Gastroduodenal ulceration following liver radioembolization with yttrium-90.

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 1.7GBq 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 (40mg twice daily) was started and produced a gradual clinical improvement. Radioembolization-associated gastroduodenal ulceration results from nontargeted flow of microspheres through inter-relatFig.1 Pretreatment hepatic angiogram in a 54-year-old woman with unresectable bilobar liver metastases from a rectal adenocarcinoma showing normal arterial anatomy.