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

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.