Angiosarcoma of the liver: a marker tumour for the late effects of Thorotrast in Great Britain

Alveolar Hemorrhage

Alveolar hemorrhage (AH) is a clinical syndrome with diverse etiologies both immune and nonimmune. The defining pathological feature of AH is the presence or absence of pulmonary capillaritis. The antineutrophil cytoplasmic antibody (ANCA) related vasculitis and systemic lupus erythematosus are the commonest causes of immune AH with pulmonary capillaritis, whereas Goodpasture's syndrome and idiopathic pulmonary hemosiderosis are common causes of immune AH without pulmonary capillaritis. The major nonimmune causes of AH are primarily drug induced, or due to hematological malignancy and disorders of coagulation. Clinical features of AH include: dyspnea, fever, hemotypsis, bilateral crackles and pallor. Hypoxemia and bilateral diffuse airspace disease on the chest radiograph with relative sparing of the bases and apices which most often clears within 48 hours after its onset further characterize this syndrome. The major clinical implications of this syndrome are its potential to cause respiratory failure in severe cases and its sequelae of pulmonary fibrosis with associated morbidity and disability. In addition, AH may be the initial manifestation of a systemic immune disorder which can be managed optimally if recognized early. The diagnosis of AH is confirmed by bronchoalveolar lavage by demonstrating a progressively bloody return on successive aliquots of instilled saline or hemosiderin laden macrophages in the bronchoalveolar lavage fluid. The open lung biopsy remains the gold standard for the diagnosis of AH but is reserved for inapparent cases in whom corticosteroids and immunosuppressive therapy may be life saving. Serologic testing and examination of the urine sediment are useful adjuncts to the diagnosis. The treatment of AH is primarily supportive while an attempt is made to determine its etiology and initiate specific therapy. Glucocorticoids and cyclophosphamide are the cornerstones of therapy in immune AH with adjunctive plasmapheresis in life-threatening cases.

Impact of radiation and hepatitis virus infection on risk of hepatocellular carcinoma

In cohort studies of atomic bomb survivors and Mayak nuclear facility workers, radiation-associated increases in liver cancer risk were observed, but hepatitis B virus (HBV) and hepatitis C virus (HCV) infections were not taken strictly into account. We identified 359 hepatocellular carcinoma (HCC) cases between 1970 and 2002 in the cohort of atomic bomb survivors and estimated cumulative incidence of HCC by radiation dose. To investigate contributions of radiation exposure and hepatitis virus infection to HCC risk, we conducted a nested case-control study using sera stored before HCC diagnosis in the longitudinal cohort of atomic bomb survivors. The study included 224 HCC cases and 644 controls that were matched to the cases on gender, age, city, and time and method of serum storage, and countermatched on radiation dose. The cumulative incidence of HCC by follow-up time and age increased significantly with radiation dose. The relative risk (RR) of HCC for radiation at 1 Gy was 1.67 (95% confidence interval: 1.22-2.35) with adjustment for alcohol consumption, body mass index (BMI), and smoking habit, whereas the RRs for HBV or HCV infection alone were 63 (20-241) and 83 (36-231) with such adjustment, respectively. Those estimates changed little when radiation and hepatitis virus infection were fit simultaneously. The RR of non-B, non-C HCC at 1 Gy was 1.90 (1.02-3.92) without adjustment for alcohol consumption, BMI, or smoking habit and 2.74 (1.26-7.04) with such adjustment.

CONCLUSION

These results indicate that radiation exposure and HBV and HCV infection are associated independently with increased HCC risk. In particular, radiation exposure was a significant risk factor for non-B, non-C HCC with no apparent confounding by alcohol consumption, BMI, or smoking habit.

Angiosarcoma in the lung

Angiosarcoma involving the lung is a rare disorder and its clinical features are not well known. We conducted a retrospective analysis of 15 patients seen at our institution from 1950 to 1990 in an attempt to better characterize the spectrum of clinical and radiographic findings of angiosarcoma in the lung. No documented case of primary angiosarcoma of the lung was seen. The diagnosis of metastatic angiosarcoma to the lung was made antemortem in 12 of 15 cases, either by lung biopsy specimen (5 patients), biopsy evidence of metastatic disease elsewhere with abnormal chest radiograph (4 patients), or a compatible clinical picture in a patient with previously documented angiosarcoma arising in an extrapulmonary site (3 patients). The median age at the time of diagnosis was 45 years with the most common presenting symptom being hemoptysis (7 of 15 patients). Other presenting complaints included weight loss (6 of 15), cough (4 of 15), and chest pain (4 of 15) occurring 6 weeks to 1 year prior to diagnosis. Chest radiographs frequently disclosed multiple pulmonary nodules (11 of 15). Primary origins of the angiosarcoma most commonly included the heart and breast. Metastatic sites other than the lung included the pericardium, liver, spleen, kidney, adrenal gland, bone, and brain. The prognosis is generally poor, with our study population surviving an average of 9 months after diagnosis.

Primary pulmonary angiosarcoma associated with multiple synchronous neoplasms

A 60-year-old man presented with a 3-month history of shortness of breath. He was found to have a right thoracic mass involving the right middle and lower lobes, pulmonary hilum, and mediastinum. Diagnosis could not be established by pleural fluid cytology, pleural biopsies, bronchoscopy, and ultrasound-guided needle biopsies. A diagnostic exploratory thoracotomy was performed. Massive hemorrhage was encountered upon opening the pleura, and bleeding was controlled by performing a radical pneumonectomy. Histology revealed angiosarcoma, pulmonary primary. The patient survived for 68 days. At autopsy, he was found to have adenocarcinoma of the prostate, adenocarcinoma of the rectum, carcinoid of the ileum, and leiomyoblastoma of the stomach as well as diffuse metastases from the angiosarcoma. This represents the fourth reported case of primary pulmonary angiosarcoma.

Thorotrast granuloma of the neck with local complications

A case of cervical granuloma with involvement of the right vocal cord is reported. The cause of the granuloma was traced to thorium dioxide contrast medium which had escaped into the surrounding tissues during arteriography performed 40 years before. The long-term toxic effects of thorium-232 irradiation and the local complications which may follow an injection of this medium are discussed.

Angiosarcoma of the lung with fatal pulmonary hemorrhage

A patient with fatal pulmonary hemorrhage was found to have angiosarcoma of the lung at postmortem examination. This case, occurring in a man with a prior history of industrial exposure in South African copper mines, is the third well-described primary occurrence of this tumor in the lung.

The British hepatic angiosarcoma register

A register of British cases of primary hepatic angiosarcoma (HAS) was established in 1974 to monitor the occurrence of cases from 1963 onwards. Details of cases dying in 1963-77 have been obtained. Thirty-five cases were agreed as HAS by panel of liver pathologists, and occupational and medical information was obtained in the majority of these. Two cases were attributable to VCM exposure, and eight others had received intra-arterial Thorotrast. In 1978-79, two more cases were confirmed in VCM polymerization workers.