A Serious Complication of Selected Internal Radiation Therapy: Case Report and Literature Review

Abstract

The use of selective internal radiation therapy (SIRT) with SIR-Spheres (Sirtex, Sydney, Australia) is increasingly recognized as a potential therapeutic modality of primary and secondary malignant liver tumors. A number of treatment-related complications have been described despite technical expertise and detailed pretreatment investigations to assess suitability. We describe a case of gastric ulceration from nontargeted deposition of SIR-spheres in the gastric mucosa with life-threatening consequences. This case highlights the need for careful screening and appropriate patient selection, and the need to recognize ulceration from SIRT as a potential complication of treatment. The characteristic endoscopic, radiologic, and histopathologic findings are illustrated and recommendations are reviewed with regard to the current literature. The Oncologist 2010;15:830 -835 CASE REPORTSelective internal radiation therapy (SIRT) with yttrium-90 ( 90 Y)-emitting microspheres is increasingly recognized as an effective therapy of both primary and secondary hepatic malignancies [1][2][3][4][5]. Increasing reports have shown this to be a useful treatment for unresectable hepatic metastases from colorectal carcinoma [6], neuroendocrine tumors [7], and primary hepatocellular carcinoma [3,8,9]. A number of treatment-related complications have been described despite technical expertise and detailed pretreatment investigations to assess suitability. We describe a case of gastric ulceration from aberrant deposition of SIR-Spheres (Sirtex, Sydney, Australia) in the gastric mucosa with lifethreatening consequences.The patient, a 63-year-old male with metastatic colorectal cancer, received SIRT 17 weeks earlier at another institution for recurrent, inoperable hepatic metastatic disease. The original diagnosis of rectosigmoid adenocarinoma was made 3 years earlier following an episode of infective endocarditis with Streptococcus viridians.

Chronic gastric ulcer disease complicating selective internal radiation therapy (SIRT) in a patient with cholangiocellular carcinoma

“…Same as in other liver malignancies like hepatocellular carcinoma and liver metastasis alternative therapeutic techniques, namely radio frequency ablation, transarterial chemoembolization and SIRT are being implemented in the treatment regime [12]. The small Yttrium 90 particles with a diameter of 20-30 µm used in SIRT therapy are able to migrate into the microcirculation of the tumor and apply local radiation within 2.5 to 11 mm [4]. Inhibitory effects on tumor growth seem to be partially promising as in cholangiocellular carcinoma patients the median survival was shown to be nearly 34 months in a small American cohort of seventeen people undergoing this therapy [10].…”

“…Gastrointestinal adverse effects can occur, one of them being caused by dislocation of Yttrium microspheres into the circulation of other parts of the gastrointestinal tract causing abdominal pain, nausea, vomiting, anorexia and gastroduodenal ulceration [1,2,[4][5][6][7][8][9]15]. These gastric complications occur with an incidence of 4-27 % [9].…”

“…These gastric complications occur with an incidence of 4-27 % [9]. Although most of the reported side effects are in general mild allowing the use of SIRT also in older patients and patients with worse performance status, isolated cases of major bleeding with the need for gastrectomy are described in the literature [1,4,8,16]. Incidence of gastric ulceration in a cohort of patients with metastatic colorectal cancer was calculated very low with 0.003 % [1].…”

“…In at least some cases these ulcers caused by acute radiation damage and ischemia during the procedure healed within weeks under PPI therapy [2]. Most frequently, the ulcers related to SIRT are located in the antrum, the pyloric region or the duodenum [4,17] which is most likely linked to reasons of vascular supply and reallocation of Yttrium microspheres from other parts of the stomach wall. Although half-life time of Yttrium 90 is 64 hours with complete determination of radiation within 14 days after the procedure, ulcers may occur months after the intervention [9] as it is documented in our present case.…”

“…Acute gastrointestinal complications from gastritis to gastric ulceration, bleeding and perforation have been reported. The clinical spectrum and management is wide from total spontaneous healing to gastrectomy and death [2,[4][5][6][7][8][9]. We herein present the case of a patient with a more than two-year-long persistent, symptomatic ulceration of the gastric antrum with pyloric stenosis after a single SIRT for treatment of intrahepatic cholangiocellular carcinoma.…”