대한흉부영상의학회 Weekly Chest Cases

Case No : 873 Date 2014-07-21

Courtesy of Bo Young Jeong, Jeung Sook Kim / Dongguk University Ilsan Hospital
Age/Sex 70 / M
Chief Complaintfebrile sense and dyspnea

Figure 1
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Figure 3

precontrast CT

Diagnosis With Brief Discussion

Diagnosis: Pulmonary lipiodol embolism
Radiologic Findings: Mediastinal window setting of chest CT shows ill-defined focal consolidation with internal high densities in posteromedial portion of right lower lobe on both pre- and post- contrast enhanced images. There is also small amount of right pleural effusion.
Lung setting of the chest CT images shows ill-defined focal consolidation with surrounding ground-glass opacities.
Brief Review: Transcatheter arterial chemoembolization (TACE) with a mixture of lipiodol is treatment for unresectable HCC. TACE is intended to deliver a highly concentrated dose of chemotherapy to tumor cells, prolong the contact time between the chemotherapeutic agents and the cancer cells.
Although TACE is relatively safe, it has relevance to rare but serious complications. For example, hepatic infarction, hepatic abscess, acute hepatic failure, spontaneous rupture of the tumor, and acute renal failure have been reported.
Pulmonary lipiodol embolism is also a rare but fatal complication associated with TACE. The incidence of symptomatic pulmonary lipiodol embolism ranged between 0.05-1.8%. Symptoms of pulmonary lipiodol embolism are dyspnea, hemoptysis and cough, and the clinical course is most severe 2-10 days after TACE. The time required to reach toxic concentrations of fatty acids and the slow release from the tumor into the pulmonary circulation might be cause of the delayed onset. The followings have been considered as the risk factors of pulmonary lipiodol embolism: the dose of lipiodol injected (> 20 mL of lipiodol or > 0.3 mL/kg), the presence of an arteriovenous shunt, and fistula between the inferior phrenic artery and an artery of the pulmonary circulation.
The effective and targeted therapy of lipiodol embolism had not known yet. Immediate symptomatic care should be started including oxygen supply, methylprednisolone, heparin, ventilator care for respiratory failure, and, careful monitoring of the patient?셲 respiratory status until his symptoms disappeared.
The radiological finding of pulmonary lipiodol embolism is focal or diffuse consolidation or ground-glass opacities. Chest radiograph shows an ill-defined increased opacities and chest CT scan reveals newly developed lipiodol-like high density materials in the lung parenchyma of after TACE.
References: 1. Chung JW, Park JH, Im JG, Han JK, Han MC. Pulmonary oil embolization after transcatheter oily chemoembolization of hepatocellular carcinoma. Radiology 1993;187:689-693
2. Ming-Tzer Lin, Ping-Hung Kuo. Pulmonary lipiodol embolism after transcatheter arterial chemoembolization for hepatocellular carcinoma. JRSM Short Rep. 2010;1:6
3. Woo Ri Park, et al. Pulmonary lipiodol embolism after transcatheter chemoembolization for hepatocellular carcinoma. Tubercolosis and respiratory disease. 2011;1:50-54
Keywords: Lung, Embolic, Thromboembolic,

No. of Applicants : 66

▶ Correct Answer : 25/66, 37.9%

- The University of Tokyo Hospital , Japan Akifumi Hagiwara
- Seoul National University Hospital , Korea (South) YongSub Song
- Korea university anam hospital , Korea (South) Sung-Hye You
- The University of Tokyo Hospital , Japan Toshihiro Furuta
- 異⑸ , Korea (South) Yunhee Jang
- , Korea (South) Choi Seul-Gi
- GHICL , France manuel toledano
- The University of Tokyo Hospital , Japan Takeyuki Watadani
- Kyung Hee University Hospital at Gangdong , Korea (South) Seong Yun
- Pusan National University Yangsan Hospital , Korea (South) yoonyoung choi
- Oita University, Faculty of Medicine , Japan Fumito Okada
- National Hospital Organization Okinawa Hospital , Japan Yasuji Oshiro
- IRSA La Rochelle , France Denis Chabassiere
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- Hanyang universitiy, radiology department , Korea (South) HyunGyu Lee
- Kizawa Memorial Hospital , Japan Yo Kaneko
- Samsung medical center , Korea (South) Hyun Su Kim
- CHU Poitiers , France CHAN paul
- National Taiwan University Hospital , Taiwan Li-Ta Keng
- Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
- Medicheck health care , Korea (South) Chae Lim
- Japanese national center hospital of neurology and psychiatry , Japan Kaoru Sumida
- Oita University , Japan Haruka Sato
- ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
- Niigata University , Japan Atsushi Uehara

▶ Correct Answer as Differential Diagnosis : 3/66, 4.5%

- Niigata City General Hospital , Japan Takao Kiguchi
- stanley medical college , India yazhini v
- Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK

▶ Semi-Correct Answer : 1/66, 1.5%

- MBAL BURGAS , Bulgaria VLADISLAV RUSINOV

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 873 Date 2014-07-21

Discussion

No. of Applicants : 66