Abstract
Background
Microsphere radioembolization is a method of delivering radiation therapy directly to tumors, thereby minimizing toxicity to adjacent structures. Despite the relatively high precision of this modality, numerous adverse effects have been recognized. One particularly untoward complication is the development of severe gastroduodenal ulceration.
Methods
In order to further characterize gastroduodenal ulceration associated with radioembolization, our institutional experience as well as the reported literature were reviewed.
Results
The current evidence suggests that radioembolization-associated gastroduodenal ulceration results from inadvertent delivery of microspheres to the microvasculature of the gastrointestinal tract, leading to direct radiation toxicity. The reported incidence of this entity ranges between 2.9% and 4.8%. Most patients with this complication present with abdominal pain, often associated with nausea, vomiting, and anorexia. Symptoms can arise from hours to months after radioembolization treatment; diagnosis is made by endoscopic biopsy and histopathologic evaluation of the ulcer specimen. Radiation-induced ulcers have proven to be extremely difficult to treat. Current therapy based on acid suppression has had limited success, and the evidence for the addition of antioxidants and anti-inflammatory agents is still sparse.
Conclusions
The increasing utilization of radioembolization will lead to adverse events including gastroduodenal ulceration. This entity must be considered in any patient treated with radioactive microspheres presenting with symptoms of dyspepsia. Accurate diagnosis and aggressive treatment are necessary to improve patient outcomes.
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References
Salem R, Thurston KG. Radioembolization with 90Yttrium microspheres: a state-of-the-art brachytherapy treatment for primary and secondary liver malignancies. Part 1: Technical and methodologic considerations. J Vasc Interv Radiol. 2006;17(8):1251–1278.
Salem R, Thurston KG. Radioembolization with 90yttrium microspheres: a state-of-the-art brachytherapy treatment for primary and secondary liver malignancies. Part 2: special topics. J Vasc Interv Radiol. 2006;17(9):1425–1439.
Gulec S, Fong Y. Yttrium 90 microsphere selective internal radiation treatment of hepatic colorectal metastases. Arch Surg. 2007;142(7):675–682.
Ibrahim S, Lewandowski R, Sato K, et al. Radioembolization for the treatment of unresectable hepatocellular carcinoma: A clinical review. World J Gastroenterol. 2008;21(11):1664–1669. 14.
Riaz A, Lewandowski R, Kulik L, et al. Complications following radioembolization with yttrium-90 microspheres: a comprehensive literature review. J Vasc Interv Radiol. 2009;20(9):1121–1130.
Schultz C, Campbell J, Bakalyar D, et al. Y-90 microsphere therapy: prevention of adverse events. Cancer Biother Radiopharm. 2009;24(4):427–433.
Ogawa F, Mino-Kenudson M, Shimizu M, et al. Gastroduodenitis associated with yttrium 90—microsphere selective internal radiation: an iatrogenic complication in need of recognition. Arch Pathol Lab Med. 2008;132(11):1734–1738.
Murthy R, Brown DB, Salem R, et al. Gastrointestinal complications associated with hepatic arterial Yttrium-90 microsphere therapy. J Vasc Interv Radiol. 2007;18(4):553–561.
Bilbao J, de Martino A, de Luis E, et al. Biocompatibility, inflammatory response, and recannalization characteristics of nonradioactive resin microspheres: histological findings. Cardiovasc Intervent Radiol. 2009;32(4):727–736.
Covey A, Maluccio M, Schubert J, et al. Particle embolization of recurrent hepatocellular carcinoma after hepatectomy. Cancer. 2006;106(10):2181–2189.
Brown K, Nevins A, Getrajdman G, et al. Particle embolization for hepatocellular carcinoma. J Vasc Interv Radiol. 1998;9(5):822–828.
Coia L, Myerson R, Tepper J. Late effects of radiation therapy on the gastrointestinal tract. Int J Radiation Oncology Biol Phys. 1995;31(5):1213–1236.
Nguyen N, Antoine J, Dutta S. Current concepts in radiation enteritis and implications for future clinical trials. Cancer. 2002;95(5):1151–1163.
Hauer-Jensen M, Wang J, Boerma M, et al. Radiation damage to the gastrointestinal tract: mechanisms, diagnosis and management. Curr Opin Support Palliat Care. 2007;1(1):23–29.
Sirtex Medical Website. www.sirtex.com. Accessed August 29, 2009
MDS Nordion Website. www.mds.nordion.com. Accessed August 29, 2009
Dancey J, Shepherd F, Paul K, et al. Treatment of nonresectable hepatocellular carcinoma with intrahepatic 90Y-microspheres. J Nucl Med. 2000;41(10):1673–1681.
Stubbs R, Cannan R, Mitchell A. Selective internal radiation therapy with 90yttrium microspheres for extensive colorectal liver metastases. J Gastrointest Surg. 2001;5(3):294–302.
Herba M, Thirlwell P. Radioembolization for hepatic metastases. Semin Oncol. 2002;29(2):152–159.
Geschwind J, Salem R, Carr B, et al. Yttrium-90 microspheres for the treatment of hepatocellular carcinoma. Gastroenterology. 2004;127(5 Suppl 1):S194–S205.
Lim L, Gibbs P, Yip D, et al. Prospective study of treatment with selective internal radiation therapy spheres in patients with unresectable primary or secondary hepatic malignancies. Intern Med J. 2005;35(4):222–227.
Lim L, Gibbs P, Yip D, et al. A prospective evaluation of treatment with Selective Internal Radiation Therapy (SIR-spheres) in patients with unresectable liver metastases from colorectal cancer previously treated with 5-FU based chemotherapy. BMC Cancer. 2005;15(5):132.
Pöpperl G, Helmberger T, Münzing W, et al. Selective internal radiation therapy with SIR-Spheres in patients with nonresectable liver tumors. Cancer Biother Radiopharm. 2005;20(2):200–208.
Kennedy A, Coldwell D, Nutting C, et al. Resin 90Y-microsphere brachytherapy for unresectable colorectal liver metastases: Modern USA experience. Int J Radiat Oncol Biol Phys. 2006;65(2):412–425.
Stubbs R, O’Brien I, Correia M. Selective internal radiation therapy with 90Y microspheres for colorectal liver metasteses: Single-centre experience with 100 patients. ANZ J Surg. 2006;76(8):696–703.
Carretero C, Munoz-Navas M, Betes M, et al. Gastroduodenal injury after radioembolization of hepatic tumors. Am J Gastroenterol. 2007;102(6):1216–1220.
Coldwell D, Kennedy A, Nutting C. Use of Yttrium-90 microspheres in the treatment of unresectable hepatic metastases from breast cancer. Int J Radiat Oncol Biol Phys. 2007;69(3):800–804.
Jakobs T, Hoffmann R, Pöpperl G, et al. Mid-term results in otherwise treatment refractory primary or secondary liver confined tumours treated with selective internal radiation therapy (SIRT) using 90Yttrium resin-microspheres. Eur Radiol. 2007;17(5):1320–1330.
Jiao L, Szyszkob T, Al-Nahhasb A, et al. Clinical and imaging experience with yttrium-90 microspheres in the management of unresectable liver tumours. Eur J Surg Oncol. 2007;33(5):597–602.
Sharma R, Van Hazel G, Morgan B, et al. Radioembolization of liver metastases from colorectal cancer using yttrium-90 microspheres with concomitant systemic oxaliplatin, fluorouracil, and leucovorin chemotherapy. J Clin Oncol. 2007;25(9):1099–1106.
Jakobs T, Hoffmann R, Dehm K. Hepatic yttrium-90 radioembolization of chemotherapy-refractory colorectal cancer liver metastases. J Vasc Interv Radiol. 2008;19(8):1187–1195.
King J, Quinn R, Glenn D, et al. Radioembolization with selective internal radiation microspheres for neuroendocrine liver metastases. Cancer. 2008;113(5):921–929.
Neff R, Abdel-Misih R, Khatri J, et al. The toxicity of liver directed yttrium-90 microspheres in primary and metastatic liver tumors. Cancer Invest. 2008;26(2):173–177.
Sato K, Lewandowski R, Mulcahy M, et al. Unresectable chemorefractory liver metastases: radioembolization with 90Y microspheres—safety, efficacy, and survival. Radiology. 2008;247(2):507–515.
South C, Meyer M, Meis G, et al. Yttrium-90 microsphere induced gastrointestinal tract ulceration. World J Surg Oncol. 2008;6:93.
Stuart J, Tan B, Myerson R, et al. Salvage radioembolization of liver-dominant metastases with a resin-based microsphere: initial outcomes. J Vasc Interv Radiol. 2008;19(10):1427–1433.
Kennedy A, McNeillie P, Dezarn W, et al. Treatment parameters and outcome in 680 treatments of internal radiation with resin 90y-microspheres for unresectable hepatic tumors. Int J Rad Onc Biol Phys. 2009;74(5):1494–1500.
Mulcahy M, Lewandowski R, Ibrahim S, et al. Radioembolization of colorectal hepatic metastases using yttrium-90 microspheres. Cancer. 2009;115(9):1849–1858.
Konda A, Savin M, Cappell M, et al. Radiation microsphere-induced GI ulcers after selective internal radiation therapy for hepatic tumors: an underrecognized clinical entity. Gastrointest Endosc. 2009;70(3):561–567.
Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Physician. 2007;76(7):1005–1012.
Gilbert D, Buckland M, Abi-Hanna D. Education and imaging. Gastrointestinal: upper gastrointestinal bleeding after radiation microspheres. J Gastroenterol Hepatol. 2009;24(2):324.
Mallach S, Ramp U, Erhardt A, et al. An uncommon cause of gastro-duodenal ulceration. World J Gastroenterol. 2008;14(16):2593–2595.
Newland L, Walsh A, Gilbert D, Buckland M. Selective internal radiation therapy: a case of SIR-Sphere associated duodenal ulceration. Pathology. 2007;39(5):526–528.
South C, Meyer M, Meis G, et al. Yttrium-90 microsphere induced gastrointestinal tract ulceration. World J Surg Oncol. 2008;6(93)
Thamboo T, Wai C, Lim L, Wang S. Late gastric ulceration and cytomegalovirus infection following selective internal radiation therapy (SIRT) of the liver. Pathology. 2007;40(3):303–305.
Yarze J, Hoffman M. Another case of severe, chronically symptomatic, nonhealing gastroduodenal injury after radioembolization of hepatic tumor. Am J Gastroenterol. 2007;102(12):2863.
Yip D, Allen R, Ashton C, Jain S. Radiation-induced ulceration of the stomach secondary to hepatic embolization with radioactive yttrium microspheres in the treatment of metastatic colon cancer. J Gastroenterol Hepatol. 2004;19(3):347–349.
Zimmermann L, Dudeck O, Schmitt J, et al. Duodenal ulcer due to yttrium microspheres used for selective internal radiation therapy of hepatocellular cancer. Gastrointest Endosc. 2009;69(4):977–978.
Chan F, Leung W. Peptic ulcer disease. Lancet. 2002;360(9337):933–941.
Goodgame RW. Gastrointestinal cytomegalovirus disease. Ann Intern Med. 1993;119(9):924–935.
Saga K, Fukui T, Kato Y, et al. Localized cytomegalovirus reactivation after radiotherapy for high-grade gastric lymphoma. Gastrointest Endosc. 2007;65(3):545–547.
Ohnuma H, Sato Y, Takayama T, et al. Esophageal cancer complicated by cytomegalovirus esophagitis during chemoradiotherapy: case report. Gastrointest Endosc. 2003;57(4):622–626.
Zimmerer T, Böcker U, Wenz F, Singer V. Medical prevention and treatment of acute and chronic radiation induced enteritis–is there any proven therapy? a short review. Z Gastroenterol. 2008;46(5):441–448.
Gottlöber P, Steinert M, Bähren W, et al. Interferon-gamma in 5 patients with cutaneous radiation syndrome after radiation therapy. Int J Radiat Oncol Biol Phys. 2001;50(1):159–166.
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Naymagon, S., Warner, R.R.P., Patel, K. et al. Gastroduodenal Ulceration Associated with Radioembolization for the Treatment of Hepatic Tumors: An Institutional Experience and Review of the Literature. Dig Dis Sci 55, 2450–2458 (2010). https://doi.org/10.1007/s10620-010-1156-y
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DOI: https://doi.org/10.1007/s10620-010-1156-y