History of Present Illness• 67 year old woman with 4 year history of metastatic carcinoid tumor to the liver• Admitted with intractable nausea and epigastric abdominal pain• Treated with regional intra-arterial radioactive Yttrium-90 of the hepatic artery one month prior

Previous Medical and Surgical History2006: • Metastatic on presentation to liver and colon• Right hemicolectomy with ileocolonic anastomsis and mesenteric excision • Received exploratory laparotomy with radio-frequency ablation (RFA) of metastatic liver lesion and wedge resection of a second lesion• Treated with Sandostatin infusions

2008: • Repeat RFA to 3 additional hepatic lesions• Repeat treatment with Sandostatin infusions

2009:• Surgical excision of aggressive mesenteric lymph nodes

Physical Exam• Vital signs:Tmax 37.2 C, RR 16, BP 109/65, P 90• Abdomen: Soft, tenderness on deep epigastric palpation

Admission Labs• A Phos 230, Bilirubin 1.4, AST 43, ALT 53

BACKGROUND:

Not Your “Y”sual Gastritis:Gastrointestinal Complications of Selective Internal Radiation Therapy

Sameer Qazi, MD; Heather Figurelli, DO; Hymie Kavin, MD Department of Medicine, Advocate Lutheran General Hospital

Not Your “Y”sual Gastritis:Gastrointestinal Complications of Selective Internal Radiation Therapy

Sameer Qazi, MD; Heather Figurelli, DO; Hymie Kavin, MD Department of Medicine, Advocate Lutheran General Hospital

REFERENCES:1. Ogawa, F. Gastroduodenitis associated with Yttrium 90-

microsphere selective internal radiation. Arch Pathol Lab Med November 2008; 132: 1734-8.

2. Crowder, C. Selective Internal Radiation Therapy-induced Extrahepatic Injury. Am J Surg Pathol July 2009; 33(7): 963-975.

3. Konda, A. Radiation microshpere-induced GI ulcers after selective internal radiation therapy for hepatic tumors: an underrecognized clinical entity 2009; 70(3): 561-7.

Intra-arterial infusion of Yttrium-90 microspheres is becoming more frequently used for loco regional radiation of unresectable hepatic neoplasms

The microspheres used in selective internal radiation therapy (SIRT) provide 3X greater local radiation in the tumor tissue compared with standard selective external beam radiation (1).

The microspheres emit β-radiation as they decay in the tumor microvasculature for resultant tumor necrosis (1).

Compared to external beam radiation, there is reduced risk of radiation hepatitis, making it a favorable treatment option (2).

Prophylactic embolization of the gastroduodenal artery and right hepatic artery is recommended to prevent inadvertent gastric and duodenal microsphere deposition (3).

The incidence of gastrointestinal ulceration is < 5% if proper pre-treatment techniques are applied (3).

Complications occur in the setting of collateral vascular circulation, unrecognized arterial anatomic variant, and change of flow dynamics during infusion (2,3).

SIRT technique is being used more frequently and awareness of complications is important.

RESULTS:Hospital Course • EGD revealed ulcerated, necrotic mucosa of the antrum, pyloric channel, and duodenal bulb (Fig 1, 2) • Biopsy consistent with moderate acute inflammation, surface erosions, and several selective internal radiation microspheres (SIR-spheres) embedded in the lamina propria (Fig 3, 4)• Findings consistent with selective internal radiation therapy (SIRT) induced gastric injury

Fig 4: Yttrium-90 microspheres embedded in lamina propria

Fig 3: Surface erosions, inflammation (dashed) Embedded Yttrium-90 microspheres (solid)

Fig 1: Gastric antrum with ulceration and necrosis

Fig 2: Pyloric channel necrosis

FOLLOW-UP:The patient was successfully managed with omeprazole and sucralfate. She did not require surgical intervention.

DISCUSSION: