대한흉부영상의학회 Weekly Chest Cases

Case No : 1334 Date 2023-05-14

Courtesy of Mi Jung Park / Gyeongsang National University Hospital
Age/Sex 79 / M
Chief ComplaintDyspnea

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Diagnosis With Brief Discussion

Diagnosis: Pulmonary oil embolism after TACE
Radiologic Findings: Diffuse ground glass opacity and consolidation in both lungs, predominantly both lower lobes dependent portion. Some necrosis and hyperdense area are seen in the right lower lobe. There is small amount of right pleural effusion. He underwent TACE, one day ago. A huge lipiodol uptake and hepatocellular carcinoma are noted in the right hepatic lobe.
Brief Review: The complications of hepatic arterial chemoembolization include postembolization syndrome, with symptoms such as fever, abdominal pain, nausea, vomiting, leukocytosis, and elevated liver enzyme levels. The incidence of pulmonary oil embolism was reported as 0.05-2.3%. However, lipiodol-induced pneumonitis following TACE is rare.
Although the mechanism of lipiodol-induced pneumonitis following TACE is still unclear, the most probable hypothesis for symptomatic lipiodol pneumonitis is pulmonary capillary leakage and edema caused by enzymatic degradation of lipiodol by lipases and formation of toxic unbound free fatty acids.
In this case, it is suspected that the progression of lipiodol pneumonitis was induced by injected lipiodol migrating into the venous system through AV shunts located in the hypervascular HCC tumors. The characteristic radiographic findings are diffuse bilateral pulmonary consolidation and ground glass opacity with a high attenuating area, after TACE with iodized oil infused into the hepatic artery
The main therapy is supportive treatment with supplemental oxygen and systemic antibiotics. Steroid therapy can be considered to reduce inflammation caused by lipiodol, but the evidence for this is still weak.
References: 1) Youn, I., Chong, S., Kwak, B. K., Shim, H. J., Seo, G. Y., Seo, J. S., & Kim, J. K. (2011). Pulmonary lipiodol accumulation after transarterial chemoembolization: CT findings and its radiologic outcomes. Journal of the Korean Society of Radiology, 65(6), 577-583.
2) Moriya, T, Kawakami, N, Wakai, Y, Saito, H, Saito, K. (2020) Pulmonary lipiodol embolism following transcatheter arterial chemoembolization Respirology Case Reports, 8( 9), e00678.
Keywords

No. of Applicants : 98

▶ Correct Answer : 38/98, 38.8%

- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- , Japan HIROAKI ARAKAWA
- The University of Tokyo Hospital , Japan JUN KANZAWA
- , Japan KYOKO NAGAI
- The University of Tokyo , Japan MOTO NAKAYA
- Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- Other , Korea (South) SEONGSU KANG
- , Korea (South) JIN YOUNG LEE
- Secomedic Hospital , Japan FUMINORI MIYOSHI
- Oita University, Faculty of Medicine , Japan FUMITO OKADA
- Seoul Medical Center , Korea (South) HYUK GI HONG
- Osaka University , Japan AKINORI HATA
- Shimada General Medical Center , Japan HAYATO NOZAWA
- Soonchunhyang University Hospital Bucheon , Korea (South) HYEJOO PARK
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- Presbyterian Medical Center , Korea (South) SOOYEON JEONG
- Gifu University Hospital , Japan Yo Kaneko
- Hukuda memorial hospital , Japan SHINTARO KANO
- , Korea (South) KIM JUNG YOON
- Chonbuk National University Hospital , Korea (South) HYUNSOO BAE
- Ajou University Hospital , Korea (South) YOU NA KIM
- Korea University Guro Hospital , Korea (South) SANGSEOK OH
- Dokkyo Medical University , Japan HIROAKI ARAKAWA
- Manipal hospital Hebbal, Bengaluru , India PRAVIN KUMAR M
- Paras hospital, Panchkula , India SHALEEN RANA
- Seoul National University Bundang Hospital , Korea (South) YOONAH DO
- Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
- Kantou Rousai Hospital , Japan KAORU SUMIDA
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi
- Nerimahikarigaoka hospital , Japan TAKANA HAYASHI
- Matsunami General Hospital , Japan TARO TAKEDA
- Shiga University of Medical Science , Japan RYO UEMURA
- Toyota Kosei Hospital , Japan YUKI HAYASHI
- The Catholic University of Korea Yoeuido St. Mary , Korea (South) CHAWOONG JEON
- Kyoto university , Japan AKIHIKO SAKATA
- Other , Korea (South) YONG HO JANG
- , Korea (South) JIN WOO YOON

▶ Correct Answer as Differential Diagnosis : 6/98, 6.1%

- Inje University Pusan Paik Hospital , Korea (South) GANGWON JEONG
- Chungbuk National University Hospital , Korea (South) SOHUI JIN
- Kyoto University Hospital , Japan YASUHISA KURATA
- Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
- , Korea (South) SONG MYUNG WON
- , Korea (South) HM PARK

▶ Semi-Correct Answer : 18/98, 18.4%

- Chonnam National University Hwasun Hospital , Korea (South) KWANGKUN CHO
- Ajou University Hospital , Korea (South) SUNG HYUN AN
- Shiga University of Medical Science , Japan AKITOSHI INOUE
- Chonnam National University Hospital , Korea (South) JUNYEOL YANG
- Chonnam National University Hwasun Hospital , Korea (South) DONGHUN HAN
- Samsung Medical Center , Korea (South) JUHYUN KIM
- The University of Tokyo Hospital , Japan WATARU GONOI
- Ajou University Hospital , Korea (South) HAEIN LEE
- , Korea (South) HWAJIN LEE
- Hanyang University Hospital , Korea (South) HYEJIN PARK
- Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
- Chungbuk National University Hospital , Korea (South) MIHYEON PARK
- Other , Korea (South) SEONG WON JANG
- Chonnam National University Hospital , Korea (South) GYERYEONG PARK
- Chonnam National University Hospital , Korea (South) KIM SANG GYUN
- Chonnam National University Hospital , Korea (South) SEUNG WAN KANG
- , Japan YUMI MAEHARA
- , Korea (South) HYEONGYU YOO

대한흉부영상의학회 Korean Society of Thoracic Radiology

Cases by Disease Category

Case No : 1334 Date 2023-05-14

Discussion

No. of Applicants : 98