Background: Selective internal radiotherapy (SIRT) utilizing yttrium-90 microspheres has been shown to be as effective as regional treatment for primary and secondary hepatic malignancies. Although there has been an increase in the utilization of SIRT, little has been reported about the extent or frequency of gastrointestinal complications. We sought to determine the frequency of symptomatic GI tract ulceration as a complication of the procedure.
Methods: Between 2004 and 2007, 27 patients underwent SIRT for hepatic malignancies. All patients underwent a pre-procedural arteriogram to evaluate vascular anatomy and a macroaggregated albumin study to quantify extra-hepatic shunting. Charts were subsequently reviewed to determine the incidence and severity of GI ulceration. No patients were lost to follow-up.
Results: SIRT was completed in 27 patients for colorectal metastases (N=15), hepatocellular carcinoma (4), cholangiocarcinoma metastases (2), neuroendocrine metastases (2), unknown primary metastases (2), prostate metastases (1), and melanoma metastases (1). Three patients presented with gastrointestinal bleeding (two with concomitant abdominal pain) and underwent upper endoscopy 2, 3.5, and 5 months after SIRT. Angiograms prior to SIRT showed normal vascular anatomy in two while one patient who had undergone prior chemoembolization had evidence of sclerosed hepatic vasculature. None had undergone prophylactic gastroduodenal artery (GDA) embolization. Endoscopic findings included diffuse inflammation, small gastric ulcerations, and large gastric ulcers (>15mm) with surrounding inflammation. Microspheres were visible on endoscopic biopsy. In two patients, gastric ulcers were persistent at the time of repeat endoscopy 1-4 months later despite proton pump inhibitor therapy. One elderly patient who refused surgical intervention died from recurrent hemorrhage.
Conclusion: Gastrointestinal ulceration is a known yet rarely reported complication of Y90 microsphere embolization with potentially life-threatening consequences. Since vague upper abdominal discomfort is common after SIRT and often not thoroughly evaluated, the true incidence of occult ulceration is not known. Once diagnosed, refractory ulcers should be considered for aggressive surgical management.