Yttrium-90 Radioembolization-Induced Liver Disease, a Rare Complication Requiring Further Investigation for Therapy

Abstract

Introduction: Radioembolization (RE) of hepatocellular carcinoma (HCC) utilizes Yttrium-90 (90-Y) tagged microspheres and is used for unresectable HCC or if there is portal vein thrombosis. Rarely, a life threatening complication called radioembolization-induced liver injury (REILD) presents with hyperbilirubinemia, worsening ascites, and coagulopathy 1 to 2 months following RE. There is limited evidence for treatment and requires further investigation. Case presentation: A 66-year-old Hispanic male with a history of hepatitis C cirrhosis and multifocal HCC with invasion of the portal vein presented with worsening jaundice, lower extremity edema, abdominal distension, and difficulty urinating for 2 weeks. 4 weeks prior, he received a second dose of 90-Y RE. On exam, scleral icterus and diffuse jaundice was noted. Abdomen was distended with a large amount of ascites appreciated. Remarkable lab values were Cr 3.4mg/dl, albumin 2.2gm/dl, AST 114U/L, ALT 27U/L, alkaline phosphatase 125U/L, INR 1.8, and PT 18.9 sec. Total bilirubin and direct bilirubin peaked at 8.0 and 4.7mg/dl, respectively. MELD score was 34 and CTP of 12 on admission. 1 month prior, MELD score was 6 and Child-Pugh A. 5.1 L of ascitic fluid removed was consistent with cirrhosis with 0 PMNs. For concern of hepatorenal syndrome, albumin then midodrine and octreotide were started. REILD due to 90-Y therapy was suspected in the absence of inciting factors. 8mg of methylprednisolone daily and ursodiol was started for 4 weeks. At 4-week follow up, ascites resolved and symptoms improved with Cr 0.99mg/dl and total bilirubin 4.4mg/dl. Discussion: REILD has been observed in 2.2 to 22.7% of patients receiving RE and more common in those that had previous chemotherapy, multiple doses of RE, or cirrhosis. Pathologically, REILD is similar to veno-occlusive disease showing sinusoidal hepatic injury. To date, there are no guidelines on the treatment of REILD. One retrospective study found that 8mg of prednisone for one month with a 1 month taper and ursodiol for 2 months reduced the incidence of REILD. In our case, this prophylaxis regimen was used as a treatment for REILD and showed improvement of the patient's lab values and symptoms. With little known on management of REILD once diagnosed, it is possible that this suggested prophylaxis regimen can be utilized as a therapeutic measure. Further research needs to be conducted to assess if this regimen can effectively treat this severe complication.