Radiation microsphere-induced GI ulcers after selective internal radiation therapy for hepatic tumors: an underrecognized clinical entity

Gastrointest Endosc. 2009 Sep;70(3):561-7. doi: 10.1016/j.gie.2009.03.015. Epub 2009 Jul 4.

Abstract

Background: Intra-arterial infusion of yttrium-90 (Y-90) microspheres is locoregional radiation therapy for unresectable hepatic neoplasms. Literature on GI complications of this novel therapy is sparse.

Objectives: Clinically and pictorially characterize selective internal radiation therapy (SIRT)-induced GI injury and review the published literature.

Design: Retrospective chart analysis.

Setting: Single-center tertiary referral community hospital.

Patients: One hundred three patients treated with SIRT for hepatic neoplasms between 2006 and 2008.

Interventions: SIRT for unresectable hepatic neoplasms followed by upper endoscopy with biopsy in symptomatic patients.

Outcome measures: GI ulcers after SIRT.

Results: Five patients with suspected GI injury after SIRT were identified. Significant postprocedural symptoms included nausea/vomiting, odynophagia, hematemesis, and melena. Radiation ulcers occurred mostly in the gastric antrum, pylorus, and duodenum. Biopsy specimens of ulcer margins in 4 patients showed pathognomonic radiation microspheres. Angiographic review of the fifth patient revealed a previously unrecognized arterial branch supplying the corresponding region of GI ulceration noted on endoscopy.

Limitations: Small retrospective study and follow-up limited by terminal disease states in most patients.

Conclusions: The reported incidence of GI complications after SIRT for hepatic neoplasia varies from 3% to 24% of patients. Incidence can be minimized by strict adherence to published SIRT protocols. Diagnosis requires a high degree of clinical suspicion along with endoscopy and biopsy of ulcer margins. Characteristic radiation microspheres in biopsy specimens are pathognomonic. Gastroenterologists and pathologists must be cognizant of this complication.

MeSH terms

  • Adult
  • Aged
  • Angiography
  • Dose-Response Relationship, Radiation
  • Duodenal Ulcer / diagnosis
  • Duodenal Ulcer / epidemiology
  • Duodenal Ulcer / etiology*
  • Duodenoscopy
  • Female
  • Gastrointestinal Diseases / epidemiology
  • Gastrointestinal Diseases / etiology
  • Gastrointestinal Diseases / pathology
  • Gastroscopy
  • Hepatic Artery
  • Humans
  • Immunohistochemistry
  • Incidence
  • Infusions, Intra-Arterial
  • Liver Neoplasms / pathology
  • Liver Neoplasms / radiotherapy*
  • Male
  • Microspheres
  • Middle Aged
  • Prognosis
  • Radiation Injuries / diagnosis*
  • Radiation Injuries / epidemiology*
  • Retrospective Studies
  • Risk Assessment
  • Salvage Therapy
  • Sampling Studies
  • Stomach Ulcer / diagnosis
  • Stomach Ulcer / epidemiology
  • Stomach Ulcer / etiology*
  • Terminally Ill
  • Tomography, Emission-Computed, Single-Photon
  • Treatment Outcome
  • Yttrium Radioisotopes / adverse effects*
  • Yttrium Radioisotopes / therapeutic use

Substances

  • Yttrium Radioisotopes