Gastroduodenal Ulceration and CMV Infection in a Patient Treated with Microsphere Radioembolization

Abstract

Purpose: Introduction: Radioembolization is an emerging tumoricidal modality that allows targeted delivery of radioactive microspheres. While the precision of this technique offers several advantages over traditional external beam radiation therapy, it still poses significant risks to non-target organs. In this report, we present a case of gastroduodenal ulceration and concomitant cytomegalovirus (CMV) infection in a patient treated with Yttrium-90 microsphere radioembolization. Case Presentation: A 66 year old man with a history of chronic hepatitis B infection and previously resected hepatocellular carcinoma, developed tumor recurrence one year prior, and was treated with Yttrium-90 microsphere radioembolization via the left hepatic artery. At the time of radioembolization, radioactivity was confirmed in the left lobe of the liver and signal was also noted in the duodenum and the head of the pancreas. The patient presented one month after radioembolization complaining of abdominal pain and 30 pound weight loss. An upper endoscopy was performed, revealing multiple erosions in the body of the stomach, a 3 cm, clean-based ulcer with pigmented spots involving most of the pylorus, and two smaller, clean-based ulcers in the duodenum. Biopsies from the ulcers revealed inflamed mucosa and submucosa with scattered synthetic microspherules and CMV inclusion bodies. The patient was treated with intravenous proton pump inhibitors and nutritional support. Symptoms resolved within one week and the patient was discharged, tolerating oral intake. Discussion: We present a case of concomitant radiation-induced gastroduodenal ulceration and CMV infection in a patient treated with intra-arterial Yttrium-90 microsphere radioembolization. Due to the interrelated arterial supply of the liver, pancreas, stomach, and duodenum, the potential delivery of radioactive microspheres to non-target organs, with subsequent injury, is a recognized phenomenon. Furthermore, radiation can lead to local immunosuppression and subsequent opportunistic infections. CMV is known to cause gastritis and ulceration in the setting of immunosuppression and may have contributed to the severity of disease in this patient. We hypothesize that the initial insult caused by ionizing radiation led to local inflammation and immunosuppression that, in turn, allowed latent CMV infection to reemerge and exacerbate the patient's condition. Conclusion: Patients undergoing radiation therapy commonly suffer damage to the alimentary tract. This case suggests that in patients with presumed radiation-induced gastrointestinal disease, infectious etiologies must be considered and ruled out in order to optimize treatment and outcome.