Endocrinol Metab.  2021 Jun;36(3):553-563. 10.3803/EnM.2021.1008.

Asian Conference on Tumor Ablation Guidelines for Adrenal Tumor Ablation

• Park BK
• Fujimori M
• Shen SH
• Pua U

• KMID: 2517644
• DOI: http://doi.org/10.3803/EnM.2021.1008

Abstract

Thermal ablation is a good alternative treatment in patients who are unable to undergo adrenalectomy. Even though the Asian Conference on Tumor Ablation (ACTA) has been held for many years, adrenal ablation guidelines have not been established. No guidelines for adrenal ablation are established in American and European countries, either. The aim of this review was to introduce the first version of ACTA guidelines for adrenal tumor ablation.

Keyword

Adrenal glands; Catheter ablation; Adrenal gland neoplasms

Figure

• 

  Fig. 1 A recurrent pheochromocytoma in a 35-year-old man with von-Hippel-Lindau disease. (A) Contrast-enhanced axial computed tomography image shows a recurrent pheochromocytoma (white arrow) in the residual left adrenal gland. The patient underwent right total adrenalectomy and left partial adrenalectomy due to recurrent pheochromocytomas. An asterisk indicates the left lung intervening between the pheochromocytoma and the skin. (B) Left pheochromocytoma is safely targeted with a radiofrequency electrode (black arrow) with the patient positioned left side down, resulting in ipsilateral collapse of the left lung to avoid pneumothorax.

• 

  Fig. 2 Hydro-dissection in a 36-year-old female with von-Hippel-Lindau disease. Axial computed tomography image shows 5% dextrose water (asterisk) which is instilled for hydro-dissection to avoid thermal damage to the pancreas body (black arrow). A white arrow indicates a radiofrequency electrode targeting a recurrent left pheochromocytoma.

Reference

1. Beland MD, Mayo-Smith WW. Ablation of adrenal neoplasms. Abdom Imaging. 2009; 34:588–92.

2. Uppot RN, Gervais DA. Imaging-guided adrenal tumor ablation. AJR Am J Roentgenol. 2013; 200:1226–33.

3. Ethier MD, Beland MD, Mayo-Smith W. Image-guided ablation of adrenal tumors. Tech Vasc Interv Radiol. 2013; 16:262–8.

4. Yamakado K. Image-guided ablation of adrenal lesions. Semin Intervent Radiol. 2014; 31:149–56.

5. Ierardi AM, Petrillo M, Patella F, Biondetti P, Fumarola EM, Angileri SA, et al. Interventional radiology of the adrenal glands: current status. Gland Surg. 2018; 7:147–65.

6. Park BK. Percutaneous adrenal radiofrequency ablation: a short review for endocrinologists. Endocrinol Metab (Seoul). 2020; 35:750–5.

7. Kim JH, Chae HW, Chin SO, Ku CR, Park KH, Lim DJ, et al. Diagnosis and treatment of growth hormone deficiency: a position statement from Korean Endocrine Society and Korean Society of Pediatric Endocrinology. Endocrinol Metab (Seoul). 2020; 35:272–87.

8. Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer. 1950; 3:74–85.

9. Bullock WK, Hirst AE Jr. Metastatic carcinoma of the adrenal. Am J Med Sci. 1953; 226:521–4.

10. Conzo G, Grillo M, Campione M, Amore A, Di Marzo M, Santini L. The role of surgery in the treatment of adrenocortical carcinoma. Ann Ital Chir. 2002; 73:619–22.

11. Carrafiello G, Lagana D, Recaldini C, Giorgianni A, Ianniello A, Lumia D, et al. Imaging-guided percutaneous radiofrequency ablation of adrenal metastases: preliminary results at a single institution with a single device. Cardiovasc Intervent Radiol. 2008; 31:762–7.

12. Swietlik JF, Knott EA, Longo KC, Abel EJ, Wells SA, Lubner MG, et al. Microwave ablation of adrenal tumors in patients with continuous intra-arterial blood pressure monitoring without prior alpha-adrenergic blockade: safety and efficacy. Cardiovasc Intervent Radiol. 2020; 43:1384–91.

13. Zhou K, Pan J, Yang N, Shi HF, Cao J, Li YM, et al. Effectiveness and safety of CT-guided percutaneous radiofrequency ablation of adrenal metastases. Br J Radiol. 2018; 91:20170607.

14. Mu L, Sun L, Pan T, Lyu N, Li S, Li X, et al. Percutaneous CT-guided radiofrequency ablation for patients with extrahepatic oligometastases of hepatocellular carcinoma: long-term results. Int J Hyperthermia. 2018; 34:59–67.

15. Venkatesan AM, Locklin J, Dupuy DE, Wood BJ. Percutaneous ablation of adrenal tumors. Tech Vasc Interv Radiol. 2010; 13:89–99.

16. Young WF, Stanson AW. What are the keys to successful adrenal venous sampling (AVS) in patients with primary aldosteronism? Clin Endocrinol (Oxf). 2009; 70:14–7.

17. Funder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016; 101:1889–916.

18. Young WF, Stanson AW, Thompson GB, Grant CS, Farley DR, van Heerden JA. Role for adrenal venous sampling in primary aldosteronism. Surgery. 2004; 136:1227–35.

19. Park JJ, Park BK, Kim JH, Jeong BC, Kim CK. Salvage computed tomography-guided transhepatic radiofrequency ablation for unresected aldosteronoma of adrenohepatic fusion after adrenalectomy. Int J Urol. 2016; 23:102–4.

20. Park JJ, Park BK, Kim CK. Direct and indirect imaging features of adrenohepatic fusion. Abdom Radiol (NY). 2016; 41:377–83.

21. Strajina V, Al-Hilli Z, Andrews JC, Bancos I, Thompson GB, Farley DR, et al. Primary aldosteronism: making sense of partial data sets from failed adrenal venous sampling-suppression of adrenal aldosterone production can be used in clinical decision making. Surgery. 2018; 163:801–6.

22. Pasternak JD, Epelboym I, Seiser N, Wingo M, Herman M, Cowan V, et al. Diagnostic utility of data from adrenal venous sampling for primary aldosteronism despite failed cannulation of the right adrenal vein. Surgery. 2016; 159:267–73.

23. Imaki T, Naruse M, Takano K. Adrenocortical hyperplasia associated with ACTH-dependent Cushing’s syndrome: comparison of the size of adrenal glands with clinical and endocrinological data. Endocr J. 2004; 51:89–95.

24. Bourdeau I, El Ghorayeb N, Gagnon N, Lacroix A. Management of endocrine disease: differential diagnosis, investigation and therapy of bilateral adrenal incidentalomas. Eur J Endocrinol. 2018; 179:R57–67.

25. Gu YL, Gu WJ, Dou JT, Lv ZH, Li J, Zhang SC, et al. Bilateral adrenocortical adenomas causing adrenocorticotropic hormone-independent Cushing’s syndrome: a case report and review of the literature. World J Clin Cases. 2019; 7:961–71.

26. Lacroix A, Bourdeau I. Bilateral adrenal Cushing’s syndrome: macronodular adrenal hyperplasia and primary pigmented nodular adrenocortical disease. Endocrinol Metab Clin North Am. 2005; 34:441–58.

27. De Venanzi A, Alencar GA, Bourdeau I, Fragoso MC, Lacroix A. Primary bilateral macronodular adrenal hyperplasia. Curr Opin Endocrinol Diabetes Obes. 2014; 21:177–84.

28. Park BK, Kim B, Ko K, Jeong SY, Kwon GY. Adrenal masses falsely diagnosed as adenomas on unenhanced and delayed contrast-enhanced computed tomography: pathological correlation. Eur Radiol. 2006; 16:642–7.

29. Builes-Montano CE, Villa-Franco CA, Roman-Gonzalez A, Velez-Hoyos A, Echeverri-Isaza S. Adrenal venous sampling in a patient with adrenal Cushing syndrome. Colomb Med (Cali). 2015; 46:84–7.

30. Pacak K, Eisenhofer G, Ilias I. Diagnosis of pheochromocytoma with special emphasis on MEN2 syndrome. Hormones (Athens). 2009; 8:111–6.

31. Sarkadi B, Patocs A. Hereditary diseases predisposing to pheochromocytoma (VHL, NF-1, paraganglioma syndromes, and novel genes). Exp Suppl. 2019; 111:129–47.

32. Park BK, Kim CK, Kwon GY, Kim JH. Re-evaluation of pheochromocytomas on delayed contrast-enhanced CT: washout enhancement and other imaging features. Eur Radiol. 2007; 17:2804–9.

33. Withey SJ, Perrio S, Christodoulou D, Izatt L, Carroll P, Velusamy A, et al. Imaging features of succinate dehydrogenase-deficient pheochromocytoma-paraganglioma syndromes. Radiographics. 2019; 39:1393–410.

34. Yamakado K, Takaki H, Uchida K, Nakatsuka A, Shiraishi T, Takeda K. Adrenal radiofrequency ablation in swine: change in blood pressure and histopathologic analysis. Cardiovasc Intervent Radiol. 2011; 34:839–44.

35. Yamakado K, Takaki H, Yamada T, Yamanaka T, Uraki J, Kashima M, et al. Incidence and cause of hypertension during adrenal radiofrequency ablation. Cardiovasc Intervent Radiol. 2012; 35:1422–7.

36. Varon J. Treatment of acute severe hypertension: current and newer agents. Drugs. 2008; 68:283–97.

37. Lo CH, Tyan YS, Ueng KC. Immediate results and long-term outcomes following percutaneous radiofrequency ablation of unilateral aldosterone-producing adenoma. Acta Cardiol Sin. 2020; 36:160–7.

38. Li X, Fan W, Zhang L, Zhao M, Huang Z, Li W, et al. CT-guided percutaneous microwave ablation of adrenal malignant carcinoma: preliminary results. Cancer. 2011; 117:5182–8.

39. Zhang W, Shi YB, Zhuang ZX, Wang JP, Sun LJ, Fu YF. Computed tomography-guided cryoablation for adrenal pheochromocytoma: safety and clinical effectiveness. Surg Laparosc Endosc Percutan Tech. 2019; 29:409–12.

40. Zheng L, Zhou F, Yu X, Liang P, Cheng Z, Han Z, et al. Hypertensive crisis during microwave ablation of adrenal neoplasms: a retrospective analysis of predictive factors. J Vasc Interv Radiol. 2019; 30:1343–50.

41. Arima K, Yamakado K, Suzuki R, Matsuura H, Nakatsuka A, Takeda K, et al. Image-guided radiofrequency ablation for adrenocortical adenoma with Cushing syndrome: outcomes after mean follow-up of 33 months. Urology. 2007; 70:407–11.

42. Yamakado K, Anai H, Takaki H, Sakaguchi H, Tanaka T, Kichikawa K, et al. Adrenal metastasis from hepatocellular carcinoma: radiofrequency ablation combined with adrenal arterial chemoembolization in six patients. AJR Am J Roentgenol. 2009; 192:W300–5.

43. Hasegawa T, Yamakado K, Nakatsuka A, Uraki J, Yamanaka T, Fujimori M, et al. Unresectable adrenal metastases: clinical outcomes of radiofrequency ablation. Radiology. 2015; 277:584–93.

44. Huang J, Xie X, Lin J, Wang W, Zhang X, Liu M, et al. Percutaneous radiofrequency ablation of adrenal metastases from hepatocellular carcinoma: a single-center experience. Cancer Imaging. 2019; 19:44.

45. Liang KW, Jahangiri Y, Tsao TF, Tyan YS, Huang HH. Effectiveness of thermal ablation for aldosterone-producing adrenal adenoma: a systematic review and meta-analysis of clinical and biochemical parameters. J Vasc Interv Radiol. 2019; 30:1335–42.

46. Atwell TD, Wass CT, Charboneau JW, Callstrom MR, Farrell MA, Sengupta S. Malignant hypertension during cryoablation of an adrenal gland tumor. J Vasc Interv Radiol. 2006; 17:573–5.

47. Miyazaki M, Iguchi T, Takaki H, Yamanaka T, Tamura Y, Tokue H, et al. Ablation protocols and ancillary procedures in tumor ablation therapy: consensus from Japanese experts. Jpn J Radiol. 2016; 34:647–56.

48. Malloy PC, Grassi CJ, Kundu S, Gervais DA, Miller DL, Osnis RB, et al. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol. 2009; 20(7 Suppl):S240–9.

49. Sommer CM, Lemm G, Hohenstein E, Stampfl U, Bellemann N, Teber D, et al. Bipolar versus multipolar radiofrequency (RF) ablation for the treatment of renal cell carcinoma: differences in technical and clinical parameters. Int J Hyperthermia. 2013; 29:21–9.

50. Mayo-Smith WW, Dupuy DE. Adrenal neoplasms: CT-guided radiofrequency ablation: preliminary results. Radiology. 2004; 231:225–30.

51. Wood BJ, Abraham J, Hvizda JL, Alexander HR, Fojo T. Radiofrequency ablation of adrenal tumors and adrenocortical carcinoma metastases. Cancer. 2003; 97:554–60.

52. Welch BT, Atwell TD, Nichols DA, Wass CT, Callstrom MR, Leibovich BC, et al. Percutaneous image-guided adrenal cryoablation: procedural considerations and technical success. Radiology. 2011; 258:301–7.

53. Espinosa De Ycaza AE, Welch TL, Ospina NS, Rodriguez-Gutierrez R, Atwell TD, Erickson D, et al. Image-guided thermal ablation of adrenal metastases: hemodynamic and endocrine outcomes. Endocr Pract. 2017; 23:132–40.

54. Pautler SE, Pavlovich CP, Mikityansky I, Drachenberg DE, Choyke PL, Linehan WM, et al. Retroperitoneoscopic-guided radiofrequency ablation of renal tumors. Can J Urol. 2001; 8:1330–3.

55. Esen T, Acar O, Tefekli A, Musaoglu A, Rozanes I, Emre A. Adrenal cortex-sparing surgery for bilateral multiple pheochromocytomas in a patient with von hippel-lindau disease. Case Rep Med. 2012; 2012:659104.

56. Nishi N, Tanaka J, Minagawa A. Cushing syndrome treated by radiofrequency ablation of adrenal gland adenoma. Jpn J Radiol. 2012; 30:274–6.

57. Dolan MF, Janovski NA. Adreno-hepatic union: (adrenal dystopia). Arch Pathol. 1968; 86:22–4.

58. Honore LH, O’Hara KE. Combined adrenorenal fusion and adrenohepatic adhesion: a case report with review of the literature and discussion of pathogenesis. J Urol. 1976; 115:323–5.

59. Honma K. Adreno-hepatic fusion: an autopsy study. Zentralbl Pathol. 1991; 137:117–22.

60. Park BK, Kim CK, Jung BC, Suh YL. Cortical adenoma in adrenohepatic fusion tissue: clue to making a correct diagnosis at preoperative computed tomography examination. Eur Urol. 2009; 56:1082–5.

61. Knavel EM, Brace CL. Tumor ablation: common modalities and general practices. Tech Vasc Interv Radiol. 2013; 16:192–200.

62. Chu KF, Dupuy DE. Thermal ablation of tumours: biological mechanisms and advances in therapy. Nat Rev Cancer. 2014; 14:199–208.

63. Nikfarjam M, Muralidharan V, Christophi C. Mechanisms of focal heat destruction of liver tumors. J Surg Res. 2005; 127:208–23.

64. Saliken JC, McKinnon JG, Gray R. CT for monitoring cryotherapy. AJR Am J Roentgenol. 1996; 166:853–5.

65. Tacke J, Speetzen R, Heschel I, Hunter DW, Rau G, Gunther RW. Imaging of interstitial cryotherapy: an in vitro comparison of ultrasound, computed tomography, and magnetic resonance imaging. Cryobiology. 1999; 38:250–9.

66. Goldberg SN, Hahn PF, Tanabe KK, Mueller PR, Schima W, Athanasoulis CA, et al. Percutaneous radiofrequency tissue ablation: does perfusion-mediated tissue cooling limit coagulation necrosis? J Vasc Interv Radiol. 1998; 9(1 Pt 1):101–11.

67. Ahmed M, Solbiati L, Brace CL, Breen DJ, Callstrom MR, Charboneau JW, et al. Image-guided tumor ablation: standardization of terminology and reporting criteria: a 10-year update. Radiology. 2014; 273:241–60.

68. Hoffmann NE, Bischof JC. The cryobiology of cryosurgical injury. Urology. 2002; 60(2 Suppl 1):40–9.

69. Mazur P. Freezing of living cells: mechanisms and implications. Am J Physiol. 1984; 247(3 Pt 1):C125–42.

70. Smith DJ, Fahssi WM, Swanlund DJ, Bischof JC. A parametric study of freezing injury in AT-1 rat prostate tumor cells. Cryobiology. 1999; 39:13–28.

71. Carrafiello G, Lagana D, Mangini M, Fontana F, Dionigi G, Boni L, et al. Microwave tumors ablation: principles, clinical applications and review of preliminary experiences. Int J Surg. 2008; 6(Suppl 1):S65–9.

72. Simon CJ, Dupuy DE, Mayo-Smith WW. Microwave ablation: principles and applications. Radiographics. 2005; 25(Suppl 1):S69–83.

73. Wright AS, Lee FT Jr, Mahvi DM. Hepatic microwave ablation with multiple antennae results in synergistically larger zones of coagulation necrosis. Ann Surg Oncol. 2003; 10:275–83.

74. Wright AS, Sampson LA, Warner TF, Mahvi DM, Lee FT Jr. Radiofrequency versus microwave ablation in a hepatic porcine model. Radiology. 2005; 236:132–9.

75. Skinner MG, Iizuka MN, Kolios MC, Sherar MD. A theoretical comparison of energy sources–microwave, ultrasound and laser–for interstitial thermal therapy. Phys Med Biol. 1998; 43:3535–47.

76. Shock SA, Meredith K, Warner TF, Sampson LA, Wright AS, Winter TC 3rd, et al. Microwave ablation with loop antenna: in vivo porcine liver model. Radiology. 2004; 231:143–9.

77. Wolf FJ, Dupuy DE, Machan JT, Mayo-Smith WW. Adrenal neoplasms: effectiveness and safety of CT-guided ablation of 23 tumors in 22 patients. Eur J Radiol. 2012; 81:1717–23.

78. Men M, Ye X, Fan W, Zhang K, Bi J, Yang X, et al. Short-term outcomes and safety of computed tomography-guided percutaneous microwave ablation of solitary adrenal metastasis from lung cancer: a multi-center retrospective study. Korean J Radiol. 2016; 17:864–73.

79. Ren C, Liang P, Yu XL, Cheng ZG, Han ZY, Yu J. Percutaneous microwave ablation of adrenal tumours under ultrasound guidance in 33 patients with 35 tumours: a single-centre experience. Int J Hyperthermia. 2016; 32:517–23.

80. Zener R, Zaleski A, Van Uum SH, Gray DK, Mujoomdar A. Successful percutaneous CT-guided microwave ablation of adrenal gland for ectopic Cushing syndrome. Clin Imaging. 2017; 42:93–5.

81. Wu S, Li X, Yu J, Yu X, Cheng Z, Liu F, et al. Ultrasound-guided percutaneous microwave ablation assisted by a three-dimensional visualization preoperative treatment planning system for larger adrenal metastasis (D ≥ 4 cm): preliminary results. J Cancer Res Ther. 2019; 15:1477–83.

82. Gao Y, Zheng L, Liang P, Cheng Z, Han Z, Tan SL, et al. Evaluating the efficacy and safety of ultrasound-guided percutaneous microwave ablation for the treatment of adrenal metastasis. J Cancer Res Ther. 2020; 16:1088–92.

83. Park SY, Park BK, Park JJ, Kim CK. Differentiation of adrenal hyperplasia from adenoma by use of CT densitometry and percentage washout. AJR Am J Roentgenol. 2016; 206:106–12.

84. Kratochwil C, Flechsig P, Lindner T, Abderrahim L, Altmann A, Mier W, et al. 68Ga-FAPI PET/CT: tracer uptake in 28 different kinds of cancer. J Nucl Med. 2019; 60:801–5.

85. Kroiss AS, Uprimny C, Shulkin BL, Gruber L, Frech A, Jazbec T, et al. 68Ga-DOTATOC PET/CT in the localization of metastatic extra-adrenal paraganglioma and pheochromocytoma compared with 18F-DOPA PET/CT. Rev Esp Med Nucl Imagen Mol. 2019; 38:94–9.

86. Xiao YY, Tian JL, Li JK, Yang L, Zhang JS. CT-guided percutaneous chemical ablation of adrenal neoplasms. AJR Am J Roentgenol. 2008; 190:105–10.

87. Liu SY, Chu CC, Tsui TK, Wong SK, Kong AP, Chiu PW, et al. Aldosterone-producing adenoma in primary aldosteronism: CT-guided radiofrequency ablation-long-term results and recurrence rate. Radiology. 2016; 281:625–34.

88. Liu SY, Ng EK, Lee PS, Wong SK, Chiu PW, Mui WL, et al. Radiofrequency ablation for benign aldosterone-producing adenoma: a scarless technique to an old disease. Ann Surg. 2010; 252:1058–64.

89. Mendiratta-Lala M, Brennan DD, Brook OR, Faintuch S, Mowschenson PM, Sheiman RG, et al. Efficacy of radiofrequency ablation in the treatment of small functional adrenal neoplasms. Radiology. 2011; 258:308–16.

90. Szejnfeld D, Nunes TF, Giordano EE, Freire F, Ajzen SA, Kater CE, et al. Radiofrequency ablation of functioning adrenal adenomas: preliminary clinical and laboratory findings. J Vasc Interv Radiol. 2015; 26:1459–64.

91. Liu SY, Chu CM, Kong AP, Wong SK, Chiu PW, Chow FC, et al. Radiofrequency ablation compared with laparoscopic adrenalectomy for aldosterone-producing adenoma. Br J Surg. 2016; 103:1476–86.

92. Nunes TF, Szejnfeld D, Xavier AC, Kater CE, Freire F, Ribeiro CA, et al. Percutaneous ablation of functioning adrenal adenoma: a report on 11 cases and a review of the literature. Abdom Imaging. 2013; 38:1130–5.

93. Mouracade P, Dettloff H, Schneider M, Debras B, Jung JL. Radio-frequency ablation of solitary adrenal gland metastasis from renal cell carcinoma. Urology. 2009; 74:1341–3.