Chronic gastric ulcer disease complicating selective internal radiation therapy (SIRT) in a patient with cholangiocellular carcinoma

Abstract

Selective internal radiation therapy (SIRT) is a therapeutic option for primary and metastatic liver tumors. Microspheres containing Yttrium 90, a beta-emitting radionuclide, are administered into the hepatic artery allowing selective internal radiation of a liver tumor. SIRT-related complications may appear due to migration of the radiation microspheres to organs distant from the tumor site. In order to prevent these complications, unintended non target embolization of Yttrium microspheres has to be avoided. However, data from external-beam radiation therapy (EBRT) suggests that the stomach/small bowel may actually be less radiosensitive than the liver. Gastric ulcers, a well-known SIRT-related complication, may therefore not only be caused by local radiation but also by unusual accumulation of microspheres in the submucosa and small vessel damage. We herein report a more than two- year-long persisting, highly symptomatic, non-neoplastic ulceration of the gastric antrum leading to pyloric stenosis caused by SIRT therapy with Yttrium 90 microspheres for the treatment of intrahepatic cholangiocellular carcinoma. The chronic courses of the ulcer disease together with the specific histological features highlight the pivotal role of radiation-induced small vessel damage in SIRT-induced adverse events.

Zusammenfasung

Die „Selective internal radiation therapy“ (SIRT) ist eine therapeutische Option für primäre und sekundäre Lebertumoren. Mikrosphären, die Yttrium 90, ein beta-emittierendes Radionuklid beinhalten, werden direkt in die Leberarterie appliziert, wodurch eine interne Bestrahlung des Malignoms möglich wird. SIRT-bedingte Komplikationen können auf Grund einer Dislokation der Mikrosphären in andere Organe auftreten. Um diesen Komplikationen vorzubeugen, muss eine unselektive Applikation dieser Yttrium-Mikrosphären verhindert werden, obwohl Daten der externen Strahlentherapie (EBRT) nahe legen, dass Magen und Dünndarm tatsächlich weniger strahlungssensitiv als die Leber sind. Ulcera ventriculi, eine bekannte SIRT-bedingte Komplikation, dürften daher nicht nur durch örtliche Radiatio verursacht werden, sondern auch durch Akkumulation von Mikrosphären in der Submucosa und durch Schäden an kleinen Gefäßen. Wir berichten über mehr als zwei Jahre lang persistierende, hochsymptomatische, nicht neoplastische Ulcera ventriculi mit Pylorusstenose, welche durch Yttrium 90-Mikrosphären zur Behandlung eines intrahepatischen cholangiozellulären Karzinoms verursacht wurden. Der chronische Verlauf der Ulkuskrankheit zusammen mit den spezifischen histologischen Merkmalen unterstreichen die zentrale Rolle strahleninduzierter Gefäßschäden bei SIRT.

Key words

selective internal radiation therapy - cholangiocellular carcinoma - Yttrium 90 microspheres - gastric ulceration

Schlüsselwörter

SIRT - cholangiozelluläres Karzinom - Yttrium 90 - Ulcuskrankheit

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