A Rare Case of Delayed Gastric Ulcerations Several Months After Y-90 Radioembolization for Hepatic Carcinoid Tumor

Abstract

Radioembolization using Yttrium-90 (Y-90) resin microspheres infused through the hepatic arteries is a common treatment modality for primary and secondary hepatic tumors. We present a case of delayed symptoms and endoscopic evidence of gastric ulcerations due to radioembolic microspheres months after Y-90 therapy. A 71 year old male presented with epigastric pain and intractable nausea with history of metastatic carcinoid tumor involving the liver. He underwent radioembolization of a unresectable liver lesion with two treatments of SIR-Spheres Yttrium-90 resin microspheres approximately 6 months previously. Endoscopic evaluation revealed several non-bleeding, cratered gastric ulcerations within the lesser curvature of the stomach and gastric antrum measuring up to 15 mm. MRI Abdomen with contrast showed stable liver lesions with no other changes and serum gastrin level was unremarkable. CD34 immunohistochemistry staining of gastric biopsies demonstrated focally ulcerated gastric mucosa, foveolar epithelial hyperplasia and decreased capillary networking. Additionally, H&E stain showed scattered basophilic globules within the gastric mucosa consistent with radioembolic Y-90 microspheres. Gastric ulceration is an uncommon, but well-described complication of locoregional treatment of hepatic tumors with radioembolization treatment such as Y-90. Typically, this occurs due to reflux of microspheres into the gastroduodenal artery from the hepatic artery at the time of non-target embolization. Damage to the mucosal and submucosal surfaces is thought to be caused by direct radiation exposure from microspheres as well as occlusion of the arterial supply to gastric tissues. Although there is no consensus on the most efficacious treatment strategy, endoscopic management of hemorrhage combined with institution of PPIs and avoidance of NSAIDs is generally enough to provide full recovery. In patients with a prior history of Y-90 treatment who present with endoscopic evidence of gastric ulcerations, non-target embolization resulting in arterial reflux of microspheres into the gastric mucosa should be considered as a possible etiology.2686_A Figure 1. Endoscopic image of large cratered ulcer2686_B Figure 2. CD34 stain, used in vascular-associated tissue, showing decrease capillary network with presence of Y-90 microspheres2686_C Figure 3. H&E, 10X stain showing foveolar and smooth muscle hyperplasia with Y-90 microspheres in gastric mucosa