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Transarterial chemoembolization in a patient with severe reactions to iodinated contrast: Successful treatment using gadolinium contrast with C-arm computed tomography.

ABSTRACT: Severe reactions to modern iodinated contrasts are uncommon. Breakthrough reactions in the setting of pretreatment with corticosteroids are even rarer. Patients with a history of these refractory reactions can create challenging situations in the diagnostic and therapeutic process. Here, we present a case of an 83-year-old male with hepatocellular carcinoma and a history of multiple severe reactions to iodinated contrast. The patient required a transarterial chemoembolization but the conventional technique was unavailable due to the allergy. Gadolinium-based contrast was substituted and used in conjunction with C-arm CT and a percutaneous ethanol injection to treat the tumor. After nearly 3 years, there is no evidence of residual or recurrent hepatocellular carcinoma.

SUBMITTER: Pugh R

PROVIDER: S-EPMC6280638 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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Transarterial chemoembolization in a patient with severe reactions to iodinated contrast: Successful treatment using gadolinium contrast with C-arm computed tomography.

Pugh Robert R Wessel Bryan B Barve Ashutosh A Vyleta Martin S MS

Radiology case reports 20181204 3

Severe reactions to modern iodinated contrasts are uncommon. Breakthrough reactions in the setting of pretreatment with corticosteroids are even rarer. Patients with a history of these refractory reactions can create challenging situations in the diagnostic and therapeutic process. Here, we present a case of an 83-year-old male with hepatocellular carcinoma and a history of multiple severe reactions to iodinated contrast. The patient required a transarterial chemoembolization but the conventiona ...[more]

PMID: 30546812

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Project description:BackgroundThe management of the use of iodinated contrast agents (ICA) in the computed tomography (CT) has clinical and financial impacts; however, the approaches in the current research setting have limitations with regard to their exploration of the theme. This work describes the application of the stages of a process of business intelligence (BI), from the formulation of business questions, the building of a research database, and the adaptation of a multidimensional model, to the creation of dashboards to give support to the decision-making process in a hospital. This research aims to apply and document a BI process that provides support to the decision making of managers, so the use of ICA can be better managed, allowing for the identification of situations in which the material was wasted using a study applied to the hospital field.MethodsAn applied exploratory research with a quantitative approach in a database made up by 24 variables and 35,388 records extracted from the RIS (Radiology Information System) that is used by the General Hospital of Porto Alegre-HCPA. The software used, supplied by AGFA Healthcare, were the Qdoc system (version 6.2.0) and the Impax BI (Version 11.1.1) for, respectively, data entry and data exploration. At the end of the process, a total of 48 variables was considered.ResultsThe BI process applied allowed for the identification of situations in which ICA was being wasted during the operationalization of the volume/mass ratio of the agent injected in the patient. It also offered the necessary substantiation for the managers to formulate plans, actions, and controls associated to the use of the material. This work made it possible to diminish in 15.65% the total consumption of ICA injected in the patients who underwent the CTAB1 exam (full CT scan of the abdomen), with a projected economy of US$ 10,039.95, for the performance of this exam from 2020 on. The measuring of the impact and the relevance of the process was 99.6% positive, according to the evaluation of the managers.ConclusionsThis research generated clinical and financial benefits for the HCPA, a positive evaluation by the managers and the generation of new knowledge, which can be shared with other public or private health organizations.

Project description:The incidence of hypersensitivity reactions (HSRs) to iodinated contrast media (ICM) has risen over last years, representing an important health problem. HSRs to ICMs are classified into immediate reactions (IRs) and non-immediate reactions (NIRs) according to if they occur within 1 h or longer after ICM administration. The diagnosis of HSRs to ICM is complex as skin test (ST) sensitivity ranges widely, and drug provocation test (DPT) protocols are heterogeneous. In this manuscript, we describe the clinical characteristics of a series of patients confirmed as HSR to ICM and the diagnosis procedure carried out, looking into those cases confirmed as HSRs to multiple ICMs. For this purpose, we prospectively evaluated patients suggestive of HSRs to ICMs and classified them as IRs or NIRs. STs were carried out using a wide panel of ICMs, and in those with a negative ST, a single-blind placebo controlled DPT was performed with the culprit. If ST or DPT were positive, then tolerance was assessed with an alternative negative ST ICM. We included 101 cases (12 IRs and 89 NIRs) confirmed as allergic. Among them, 36 (35.64%) cases were allergic to more than one ICM (8 IRs and 28 NIRs). The most common ICM involved were iomeprol and iodixanol. Although not statistically significant, the percentage of patients reporting anaphylaxis was higher in patients allergic to multiple ICMs compared with patients allergic to a single ICM (50 vs. 25%). Likewise, the percentage of positive results in STs was higher in patients allergic to multiple ICMs compared with those allergic to a single ICM (for IR 62.5 vs. 25%, p > 0.05; and for NIR, 85.71 vs. 24.59%, p < 0.000). In cases allergic to more than one ICM, DPT with negative-ST ICM was positive in more than 60% (24/36) of cases. Therefore, allergy to multiple ICMs is common, associated to severe reactions in IRs, and confirmed frequently by positive STs. The allergological work-up should include DPT not only to establish the diagnosis but also to identify safe alternative ICM, even if ICM is structurally unrelated and ST is negative. More studies are needed to clarify mechanisms underlying cross-reactivity among ICMs.

Project description:IntroductionDue to the high heterogeneity of hepatocellular carcinoma (HCC), patients with non-advanced disease who are unsuitable for initial transarterial chemoembolization (TACE) monotherapy may have the potential to develop extrahepatic spread or vascular invasion. We aimed to develop and independently validate a radiomics-based model for predicting which patients will develop extrahepatic spread or vascular invasion after initial TACE monotherapy (EVIT).Materials and methodsThis retrospective study included 256 HCC patients (training set: n = 136; testing set: n = 120) who underwent TACE as initial therapy between April 2007 and June 2018. Clinicoradiological predictors were selected using multivariate logistic regression and a clinicoradiological model was constructed. The radiomic features were extracted from contrast-enhanced computed tomography (CT) images and a radiomics signature was constructed based on a machine learning algorithm. A combined model integrated clinicoradiological predictor and radiomics signature was developed. The predictive performance of the two models was evaluated and compared based on its discrimination, calibration, and clinical usefulness.ResultsIn the training set, 34 (25.0%) patients were confirmed to have EVIT, whereas 26 (21.7%) patients in the testing set had EVIT. When the radiomics signature was added, the combined model showed improved discrimination performance compared to the clinicoradiological model (area under the curves [AUCs] 0.911 vs. 0.772 in the training set; AUCs 0.847 vs. 0.746 in the testing set) and could divide HCC patients into three strata of low, intermediate, or high risk in the two sets. Decision curve analysis demonstrated that the two models were clinically useful, and the combined model provided greater benefits for discriminating patients than the clinicoradiological model.ConclusionsThis study presents a model that integrates clinicoradiological predictors and CT-based radiomics signature that could provide a preoperative individualized prediction of EVIT in patients with HCC.

Project description:In recent years, there has been a large-scale dissemination of guidelines in radiology in the form of Reporting & Data Systems (RADS). The use of iodinated contrast media (ICM) has a fundamental role in enhancing the diagnostic capabilities of computed tomography (CT) but poses certain risks. The scope of the present review is to summarize the current role of ICM only in clinical reporting guidelines for CT that have adopted the "RADS" approach, focusing on three specific questions per each RADS: (I) what is the scope of the scoring system; (II) how is ICM used in the scoring system; (III) what is the impact of ICM enhancement on the scoring. We analyzed the original articles for each of the latest versions of RADS that can be used in CT [PubMed articles between January, 2005 and March, 2023 in English and American College of Radiology (ACR) official website]. We found 14 RADS suitable for use in CT out of 28 RADS described in the literature. Four RADS were validated by the ACR: Colonography-RADS (C-RADS), Liver Imaging-RADS (LI-RADS), Lung CT Screening-RADS (Lung-RADS), and Neck Imaging-RADS (NI-RADS). One RADS was validated by the ACR in collaboration with other cardiovascular scientific societies: Coronary Artery Disease-RADS 2.0 (CAD-RADS). Nine RADS were proposed by other scientific groups: Bone Tumor Imaging-RADS (BTI-RADS), Bone‑RADS, Coronary Artery Calcium Data & Reporting System (CAC-DRS), Coronavirus Disease 2019 Imaging-RADS (COVID-RADS), COVID-19-RADS (CO-RADS), Interstitial Lung Fibrosis Imaging-RADS (ILF-RADS), Lung-RADS (LU-RADS), Node-RADS, and Viral Pneumonia Imaging-RADS (VP-RADS). This overview suggests that ICM is not strictly necessary for the study of bones and calcifications (CAC-DRS, BTI-RADS, Bone-RADS), lung parenchyma (Lung-RADS, LU-RADS, COVID-RADS, CO-RADS, VP-RADS and ILF-RADS), and in CT colonography (C-RADS). On the other hand, ICM plays a key role in CT angiography (CAD-RADS), in the study of liver parenchyma (LI-RADS), and in the evaluation of soft tissues and lymph nodes (NI-RADS, Node-RADS). Future studies are needed in order to evaluate the impact of the new iodinated and non-iodinate contrast media, artificial intelligence tools and dual energy CT in the assignment of RADS scores.

Dataset Information

Transarterial chemoembolization in a patient with severe reactions to iodinated contrast: Successful treatment using gadolinium contrast with C-arm computed tomography.

Publications

Transarterial chemoembolization in a patient with severe reactions to iodinated contrast: Successful treatment using gadolinium contrast with C-arm computed tomography.

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