Endoscopy 2013; 45(S 02): E108-E109
DOI: 10.1055/s-0032-1326346
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Gastroduodenal ulceration following liver radioembolization with yttrium-90

N. Veloso
1  Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
,
C. Brandão
1  Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
,
B. Gonçalves
2  Department of Interventional Radiology, Portuguese Oncology Institute of Porto, Porto, Portugal
,
L. Costa
2  Department of Interventional Radiology, Portuguese Oncology Institute of Porto, Porto, Portugal
,
N. Coimbra
3  Department of Pathology, Portuguese Oncology Institute of Porto, Porto, Portugal
,
M. Jacome
3  Department of Pathology, Portuguese Oncology Institute of Porto, Porto, Portugal
,
L. Moreira Dias
1  Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
› Author Affiliations
Further Information

Corresponding author

N. Veloso, MD
Department of Gastroenterology
Hospital Espírito Santo
Évora
Portugal   
Fax: +351-266-740117   

Publication History

Publication Date:
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 [1]. 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]).

Zoom Image
Fig. 1 Pretreatment hepatic angiogram in a 54-year-old woman with unresectable bilobar liver metastases from a rectal adenocarcinoma showing normal arterial anatomy.
Zoom Image
Fig. 2 Single-photon emission computed tomography (SPECT) scan after selective internal radiation therapy with yttrium-90 (90Y-SIRT) showing radioactivity in the liver only with no evidence of extrahepatic shunting into the gastrointestinal tract or lung.

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.

Zoom Image
Fig. 3 Views during an upper gastrointestinal endoscopy performed 12 weeks after selective internal radiation therapy (SIRT) showing: a, b a large gastric ulcer with a clean base, regular borders and whitish exudate at the lesser curvature of the antrum and marked erythema in the prepyloric region; c appearance after biopsies were taken; d a superficial ulcer in the anterior wall of duodenal bulb.
Zoom Image
Zoom Image
Zoom Image
Zoom Image
Fig. 4 Histological appearance of the biopsy specimens stained by hematoxylin and eosin (H&E) showing extensively ulcerated antral gastric mucosa with granulation tissue and the presence of numerous 90Y resin microspheres in the lamina propria. Scattered residual gastric glands showing marked cytological atypia are also present.

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 % [2], with complications resulting from direct radiation toxicity rather than ischemia [3].

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 [2] [4].

Endoscopy_UCTN_Code_CCL_1AB_2AD_3AC


#

Competing interests: None


Corresponding author

N. Veloso, MD
Department of Gastroenterology
Hospital Espírito Santo
Évora
Portugal   
Fax: +351-266-740117   


Zoom Image
Fig. 1 Pretreatment hepatic angiogram in a 54-year-old woman with unresectable bilobar liver metastases from a rectal adenocarcinoma showing normal arterial anatomy.
Zoom Image
Fig. 2 Single-photon emission computed tomography (SPECT) scan after selective internal radiation therapy with yttrium-90 (90Y-SIRT) showing radioactivity in the liver only with no evidence of extrahepatic shunting into the gastrointestinal tract or lung.
Zoom Image
Fig. 3 Views during an upper gastrointestinal endoscopy performed 12 weeks after selective internal radiation therapy (SIRT) showing: a, b a large gastric ulcer with a clean base, regular borders and whitish exudate at the lesser curvature of the antrum and marked erythema in the prepyloric region; c appearance after biopsies were taken; d a superficial ulcer in the anterior wall of duodenal bulb.
Zoom Image
Zoom Image
Zoom Image
Zoom Image
Fig. 4 Histological appearance of the biopsy specimens stained by hematoxylin and eosin (H&E) showing extensively ulcerated antral gastric mucosa with granulation tissue and the presence of numerous 90Y resin microspheres in the lamina propria. Scattered residual gastric glands showing marked cytological atypia are also present.