymphography?]

Pulmonary fibrosis with marked calcifications in an 83 year old female patient is reported. Following previously inconspicuous thoracic x-ray findings (1975 and 1978) a bipedal oil lymphography was carried out for diagnosis of a systemic malignant lymphoma. The calcifying pulmonary fibrosis was investigated with the help of tomography, computed tomography, xeroradiography and scintigraphy of the lung and the skeletal system as well as magnetic resonance imaging. A biopsy was refused by the patient. The etiological possibilities of an idiopathic disease as well as an induction by the oil contrast medium and a concomitant malignant lymphoma are discussed.

Iodized oil treatment for endemic goiter does not induce the surge of positive serum concentrations of anti-thyroglobulin or anti-microsomal autoantibodies

Forty-three goitrous patients (grade II and III, WHO classification), living in areas of chronic iodine deficiency, were treated with an injection of iodized oil (470 mg iodine). Serial measurements of serum thyroid hormone levels after the therapy revealed increasing concentrations of both hormones, with a significantly lower serum T3/T4 ratio, and progressively significantly lower serum TSH mean values. Serum Tg mean value, initially elevated (58 +/- 9 ng/ml), decreased after 6 months and returned to the normal range at 36 months of therapy. In none of the examined patients (except for one subject with positive autoantibodies before therapy), it was observed the surge of positive anti-thyroglobulin or anti-microsomal autoantibodies after the iodized oil. We conclude that iodized oil therapy does not induce an abnormal autoimmune reaction in endemic goiter patients.

[Transitory hypothyroidism of the newborn infant following amniofetography with an iodine-containing contrast medium]

In the foetus and neonate the thyroid follicular cells are immature and hence incapable of protecting the organism against an iodide-induced inhibition of hormone synthesis (Wolff-Chaikoff effect). Thus, an iodide excess during pregnancy can lead to transient hypothyroidism in the foetus and neonate. Transient hypothyroidism due to iodide toxicity following amniofoetography in the newborn period is described.