(Radiology. 1999;213:612-615.)
© RSNA, 1999
Small Functional Adrenal Cortical Adenoma: Treatment with CT-guided Percutaneous Acetic Acid Injection-Report of Three Cases1
Huei-Lung Liang, MD,
Huay-Ban Pan, MD,
Ying-Huei Lee, MD, PhD,
Jer-Shyung Huang, MD,
Tony D. L. Wu, MD,
Cheng-Tsung Chang, MD,
Hsin-Lee Liang, MD,
Tsung-Lung Yang, MD and
Chien-Fang Yang, MD
1 From the Departments of Radiology (Huei-Lung L., H.B.P., J.S.H., T.L.Y., C.F.Y.), Surgery (Y.H.L., T.D.L.W.), and Medicine (C.T.C., Hsin-Lee L.), Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Rd, Kaohsiung, Taiwan 813, Republic of China, and National Yang-Ming University, Taipei, Taiwan. Received November 24, 1998; revision requested December 23; revision received January 25, 1999; accepted April 30. Address reprint requests to Huei-Lung L. (e-mail: hlliang@isca.vghks .gov.tw).
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Abstract
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Two patients with Conn syndrome and one patient with Cushing syndrome underwent computed tomography (CT)-guided tumor ablation with a total of 5–11 mL of 50% acetic acid injected into their adrenal nodule (1.3–3.3 cm in diameter). No major complications were encountered during or after the procedure. All patients were symptom free with normal laboratory test results for at least 1-year follow-up. CT images showed complete cystic change with tumor size regression. Our preliminary results suggest that percutaneous acetic acid injection is a safe and effective alternative for treatment of small functional adrenal cortical adenoma.
Index terms: Acetic acid • Adrenal gland, neoplasms, 86.31 • Interventional procedures, 86.1266
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Introduction
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Percutaneous ethanol injection has become a widely accepted therapy for small hepatocellular carcinoma with an effect equal to or better than that with surgical resection (1–3). Ultrasonography-guided percutaneous ethanol injection has also been proposed as an alternative therapy to surgery in the management of parathyroid adenoma and autonomously functioning thyroid nodules (4,5). Ohnishi et al (6,7) reported that acetic acid had a stronger cytotoxic effect than did pure ethanol in both animal studies and treatment of hepatocellular carcinoma clinically. On the basis of the therapeutic effect of acetic acid, wider clinical application may be anticipated. The aim of this study was to evaluate the feasibility of one-time percutaneous acetic acid injection in the treatment of small functional adrenal cortical adenoma.
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Materials and Methods
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Patients
From July 1997 through November 1997, three patients (two women, one man; mean age, 46 years; age range, 40–56 years) underwent computed tomography (CT)-guided percutaneous acetic acid injection for the treatment of their small functional adrenal cortical adenoma. The clinical diagnosis in two patients was Conn syndrome and in one patient was Cushing syndrome. The diagnosis of Cushing syndrome was confirmed by means of nonsuppression in the large-dose dexamethasone test. The clinical characteristics, blood pressure, and results of biochemical studies, including serum levels of potassium, aldosterone, renin activity, and morning cortisol, are listed in the Table.
In the two patients with Conn syndrome, CT images showed a nodule, 2.2 and 1.3 cm in anteroposterior diameter, respectively, in the right adrenal gland; in the patient with Cushing syndrome, a 3.3-cm-diameter nodule was depicted in the left adrenal gland (Fig 1). One of the patients with Conn syndrome also had Bechet syndrome for more than 20 years. He was not considered a good surgical candidate. The other two patients refused conventional surgical resection. The institutional research committee approved our study for patients in either of those two categories. With detailed explanation and full understanding of the advantages and risks of this therapy, written informed consent was obtained from each patient and family member(s). To avert hypokalemia, which might occur during or after the procedure owing to excessive release of aldosterone, a supplement of potassium chloride was given if the serum potassium level was less than 3 mmol/L before treatment.
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Figure 1. A-C, CT scans before treatment in the three cases. A, Patient 1, Conn syndrome. CT scan depicts a 2.2 x 1.7-cm nodule (arrow) in the right adrenal gland. B, Patient 2, Conn syndrome. CT scan depicts a 1.3 x 1.3-cm nodule (arrow) in the right adrenal gland. C, Patient 3, Cushing syndrome. CT scan depicts a 3.3 x 3.0-cm nodule (arrow) in the left adrenal gland.
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Procedure
The coagulation profile of each patient was checked, and they were instructed to fast for 6 hours. Meperidine hydrochloride (40 mg) was injected intramuscularly 30 minutes before treatment. Each patient was prone, and local anesthetic of 1% lidocaine was injected at the site of skin puncture. With CT guidance, a 10-cm-long guiding needle (19 gauge) was inserted into the posterior paraspinal muscle. Another thin (22-gauge) multiple-side-hole needle (Cliny, Yokohama, Japan) was advanced coaxially into the center of the lesion. To avoid a needle path through the posterior pleura, the CT gantry was angled for guidance in one patient. The needle was connected to a 1-mL tuberculin syringe, which was filled with 50% acetic acid via an extension tube.
Acetic acid was injected slowly into the three adrenal nodules for a total of 5, 5, and 11 mL (Fig 2). The injected volume was determined on the basis of two factors. (a) The potency of 50% acetic acid is presumed to be three times that of absolute alcohol (7). (b) The formula for the injected volume in the treatment of a malignancy is V = 4/3 
(R + 0.5)3, where V is volume and R is radius of the tumor. Less volume may be used in the treatment of a benign nodule because there seems to be no requirement for a 0.5-cm safe margin. We injected at least 3–5 mL acetic acid into lesions because the small dose was well tolerated and small foci of the lesion were protected from agent diffusion as a result of needle tip insertion that might not be exactly at the center of the lesion.
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Figure 2. A-C, Images depict CT-guided percutaneous acetic acid injection in adrenal tumors with the patient prone. A thin needle was inserted coaxially into the nodule. Because there is no end hole in this thin needle, the needle tip was inserted to the anterior surface of the lesion. The lesion in A appears smaller than the lesion in Figure 1, A because the needle tip was slightly off center in the lesion.
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During the whole procedure, the electrocardiogram, blood pressure, and peripheral blood oxygen saturation level were carefully monitored. Vital signs were also closely observed for another 4 hours after the patients were sent back to their ward. To evaluate the efficacy of treatment, follow-up biochemical studies were performed every 2–4 months, and follow-up CT was performed every 6 months in each patient.
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Results
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The whole procedure lasted 30–50 minutes. All the patients tolerated the procedure well. Transient elevation in blood pressure (
20–30 mm Hg) was noted during and shortly after the procedure, and it was easily controlled with oral nifedipine. Mild to moderate flank tenderness was experienced during and after the percutaneous acetic acid injection, and two of the patients needed one injection of meperidine hydrochloride (40 mg) for pain relief. The tenderness may be related to reflux of a small amount of acetic acid along the needle track, tumor necrosis, or both.
The two patients with Conn syndrome were discharged in stable condition 2 days after the procedure. The patient with Cushing syndrome developed symptoms of adrenal insufficiency 24 hours after percutaneous acetic acid injection that were similar to those seen after surgical resection. A supplemental double dose of cortisone acetate (50 mg daily) was prescribed for her for 4 days. She was discharged on the 4th day after percutaneous acetic acid injection with a supplemental physiologic dose (25 mg daily) of cortisol.
All the patients were symptom free at 1
-year follow-up and as of May 1999. Follow-up CT images obtained at 6 and 12 months showed complete cystic change with regression of tumor size (Fig 3). No renal parenchymal damage was noted on the follow-up CT images or in the laboratory study results (Table).
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Figure 3. A-C, Follow-up CT images show cystic change in each nodule (arrow) 12 months after percutaneous acetic acid injection. Mild fibrotic change in the perirenal fat space (arrowhead in B and C) is a result of reflux of acetic acid during injection.
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Discussion
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Primary hyperaldosteronism accounts for less than 1% of disease in the hypertensive population. Unilateral benign adrenal tumor is the most common cause of low renin aldosteronism, which occurs in 80%–90% of patients. The remaining cases are caused by bilateral adrenal hyperplasia (8). Adrenocortical carcinoma that produces aldosterone is a rare disorder, occurring in 1%–2% of patients with aldosteronism. The tumors are almost always larger than 4 cm in diameter and are often very large (9). Cushing syndrome is caused by autonomic excessive secretion of cortisol by an adrenal adenoma or carcinoma. Carcinoma tumors that weigh less than 100 g (<5.5-cm diameter) are rare (8). The treatment of choice for patients with endocrine-producing adenoma is unilateral total adrenalectomy (10). Recently developed laparoscopic techniques have gained wide acceptance because of their ease and feasibility, with limited surgical problems. The disadvantages include a longer surgery time (135–269 minutes) and the risk of vascular or internal organ injuries (11–13).
Rossi et al (14) report a case of aldosterone-producing adenoma successfully treated with percutaneous local injection of pure ethanol. They injected 4 mL of pure ethanol into a 2-cm-diameter adrenal adenoma. The injected volume was far less than the standard volume (14 mL) used in the treatment of hepatocellular carcinoma, as calculated by means of the formula V = 4/3 (R + 0.5)3. With a benign functional adenoma, even partial ablation of the tumor may have noticeable clinical benefits.
Ohnishi et al (6) report the capacity to necrotize a hepatocyte with 50% acetic acid is more than three times that with absolute alcohol. They treated small hepatocellular carcinomas (
3-cm diameter) with small-volume, multiple injections. They stated that percutaneous acetic acid injection was superior to percutaneous ethanol injection in terms of both survival and local recurrence rates (7).
In our study, we selected patients with lesions less than 3.5 cm in diameter because smaller lesions (a) are rarely malignant and (b) can be treated completely with one-time percutaneous acetic acid injection. In rare instances in a small malignant adrenal lesion, alcohol injection with incomplete ablation or surgical resection by means of laparoscopic removal may result in tumor recurrence or dissemination.
Imaging-guided adrenal intervention is considered a safe procedure. The posterior approach involves the risk of pneumothorax from transgression of the posterior costophrenic sulcus (15,16). Hussain (17) reported a method for adrenal biopsy to reduce the risk of pneumothorax by using an angled CT gantry and angled insertion of a biopsy needle with the patient prone. In our study, we used a posterior approach, combined if necessary with an angled CT gantry, to avoid major visceral organ transgression. No pneumothorax or hemorrhage was encountered in any of our patients, but transient elevation of blood pressure was noted during and shortly after the procedure. The temporary hypertension did not cause a crisis and could be easily controlled with oral nifedipine. This reaction is most likely related to a transient release of aldosterone and cortisol into the blood circulation that is induced by cytolysis of a functioning adenoma, stress stimulation, or both.
In our limited experience, CT-guided percutaneous acetic acid injection has been a safe, effective, and minimally invasive therapy for the treatment of small functional adrenal cortical adenoma. It can be a good alternative treatment in patients with high surgical risk. However, the application of this technique to replace surgical adrenalectomy in all patients with small functional adenoma requires further investigations in larger numbers of patients.
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Footnotes
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Author contributions: Guarantor of integrity of entire study, Huei-Lung L.; study concepts and design, Huei-Lung L.; definition of intellectual content, Huei-Lung L.; literature research, Huei-Lung L., H.B.P., T.L.Y., Hsin-Lee L.; clinical studies, Huei-Lung L., Y.H.L., T.D.L.W., C.T.C.; data acquisition and analysis, Huei-Lung L., J.S.H.; manuscript preparation, Huei-Lung L.; manuscript editing, Huei-Lung L., C.F.Y.; manuscript review, Huei-Lung L., H.B.P., Y.H.L.
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References
|
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-
Shina S, Tagawa K, Niwa Y, et al. Percutaneous ethanol injection therapy for hepatocellular carcinoma: results in 146 patients. AJR 1993; 160:1023-1028.[Abstract/Free Full Text]
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Livraghi T, Giorgio A, Marin G, et al. Hepatocellular carcinoma and cirrhosis in 746 patients: long-term results of percutaneous ethanol injection. Radiology 1995; 197:101-108.[Abstract/Free Full Text]
-
Castells A, Bruix J, Bru C, et al. Treatment of small hepatocellular carcinoma in cirrhotic patients: a cohort study comparing surgical resection and percutaneous ethanol injection. Hepatology 1993; 18:1121-1126.[Medline]
-
Solbiati L, Giangrande A, De Pra L, Bellotti E, Cantu PP, Ravetto C. Percutaneous ethanol injection of parathyroid tumors under US guidance: treatment for secondary hyperparathyroidism. Radiology 1985; 155:607-610.[Abstract/Free Full Text]
-
Livraghi T, Paracchi A, Ferrari C, Reschini E, Macchi RM, Bonifacino A. Treatment of autonomous thyroid nodules by percutaneous ethanol injection: 4 years experience. Radiology 1994; 190:529-534.[Abstract/Free Full Text]
-
Ohnishi K, Ohyama N, Ito S, Fujiwara K. Small hepatocellular carcinoma: treatment with US-guided intratumoral injection of acetic acid. Radiology 1994; 193:747-752.[Abstract/Free Full Text]
-
Ohnishi K, Yoshioka HF, Ito S, Fujiwara K. Prospective randomized controlled trial comparing percutaneous acetic acid injection and percutaneous ethanol injection for small hepatocellular carcinoma. Hepatology 1998; 27:67-72.[Medline]
-
Wilson JD, Foster DW. Textbook of endocrinology 8th ed. Philadelphia, Pa: Saunders, 1992; 557-563.
-
Mazzaferri EL, Samaan NA. Endocrine tumors Boston, Mass: Blackwell, 1993; 409-411.
-
Young WF, Jr, Hogan MJ, Klee GG, Grant CS, van Heerden JA. Primary aldosteronism: diagnosis and treatment. Mayo Clin Proc 1990; 65:96-110.[Medline]
-
Ganger M, Lacroix A, Prinza RA, et al. Early experience with laparascopic approach for adrenalectomy. Surgery 1993; 114:1120-1125.[Medline]
-
Go H, Takeda M, Imai T, Komeyama T, Nishiyama T, Morishita H. Laparoscopic adrenalectomy for Cushing's syndrome: comparison with primary aldosteronism. Surgery 1995; 117:11-17.[Medline]
-
Chee C, Ravinthiran T, Cheng C. Laparoscopic adrenalectomy: experience with transabdominal and retroperitoneal approaches. Urology 1998; 51:29-32.[Medline]
-
Rossi R, Savastano S, Tommaselli AP, et al. Percutaneous computed tomography-guided ethanol injection in aldosterone-producing adrenocortical adenoma. Eur J Endocrinol 1995; 132:302-305.[Abstract/Free Full Text]
-
Welch TJ, Sheedy PF, II, Stephens DH, Johnson CM, Swensen SJ. Percutaneous adrenal biopsy: review of a 10-year experience. Radiology 1994; 193:341-344.[Abstract/Free Full Text]
-
Regge D, Balma E, Lasciarrea P, Martina C, Serrallonga M, Gandini G. Interventional radiology of the adrenal glands. Minerva Endocrinol 1995; 20:15-26.[Medline]
-
Hussain S. Gantry angulation in CT-guided percutaneous adrenal biopsy. AJR 1996; 166:537-539.[Abstract/Free Full Text]
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Abstract
Introduction
