Gastric Ulceration and Microsphere Seeding Occur after Intra-Hepatic Yttrium-90 Microsphere Therapy Despite Prophylactic Embolization of the Gastroduodenal Artery

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Purpose: The purpose of this report is to present two consecutive cases of large gastric ulceration occurring after yttrium-90 microsphere infusion for hepatic tumors despite radiographically confirmed ablation of the gastroduodenal artery. Methods: The medical records of two consecutive patients presenting with gastric ulceration after intrahepatic yttrium-90 microsphere therapy were reviewed. Details on the clinical history, visceral angiography, the use of antisecretory medications before and after therapy, EGD, and pathology were reviewed. Results: Two patients having hepatic metastases presented to the interventional radiology department for yttrium-90 microsphere therapy. Each had preprocedural visceral angiography with ablation of the gastroduodenal artery to prevent extrahepatic seeding of microspheres. Success of ablation was confirmed with routine fluoroscopic imaging. Infusion of microspheres occurred without obvious complication via the hepatic artery by an experienced interventional radiologist. Approximately one week after therapy, each patient presented with post prandial abdominal pain, nausea, and vomiting with no hemetemesis. CT demonstrated thickening of gastric wall but no other lesions. In each patient EGD demonstrated a large gastric ulcer along the lesser curvature. Ulcers were greater than 2cm and were associated with otherwise normal appearing mucosa in the rest of the stomach. Biopsies revealed ulcerated lamina propria and foreign body microspheres within the specimens. One patient was on omeprazole prior to the procedure. Both required hospitalization for parenteral nutrition and bowel rest after the ulcers were diagnosed. Conclusions: Prophylactic embolization of the gastroduodenal artery prior to intrahepatic yttrium-90 therapy for liver malignancies does not adequately protect against aberrant seeding of gastric mucosa by yttrium microspheres. Severe, symptomatic gastric ulceration requiring hospital admission and parenteral nutrition was a result in both patients. In patients presenting with abdominal pain, nausea, and vomiting after this treatment, it is important to consider gastric ulceration related to aberrant microspheres.