title: Gastric radiation enteritis after intra-arterial yttrium-90 microsphere therapy for early stage hepatocellular carcinoma.
abstract: OBJECTIVE
  As clinicians who treat hepatocellular carcinoma move yttrium-90 intra-arterial radiotherapy from the palliative setting to the treatment of patients with potentially curable early stage disease, more intense scrutiny of the safety of that procedure is warranted. To demonstrate the potential risks associated with this treatment, in the following case report, we describe a patient with early stage hepatocellular carcinoma who experienced severe toxicity from intra-arterial radiotherapy.
  
  
  METHODS
  Screening studies in a 64-year-old Asian woman with a history of hepatitis C virus infection and cirrhosis identified a 3.5-cm well-differentiated hepatocellular carcinoma with no vascular invasion. After initial evaluation, the patient received treatment with intra-arterial radiotherapy. Four weeks after the conclusion of that therapy, she experienced nausea, vomiting, and weight loss. Upper endoscopy with biopsy identified antral gastritis and embolic microspheres in the submucosal layer of the gastric antrum.
  
  
  RESULTS
  When she was subsequently referred for a liver transplant evaluation, her symptoms included failure to thrive and persistent weight loss. She was initially treated with feeding via a jejunostomy tube and ultimately received a liver transplant. However, 8 months after transplant she required an urgent gastrojejunostomy to bypass a progressive pyloric outlet obstruction. At the time of this writing, 1 year has elapsed since this patient received a liver transplant. No evidence of malignancy has been identified, but she remains partially dependent on tube feedings.
  
  
  CONCLUSIONS
  This case highlights the potential risks associated with radioactive microsphere embolization in patients with hepatocellular carcinoma. Given the paucity of data regarding the efficacy of this therapy in treating early stage disease, the use of radioactive microsphere therapy in that patient population should be prospectively studied. To minimize the risk of complications, internationally approved consensus guidelines for the delivery of yttrium-90 should be followed.
authors.affiliation: Department of Surgery, Division of Transplantation, The Methodist Hospital, Houston, Texas 77030, USA. taaloia@tmhs.org
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Aloia
authors.forename: Omar
authors.initials: O
authors.lastname: Barakat
authors.forename: John
authors.initials: J
authors.lastname: Connelly
authors.forename: Nadine
authors.initials: N
authors.lastname: Haykal
authors.forename: David
authors.initials: D
authors.lastname: Michel
authors.forename: A Osama
authors.initials: AO
authors.lastname: Gaber
authors.forename: R Mark
authors.initials: RM
authors.lastname: Ghobrial
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery / Q000821:virology; D004750:Enteral Nutrition; D005260:Female; D015390:Gastric Bypass; D005756:Gastritis / Q000209:etiology* / Q000473:pathology / Q000601:surgery; D005773:Gastroscopy; D006526:Hepatitis C / Q000150:complications; D006801:Humans; D007269:Injections, Intra-Arterial; D007582:Jejunostomy; D008113:Liver Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery / Q000821:virology; D016031:Liver Transplantation; D008279:Magnetic Resonance Imaging; D008863:Microspheres; D008875:Middle Aged; D009367:Neoplasm Staging; D011832:Radiation Injuries / Q000209:etiology* / Q000473:pathology / Q000601:surgery; D019275:Radiopharmaceuticals / Q000008:administration & dosage / Q000009:adverse effects*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D015021:Yttrium Radioisotopes / Q000008:administration & dosage / Q000009:adverse effects*
chemical_list: D019275:Radiopharmaceuticals; D015021:Yttrium Radioisotopes