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Pathological changes of lymph nodes in Thorotrast patients
ENVIRONMENTAL
RESEARCH
Pathological
l&245-255
(1979)
Changes of Lymph Patients
Pathoanatomical,
Nodes in Thorotrast
Autoradiographical, InvesGgations
and QuanMaGve
K. WEGENER AND H. WESCH* Pathological institute of the Municipal Hospital of Ludwigshafen, Bremserstr. 79, 6700 Ludw~gshafen~Rhein, Federal Republic of Germany, and *Znstitute of Nuclear Medicine, German Cancer Research Znstitute- Federal Republic of Germany Received May 1, 1978 Which concentrations of thorotrast are deposited in the lymph nodes of thorotrast patients? Which late effects do occur in organs with different quantities of thorotrast deposited? Which late effects of thorotmst are detected in lymph nodes compared to those in liver and spleen? We studied 38 postmortem cases and investigated 120 lymph nodes taken from various regions of the body. We also investigated the liver and spleen of all the cases and thorotrastomas of six cases. All 38 patients had suffered from thorotrastosis and died approximately 28 years after the injection. Paraffin sections, autoradiography and neutron activation analysis were used. In lymph nodes, the mean concentration of Th-232 is higher than in the liver; it is, however, a little lower than in the spleen. The highest concentration of Th-232 is measured in the lymph nodes of the liver hilus, those in the area behind the pancreas, and around the hilus of the spleen. Lower concentrations are measured in the lymph nodes around the bifurcatio aortae, around the hilus of the lung, and in the groin. The contrast medium is deposited in small concentrations in the sinuses of the lymph nodes without showing any vital reaction in the surrounding area. Th-232 is stored only in a few reticulum cells. The follicles are free of Th-232. In lymph nodes with a higher concentration of Th-232, a strong fibrosis can be seen, occluding the lymph vessels. Spleen and thorotrastomas show a similar fibrosis to that seen in the lymph nodes. We find a large number of carcinomas and sarcomas of the liver. No malignant growth is seen, on the other hand, in either lymph nodes, spleen, or thorotrastoma. In the final section of the paper the special localization of tumors in human thorotrastosis is considered.
INTRODUCTION
The use of thorotrast during the 1930s and 1940s (Bliihbaum ef al., 1928; Radt, 1929, 1930; Oka, 1929) has led to catastrophic results because this medium is deposited almost entirely in the reticuloendothelial system (RES), that is to say in liver, spleen, bone marrow, and lymph nodes (Muth e? af., 1970). Therefore, over decades, the amount of thorotrast deposited has resulted in enormous exposure to radiation in these particular organs. There is evidence in literature, however, that fafal late effects in thorotrastosis patients are, on the whole, confined to liver and bone marrow, whereas lymph nodes, spleen, and thorotrastomas are hardly affected. It is clear. on the other hand, working on the evidence produced by X rays ot many thorotrastosis patients, that spleen and lymph nodes have stored thorotrast at least in the same, if not in even greater concentration than for instance the liver has. 245 0013-9351/79/010245-11$02.00/O Copyright
@ I979 by Academic
fiess,
Inc.
246
WEGENER
AND
Data of the autopsied
WESCH
patients
Age at the time
Injection method Injection wlurne Latency
period
FIG. I. Data of patients
Three main questions occur at this stage. (1) In what concentration is thorotrast deposited in the lymph nodes of various parts of the body decades after the injection? (2) In what way is thorotrast deposited in the lymph nodes of various parts of the body decades after the injection? (3) Which late effects are detectable in the lymph nodes? MATERIAL
AND METHODS
During the past years we had the opportunity of studying 38 postmortem cases of thorotrastosis patients (Fig. 1). Of these cases, 31 were males and 7 females. Their ages at the time of death lay between 34 and 82 years, and their ages at the time of the injection between 11 and 47 years. In all patients thorotrast in an unspecified quantity was injected intravascularily, to clarify aneurysms, arteriovenous listulae, brain tumors, or blood vessel obliterations in various regions. The latency period, here defined as the time between injection and death, lay between 24 and 38 years. Among nearly 2500 organ specimens we investigated a total of 120 lymph nodes from various parts of the body. In this investigation we used the following techniques. (1) The usual histological preparation of lymph nodes into paraffin sections stained with various dyes, in order to establish morphologically determinable late effects. (2) The technique of autoradiography with stripping-film and special emulsion to establish localization and deposition pattern of particularly small thorotrast particles (Technique of Autoradiography: Schultze, 1%8).
Neutron
activation
of “‘thorium
*33Th &- z33Pa 23zTh I,,+) FIG. 2. Scheme of neutron activating analysis.
THOROTRAST:
LYMPH
247
NODES
(3) The neutron activating analysis which enables us to ascertain quantity and concentration of the deposited Th-232 (Edgington, 1%7; Scheer et uf., 1%7; Kampmann et ul., 1%8, 1%9). During the neutron activating analysis, dried organ specimens with an average weight of 1 or 2 g are exposed in a reactor to a neutron radiation with a flux of rng lh- 232/g Cssue
10 2 splttn lymph II
nodts
0
10’
I
livtr
0
bont 10’
marrow
1 0
T
tonsil
0
T
adrtnak
I
lo-
lung
0
1
kidnty
gland
pancrtos
1T
vtnts
0
T 0
lo-
digtstivt
1 T
conntctivt Gssut
0
arkrits
1 ‘7’ 1
thyroid
0
~
gland
0
muscks
tract
0
I
brain
lo-
0
organs
FIG. 3. Itieal I concentration gram
tissue
(logarithmic
sense).
(with scattering) of Th-232 for 17 organs and tissues in milligram per Scattering
is drawn
in one direction
only.
248
WEGENER
AND
WESCH
2 X 10” particles per square centimeter and second for a duration of 8 hr. The neutron capture of Th-232 causes the conversion to Th-233, which decays with a half-life of 22 min to protactinium-233. This decays with a half-life of 27 days to uranium-233. The radiation of the protactinium-233 is measured with a germanium-lithium driftet detector or a Na-J well-type detector. The amount of radiation, in comparison with the control specimens is an indication of the amount of Th-232 that had been present initially. In this way Th-232 can be established up to a concentration of 2 X low7 g/g tissue (Fig. 2). RESULTS
When we look at, in a logarithmic sense, medium concentrations of Th-232 for various organs and tissues measured in the way we have described, it becomes apparent that the organs of the RES (spleen, lymph nodes, liver, and bone marrow) show the highest degree of concentrations but also the highest degree of scattering compared, for instance, with the degree of concentrations and scattering found in walls of arteries, heart muscle, thyroid gland, and other organs. It is striking that the medium concentration of Th-232 is higher in lymph nodes than in the liver (Fig. 3). The great scattering of the values in the organs of the RES is due to the inhomogeneous distribution in liver, spleen, and bone marrow (Wegener et al., 1976) and to the different amount of thorotrast in lymph nodes of various parts of the body. The mean values in Fig. 4 are obtained by checking the concentration of ~gTh-232/g
tissue
10‘
10’
1
inguinal
region
102 I
-
FIG. 4. Mean concentration (logarithmic sense).
with scattering of Th-232 from lymph nodes of various parts of the body
THOROTRAST:
FIG. 5. Inter- and intracellular surrounding (I-I&E; X 375).
LYMPH
NODES
249
deposition of thorotrast in a lymph node without vital reaction in the
Th-232 in lymph nodes taken from various parts of the body. The lymph nodes around the liver and spleen, that is to say those around the portal fissure, have stored far more thorotrast than those in the hilar region of the lung, around the neck, in the lumbar region of the aorta, and in the inguinal flexure. These differences in concentrations are not dependent on the body region into which thorotrast was originally injected intravenously. In lymph nodes with low concentration of Th-232, thorotrast is mainly deposited in smaller conglomerates in the sinuses of the reticulum, on the whole extracellularily, and only occasionally within the cells of the reticulum. There is no evidence of a vital reaction in the areas surrounding the depositions, such as cell necrosis or necrobiosis, bleeding, inflammation, or formation of fibers (Fig. 5). The follicles and their germinal centers contain no or very little thorotrast, thus the particles avoid these structures during the process of deposition. Lymph nodes from the hilar region of the lungs show the same deposition pattern of thorotrast as anthracotic pigment, which, incidentally, accompanies thorotrast in the lymphatic vessels of the lung. The same pattern of deposition without vital reaction is seen in the red pulp of the spleen, remote from the trabeculae and also in the tonsil, in the lymphocyte-enriched reticulum. These lindings could lead us to assume a mobility of thorotrast which is transported
250
FIG. 6. Inter- and intracellular gram; H&E; X 100.)
WEGENER
AND
WESCH
deposition of thorotrast in a lymph node in great islets. (Autoradio-
continuously along the numerous unblocked lymphatic vessels. Greater accumulations of thorotrast (Fig. 6) do not necessarily cause necroses or other vital reactions. They seemingly can lie dormant for a longer period of time. It is interesting to note that, when larger quantities of thorotrast are present, pockets of contrast medium are formed in the spleen and its surrounding lymph nodes. It is not clear, at which stage of deposition the first vital reactions occur. They consist, as we know from animal experiments and early observations in men (Anders and Leitner, 1932; Naegeli and Lauche, 1933; Rotter, 1950; Ballif, 1953; Zollinger, 1960; da Silva Horta, 1965), of pyknosis of nuclei, cell necrosis, fiber destruction, regeneration of these structures, renewed cellular and intercellular intake of the particles, and other necroses, that is to say, a repeated cycle of degeneration and regeneration. In our cases, these alterations can no longer be proved. We only find lute effects. In lymph nodes with greater quantities of thorotrast, these late effects are fibroses and cicatrization (Friihling ef ul., 1956; da Silva Horta, 1%5). This fibrosis is a terminal state, as it were. We use this particular expression because of the fact, that even years later the complex of collagenous fibers and embedded thorotrast is never stationary. Time and again, cells and fibers are destroyed, particles are shifted about, and new fibers are developed around the depositions. Eventually, this process results in a complete obliteration of the lymph node, which can now only be identified by its shape and
THOROTRAST:
LYMPH
NODES
251
FIG. 7. Fibrosis of a lymph node with enormous depositions of thorotrast. At the upper end of the pic:ure reticulum with lymphocytes. (Auioradiogram; H&E; X 150.)
position. Reticular tissue with follicles and germinal centers are no longer existent (Figs. 7 and 8). These late effects are comparable with those around the trabecula in the spleen, resulting in insular thorotrast conglomerates with excessive pulp fibrosis and enlargement of the intima of the arteries and their lumen restriction. They are also found in so-called thorotrastomas, that is to say, in large scars of fibrous tissue surrounding thorotrast depositions located in the area of the original site of the injection. Sometimes, these processes are accompanied by foreign-body giant cells with deposited thorotrast particles (Brady et cd., 1960). DISCUSSION
Now, which consequences result in these massive depositions and consecutive fibrosis? (1) Unfortunately, only a small part of the thorotrast is eliminated from the circulation. (2) The exposure to radiation of the surrounding area is reduced because a rays in tissue only reach as far as 80 pm, and also, a high percentage of them is destroyed by a self-absorption caused by the dense agglomeration of the thorotrast particles.
252
WEGENER
FIG. 8. Total fibrosis of a parapancreatic thorotrast. (H&E; X 150.)
AND
WESCH
lymph node with irregularly
intercellular
deposition
of
(3) The lymph system atrophies. This phenomenon in the liver for instance, leads to the subcapsular lymphatic vessels not being drained any longer. Therefore, plenty of thorotrast remains here and the physiological process by which the liver purifies itself is curtailed. (4) Contrary to all expectations, malignant degeneration is very rare. Having investigated all the late effects produced in the organs of the RES of our 3g specified cases, it becomes clear that the morphologically uncharacteristic fibrosis in lymph nodes, spleen, thorotrastomas, and liver must also be seen as a late effect. Specific late effects, such as tumors or systemic diseases, did not occur, either in lymph nodes or in thorotrastomas. Pathological changes in either lymph nodes, spleen, or thorotrastomas could be identified as the cause of the patients’ death. In the liver, however, malignant tumors were frequently found next to fibrosis and cirrhosis; there were ten hemangiosarcomas, five hepatoceliular carcinomas, and seven cholangiocellular carcinomas, Seventeen of the 38 patients died directly or indirectly because of pathological changes in the liver; 11 died of other diseases, none of which could be traced back to a general thorotrastosis. These observations conform with published findings. As far as is evident from our study of the literature on the subject, among the hundreds of clinical and
THOROTRAST:
LYMPH
NODES
253
pathological anatomically investigated human thorotrast cases of special lymph node late effects, only two cases of Brill-Symmers (Gardner and Ogilvie, 1959; Ascroft and Maccabe, 1%2) and one case of Morbus Hodgkin (Verner and Smith, 1%3) have been described. Schmidt er ul. (1950) in one case of thorotrastosis mentions spleen tumors that could not specifically be detined. In 21 cases, sarcomas were discovered in the area surrounding thorotrastomas (Plenge and KCkemeyer, 1954; Scheibe, 1955; Dahlgren, 1961, 1967; Krick, 1962; Blomberg, 1%3; Kemnitz and Vinz, 1964; da Silva Horta, 1967; Schajowicz et ul., 1967). These few malignant growths in lymph nodes, spleen, and thorotrastomas contrast with more than 250 cases in the literature concerning liver tumors of various histogenesis. No investigations have been made as to how these different late effects in the various organs, with roughly equal concentration of thorotrast, come into being. There are several hypothetical conceptions. It is important in this context to note that the amount of cxself-absorption in the various organs is different. With the stronger agglomeration of thorotrast particles in lymph nodes, spleen, and thorotrastomas, a large proportion of the cx rays is halted within the depots. In liver and bone marrow, however, the thorotrast which is distributed everywhere is much more tine grained, the cxself-absorption is low, and the probability of cell damage by radiation, therefore, is comparatively higher (Wegener and Zahnert, 1970; Wegener er ul., 1971; Kaul and Heyder, 1971; Muth et ul., 1971). What also seems to play an important part is that thorotrast after injection into the liver can be distributed over a much bigger sinusoidal area than is the case in lymph nodes and spleen. In lymph nodes and spleen the radiation is confined to a relatively small area and leads therefore much more quickly to recurrent necroses with extreme pathological mutation in the organ, as we have pointed out, This process of pathological change in the liver develops slowly over decades. It affects only small cell groups and is combined with a continuous regeneration. Frequently, liver cirrhosis results, and in these cases it is not possible to ascertain whether the subsequent liver carcinoma has developed from the cirrhosis or from radiation damage caused by thorotrast, or whether it is the product of both, cirrhosis and radiation, a cocarcinogenesis so to speak. A third consideration is that lymph nodes, spleen, and thorotrastomas develop so few tumors because the radiation that turned the cells malignant also destroys them again after a short period of time (Wenz and van Kaick, 1969). Should this theory prove to be correct, then it should also apply to the liver in which case it would not make sense, for such frequent liver tumors to occur in cases of thorotrastosis unless one supposes that thorotrast is permanently shifted around within the liver, thereby providing no opportunity for the cell to be turned malignant by radiation of a single thorotrast particle, and then, after a while, being necrotized by it. TO conclude, here is a resume based on proven observation material of human thorotrastosis: (I) The development of a local or systemic malignant process in lymph nodes is very rare, even with high concentration of thorotrast. Fibrosis is the predominant
254
WEGENER
AND
WESCH
late effect. Thorotrast patients therefore hardly ever die of complications initiated by this part of the RES. (2) A similar pattern to that found in the lymph nodes is shown in spleen and muscle and fibrous tissue in the area surrounding thorokastomas, (3) The one exception, within the RES, in cases of thorotrastosis is the liver. Here cirrhosis and tumors are developed, the complicaGons of which, in most cases, determine the final stages of the disease. ACKNOWLEDGMENTS These investigationshave been made possible by the generosity of my colleagues, who provided me with specimens and postmortem material. I would like to thank most sincerely: Professor Dr. W. Doerr, Director of the Pathological Institute, University of Heidelberg; Professor Dr. H Rtibsaamen, Pathological Institute, Municipal Hospital Singen (Htw.); Professor Dr. H. Bohle, Pathological Institute, Tiibingen University; Professor Dr. P. B. Diesel, Pathological Institute, Municipal Hospital Pforzheim; Professor Dr. H. H. Jansen, Pathological Institute, Municipal Hospital Darmstadt; Professor Dr. U. Bleyl, Pathological Institute, United Municipal Hospital Mannheim; Dr. H. Schumacher, Pathological Institute, Municipal Hospital Recklinghausen; Dr. H. Schwarzkopf, Pathological Institute, County Hospital Goppingen; Professor Dr. G. Wegner, Pathological Institute, Robert-Bosch-Hospital Stuttgart; Professor Dr. H. Schulz, Pathological Institute, Municipal Hospital Osnabtick; Dr. H. Peter, Pathological Institute, Municipal Hospital Barnberg; and Professor Dr. 0. Klinge, Pathological Institute, Municipal Hospital Kassel.
REFERENCES Anders, H. E., and Leitner, Z. (1932). mer die rtintgenologische DarsteIIung von Milz, Leber, Knochenmark durch Thoroiumdioxyd und ihre histologischen Grundlagen. Klin. Wochenschr. 11, 1097-l loo. Ascroft, P. B., and Maccabe, J. J. (1%2). Late effects of thorotrast in man. J. Roy. C&i. Surg. Edinburg.
7, 221-222.
Ballif, R. N. (1953). Splenic reactions to colloidaI thorium dioxide in the albino rat. Amer. J. Anat. 92, 55-l IS. Bltihbaum, T., Frick, K., and Kalkbrenner, H. (1928). Eine neue Anwendungsart der Kolloide in der Rcntgendiagnostik. Fortschr. R&tgenstr. 37, 18-26. Brady, L. W., Chandler, D. E., Carson, R. O., and Culberson, J. (1960). Perivascular extravasation of thorotrast. Report of a case with eleven-year follow-up. Radiology, 74, 392-398. DahIgren, S. (l%l). Thorotrast tumors. A review of the literature and report of two cases. Acta Pathol. Microbial. &and. 53, 147-161. Dahlgren, S. (1967). Effects of IocalIy deposited colloidal thorium dioxide. Ann. N. Y. Acad. Sci. 145, 786-790. Edgington, D. N. (1%7). The estimation of thorium and uranium at the submicrogmm level in bone by neutron activation. In?. J. Appi. Rudiat. 18, I I-18. Friihling, L., Gross, C. M., Batzenschlager, A., and Dorner, M. (1956). II, Anatomie pathologique des l&ions tardives dues i l’injection de thorotrast chez l’homme. Ann. Med. 57, 297-350. Gardner, D. L., and OgiIvie, R. F. (1959). The late results of injection of thorotrast: two cases of neoplastic disease following contrast angiography. J. Pathol. Bacterial. 78. 133-144. Kampmann, H., Krauss, O., Rtiger, W., Scheer, K. E., and Lorenz, W. J. (1968). Quantitative Organverteilungsuntersuchungen mit Thorotrast durch Neutronenaktivierungs-Analyse: 6, Jahrestagung d. Ges. f. Nuklear-Medizin, Wiesbaden, Spetmeber 26-28. Kampmann, H., Wesch, H., and Wegener, K. (1%9). Quantitative Thoriumbestimmungen in 30 Organen bei menschlicher Thorotrastose: 7, Jahrestag. d. Ges. f. Nuklear-Medizin, Ziirich, September 25-27. Kaul, A., and Heyder, J. (1971). Kinetik der VerteiIung und Ausscheidung von Radium-Isotopen nach Thorotrastinjektion. Biophysik 7, 74-84. Kemnitz, P., and Vinz, H. (1964). ober ein durch paravasale Injektion von Thorotrast am Applikationsort entstandenes Sarkom. Zentralbl. Pathol. 106, 502-511.
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Krick, W., and Heck, G. (1962). Abdominales Spindelzell-Sarkom nach Thorotrast. Med. K/in. 4% 1899-1901. Muth, H., Heyer, J., van Kaick, G., Kaul, A., Kemmer, W., Koeppe, P., Lorenz, D., Oberhausen, E., Roeder, D., and Schneidlin, P. (1971). Results of biophysical and clinical examination of thorotrast patients and their importance for better knowledge about radiation late effects: 4, U.N. International Conference Peaceful Use of Atomic Energy, Geneva, September 6-16. Naegeli, Th., and Lauche, A. (1933). Uber Thoriumdioxyd-Spatschadigungen in Lymphknoten, drei Jahre nach der intravenosen Injektion. Klin. Wochenschr. 12, 1730-1731. Oka, M. (1929). Eine neue Methode zur rontgenologischen Darstellung der Milz (Lienographie). Fortschr. Rzntgenstr. 41, 892. Plenge, K., and Kruckemeyer, K. (1954). Uber ein Sarkom am Ort der Thorotrastinjektion. Zentralbl. Pathol. 92, 255-260. Radt, P. (1929). Eine Methode zur rontgenologischen Kontrastdarstellung von Milz und Leber. K/in. Wochenschr. 46,2128. Radt, P. (1930). Eine neue Methode zur rontgenologischen Sichtbarmachung von Leber und Milz durch Injektion eines Kontrastmittels. Med. Klin. (Munich) 51. Rotter, W. (1950). Uber Gewebsschaden durch Thorotrast. Unter besonderer Beriicksichtigung der GeR+veranderungen und aplastischer Knochenmarksreaktionen. Beiir. Patho/. Anat. 111, 144-157. Schajowicz, F., Detilippi-Novoa, C. A., and Firpo, C. A. (1967). Thorotrast induced chondrosarcoma of the axilla. Amer. J. Roentgenol. 100, 931-937. Scheer, K. E., Krauss, O., and Varga, L. (1967). Neutronen-Aktivierungsanalyse zur Bestimmung von Thorotrast in Gewebsproben. Afompraxis 13, 451-453. Scheibe, G. (1955). Malignes intraperitoneales Thorotrastom beim Menschen. Zenrralbl. Chir. 80, 588-592. Schmidt, W., Schulte, A., and Lapp, H. (1950). Klinischer und pathologisch-anatomischer Beitrag zur Frage der Schadigung durch Thorotrast. Strahlenrherapie 81, 39-102. Schultze, B. (1%8). Die Orthologie und Pathologie des Nukleinsaure-und Eiweissoffwechsels der Zelle im Autoradiogmmm Handb. d. Allg. Pathol. Hrsg. H. W. Altmann u. Mitarb. Bd. 2/5. S. 466-667. Berlin-Heidelberg-New York. da Silva Horta, J. (1965). Thorotrast induced fibrosis. In “Dosimetry and Toxicity of Thorotrast.” pp. 121-134. International Atomic Energy Agency, Vienna. da Silva Horta, J. (1967). Effects of colloidal thorium dioxide extravasates in the subcutaneous tissues of the cervical region in man. Ann. N. Y. Acad. Sci. 145, 776-785. Verner, J. V., and Smith, AT G. (1%3). Hodgkin’s disease following administration of thorotrast. South. Med. J. 56, 524-528. Wegener, K., and Zahnert, R. (1970). Bericht uber pathologisch-anatomische und autoradiographische Untersuchungen an 9 Fallen menschlicher Thorotrastose. Virchows Arch. A 351,316332. Wegener, K., Wesch, H., and Kampmann, H. (1971). Retikuloendotheliales System und Thorotrastose nach diagnostischer Angiographie. Deut. Med. Wochenschr. 96, 1977-1981. Wegener, K., Wesch. H., and Kampmann, H. (1976). Investigations into human thorotrast. Virchows’ Arch. A 371, 131-143. Wenz, W., and van Kaick, G. (1969). Strahlenspatwirkungen nach Thorotrastablagerungen. Langenbecks Arch. Chir. 325, 1008-1019. Zollinger, H. U. (196Q. Radio-histologie und radio-histopathologie. Zn “Handbuch der Allgemeinen Pathologie. Band 10/l.” Springer-Verlag, Berlin-Gottingen-Heidelberg.
RESEARCH
Pathological
l&245-255
(1979)
Changes of Lymph Patients
Pathoanatomical,
Nodes in Thorotrast
Autoradiographical, InvesGgations
and QuanMaGve
K. WEGENER AND H. WESCH* Pathological institute of the Municipal Hospital of Ludwigshafen, Bremserstr. 79, 6700 Ludw~gshafen~Rhein, Federal Republic of Germany, and *Znstitute of Nuclear Medicine, German Cancer Research Znstitute- Federal Republic of Germany Received May 1, 1978 Which concentrations of thorotrast are deposited in the lymph nodes of thorotrast patients? Which late effects do occur in organs with different quantities of thorotrast deposited? Which late effects of thorotmst are detected in lymph nodes compared to those in liver and spleen? We studied 38 postmortem cases and investigated 120 lymph nodes taken from various regions of the body. We also investigated the liver and spleen of all the cases and thorotrastomas of six cases. All 38 patients had suffered from thorotrastosis and died approximately 28 years after the injection. Paraffin sections, autoradiography and neutron activation analysis were used. In lymph nodes, the mean concentration of Th-232 is higher than in the liver; it is, however, a little lower than in the spleen. The highest concentration of Th-232 is measured in the lymph nodes of the liver hilus, those in the area behind the pancreas, and around the hilus of the spleen. Lower concentrations are measured in the lymph nodes around the bifurcatio aortae, around the hilus of the lung, and in the groin. The contrast medium is deposited in small concentrations in the sinuses of the lymph nodes without showing any vital reaction in the surrounding area. Th-232 is stored only in a few reticulum cells. The follicles are free of Th-232. In lymph nodes with a higher concentration of Th-232, a strong fibrosis can be seen, occluding the lymph vessels. Spleen and thorotrastomas show a similar fibrosis to that seen in the lymph nodes. We find a large number of carcinomas and sarcomas of the liver. No malignant growth is seen, on the other hand, in either lymph nodes, spleen, or thorotrastoma. In the final section of the paper the special localization of tumors in human thorotrastosis is considered.
INTRODUCTION
The use of thorotrast during the 1930s and 1940s (Bliihbaum ef al., 1928; Radt, 1929, 1930; Oka, 1929) has led to catastrophic results because this medium is deposited almost entirely in the reticuloendothelial system (RES), that is to say in liver, spleen, bone marrow, and lymph nodes (Muth e? af., 1970). Therefore, over decades, the amount of thorotrast deposited has resulted in enormous exposure to radiation in these particular organs. There is evidence in literature, however, that fafal late effects in thorotrastosis patients are, on the whole, confined to liver and bone marrow, whereas lymph nodes, spleen, and thorotrastomas are hardly affected. It is clear. on the other hand, working on the evidence produced by X rays ot many thorotrastosis patients, that spleen and lymph nodes have stored thorotrast at least in the same, if not in even greater concentration than for instance the liver has. 245 0013-9351/79/010245-11$02.00/O Copyright
@ I979 by Academic
fiess,
Inc.
246
WEGENER
AND
Data of the autopsied
WESCH
patients
Age at the time
Injection method Injection wlurne Latency
period
FIG. I. Data of patients
Three main questions occur at this stage. (1) In what concentration is thorotrast deposited in the lymph nodes of various parts of the body decades after the injection? (2) In what way is thorotrast deposited in the lymph nodes of various parts of the body decades after the injection? (3) Which late effects are detectable in the lymph nodes? MATERIAL
AND METHODS
During the past years we had the opportunity of studying 38 postmortem cases of thorotrastosis patients (Fig. 1). Of these cases, 31 were males and 7 females. Their ages at the time of death lay between 34 and 82 years, and their ages at the time of the injection between 11 and 47 years. In all patients thorotrast in an unspecified quantity was injected intravascularily, to clarify aneurysms, arteriovenous listulae, brain tumors, or blood vessel obliterations in various regions. The latency period, here defined as the time between injection and death, lay between 24 and 38 years. Among nearly 2500 organ specimens we investigated a total of 120 lymph nodes from various parts of the body. In this investigation we used the following techniques. (1) The usual histological preparation of lymph nodes into paraffin sections stained with various dyes, in order to establish morphologically determinable late effects. (2) The technique of autoradiography with stripping-film and special emulsion to establish localization and deposition pattern of particularly small thorotrast particles (Technique of Autoradiography: Schultze, 1%8).
Neutron
activation
of “‘thorium
*33Th &- z33Pa 23zTh I,,+) FIG. 2. Scheme of neutron activating analysis.
THOROTRAST:
LYMPH
247
NODES
(3) The neutron activating analysis which enables us to ascertain quantity and concentration of the deposited Th-232 (Edgington, 1%7; Scheer et uf., 1%7; Kampmann et ul., 1%8, 1%9). During the neutron activating analysis, dried organ specimens with an average weight of 1 or 2 g are exposed in a reactor to a neutron radiation with a flux of rng lh- 232/g Cssue
10 2 splttn lymph II
nodts
0
10’
I
livtr
0
bont 10’
marrow
1 0
T
tonsil
0
T
adrtnak
I
lo-
lung
0
1
kidnty
gland
pancrtos
1T
vtnts
0
T 0
lo-
digtstivt
1 T
conntctivt Gssut
0
arkrits
1 ‘7’ 1
thyroid
0
~
gland
0
muscks
tract
0
I
brain
lo-
0
organs
FIG. 3. Itieal I concentration gram
tissue
(logarithmic
sense).
(with scattering) of Th-232 for 17 organs and tissues in milligram per Scattering
is drawn
in one direction
only.
248
WEGENER
AND
WESCH
2 X 10” particles per square centimeter and second for a duration of 8 hr. The neutron capture of Th-232 causes the conversion to Th-233, which decays with a half-life of 22 min to protactinium-233. This decays with a half-life of 27 days to uranium-233. The radiation of the protactinium-233 is measured with a germanium-lithium driftet detector or a Na-J well-type detector. The amount of radiation, in comparison with the control specimens is an indication of the amount of Th-232 that had been present initially. In this way Th-232 can be established up to a concentration of 2 X low7 g/g tissue (Fig. 2). RESULTS
When we look at, in a logarithmic sense, medium concentrations of Th-232 for various organs and tissues measured in the way we have described, it becomes apparent that the organs of the RES (spleen, lymph nodes, liver, and bone marrow) show the highest degree of concentrations but also the highest degree of scattering compared, for instance, with the degree of concentrations and scattering found in walls of arteries, heart muscle, thyroid gland, and other organs. It is striking that the medium concentration of Th-232 is higher in lymph nodes than in the liver (Fig. 3). The great scattering of the values in the organs of the RES is due to the inhomogeneous distribution in liver, spleen, and bone marrow (Wegener et al., 1976) and to the different amount of thorotrast in lymph nodes of various parts of the body. The mean values in Fig. 4 are obtained by checking the concentration of ~gTh-232/g
tissue
10‘
10’
1
inguinal
region
102 I
-
FIG. 4. Mean concentration (logarithmic sense).
with scattering of Th-232 from lymph nodes of various parts of the body
THOROTRAST:
FIG. 5. Inter- and intracellular surrounding (I-I&E; X 375).
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deposition of thorotrast in a lymph node without vital reaction in the
Th-232 in lymph nodes taken from various parts of the body. The lymph nodes around the liver and spleen, that is to say those around the portal fissure, have stored far more thorotrast than those in the hilar region of the lung, around the neck, in the lumbar region of the aorta, and in the inguinal flexure. These differences in concentrations are not dependent on the body region into which thorotrast was originally injected intravenously. In lymph nodes with low concentration of Th-232, thorotrast is mainly deposited in smaller conglomerates in the sinuses of the reticulum, on the whole extracellularily, and only occasionally within the cells of the reticulum. There is no evidence of a vital reaction in the areas surrounding the depositions, such as cell necrosis or necrobiosis, bleeding, inflammation, or formation of fibers (Fig. 5). The follicles and their germinal centers contain no or very little thorotrast, thus the particles avoid these structures during the process of deposition. Lymph nodes from the hilar region of the lungs show the same deposition pattern of thorotrast as anthracotic pigment, which, incidentally, accompanies thorotrast in the lymphatic vessels of the lung. The same pattern of deposition without vital reaction is seen in the red pulp of the spleen, remote from the trabeculae and also in the tonsil, in the lymphocyte-enriched reticulum. These lindings could lead us to assume a mobility of thorotrast which is transported
250
FIG. 6. Inter- and intracellular gram; H&E; X 100.)
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deposition of thorotrast in a lymph node in great islets. (Autoradio-
continuously along the numerous unblocked lymphatic vessels. Greater accumulations of thorotrast (Fig. 6) do not necessarily cause necroses or other vital reactions. They seemingly can lie dormant for a longer period of time. It is interesting to note that, when larger quantities of thorotrast are present, pockets of contrast medium are formed in the spleen and its surrounding lymph nodes. It is not clear, at which stage of deposition the first vital reactions occur. They consist, as we know from animal experiments and early observations in men (Anders and Leitner, 1932; Naegeli and Lauche, 1933; Rotter, 1950; Ballif, 1953; Zollinger, 1960; da Silva Horta, 1965), of pyknosis of nuclei, cell necrosis, fiber destruction, regeneration of these structures, renewed cellular and intercellular intake of the particles, and other necroses, that is to say, a repeated cycle of degeneration and regeneration. In our cases, these alterations can no longer be proved. We only find lute effects. In lymph nodes with greater quantities of thorotrast, these late effects are fibroses and cicatrization (Friihling ef ul., 1956; da Silva Horta, 1%5). This fibrosis is a terminal state, as it were. We use this particular expression because of the fact, that even years later the complex of collagenous fibers and embedded thorotrast is never stationary. Time and again, cells and fibers are destroyed, particles are shifted about, and new fibers are developed around the depositions. Eventually, this process results in a complete obliteration of the lymph node, which can now only be identified by its shape and
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FIG. 7. Fibrosis of a lymph node with enormous depositions of thorotrast. At the upper end of the pic:ure reticulum with lymphocytes. (Auioradiogram; H&E; X 150.)
position. Reticular tissue with follicles and germinal centers are no longer existent (Figs. 7 and 8). These late effects are comparable with those around the trabecula in the spleen, resulting in insular thorotrast conglomerates with excessive pulp fibrosis and enlargement of the intima of the arteries and their lumen restriction. They are also found in so-called thorotrastomas, that is to say, in large scars of fibrous tissue surrounding thorotrast depositions located in the area of the original site of the injection. Sometimes, these processes are accompanied by foreign-body giant cells with deposited thorotrast particles (Brady et cd., 1960). DISCUSSION
Now, which consequences result in these massive depositions and consecutive fibrosis? (1) Unfortunately, only a small part of the thorotrast is eliminated from the circulation. (2) The exposure to radiation of the surrounding area is reduced because a rays in tissue only reach as far as 80 pm, and also, a high percentage of them is destroyed by a self-absorption caused by the dense agglomeration of the thorotrast particles.
252
WEGENER
FIG. 8. Total fibrosis of a parapancreatic thorotrast. (H&E; X 150.)
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lymph node with irregularly
intercellular
deposition
of
(3) The lymph system atrophies. This phenomenon in the liver for instance, leads to the subcapsular lymphatic vessels not being drained any longer. Therefore, plenty of thorotrast remains here and the physiological process by which the liver purifies itself is curtailed. (4) Contrary to all expectations, malignant degeneration is very rare. Having investigated all the late effects produced in the organs of the RES of our 3g specified cases, it becomes clear that the morphologically uncharacteristic fibrosis in lymph nodes, spleen, thorotrastomas, and liver must also be seen as a late effect. Specific late effects, such as tumors or systemic diseases, did not occur, either in lymph nodes or in thorotrastomas. Pathological changes in either lymph nodes, spleen, or thorotrastomas could be identified as the cause of the patients’ death. In the liver, however, malignant tumors were frequently found next to fibrosis and cirrhosis; there were ten hemangiosarcomas, five hepatoceliular carcinomas, and seven cholangiocellular carcinomas, Seventeen of the 38 patients died directly or indirectly because of pathological changes in the liver; 11 died of other diseases, none of which could be traced back to a general thorotrastosis. These observations conform with published findings. As far as is evident from our study of the literature on the subject, among the hundreds of clinical and
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pathological anatomically investigated human thorotrast cases of special lymph node late effects, only two cases of Brill-Symmers (Gardner and Ogilvie, 1959; Ascroft and Maccabe, 1%2) and one case of Morbus Hodgkin (Verner and Smith, 1%3) have been described. Schmidt er ul. (1950) in one case of thorotrastosis mentions spleen tumors that could not specifically be detined. In 21 cases, sarcomas were discovered in the area surrounding thorotrastomas (Plenge and KCkemeyer, 1954; Scheibe, 1955; Dahlgren, 1961, 1967; Krick, 1962; Blomberg, 1%3; Kemnitz and Vinz, 1964; da Silva Horta, 1967; Schajowicz et ul., 1967). These few malignant growths in lymph nodes, spleen, and thorotrastomas contrast with more than 250 cases in the literature concerning liver tumors of various histogenesis. No investigations have been made as to how these different late effects in the various organs, with roughly equal concentration of thorotrast, come into being. There are several hypothetical conceptions. It is important in this context to note that the amount of cxself-absorption in the various organs is different. With the stronger agglomeration of thorotrast particles in lymph nodes, spleen, and thorotrastomas, a large proportion of the cx rays is halted within the depots. In liver and bone marrow, however, the thorotrast which is distributed everywhere is much more tine grained, the cxself-absorption is low, and the probability of cell damage by radiation, therefore, is comparatively higher (Wegener and Zahnert, 1970; Wegener er ul., 1971; Kaul and Heyder, 1971; Muth et ul., 1971). What also seems to play an important part is that thorotrast after injection into the liver can be distributed over a much bigger sinusoidal area than is the case in lymph nodes and spleen. In lymph nodes and spleen the radiation is confined to a relatively small area and leads therefore much more quickly to recurrent necroses with extreme pathological mutation in the organ, as we have pointed out, This process of pathological change in the liver develops slowly over decades. It affects only small cell groups and is combined with a continuous regeneration. Frequently, liver cirrhosis results, and in these cases it is not possible to ascertain whether the subsequent liver carcinoma has developed from the cirrhosis or from radiation damage caused by thorotrast, or whether it is the product of both, cirrhosis and radiation, a cocarcinogenesis so to speak. A third consideration is that lymph nodes, spleen, and thorotrastomas develop so few tumors because the radiation that turned the cells malignant also destroys them again after a short period of time (Wenz and van Kaick, 1969). Should this theory prove to be correct, then it should also apply to the liver in which case it would not make sense, for such frequent liver tumors to occur in cases of thorotrastosis unless one supposes that thorotrast is permanently shifted around within the liver, thereby providing no opportunity for the cell to be turned malignant by radiation of a single thorotrast particle, and then, after a while, being necrotized by it. TO conclude, here is a resume based on proven observation material of human thorotrastosis: (I) The development of a local or systemic malignant process in lymph nodes is very rare, even with high concentration of thorotrast. Fibrosis is the predominant
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late effect. Thorotrast patients therefore hardly ever die of complications initiated by this part of the RES. (2) A similar pattern to that found in the lymph nodes is shown in spleen and muscle and fibrous tissue in the area surrounding thorokastomas, (3) The one exception, within the RES, in cases of thorotrastosis is the liver. Here cirrhosis and tumors are developed, the complicaGons of which, in most cases, determine the final stages of the disease. ACKNOWLEDGMENTS These investigationshave been made possible by the generosity of my colleagues, who provided me with specimens and postmortem material. I would like to thank most sincerely: Professor Dr. W. Doerr, Director of the Pathological Institute, University of Heidelberg; Professor Dr. H Rtibsaamen, Pathological Institute, Municipal Hospital Singen (Htw.); Professor Dr. H. Bohle, Pathological Institute, Tiibingen University; Professor Dr. P. B. Diesel, Pathological Institute, Municipal Hospital Pforzheim; Professor Dr. H. H. Jansen, Pathological Institute, Municipal Hospital Darmstadt; Professor Dr. U. Bleyl, Pathological Institute, United Municipal Hospital Mannheim; Dr. H. Schumacher, Pathological Institute, Municipal Hospital Recklinghausen; Dr. H. Schwarzkopf, Pathological Institute, County Hospital Goppingen; Professor Dr. G. Wegner, Pathological Institute, Robert-Bosch-Hospital Stuttgart; Professor Dr. H. Schulz, Pathological Institute, Municipal Hospital Osnabtick; Dr. H. Peter, Pathological Institute, Municipal Hospital Barnberg; and Professor Dr. 0. Klinge, Pathological Institute, Municipal Hospital Kassel.
REFERENCES Anders, H. E., and Leitner, Z. (1932). mer die rtintgenologische DarsteIIung von Milz, Leber, Knochenmark durch Thoroiumdioxyd und ihre histologischen Grundlagen. Klin. Wochenschr. 11, 1097-l loo. Ascroft, P. B., and Maccabe, J. J. (1%2). Late effects of thorotrast in man. J. Roy. C&i. Surg. Edinburg.
7, 221-222.
Ballif, R. N. (1953). Splenic reactions to colloidaI thorium dioxide in the albino rat. Amer. J. Anat. 92, 55-l IS. Bltihbaum, T., Frick, K., and Kalkbrenner, H. (1928). Eine neue Anwendungsart der Kolloide in der Rcntgendiagnostik. Fortschr. R&tgenstr. 37, 18-26. Brady, L. W., Chandler, D. E., Carson, R. O., and Culberson, J. (1960). Perivascular extravasation of thorotrast. Report of a case with eleven-year follow-up. Radiology, 74, 392-398. DahIgren, S. (l%l). Thorotrast tumors. A review of the literature and report of two cases. Acta Pathol. Microbial. &and. 53, 147-161. Dahlgren, S. (1967). Effects of IocalIy deposited colloidal thorium dioxide. Ann. N. Y. Acad. Sci. 145, 786-790. Edgington, D. N. (1%7). The estimation of thorium and uranium at the submicrogmm level in bone by neutron activation. In?. J. Appi. Rudiat. 18, I I-18. Friihling, L., Gross, C. M., Batzenschlager, A., and Dorner, M. (1956). II, Anatomie pathologique des l&ions tardives dues i l’injection de thorotrast chez l’homme. Ann. Med. 57, 297-350. Gardner, D. L., and OgiIvie, R. F. (1959). The late results of injection of thorotrast: two cases of neoplastic disease following contrast angiography. J. Pathol. Bacterial. 78. 133-144. Kampmann, H., Krauss, O., Rtiger, W., Scheer, K. E., and Lorenz, W. J. (1968). Quantitative Organverteilungsuntersuchungen mit Thorotrast durch Neutronenaktivierungs-Analyse: 6, Jahrestagung d. Ges. f. Nuklear-Medizin, Wiesbaden, Spetmeber 26-28. Kampmann, H., Wesch, H., and Wegener, K. (1%9). Quantitative Thoriumbestimmungen in 30 Organen bei menschlicher Thorotrastose: 7, Jahrestag. d. Ges. f. Nuklear-Medizin, Ziirich, September 25-27. Kaul, A., and Heyder, J. (1971). Kinetik der VerteiIung und Ausscheidung von Radium-Isotopen nach Thorotrastinjektion. Biophysik 7, 74-84. Kemnitz, P., and Vinz, H. (1964). ober ein durch paravasale Injektion von Thorotrast am Applikationsort entstandenes Sarkom. Zentralbl. Pathol. 106, 502-511.
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Krick, W., and Heck, G. (1962). Abdominales Spindelzell-Sarkom nach Thorotrast. Med. K/in. 4% 1899-1901. Muth, H., Heyer, J., van Kaick, G., Kaul, A., Kemmer, W., Koeppe, P., Lorenz, D., Oberhausen, E., Roeder, D., and Schneidlin, P. (1971). Results of biophysical and clinical examination of thorotrast patients and their importance for better knowledge about radiation late effects: 4, U.N. International Conference Peaceful Use of Atomic Energy, Geneva, September 6-16. Naegeli, Th., and Lauche, A. (1933). Uber Thoriumdioxyd-Spatschadigungen in Lymphknoten, drei Jahre nach der intravenosen Injektion. Klin. Wochenschr. 12, 1730-1731. Oka, M. (1929). Eine neue Methode zur rontgenologischen Darstellung der Milz (Lienographie). Fortschr. Rzntgenstr. 41, 892. Plenge, K., and Kruckemeyer, K. (1954). Uber ein Sarkom am Ort der Thorotrastinjektion. Zentralbl. Pathol. 92, 255-260. Radt, P. (1929). Eine Methode zur rontgenologischen Kontrastdarstellung von Milz und Leber. K/in. Wochenschr. 46,2128. Radt, P. (1930). Eine neue Methode zur rontgenologischen Sichtbarmachung von Leber und Milz durch Injektion eines Kontrastmittels. Med. Klin. (Munich) 51. Rotter, W. (1950). Uber Gewebsschaden durch Thorotrast. Unter besonderer Beriicksichtigung der GeR+veranderungen und aplastischer Knochenmarksreaktionen. Beiir. Patho/. Anat. 111, 144-157. Schajowicz, F., Detilippi-Novoa, C. A., and Firpo, C. A. (1967). Thorotrast induced chondrosarcoma of the axilla. Amer. J. Roentgenol. 100, 931-937. Scheer, K. E., Krauss, O., and Varga, L. (1967). Neutronen-Aktivierungsanalyse zur Bestimmung von Thorotrast in Gewebsproben. Afompraxis 13, 451-453. Scheibe, G. (1955). Malignes intraperitoneales Thorotrastom beim Menschen. Zenrralbl. Chir. 80, 588-592. Schmidt, W., Schulte, A., and Lapp, H. (1950). Klinischer und pathologisch-anatomischer Beitrag zur Frage der Schadigung durch Thorotrast. Strahlenrherapie 81, 39-102. Schultze, B. (1%8). Die Orthologie und Pathologie des Nukleinsaure-und Eiweissoffwechsels der Zelle im Autoradiogmmm Handb. d. Allg. Pathol. Hrsg. H. W. Altmann u. Mitarb. Bd. 2/5. S. 466-667. Berlin-Heidelberg-New York. da Silva Horta, J. (1965). Thorotrast induced fibrosis. In “Dosimetry and Toxicity of Thorotrast.” pp. 121-134. International Atomic Energy Agency, Vienna. da Silva Horta, J. (1967). Effects of colloidal thorium dioxide extravasates in the subcutaneous tissues of the cervical region in man. Ann. N. Y. Acad. Sci. 145, 776-785. Verner, J. V., and Smith, AT G. (1%3). Hodgkin’s disease following administration of thorotrast. South. Med. J. 56, 524-528. Wegener, K., and Zahnert, R. (1970). Bericht uber pathologisch-anatomische und autoradiographische Untersuchungen an 9 Fallen menschlicher Thorotrastose. Virchows Arch. A 351,316332. Wegener, K., Wesch, H., and Kampmann, H. (1971). Retikuloendotheliales System und Thorotrastose nach diagnostischer Angiographie. Deut. Med. Wochenschr. 96, 1977-1981. Wegener, K., Wesch. H., and Kampmann, H. (1976). Investigations into human thorotrast. Virchows’ Arch. A 371, 131-143. Wenz, W., and van Kaick, G. (1969). Strahlenspatwirkungen nach Thorotrastablagerungen. Langenbecks Arch. Chir. 325, 1008-1019. Zollinger, H. U. (196Q. Radio-histologie und radio-histopathologie. Zn “Handbuch der Allgemeinen Pathologie. Band 10/l.” Springer-Verlag, Berlin-Gottingen-Heidelberg.