A Woman with Black Beads in Her Stomach: Severe Gastric Ulceration Caused by Yttrium-90 Radioembolization

Abstract

Radioembolization (RE) is a selective internal radiation therapy (SIRT) delivering targeted, high-dose, intra-arterial radiation directly to the vascular supply of liver tumors. Complications can occur due to aberrant deposition or migration of radiation microspheres into nontarget locations, including normal hepatic parenchyma, lungs, pancreas, and upper gastrointestinal (UGI) tract. We report a case of gastric ulcers due to yttrium-90 (90Y) seed migration to the stomach to alert clinicians to this rare cause of gastric injury. A 57-year-old woman with stage IV breast cancer with liver and lung metastases presented to the hospital with 2 months of worsening nausea and vomiting. Two months prior, she had received SIRT with 90Y microspheres without complications. Upper GI endoscopy showed diffuse gastritis and extensive antral ulceration. Biopsies revealed black, spherical foreign bodies, consistent with 90Y microspheres, documenting radiation injury. Radiation-induced UGI ulceration is caused by direct radiation injury from beta-radiation. Delay in diagnosis may be due to the nonspecificity of symptoms and temporal delay of symptom onset from SIRT, which was 2 months in our patient. Also, complaints may be attributed erroneously to adjuvant chemotherapy or widespread metastatic disease. Clinicians must consider radiation-associated toxicity in any SIRT-treated patient developing abdominal symptoms.

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

“…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.…”

“…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].…”

“…Selective internal radiation therapy (SIRT), also known as transarterial radio-embolization, represents a minimal invasive radiological treatment option for primary and secondary hepatic malignancies [1,2]. This procedure was first studied in Australia and the U.S. in the 1990 s [3].…”

“…The method works via the application of microspheres containing a beta-emitting radionuclide, Yttrium 90, into the tumor vessels through the hepatic artery in order to apply internal radiation. The main adverse events of this method are related to the migration of radiation microspheres to nontargeted organs distant from the tumor such as the upper gastrointestinal tract, the lungs or the pancreas [2]. Acute gastrointestinal complications from gastritis to gastric ulceration, bleeding and perforation have been reported.…”

“…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.…”