Gastroduodenal ulceration following liver radioembolization with yttrium-90
22 March 2013 (online)
Radioembolization or selective internal radiation therapy (SIRT) with yttrium-90 (90Y) resin microspheres is an effective locoregional treatment for unresectable primary and metastatic malignancies of the liver . SIRT is a straightforward method of delivering microspheres containing 90Y (a high-energy β-emitting radioisotope) to the microvasculature of malignancies whilst sparing the normal liver parenchyma.
A 54-year-old woman with unresectable bilobar liver metastases from a rectal adenocarcinoma was recommended to undergo 90Y-SIRT. Pretreatment hepatic angiography revealed normal arterial anatomy ([Fig. 1]). The gastroduodenal artery was embolized with eight coils to prevent nontargeted flow to the stomach and duodenum. Afterwards a 99Tc-macroaggregated albumin solution (to simulate the 90Y microspheres) was selectively injected into the hepatic artery. This was followed by a single-photon emission computed tomography (SPECT) scan, which excluded extrahepatic shunting into the gastrointestinal tract and the lung. 90Y-SIRT was performed 2 weeks later. Selective catheterization of the left and right lobes of the liver permitted delivery a 1.7 GBq dose of 90Y resin microspheres. A post-treatment SPECT scan confirmed uptake in the liver only ([Fig. 2]).
The patient presented again having developed epigastric pain 12 weeks after undergoing the 90Y-SIRT. An upper gastrointestinal endoscopy showed a large gastric ulcer at the antrum and a superficial ulcer in the duodenal bulb ([Fig. 3]). Biopsies revealed deep purple, round, acellular foreign bodies, compatible with 90Y resin microspheres ([Fig. 4]). Esomeprazole (40 mg twice daily) was started and produced a gradual clinical improvement.
Radioembolization-associated gastroduodenal ulceration results from nontargeted flow of microspheres through inter-related gastrointestinal tract blood vessels that may sometimes be obscured in liver angiograms despite a detailed pretreatment hepatic angiographic study. The literature reports gastrointestinal complications rates from SIRT of 3 % – 24 % , with complications resulting from direct radiation toxicity rather than ischemia .
A high degree of suspicion is required to make this diagnosis because there are no specific clinical or endoscopic features. Definitive diagnosis is made pathologically by visualization of the pathognomonic microspheres. Treatment with high-dose proton pump inhibitors is recommended, although a response rate under 50 % is to be expected  .
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