Caren van Roekel

42 Chapter 2 radioembolization. Symptoms consist of an increased spleen volume and possibly gastro-oesofageal varices. Bile duct necrosis and strictures are often asymptomatic and seen in about 2-4% of patients (79). Furthermore, radiation cholecystitis is occasionally reported. The incidence ranges from 0-7%. It is characterized by upper right quadrant abdominal pain, nausea, vomiting, malaise and occasional fever (81). The diagnosis is confirmed by the presence of a thickened, hyperenhanced gallbladder wall with pericholecystic fluid, intramural gas or hydrops, seen on ultrasound, CT or MRI. The mainstay of treatment is analgetic treatment. However in severe cases, a cholecystectomy can be considered (79). Prince et al. propose the following strategies for gallbladder protection during radioembolization: if possible, placing the microcatheter distal to the cystic artery, or adjustment of the catheter position to alter the direction of blood flow. It is advised not to apply temporarily or permanently occluding of the cystic artery, since this can lead to ischemic cholecystitis (81). In some patients, extrahepatic deposition is seen in the falciform ligament, due to a patent hepatic falciform artery (HFA). Theoretically, this could cause radiation dermatitis or abdominal pain. However, this is rarely seen and only a few cases have been described. In a review of 410 radioembolization treatments, Braat et al. have found only 16 cases of extrahepatic deposition in the falciform ligament. None of these patients experienced symptoms compatible with the extrahepatic deposition. These results show that there is no need for prophylactic measures or even exclusion from therapy of patients with a patent HFA (82). 5.5 Long-term hepatic changes Su et al. have investigated the long-term hepatotoxicity after radioembolization in patients with NENs. The median follow-up time was 3.5 years. Twenty-six of 54 evaluated patients developed cirrhosis-like morphology after a median time of 1.8 years, but only 5 of them exhibited clinical symptoms that were attributable to radioembolization. Splenic volume increased by 64.7% in patients treated with whole-liver radioembolization and by 21.9% in patients treated with unilobar radioembolization. Findings of portal hypertension, such as ascites and varices, also developed more frequently in patients who received