Scientific letter
Thorotrast®: Lessons from the past for present radiological practice
Thorotrast®: lecciones del pasado para la práctica radiológica del presente
A. Aranaz Murillo
, E. Pascual Pérez, R. Larrosa López, L. Sarría Octavio de Toledo
Corresponding author
Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spain
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Aranaz Murillo, E. Pascual Pérez, R. Larrosa López, L. Sarría Octavio de Toledo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Aranaz Murillo" "email" => array:1 [ 0 => "aaranaz@salud.aragon.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Pascual Pérez" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Larrosa López" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Sarría Octavio de Toledo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Thorotrast®: lecciones del pasado para la práctica radiológica del presente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 702 "Ancho" => 2352 "Tamanyo" => 182157 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A) Axial contrast-enhanced CT with spleen ROI. Small, hyperdense spleen (334 HU), with punctate images of diffuse distribution. B) Coronal reconstruction where the small spleen is seen. C) Ultrasound focused on the left hypochondrium. Subcostal longitudinal section of the spleen. Hyperechoic linear image with posterior acoustic shadowing (arrow) corresponding to the spleen.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Thorium dioxide in suspension (ThO<span class="elsevierStyleInf">2</span>), known commercially as “Thorotrast®”, was, until the 1950s, considered an apparently harmless contrast medium without adverse effects. It was initially used in angiography and, later, due to its high X-ray absorption capacity, in practically all radiological studies. However, it is a radioactive element, which is deposited in the reticuloendothelial system, including the liver, spleen and lymph nodes, so these organs are exposed to ionising radiation throughout life.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the complex case of Thorotrast® deposition in a 54-year-old female patient under follow-up by Internal Medicine and Gastroenterology. The patient's history included type 2 diabetes mellitus, high blood pressure, Sjögren’s syndrome and chronic autoimmune gastritis with vitamin B12 deficiency. No Thorotrast® deposition was found in the biopsies.</p><p id="par0015" class="elsevierStylePara elsevierViewall">An intestinal MRI was performed due to diarrhoea and diffuse abdominal pain, which showed findings suggestive of Thorotrast® deposition in the spleen (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), even though the patient denied having had contact with this contrast. CT of chest and abdomen was requested to look for other possible causes of the findings, but the additional studies ruled out other differential diagnoses. The patient is currently being followed up with ultrasounds due to the risk of developing radiation-induced cancer (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The thorium in Thorotrast® is an alpha and beta radiation emitter, with a biological half-life of 400 years, retained in the body if administered intravascularly.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> All this exposure to ionising radiation has been associated with a 100-fold increase in the risk of abdominal cancer and even vascular neoplasms such as angiosarcomas.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Diagnosis of Thorotrast® deposition can be challenging, especially when the patient denies exposure. The differential diagnosis includes previous granulomatous infections, mineral deposition diseases such as iron overload, amiodarone deposition in cardiac patients, or gold deposition in those treated for rheumatoid arthritis. Glycogen storage diseases and exposure to cisplatin may also present similar findings.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The possibility of other conditions, such as sickle cell disease, lupus erythematosus and autosplenectomy, was also considered in our patient.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A thorium density with Hounsfield units greater than 500 on CT can be key in the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However, in our case, these attenuation values were not observed. In a study evaluating the performance of Thorotrast® on MRI, a marked decrease in signal intensity was observed on T1- and T2-weighted images. However, this study concluded that Thorotrast® deposition does not cause artifacts on MRI,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> which differs from our case. These discrepancies may be due to differences in magnetic field intensity (0.5 T vs 1.5 T), as there are currently sequences which are very sensitive to magnetic field heterogeneities.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Lastly, because radium-228 (the first product of thorium decay) is chemically similar to calcium,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> we believe that the ultrasound artefact of the spleen, with acoustic shadowing, could be due to this similarity between the elements. Although there are few scientific references on autoimmune disorders and Thorotrast®,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> given its mutagenic nature, it is conceivable that it played a role in the development of the patient’s autoimmune syndromes, despite the absence of Thorotrast® deposition in the biopsies.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Thorotrast® is a clear example of how an initially promising radiological contrast agent became a health risk and continues to affect patients who received it many years ago. The current generation of radiologists must therefore be able to recognise its imaging presentation for cases in which the exposure is not described in the patient's medical records.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Informed consent</span><p id="par0045" class="elsevierStylePara elsevierViewall">Informed consent was obtained from the patient.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authorship/collaborators</span><p id="par0050" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0055" class="elsevierStylePara elsevierViewall">Responsible for the integrity of the study: AAM.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0060" class="elsevierStylePara elsevierViewall">Study conception: AAM.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0065" class="elsevierStylePara elsevierViewall">Study design: AAM and EPP.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0070" class="elsevierStylePara elsevierViewall">Data collection: AAM.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0075" class="elsevierStylePara elsevierViewall">Data analysis and interpretation: AAM.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6</span><p id="par0080" class="elsevierStylePara elsevierViewall">Literature search: AAM and EPP.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7</span><p id="par0085" class="elsevierStylePara elsevierViewall">Drafting of the article: AAM and EPP.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8</span><p id="par0090" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant contributions: AAM, EPP, RLL and LSO.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9</span><p id="par0095" class="elsevierStylePara elsevierViewall">Approval of the final version: AAM, EPP, RLL and LSO.</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Informed consent" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authorship/collaborators" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1621 "Ancho" => 2102 "Tamanyo" => 295804 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) T2-weighted axial sequence, showing the small, hypointense spleen (arrow). B) Axial TRUFI sequence (True Fisp) showing a concentric magnetic susceptibility artefact in the spleen (arrowhead). C) Diffusion study. ADC where the artefact produced by the spleen can be seen. D) Coronal T1 VIBE (Volume Interpolated Breath-hold Examination) sequence after contrast administration, again showing a magnetic susceptibility artefact in the spleen (arrowhead and arrow).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 702 "Ancho" => 2352 "Tamanyo" => 182157 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A) Axial contrast-enhanced CT with spleen ROI. Small, hyperdense spleen (334 HU), with punctate images of diffuse distribution. B) Coronal reconstruction where the small spleen is seen. C) Ultrasound focused on the left hypochondrium. Subcostal longitudinal section of the spleen. Hyperechoic linear image with posterior acoustic shadowing (arrow) corresponding to the spleen.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "History note: tragedy of Thorotrast" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Takekawa" 1 => "Y. Ueda" 2 => "Y. Hiramatsu" 3 => "K. Komiyama" 4 => "H. 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