Gastroduodenitis Associated With Yttrium 90 Microsphere Selective Internal Radiation An Iatrogenic by ProQuest


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									              Gastroduodenitis Associated With
     Yttrium 90–Microsphere Selective Internal Radiation
                         An Iatrogenic Complication in Need of Recognition
     Fumihiro Ogawa, MD; Mari Mino-Kenudson, MD; Michio Shimizu, MD; Saverio Ligato, MD; Gregory Y. Lauwers, MD

● Context.—Selective internal radiation (SIR) therapy                  mucosal ulceration to epithelial changes were seen. Fibri-
(SIRT) with yttrium 90 microspheres is increasingly used               nopurulent exudate was admixed with granulation tissue
as an alternative therapeutic modality for patients with in-           and reactive stromal cells. Epithelial changes included ap-
operable liver tumors. During administration of micro-                 optosis and mucin depletion. Glandular cystic dilatation
spheres via the hepatic artery branches, some may on oc-               and epithelial flattening were also common as well as fo-
casion be misdirected and be caught in the capillary bed               veolar hyperplasia, suggestive of reparative changes in one
of the duodenal and/or stomach.                                        case. Capillary ectasia and prominent plump endothelial
   Objective.—To better characterize the histopathologic               cells were also present.
features of these complications.
                                                                          Conclusion.—The spectrum of the alterations is consis-
   Design.—We report herein our experience with 3 pa-
tients who received SIR and developed gastroduodenal                   tent with radiotherapy-induced changes. Given the recent
complications.                                                         approval by the US Food and Drug Administration for the
   Results.—SIR-microsphere–induced gastroduodenitis was               use of SIRT, it is anticipated that more patients will be
diagnosed from 10 days to 5 months after treatment. In all             treated with this modality. Pathologists should become
3 cases, purple particles measuring about 40 m in di-                  aware of the adverse effects associated with its use.
ameter were observed. An array of changes ranging from                    (Arch Pathol Lab Med. 2008;132:1734–1738)

C    olorectal cancer (CRC) is one of the most common sol-
      id tumors, accounting for about 10% of cancer deaths
in the Western world.1 Although surgical resection com-
                                                                       have been expected to improve survival for patients with
                                                                       frequently unresectable CRC liver metastases.2
                                                                          Within this therapeutic armamentarium, selective inter-
bined with adjuvant chemotherapy and radiotherapy is                   nal radiation therapy (SIRT) with biocompatible resin-
effective for many patients, metachronous metastases de-               based yttrium 90 (90Y)–labeled microspheres, adminis-
velop in up to 20% to 25% of patients with CRC, in ad-                 tered via hepatic artery branches, is a method used to se-
dition to the 10% to 25% who already have synchronous                  lectively deliver internal radiation therapy to inoperable
metastases at the time of diagnosis.2 Yet, for these patients,         colorectal liver metastases.4,5 To date, some early reports
surgical metastasectomy, whether associated with adju-                 indicate the potential benefits of this approach in selected
vant or neoadjuvant therapy, may produce longer-term                   patients.6 Selective internal radiation therapy, however, has
survival, if not cure.3                                                the potential to cause extrahepatic adverse effects if the
   In addition to traditional systemic chemotherapy, some              microspheres are incorrectly delivered to arteries supply-
novel modalities (eg, hepatic arterial infusion chemother-
                                                                       ing the stomach, duodenum, or pancreas, as well as other
apy, portal vein embolization, radiofrequency ablation,
                                                                       organs. To date, a few reports have shown that even small
cryotherapies, selective intra-artery radiation therapy)
                                                                       quantities of microspheres caught in the gastric and/or
                                                                       duodenal capillary bed may lead to ulceration, bleeding,
                                                                       and even perforation.4–8 Given the recent approval by the
                                                                       US Food and Drug Administration for the use of SIRT, it
  Accepted for publication July 15, 2008. 
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