Radiology
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Published online before print February 27, 2004, 10.1148/radiol.2311031007
This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
2311031007v1
231/1/225    most recent
Right arrow Submit a response
Right arrow View responses
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mayo-Smith, W. W.
Right arrow Articles by Dupuy, D. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mayo-Smith, W. W.
Right arrow Articles by Dupuy, D. E.
(Radiology 2004;231:225-230.)
© RSNA, 2004

Vascular and Interventional Radiology

Adrenal Neoplasms: CT-guided Radiofrequency Ablation—Preliminary Results1

William W. Mayo-Smith, MD and Damian E. Dupuy, MD

1 From the Department of Radiology, Rhode Island Hospital, Brown Medical School, 593 Eddy St, Providence, RI 02903. From the 2002 RSNA scientific assembly. Received June 27, 2003; revision requested August 26; revision received September 11; accepted October 20. Address correspondence to W.W.M.S. (e-mail: wmayo-smith@lifespan.org).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 ADDENDUM
 REFERENCES
 
PURPOSE: To evaluate initial experience with radiofrequency (RF) ablation of adrenal neoplasms.

MATERIALS AND METHODS: Thirteen adrenal masses in 12 patients (bilateral metastases in one patient) were treated with computed tomography (CT)-guided percutaneous RF ablation. Eleven adrenal lesions were metastases (five from lung cancer, four from renal cell carcinoma, and two from melanoma); one lesion was a pheochromocytoma and one was an aldosteronoma. There were 10 men and two women (average age, 58 years; range, 40–77 years) in the study; average adrenal mass diameter was 3.9 cm (range, 1–8 cm). Average number of RF applications per adrenal mass was 2.7 (range, 1–5 applications); average time per application was 7.8 minutes (range, 4–13 minutes). An internally cooled single electrode was used in five sessions; an internally cooled cluster electrode was used in eight sessions.

RESULTS: Average follow-up was 11.2 months (range, 1–46 months). Eleven of 13 lesions were treated successfully with RF ablation after one session. Successful treatment was defined as lack of enhancement of the treated region on follow-up CT images and resolution of the biochemical abnormality in two patients. In two patients with large adrenal lesions (4 and 8 cm in diameter), enhancement of residual tissue was observed after one treatment session; this finding was indicative of residual tumor. One patient with thrombocytopenia that resulted from chemotherapy had a small hematoma, but no transfusion was required. No patient developed hypertension during the RF application. No patient with metastases had recurrent tumor at the treated site, and this lack of recurrence indicated effective local control; 11 patients had progression of metastatic disease at extraadrenal sites.

CONCLUSION: Preliminary data suggest that CT-guided RF ablation is an effective technique for local control of adrenal neoplasms.

© RSNA, 2004

Index terms: Adrenal gland, CT, 86.12112 • Adrenal gland, neoplasms, 86.317, 86.32, 86.328, 86.33 • Computed tomography (CT), guidance • Pheochromocytoma, 86.328 • Radiofrequency (RF) ablation


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
 ADDENDUM
 REFERENCES
 
Primary neoplasms of the adrenal gland include adrenal cortical carcinomas, cortisol-producing adenomas, pheochromocytomas, and aldosteronomas. The traditional treatment for primary adrenal neoplasms has been open surgical resection and laparoscopic resection (1–7). The adrenal gland is also a common site of metastases (8–10). Surgical resection for isolated adrenal metastatic disease has been advocated by some authors, although this treatment remains controversial (11–13). Less invasive techniques to treat adrenal neoplasms have been described. These techniques include selective arterial embolization and injection of alcohol and acetic acid (14–19).

Radiofrequency (RF) ablation is a technique in which alternating RF current is used to generate heat and induce tissue necrosis. RF electrodes placed in the tumor cause local ion agitation and heat, and local tissue destruction occurs. RF ablation was used originally to treat cardiac conduction abnormalities and trigeminal neuralgia, but it has been used to treat neoplasms of the liver, bone, kidney, lung, and other organs (20–27). In addition, RF ablation has also been used to treat primary and metastatic adrenal cortical carcinoma in eight patients (28). The purpose of our study was to evaluate our initial experience with RF ablation of adrenal neoplasms.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 ADDENDUM
 REFERENCES
 
Patients
This retrospective study was approved by our institutional review board. Informed consent was obtained from all patients before the procedure. Informed consent for participation in this retrospective study was waived by the institutional review board. Separate informed consent for use of the RF device was not required by our institution, as it is a Food and Drug Administration–approved device that is accepted in clinical practice for treatment of focal malignancy. Patient confidentiality protocols were followed to ensure compliance with Health Insurance Portability and Accountability Act regulations (29). Twelve consecutive patients were referred to our institution from 1999 through 2003 for imaging-guided percutaneous RF ablation of a solid adrenal mass. All patients referred to our institution for this procedure were included in this study. One patient had isolated bilateral adrenal metastases. Referred patients were not surgical candidates because of comorbid conditions, disease at other sites, or refusal to undergo surgery. The average patient age was 58 years (range, 40–77 years). There were 10 men and two women.

Tumor Characteristics
Thirteen adrenal tumors were treated, and six were in the right adrenal gland and seven were in the left adrenal gland. The average diameter of the treated adrenal tumor was 3.9 cm (range, 1–8 cm). In 12 of 13 lesions, pathologic confirmation of the diagnosis was obtained with a computed tomography (CT)-guided biopsy performed at the time of the adrenal RF ablation; one patient had biochemical evidence to support the diagnosis of an aldosteronoma. The patient with the aldosteronoma had hypertension, a 1-cm-diameter mass in the left adrenal gland, and elevated aldosterone levels. These levels lateralized to the left adrenal gland at selective venous sampling, and the patient required oral potassium supplements before treatment. In one patient, results of biochemical evaluation were consistent with a pheochromocytoma, which was histologically confirmed at biopsy performed before the RF ablation. Eleven adrenal tumors were metastases (five from lung cancer, four from renal cell carcinoma, two from melanoma). Of the 11 adrenal metastases, six were isolated to the adrenal gland at the time of the RF treatment, and five were associated with limited localized disease elsewhere that had been successfully controlled with chemotherapy, radiation therapy, and/or surgical resection. In one patient with bilateral adrenal metastases, adrenal glucocorticoid and mineralocorticoid function was measured with cosyntropin (Cortrosyn; Organon, West Orange, NJ) stimulation tests and renin levels before RF treatment, after RF treatment of one adrenal gland, and after RF treatment of both adrenal glands.

Sedation
Twelve treatments were performed with intravenous conscious sedation. Thirty to 60 minutes before the procedure, the patients received 1.25 mg of droperidol (Taylor Pharmaceuticals, Decatur, Ill) administered intravenously for 1 minute; afterward, midazolam hydrochloride (Versed; Roche Pharmaceuticals, Nutley, NJ) and fentanyl citrate (Abbott Laboratories, Abbott Park, Ill) were administered with titration by dedicated nursing personnel to treat individual patient symptoms. Continuous monitoring of heart rate, electrocardiographic tracing, oxygen saturation, and respiratory rate was performed, and blood pressure was determined every 3–5 minutes according to the conscious sedation protocol of our hospital. The patient with the pheochromocytoma received the beta blocker atenolol (Tenormin; Astrazeneca Pharmaceuticals, Westborough, Mass) and the alpha blocker phenoxybenzamine (Wellspring Pharmaceutical, Oakville, Ontario, Canada) orally for 3 weeks before the procedure. This patient had extensive comorbid conditions (chronic obstructive pulmonary disease, sleep apnea, diabetes, cirrhosis, portal hypertension, esophageal varices, and a cardiac ejection fraction of 18%) and underwent the procedure with conscious sedation and administration of propofol (Astrazeneca Pharmaceuticals). A dedicated anesthesiologist with experience in surgical resection of pheochromocytomas administered the sedatives.

Imaging Guidance
CT (GE Medical Systems, Milwaukee, Wis) fluoroscopic guidance was performed for accurate localization of the tumor in RF ablation of all 13 tumors. The average time for CT fluoroscopy per procedure was 54 seconds (range, 17–94 seconds), and the average room time for performance of the procedure (defined as the time when the patient entered the room until the time when the room was cleaned and ready to receive the next patient) was 120 minutes (range, 80–190 minutes). In general, we preferred the posterior approach, with the patient in the ipsilateral decubitus position for treatment of small adrenal lesions. This position afforded ready access to the adrenal gland, and the dependent position compressed the ipsilateral lung, eliminating the need to traverse lung parenchyma. For larger lesions, we performed ablation with the patient in the prone position.

RF Ablation Technique
A session was defined as a visit to the radiology department when the mass was treated with RF ablation. An RF application referred to placement of an RF electrode into the lesion and application of RF energy. Thus, a patient could undergo more than one RF application in a single session. RF ablation was performed with an internally cooled RF system. The RF generator (Cosman coagulator-1; Radionics, Burlington, Mass) produces a maximum output of 200 W, and internal cooling of the electrode is performed with a peristaltic pump (Radionics) that recirculates ice water (80 mL/min) and keeps the electrode tip temperature below 20°C. When the cluster electrode was used, four grounding pads were placed on the patient’s thighs; when the single electrode was used, two grounding pads were used. Time of treatment was determined according to measurement of posttreatment intratumoral temperature.

All treatments were performed by one of two radiologists (W.W.M.S., D.E.D.), each of whom had more than 6 years of experience in the performance of RF ablation. Treatment parameters were as follows: The average tumor baseline impedance was 65 {Omega} (range, 58–80 {Omega}), power deposition was 143 W (range, 110–171 W), and current was 1.4 A (range 0.6–1.7 A). The average treatment time was 7.8 minutes (range, 4–13 minutes). Our treatment time started with 8 minutes (determined from our experience in the treatment of other extrahepatic tumors); after 8 minutes, we measured the temperature at the electrode tip. A temperature higher than 50°C was considered adequate to induce tissue necrosis, as described by Goldberg and colleagues (30). If a temperature higher than 50°C was not achieved, we continued treatment until this temperature was reached. Shorter applications were used when overlapping regions were treated. The average posttreatment maximum temperature was 79.2°C (range, 61°–95°C), and the average number of applications per session was 2.7 (range, 1–5 applications per session). A cluster electrode (three 2.5-cm-long active-tip electrodes) was used in eight sessions, and a single electrode (with a 2–3-cm-long active tip) was used in five sessions. A single electrode was originally used for treatment of small lesions, but we prefer the cluster electrode for all treatments because the area of tumor necrosis is greater, and the need for multiple applications per session is reduced.

Follow-up
Three patients were admitted for overnight observation and discharged to home the following day. The first two patients were admitted electively for observation, as we were not familiar with patient tolerance of adrenal RF ablation. The third patient, who had pheochromocytoma, had an episode of shortness of breath and responded to treatment with diuretics. The remainder of adrenal RF ablation procedures were performed on an outpatient basis, and patients were discharged after appropriate monitoring during recovery from conscious sedation. No patient received prophylactic antibiotics before or after the procedure.

After the ablation session, patients were followed up, and CT with contrast material (iohexol, Omnipaque 240; Amersham Health, Princeton, NJ) was used to assess necrosis of the tumor (lack of enhancement indicated complete treatment, and residual enhancement indicated residual disease), to determine if new adrenal enhancement had occurred (indication of recurrent disease), and to stage extraadrenal disease. Originally, CT was performed at 3- and then at 6-month intervals after the original session. Later, we performed dedicated adrenal contrast-enhanced CT after the RF treatment, with the patient still in the CT gantry, to determine the extent of tumor necrosis immediately after treatment. Abdominal and pelvic CT examinations were performed at 6-month intervals thereafter. Follow-up information was gathered by both authors to evaluate resolution of symptoms in the two patients with biochemically active tumors and to evaluate residual disease, recurrent disease, new metastatic disease, and patient outcome (whether alive or dead) in those with adrenal metastases. This information was obtained with review of follow-up CT scans, direct interview of patients, contact with the referring physician, examination of the patient’s medical record, and contact with the state tumor registry.

Statistical Analysis
Statistical comparison of adrenal tumor diameter in patients with and without residual adrenal tumor after RF ablation was performed by using the unpaired Student t test. Statistical analysis was performed with a software program (Statview, version 5.0.1; SAS Institute, Cary, NC). A difference with a P value of less than .05 was considered significant.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 ADDENDUM
 REFERENCES
 
Clinical Data
The results are summarized in the Table. The average follow-up interval for all patients was 11.2 months (range, 1–46 months). In 11 of 13 lesions, there was no residual enhancement in the treated tumor and no evidence of subsequent adrenal enlargement or recurrent biochemical activity, which were indicative of completely ablated tumor. In one patient with isolated bilateral adrenal metastases from renal cell carcinoma, each lesion was treated at a separate session; this patient’s case is illustrative of the biochemical sequelae of RF ablation treatment (Fig 1). The patient’s baseline adrenal function was assessed before treatment, after treatment of the left adrenal metastasis, and after treatment of the right adrenal metastasis, as described later. Cosyntropin stimulation test results and renin levels were normal before RF ablation and after treatment of one adrenal gland, and these findings were indicative of normal glucocorticoid and mineralocorticoid function. After RF ablation of the residual right adrenal tumor, the cosyntropin test results and renin levels were markedly abnormal, and these findings were consistent with complete ablation of all normal adrenal tissue. It is estimated that more than 90% of adrenal tissue must be destroyed for biochemical adrenal function to be compromised (31). In this patient, follow-up contrast-enhanced CT 19 months after the bilateral adrenal ablation procedures showed no residual enhancement of the adrenal glands (Fig 1c). This patient began receiving oral glucocorticoid and mineralocorticoid replacement therapy with prednisone (Roxane Laboratories, Columbus, Ohio) and fludrocortisone acetate (Monarch Pharmaceuticals, Bristol, Tenn) to maintain adrenal gland function.


View this table:
[in this window]
[in a new window]

  		Adrenal Tumor Characteristics and Follow-up Data after RF Ablation in 13 Lesions

 


View larger version (161K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1a. Isolated bilateral adrenal metastases from renal cell carcinoma in 60-year-old man. (a) Transverse CT fluoroscopic image obtained with patient in left decubitus position shows cluster electrode (arrow) in left adrenal mass. (b) Transverse contrast-enhanced CT image obtained with patient in supine position 1 month after RF treatment shows no enhancement of treated left adrenal metastasis (arrow) and enhancement of right adrenal metastasis (arrowhead). (c) Transverse contrast-enhanced CT image obtained with patient in supine position 20 months after RF ablation of left adrenal metastasis and 19 months after treatment of right adrenal metastasis shows stability in size of lesions and no enhancement of either gland (arrows). Enhancement of inferior vena cava (arrowhead), which lies anterior to right adrenal gland, is observed. Biochemical assays showed no residual adrenal function, and this finding was consistent with complete destruction of adrenal tissue.

 


View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1b. Isolated bilateral adrenal metastases from renal cell carcinoma in 60-year-old man. (a) Transverse CT fluoroscopic image obtained with patient in left decubitus position shows cluster electrode (arrow) in left adrenal mass. (b) Transverse contrast-enhanced CT image obtained with patient in supine position 1 month after RF treatment shows no enhancement of treated left adrenal metastasis (arrow) and enhancement of right adrenal metastasis (arrowhead). (c) Transverse contrast-enhanced CT image obtained with patient in supine position 20 months after RF ablation of left adrenal metastasis and 19 months after treatment of right adrenal metastasis shows stability in size of lesions and no enhancement of either gland (arrows). Enhancement of inferior vena cava (arrowhead), which lies anterior to right adrenal gland, is observed. Biochemical assays showed no residual adrenal function, and this finding was consistent with complete destruction of adrenal tissue.

 


View larger version (149K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1c. Isolated bilateral adrenal metastases from renal cell carcinoma in 60-year-old man. (a) Transverse CT fluoroscopic image obtained with patient in left decubitus position shows cluster electrode (arrow) in left adrenal mass. (b) Transverse contrast-enhanced CT image obtained with patient in supine position 1 month after RF treatment shows no enhancement of treated left adrenal metastasis (arrow) and enhancement of right adrenal metastasis (arrowhead). (c) Transverse contrast-enhanced CT image obtained with patient in supine position 20 months after RF ablation of left adrenal metastasis and 19 months after treatment of right adrenal metastasis shows stability in size of lesions and no enhancement of either gland (arrows). Enhancement of inferior vena cava (arrowhead), which lies anterior to right adrenal gland, is observed. Biochemical assays showed no residual adrenal function, and this finding was consistent with complete destruction of adrenal tissue.

 
The patient with a biopsy-proved pheochromocytoma became normotensive when all antihypertensive therapy was discontinued. No significant enhancement of the adrenal mass was observed at follow-up CT (Fig 2). The patient with the aldosteronoma had a normal serum aldosterone level after treatment, and administration of potassium supplements for hypokalemia was discontinued.



View larger version (153K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2a. Biopsy-proved right adrenal pheochromocytoma in 66-year-old man with obesity, chronic obstructive pulmonary disease, sleep apnea, diabetes, cirrhosis, portal hypertension, esophageal varices, cardiac ejection fraction of 18%, and hypertension. (a) Transverse CT image obtained with patient in right decubitus position before ablation shows small right adrenal mass (arrow). (b) Transverse CT fluoroscopic image obtained with patient in right decubitus position shows cluster electrode (arrow) in right adrenal mass. (c) Transverse contrast-enhanced CT image obtained with patient in supine position 1 month after RF ablation shows no enhancement of mass (arrow). Poor image quality is due to patient’s large body habitus. Patient’s blood pressure was normal when all antihypertensive medications were discontinued after treatment.

 


View larger version (154K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2b. Biopsy-proved right adrenal pheochromocytoma in 66-year-old man with obesity, chronic obstructive pulmonary disease, sleep apnea, diabetes, cirrhosis, portal hypertension, esophageal varices, cardiac ejection fraction of 18%, and hypertension. (a) Transverse CT image obtained with patient in right decubitus position before ablation shows small right adrenal mass (arrow). (b) Transverse CT fluoroscopic image obtained with patient in right decubitus position shows cluster electrode (arrow) in right adrenal mass. (c) Transverse contrast-enhanced CT image obtained with patient in supine position 1 month after RF ablation shows no enhancement of mass (arrow). Poor image quality is due to patient’s large body habitus. Patient’s blood pressure was normal when all antihypertensive medications were discontinued after treatment.

 


View larger version (143K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2c. Biopsy-proved right adrenal pheochromocytoma in 66-year-old man with obesity, chronic obstructive pulmonary disease, sleep apnea, diabetes, cirrhosis, portal hypertension, esophageal varices, cardiac ejection fraction of 18%, and hypertension. (a) Transverse CT image obtained with patient in right decubitus position before ablation shows small right adrenal mass (arrow). (b) Transverse CT fluoroscopic image obtained with patient in right decubitus position shows cluster electrode (arrow) in right adrenal mass. (c) Transverse contrast-enhanced CT image obtained with patient in supine position 1 month after RF ablation shows no enhancement of mass (arrow). Poor image quality is due to patient’s large body habitus. Patient’s blood pressure was normal when all antihypertensive medications were discontinued after treatment.

 
Two of 13 treated lesions demonstrated small areas of residual enhancement of the tumor after treatment, and this finding indicated residual disease. The average diameter of the two adrenal masses with residual tumor was 6.0 cm, compared with 3.6 cm for treated masses with no residual tumor, but this difference was not significant (P = .102). One of these two patients with residual disease had subsequent enlargement of the adrenal gland, a finding that was indicative of progression of residual disease (Fig 3).



View larger version (151K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 3a. Images obtained in 74-year-old man who had melanoma metastatic to the right adrenal gland and residual disease at follow-up. (a) Transverse CT fluoroscopic image obtained with patient in prone position during RF ablation shows cluster electrode (arrow) in large adrenal mass. (b) Transverse contrast-enhanced CT image obtained with patient in supine position 6 months after original RF ablation shows central necrosis with peripheral residual enhancement of tumor (arrow).

 


View larger version (118K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 3b. Images obtained in 74-year-old man who had melanoma metastatic to the right adrenal gland and residual disease at follow-up. (a) Transverse CT fluoroscopic image obtained with patient in prone position during RF ablation shows cluster electrode (arrow) in large adrenal mass. (b) Transverse contrast-enhanced CT image obtained with patient in supine position 6 months after original RF ablation shows central necrosis with peripheral residual enhancement of tumor (arrow).

 
Complications
All patients tolerated the procedure with no major complications. One patient who was receiving chemotherapy and had thrombocytopenia (platelet count, 66,000/µL [66 x 109/L]) had a small retroperitoneal hematoma after the procedure. This hematoma was stable at follow-up imaging, and the patient did not require transfusion. The patient with the pheochromocytoma had a transient episode of shortness of breath in the recovery room after the procedure; this episode resolved with diuresis, and he was discharged to home the following day. No patient developed hypertension during or after the procedure. Patients had minimal pain after the procedure, and the pain was generally treated with acetaminophen alone or a combination of acetominophen and hydrocodone bitartrate (Mallinckrodt Laboratories, Hazelwood, Mo).

Follow-up
No patient with complete treatment (defined as no enhancement of the treated adrenal tumor) subsequently developed enhancement or enlargement of the treated adrenal gland, and this finding is consistent with local control. Six of the ten patients with an extraadrenal primary tumor subsequently died of metastatic disease to other sites. The average time of death was 8 months after the adrenal tumor treatment (range, 3–16 months). The four remaining patients of the 10 with extraadrenal primary tumor had new metastatic disease in extraadrenal sites.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
ADDENDUM
 REFERENCES
 
CT-guided RF ablation shows promise as a minimally invasive therapy for the treatment of adrenal neoplasms. Our preliminary results show that there is minimal morbidity associated with this procedure. Follow-up imaging and biochemical assay results indicate that RF ablation can effectively destroy both native adrenal tissue and metastatic disease to the adrenal gland. Although we studied different neoplasms in the adrenal gland, our findings are similar to results described by Wood and colleagues (28) who treated primary and metastatic adrenal cortical carcinomas in eight patients. They found that RF ablation had minimal morbidity and was effective for local control of adrenal cortical carcinomas, particularly those smaller than 5 cm in diameter. Our results suggest that larger lesions may be associated with a higher incidence of residual tumor: This finding is not surprising, given that RF ablation is a local treatment and, with current electrodes, we can only treat a lesion with a diameter of 5 cm or smaller with each application.

Although our results indicate that RF ablation is effective for local control of disease, proper selection of patients who are candidates for this procedure will be critical in assessment of the overall role of adrenal RF ablation in patient care. In the 10 patients with extraadrenal primary tumors, progression of disease at extraadrenal sites was observed in all at follow-up. This progression of disease is important, because at the time of the adrenal RF ablation, these patients had either no other disease or controlled disease at several sites. If adrenal RF ablation is shown to be comparable with surgical resection, then selection of appropriate patients who should receive treatment will need to be investigated in future randomized trials. Our patient cohort was too small to allow assessment of whether there was increased survival associated with this procedure. Alternatively, RF ablation could play a more defined role in treatment of primary adrenal neoplasms. Results of our work and those of Wood and colleagues (28) indicate that RF treatment of the adrenal gland can be performed on an outpatient basis with minimal morbidity. If this technique proves to be effective with long-term follow-up, it could play a role in the treatment of biochemically active adrenal neoplasms such as aldosteronomas, pheochromocytomas, and cortisol-producing adenomas.

We found that CT is the preferred imaging modality for performance of adrenal RF ablation because both the adrenal mass and electrode location are reliably seen. Placement of the patient in the decubitus position with the lesion side dependent minimizes intervening pulmonary parenchyma. On the basis of our experience in this small cohort of patients, we recommend use of a cluster electrode rather than a single electrode for treatment of most adrenal tumors, as greater areas of tumor necrosis can be achieved with a single application. Fewer applications should therefore be needed per session. Our results suggest that treatment times of 8 minutes can reliably induce tumor necrosis. Our study was limited because of its retrospective design, the small sample size, and the varied types of tumors treated.

In summary, our preliminary results suggest that CT-guided percutaneous RF ablation is effective for local control of adrenal neoplasms. Long-term follow-up will need to be performed, and appropriate patient selection criteria will need to be determined in future randomized trials.


   ADDENDUM
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 ADDENDUM
REFERENCES
 
In a recent publication by Onik and colleagues (32), which was published while this article was in press, the authors reported hypertensive crises in two patients who underwent RF ablation of a liver metastasis adjacent to a normal right adrenal gland. In one of these patients, markedly elevated levels of serum catecholamines were recorded at the time of RF ablation, and they returned to normal after treatment. None of our patients had hypertensive events, and Wood et al (28) did not describe hypertension in patients treated in their series. Onik and colleagues (32) hypothesized that the catecholamine release in their patient may have been more prominent because the adrenal gland was normal, whereas the adrenal gland in the series of Wood et al (28) was replaced by tumor. This theory does not explain the data in one of our patients who underwent RF ablation in both adrenal glands and who did not have hypertension. The findings of Onik and colleagues are of concern, as a hypertensive crisis has high potential morbidity. As such, administration of alpha and beta blockers may be considered in patients who undergo RF ablation of adrenal lesions until more data about this procedure are obtained.


   FOOTNOTES
 
D.E.D. has received grant support from Radionics for clinical studies in the past.

Abbreviation: RF = radiofrequency

Author contributions: Guarantors of integrity of entire study, W.W.M.S., D.E.D.; study concepts and design, W.W.M.S., D.E.D.; literature research, W.W.M.S., D.E.D.; clinical studies, W.W.M.S., D.E.D.; data acquisition and analysis/interpretation, W.W.M.S., D.E.D.; statistical analysis, W.W.M.S.; manuscript preparation, definition of intellectual content, editing, revision/review, and final version approval, W.W.M.S., D.E.D.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 ADDENDUM
 REFERENCES
 

  1. Weigel RJ, Wells SA, Gunnells C, Leight GS. Surgical treatment of primary hyperaldosteronism. Ann Surg 1994; 219:347-352.[Medline]
  2. 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]
  3. Demeure MJ, Somberg LB. Functioning and nonfunctioning adrenocortical carcinoma: clinical presentation and therapeutic strategies. Surg Oncol Clin N Am 1998; 7:791-805.[Medline]
  4. Pommier RF, Brennan MF. An eleven-year experience with adrenocortical carcinoma. Surgery 1992; 112:963-971.[Medline]
  5. Sung GT, Gill IS. Laparoscopic adrenalectomy. Semin Laparosc Surg 2000; 7:211-222.[CrossRef][Medline]
  6. Chee C, Ravinthiran T, Cheng C. Laparoscopic adrenalectomy: experience with transabdominal and retroperitoneal approaches. Urology 1998; 51:29-32.[CrossRef][Medline]
  7. Raeburn CD, McIntyre RC, Jr. Laparoscopic approach to adrenal and endocrine pancreatic tumors. Surg Clin North Am 2000; 80:1427-1441.[CrossRef][Medline]
  8. Abrams HL, Spiro R, Goldstein N. Metastasis in carcinoma: analysis of 1000 autopsied cases. Cancer 1950; 3:74-85.[CrossRef][Medline]
  9. Bullock WK, Hirst AE, Jr. Metastatic carcinoma of the adrenal. Am J Med Sci 1953; 226:521-524.[CrossRef][Medline]
  10. Cedermark BJ, Blumenson LE, Pickren JW, Holyoke DE, Elias EG. The significance of metastases to the adrenal glands in adenocarcinoma of the colon and rectum. Surg Gynecol Obstet 1977; 144:537-546.[Medline]
  11. Paul CA, Virgo KS, Wade TP, Audisio RA, Johnson FE. Adrenalectomy for isolated adrenal metastases from non-adrenal cancer. Int J Oncol 2000; 17:181-187.[Medline]
  12. Lo CY, Van Heerden JA, Soreide JA, et al. Adrenalectomy for metastatic disease to the adrenal glands. Br J Surg 1996; 83:528-531.[Medline]
  13. Kim SH, Brennan MF, Russo P, Burt ME, Coit DG. The role of surgery in the treatment of clinically isolated adrenal metastasis. Cancer 1998; 82:389-394.[CrossRef][Medline]
  14. Hokotate H, Inoue H, Baba Y, Tsuchimochi S, Nakajo M. Aldosteronomas: experience with superselective adrenal arterial embolization in 33 cases. Radiology 2003; 227:401-406.[Abstract/Free Full Text]
  15. Inoue H, Nakajo M, Miyazono N, Nishida H, Ueno K, Hokotate H. Transcatheter arterial ablation of aldosteronomas with high-concentration ethanol: preliminary and long-term results. AJR Am J Roentgenol 1997; 168:1241-1245.[Abstract/Free Full Text]
  16. Miyazono N, Ueno K, Nakajo M, et al. Transcatheter arterial and adrenal embolization with iohexol-ethanol solutions: animal experimental study and clinical application. Invest Radiol 1996; 31:755-760.[CrossRef][Medline]
  17. Shibata T, Maetani Y, Ametani F, Itoh K, Konshi J. Percutaneous ethanol injection for treatment of adrenal metastasis from hepatocellular carcinoma. AJR Am J Roentgenol 2000; 174:333-335.[Abstract/Free Full Text]
  18. Maki DD, Haskal ZJ, Matthies A, et al. Percutaneous ethanol ablation of an adrenal tumor. AJR Am J Roentgenol 2000; 174:1031-1032.[Free Full Text]
  19. Liang HL, Pan HB, Lee YH, et al. Small functional adrenal cortical adenoma: treatment with CT-guided percutaneous acetic acid injection—report of three cases. Radiology 1999; 213:612-615.[Abstract/Free Full Text]
  20. Gazelle GS, Goldberg SN, Solbiati L, Livraghi T. Tumor ablation with radio-frequency energy. Radiology 2000; 217:633-646.[Abstract/Free Full Text]
  21. Goldberg SN, Dupuy DE. Image-guided radiofrequency tumor ablation: challenges and opportunities. I. J Vasc Interv Radiol 2001; 12:1021-1032.
  22. Dupuy DE, Goldberg SN. Image-guided radiofrequency tumor ablation: challenges and opportunities. II. J Vasc Interv Radiol 2001; 12:1135-1148.
  23. Wood BJ, Ramkaransingh JR, Fojo T, Walther MM, Libutti SK. Percutaneous tumor ablation with radiofrequency. Cancer 2002; 94:443-451.[CrossRef][Medline]
  24. Rosenthal DI, Hornicek FJ, Wolfe MW, Jennings LC, Gebhardt MC, Mankin HJ. Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. J Bone Joint Surg Am 1998; 80:815-821.[Abstract/Free Full Text]
  25. Gervais DA, McGovern FJ, Arellano RS, McDougal WS, Mueller PR. Renal cell carcinoma: clinical experience and technical success with radio-frequency ablation of 42 tumors. Radiology 2003; 226:417-424.[Abstract/Free Full Text]
  26. Mayo-Smith WW, Dupuy DE, Parikh PM, Pezzullo JA, Cronan JJ. Image guided percutaneous radiofrequency ablation of solid renal mass: techniques and results of 38 treatment sessions in 32 consecutive patients. AJR Am J Roentgenol 2003; 180:1503-1508.[Abstract/Free Full Text]
  27. Dupuy DE, Abbott GF, Mayo-Smith WW, DiPetrillo T. Clinical applications of radio-frequency ablation in the thorax. RadioGraphics 2002; 22:S259-S269.
  28. Wood BJ, Abraham J, Hvizda JL, Alexander HR, Fojo T. Radiofrequency ablation of adrenal tumors and adrenocortical carcinoma metastases. Cancer 2003; 97:554-560.[CrossRef][Medline]
  29. Health Insurance Portability and Accountability Act regulations. Centers for Medicare and Medicaid Services (CMS) website. Available at: www.cms.hhs.gov/hipaa/. Accessed June 24 2003.
  30. Goldberg SN, Gazelle GS, Dawson SL, Rittman WJ, Mueller PR, Rosenthal DI. Tissue ablation with radiofrequency: effect of probe size, gauge, duration and temperature on lesion volume. Acad Radiol 1995; 2:399-404.[CrossRef][Medline]
  31. Williams GH, Dluhy RG. Diseases of the adrenal cortex. In: Isselbacher KJ, Braunwaald EJ, Wildson JD, Martin JB, Fauci AS, Kasper DL, eds. Harrison’s principles of internal medicine. 13th ed. New York, NY: McGraw-Hill, 1994; 1953-1976.
  32. Onik G, Onik C, Medary I, et al. Life threatening hypertensive crises in two patients undergoing hepatic radiofrequency ablation. AJR Am J Roentgenol 2003; 181:495-497.[Free Full Text]



This article has been cited by other articles:


Home page
 Am. J. Roentgenol.Home page
Y.-Y. Xiao, J.-L. Tian, and J.-S. Zhang
Reply
Am. J. Roentgenol., August 1, 2008; 191(2): W75 - W75.
[Full Text] [PDF]

Home page
 Eur J EndocrinolHome page
I G C Hermsen, H Gelderblom, J Kievit, J A Romijn, and H R Haak
Extremely long survival in six patients despite recurrent and metastatic adrenal carcinoma.
Eur. J. Endocrinol., June 1, 2008; 158(6): 911 - 919.
[Abstract] [Full Text] [PDF]

Home page
 J Ultrasound MedHome page
S.-Y. Chiou, J.-B. Liu, and L. Needleman
Current Status of Sonographically Guided Radiofrequency Ablation Techniques
J. Ultrasound Med., April 1, 2007; 26(4): 487 - 499.
[Abstract] [Full Text] [PDF]

Home page
 JCOHome page
E. Liapi and J.-F. H. Geschwind
Transcatheter and Ablative Therapeutic Approaches for Solid Malignancies
J. Clin. Oncol., March 10, 2007; 25(8): 978 - 986.
[Abstract] [Full Text] [PDF]

Home page
 The OncologistHome page
I. C. Mitchell and F. E. Nwariaku
Adrenal Masses in the Cancer Patient: Surveillance or Excision
Oncologist, February 1, 2007; 12(2): 168 - 174.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Roentgenol.Home page
B. C. Lucey
Radiofrequency ablation: the future is now.
Am. J. Roentgenol., May 1, 2006; 186(5 Suppl): S237 - S240.
[Full Text] [PDF]

Home page
 Am. J. Roentgenol.Home page
J. L. Hinshaw, P. F. Laeseke, T. C. Winter III, M. A. Kliewer, J. P. Fine, and F. T. Lee Jr.
Radiofrequency ablation of peripheral liver tumors: intraperitoneal 5% dextrose in water decreases postprocedural pain.
Am. J. Roentgenol., May 1, 2006; 186(5 Suppl): S306 - S310.
[Abstract] [Full Text] [PDF]

Home page
 RadiologyHome page
J. R. Haaga, A. A. Exner, Y. Wang, N. T. Stowe, and P. J. Tarcha
Combined Tumor Therapy by Using Radiofrequency Ablation and 5-FU-Laden Polymer Implants: Evaluation in Rats and Rabbits
Radiology, December 1, 2005; 237(3): 911 - 918.
[Abstract] [Full Text] [PDF]

Home page
 RadiologyHome page
R. F. Munden, S. S. Swisher, C. W. Stevens, and D. J. Stewart
Imaging of the Patient with Non-Small Cell Lung Cancer
Radiology, December 1, 2005; 237(3): 803 - 818.
[Abstract] [Full Text] [PDF]

Home page
 RadiologyHome page
T. Hiraki, K. Yasui, H. Mimura, H. Gobara, T. Mukai, S. Hase, H. Fujiwara, N. Tajiri, Y. Naomoto, T. Yamatsuji, et al.
Radiofrequency Ablation of Metastatic Mediastinal Lymph Nodes during Cooling and Temperature Monitoring of the Tracheal Mucosa to Prevent Thermal Tracheal Damage: Initial Experience
Radiology, December 1, 2005; 237(3): 1068 - 1074.
[Abstract] [Full Text] [PDF]

Home page
 RadioGraphicsHome page
C. J. Simon, D. E. Dupuy, and W. W. Mayo-Smith
Microwave Ablation: Principles and Applications
RadioGraphics, October 1, 2005; 25(suppl_1): S69 - S83.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Roentgenol.Home page
J. D. Bojarski, D. E. Dupuy, and W. W. Mayo-Smith
CT Imaging Findings of Pulmonary Neoplasms After Treatment with Radiofrequency Ablation: Results in 32 Tumors
Am. J. Roentgenol., August 1, 2005; 185(2): 466 - 471.
[Abstract] [Full Text] [PDF]

Home page
 ChestHome page
J. Ricke, P. Wust, G. Wieners, S. Hengst, M. Pech, E. L. Hanninen, and R. Felix
CT-Guided Interstitial Single-Fraction Brachytherapy of Lung Tumors: Phase I Results of a Novel Technique
Chest, June 1, 2005; 127(6): 2237 - 2242.
[Abstract] [Full Text] [PDF]

Home page
 Anesth. Analg.Home page
E. N. Chini, M. J. Brown, M. A. Farrell, and J. W. Charboneau
Hypertensive Crisis in a Patient Undergoing Percutaneous Radiofrequency Ablation of an Adrenal Mass Under General Anesthesia
Anesth. Analg., December 1, 2004; 99(6): 1867 - 1869.
[Abstract] [Full Text] [PDF]

eLetters:

Read all eLetters

Hypertension during radiofrequency ablation of pheochromocytoma
Bradford J. Wood, MD
Radiology Online, 24 May 2004 [Full text]
This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
2311031007v1
231/1/225    most recent
Right arrow Submit a response
Right arrow View responses
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mayo-Smith, W. W.
Right arrow Articles by Dupuy, D. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mayo-Smith, W. W.
Right arrow Articles by Dupuy, D. E.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
RADIOLOGY RADIOGRAPHICS RSNA JOURNALS ONLINE