Interventions for Adrenal Malignancy

Interventional radiologists who are interested in performing adrenal ablations would benefit from reviewing the literature and including both an endocrinologist and anesthesiologist on the treatment team, according to a presentation by Debra Gervais, MD, at the Symposium on Clinical Interventional Oncology.

Dr. Gervais began the presentation by reviewing the history of adrenal ablation. “Most of what we think about is percutaneous ablation of the metastatic lesion. But ablation has been around much longer than I realized, and one of the earliest case reports came not from the radiology literature but from the endocrine literature.” She explained that this case report involved normal, noncancerous, hypertrophied adrenal glands in the setting of atopic ACTH production that were ablated in patients who had metastatic disease and symptoms that could not be otherwise controlled.

There were few papers published on adrenal metastases and adrenal ablation in the 1980s, and there was a spike in the amount of literature on adrenal metastases and adrenal ablation starting around 2000, with the work of Bradford Wood, MD. In the 1970s, there were only a few papers, said Dr. Gervais, but they were reported by endocrinologists who worked with radiologists.

Another group used microwave ablation.2 “I only emphasize this not because it’s common but because you can think about this as an option,” said Dr. Gervais.

Dr. Gervais then directed the audience’s attention to adrenal metastases, explaining that the literature contains papers with both endocrine (benign adenomas) or metastases with multiple primaries. There are some papers with focused disease, but with small cohorts. She noted that most papers have few patients and lesions and are not prospective.

Next, Dr. Gervais focused on a paper that she had coauthored.3 “Please be aware of catecholamine surges,” she said, adding that ventricular tachychardia, new-onset atrial fibrillation, and blood pressure surges had occurred before she realized an anesthesiologist was needed.

Finally, she shared information on Takotsubo syndrome, which is thought to be due to local catecholamine effects on the heart. The syndrome is usually seen in young women and resolves over weeks.4 “Please have respect for [Takotsubo syndrome] as the Mayo group has taught us. They have every patient seen by an endocrinologist with alpha blockade if necessary.” Additionally, they have a bag of nitroprusside ready if needed, she added.

To conclude, Dr. Gervais invited everyone interested in performing adrenal ablations to read the literature and to include an endrocrinologist and anesthesiologist on the team in order to take proper precautions.

—Lauren LeBano

References

1. Eddy RL, McMurry JF Jr, Best EB, Henderson BW, Smith VT. Adrenal ablation by venous catheter. Ann Intern Med. 1973;79(2):273-274.

2. Sarma A, Shyn PB, Vivian MA, et al. Single-session CT-guided percutaneous microwave ablation of bilateral adrenal gland hyperplasia due to ectopic ACTH syndrome. Cardiovasc Intervent Radiol. 2015;38:1335-1338.

3. Fintelmann FJ, Tuncali K, Puchner S, et al. Catecholamine surge during image-guided ablation of adrenal gland metastases: predictors, consequences, and recommendations for management. J Vasc Interv Radiol. 2016;27:395-402.

4. Tsoumakidou G, Buy X, Zickler P, Zupan M, Douchet MP, Gangi A. Life-threatening complication during percutaneous ablation of adrenal gland metastasis: Takotsubo syndrome. Cardiovasc Intervent Radiol. 2010;33:646-649.