ELSEVIER
”How We Do It” - A Practical Approach to Percutaneous Adrenal Ablation Techniques
Check for updates
Barbara Manchec, MD,* Yilun Koethe, MD,+ Brian Schiro, MD,+ Constantino Peña, MD,+ and Ripal Gandhi, MD+
Incidental adrenal masses are common and are found in 4% of the CT scans.1 While clinical history, laboratory results, and imaging characteristics are typically sufficient for diagnosis of an adrenal lesion, a biopsy is sometimes warranted. In some cases, adrenal mass abla- tion is subsequently indicated. This article serves as a brief but comprehensive review of preprocedural work-up and planning before an adrenal mass ablation, as well as a discus- sion on ablation techniques, associated challenges and solutions, and management of expected and unexpected outcomes.
Tech Vasc Interventional Rad 23:100676 @ 2020 Elsevier Inc. All rights reserved.
| KEYWORDS Radiofrequency | Ablation, | Ablation | Techniques, | Pheochromocytoma, |
|---|---|---|---|---|
| Adrenocortical Carcinoma, Adrenocortical Adenoma, Cryosurgery | ||||
Introduction
I ncidental adrenal masses are common and can be found on approximately 4% of CT scans.” According to recom- mendations by the American Association of Clinical Endocri- nologists (AACE), American Associates of Endocrine Surgeons (AAES) and European Society of Endocrinology (ESE), all adrenal incidentalomas necessitate further clinical and laboratory evaluation.2,3
Imaging Evaluation
Dedicated adrenal protocol CT and MRI can make the first-step differentiation between adenomas and other lesions. An attenu- ation of <10 Hounsfield units on noncontrast CT is diagnostic for adenoma.4 On adrenal protocol CT, a relative washout <40% and an absolute washout <60% has a sensitivity >95% and specificity of 60%-75% for adrenal malignancy.4,5
*Department of Radiology, Advent Health Medical Group/Central Florida Division, Orlando, FL.
Miami Cardiac and Vascular Institute, Miami Cancer Institute, Miami, FL.
Funding: None.
Conflicts of Interest: The authors reported no conflicts of interest.
Address reprint requests to Ripal Gandhi, MD, Miami Cardiac and Vascular Institute, Miami Cancer Institute, 8900 N Kendall Dr., Miami, FL 33176. E-mail: ripgandhi@yahoo.com
Abnormal washout can be seen in pheochromocytomas and adrenocortical carcinomas.4 In a patient with malignancy, abnormal washout is suspicious but not diagnostic of metasta- sis.3,4 If there are bilateral or extra-adrenal masses, one should be concerned about metastasis or pheochromocytomas.
MRI can help identify intracellular lipids commonly asso- ciated with adenomas.4 Decreased signal intensity on out-of- phase sequences relative to in-phase sequences is diagnostic of intracellular lipids.4 Pheochromocytomas are classically T2 hyperintense, but if large enough, can be heterogeneous in signal intensity.4 Adrenal myelolipomas are benign and contain macroscopic fat, also visible on CT. 18 8F-FDG PET is useful in patients with a history of malig- nancy, as a metastatic lesion is typically FDG avid.4 Other FDG avid lesions include pheochromocytoma and adreno- cortical carcinoma (ACC).4
Clinical History and Preablation Testing
ESE, AACE, and AAES recommend that all patients with adre- nal incidentalomas undergo clinical examination and laboratory testing to exclude hormonal hypersecretion.2,3 One should be familiar with the following presentations and tests. A history of hypertension, glucose intolerance, obesity, easy bruising,
dyslipidemia, and osteoporosis should raise the suspicion of Cushing’s syndrome.3,6 Treatment-resistant hypertension, hypokalemia, and metabolic alkalosis in a patient in 30 to 60 years old should raise the suspicion of primary aldosteron- ism.7-10 Patients with testosterone hypersecretion can lead to precocious puberty in men and virilization in women. Finally, palpitations, cardiac arrhythmia, hypertension (sometimes par- oxysmal), headache, and diaphoresis are indicative of catechol- amine (ie, norepinephrine) surge and are concerning for pheochromocytomas.3,6,1.
Confirmatory laboratory tests are numerous and targeted to suspected clinical diagnosis based on history. Cushing’s syn- drome can be confirmed with a 1 mg overnight dexametha- sone suppression test when postsuppression cortisol level is greater than 138 nmol/L (5 ug/dL).2,3 Elevated late-night sali- vary cortisol, 24-hour urine free cortisol, serum cortisol and low serum adrenocorticotropic hormone (ACTH) are addi- tional indicators of hypercortisolism.3,6,13 In hyperaldosteron- ism, the plasma aldosterone-to-renin ratio is greater than 20- 30.3,9,10,14 For accurate testing, diuretics, angiotensin-convert- ing enzyme inhibitors, angiotensin receptor blockers, spirono- lactone, beta-adrenergic antagonists, clonidine, and nonsteroidal anti-inflammatory drugs should be stopped for 4-6 weeks before testing.3,15 The AACE and AAES recom- mend adrenal venous sampling to lateralize aldosterone secre- tion in older patients, patients with bilateral morphologically abnormal glands, or patients with unilateral microadenoma(s) who are being considered for surgical intervention.3
Adrenal biopsy is only indicated when the combination of clinical history, laboratory testing and imaging is inconclu- sive to differentiate a benign or a malignant lesion, when sus- pecting metastasis from extra-adrenal malignancy or to identify an unknown primary.4,16,17 If pheochromocytoma is suspected, adrenal biopsy should be avoided.3,4
Indications and Contraindications for Adrenal Ablation
According to ESE, AACE, and AAES guidelines, adrenalec- tomy is recommended for nonfunctional adenomas >4 cm (due to increased risk of malignancy), unilateral clinically sig- nificant functional adenomas, and noninvasive pheochromo- cytomas <6 cm.2,3 Patients with ACC should undergo open resection with lymphadenectomy with adjuvant mitotane chemotherapy when possible.3 In cases of adrenal metastasis with limited extra-adrenal malignancy, a patient may derive survival benefit from adrenalectomy.3,18-20
Ideal candidates for image-guided adrenal ablation include all patients with tumors <4 cm, who would otherwise benefit from surgical resection, but either are not optimal surgical can- didates or refuse surgery.13,21-24 Absolute contraindications for image-guided adrenal ablation are few. These include the inability to safely access the ablation target despite protective maneuvers, uncorrectable coagulopathy (INR >1.5 and plate- let count <50 K/uL),13,19,25 and the patient’s inability to toler- ate sedation.
Preoperative Management and Planning
Life-threatening hypertensive crisis from intraprocedural cat- echolamine surge is a true risk during ablation of any adrenal lesion and is not limited to pheochromocytoma. In our prac- tice, premedication guidelines from AACE and AAES for sur- gical resection of pheochromocytomas is applied to all adrenal mass ablation.
An a-adrenergic inhibitor, such as phenoxybenzamine or doxazosin, is initiated 1-3 weeks before the procedure and the dose is increased every 2 days until the patient’s average blood pressure is around 130/85 mm Hg or patient develops symptomatic orthostatic hypotension.3,12 Nonselective B-adrenergic inhibitors are also frequently added to the regi- men after «-blockade has been achieved if the patient has persistent tachycardia.3,26 A B-blocker should never be administered in the absence of a-blockade because it can result in decreased myocardial contractility in the setting of increased systemic vascular resistance and lead to hyperten- sive crisis and heart failure.12,16,23 Commonly used medica- tions regimens are listed in Table 1.3,21,27 The use of tyrosine hydroxylase inhibitor, a-methyl-para-tyrosine, is not rou- tinely recommended but can be used in addition to an a-adrenergic inhibitor. While tyrosine hydroxylase inhibitors reduce intraoperative hypertension and arrhythmia, postop- erative hypotension is more likely to occur.12 Finally, a pre- operative high-sodium diet with fluid intake to counter postoperative hypotension secondary to catecholamine- induced intravascular volume contraction is recommended.3,26
In the absence of contraindications, our practice premedi- cates the patient with an @-adrenergic inhibitor for 2 weeks followed by the addition of a B-blocker if the patient has per- sistent tachycardia. Additionally, we advise patients have a high-sodium diet with ample fluid intake immediately prior to the procedure. Antiplatelet agents are stopped 5 days before the procedure, and heparin is held for at least 24 hours.25
Intraoperative Management Sedation
Only an anesthesiologist trained in managing catechol- amine-induced complications should be providing either general anesthesia or monitored anesthesia care. Continu- ous blood pressure monitoring with an arterial line is strongly recommended as changes in blood pressure can be rapid and expeditious treatment is necessary to avoid com- plications. Furthermore, it is critical that alpha and beta blockers are available in the interventional suite, and ready to be administered. Central venous access can also be con- sidered.
Prophylactic Antibiotics
There is no consensus for routine prophylactic antibiotic administration prior to adrenal ablation.28 Previously
| Class | Initiation | Treatment Target | Medication | Recommended Starting Dose | Titration |
|---|---|---|---|---|---|
| a-adrenergic inhibitor | 1-3 weeks before ablation | Until BP 130/85 mm Hg or patient develops orthostatic hypotension | Phenoxybenzamine Doxazosin | 10 mg BID 1 mg QD | May increase by 10 mg/day every other day, maximum dose 300-400 mg daily May double dose every week, maximum dose 16 mg/day |
| Nonselective b-adrenergic inhibitor | After adequate a blockade | Resolution of tachycardia | Propranolol Atenolol | 10-40 mg TID | May increase every 3-7 days |
| 12.5 mg QD or BID | May increase dose every 7 days, maximum dose 200 mg/day | ||||
| Tyrosine hydroxylase inhibitor | 1-3 weeks before ablation | Until BP 130/85 mm Hg or patient develops orthostatic hypotension | a-methyl-para- tyrosine (Metyrosine) | 250 mg QID | May increase by 250-500 mg every 3-4 days, maximum dose 4 g/day. |
reported antibiotics include cephalosporins (cefuroxime or cefazolin), ciprofloxacin or amoxicillin/clavulanate.7,9,13- 15,20,22,29,30
Ablation
Equipment Selection
Radiofrequency ablation (RFA), cryoablation, and microwave ablation (MWA) are most commonly performed for adrenal masses. Although RFA is the most widely studied form of ablation, it has largely been replaced in common practice by MWA or cryoablation. MWA creates a larger and faster abla- tion compared to RFA ablation, and may be preferable for cystic masses as these lesions may boil with RFA but not
with MWA.31 Percutaneous chemical ablation with ethanol or acetic acid solution has also been described, but usually requires several treatment sessions.
Technique
CT guidance is the preferred and most commonly used modality because it allows easy visualization of the ablation target and potential anatomic obstacles. Ultrasound has also been used and may be preferable for large lesions.32 The patient can be positioned in the prone or ipsilateral decubitus position. 7,9,14,19-21,29,33 One potential advantage of the ipsi- lateral decubitus position is that it causes lung hypoinflation and reduces diaphragmatic motion, which may lower the risk of pneumothorax or diaphragmatic injury (Fig. 1C
A
B
C
D
E
F
A
B
and D).16,21 Access to the adrenal mass can be performed through the paraspinal muscles, posterior intercostal muscles or via a transhepatic approach.7,9,14,19-21,29,33 It is critical to alert the anesthesiologist before manipulating the probe as well as prior to the start of ablation (or in the case of cryoa- blation between freeze-thaw cycles), so they can be prepared to promptly respond to catecholamine-induced hemody- namic changes.16 The type and quantity of applicators used should be based on manufacturer recommendations in order to achieve an ablation margin of 1 cm.8,23,34 If MWA or RFA is used, thermal mapping may be performed, typically through the applicator, to monitor intratumoral tempera- tures and ensure the treatment zone reaches at least 50 ° C.8,32 Once the ablation is complete, we recommend cauteri- zation of the track to reduce the possibility of track seeding or bleeding. 22,27,31,32
To avoid nontarget injury of adjacent tissues, either hydro- dissection or pneumodissection (Fig. 2) can be performed.34 Ionic solutions, such as saline, should not be used for RFA ablations because they are capable of conducting electricity.16 One can also use a balloon catheter to displace the adrenal mass from adjacent thermo-sensitive organs (ie, bowel). Finally, CT gantry angling can help with off-axis needle placement.33
Immediate Postoperative Management
Most patients are monitored overnight, as postprocedure refractory hypertension can last for a up to 2 days.14 In select cases, patients can be discharged after a few hours of recov- ery. Postprocedural pharmacologic management can be com- plex and highlights the importance of multidisciplinary care. For example, after ablation of a cortisol-secreting adenoma, the hypothalamic-pituitary-adrenal (HPA) axis remains sup- pressed. In these cases, stress dose glucocorticoids should be initiated on postoperative day 1 and gradually titrated as the HPA axis recovers, a process that can take up to 18 months.3,8,13 Some have also recommended replacement with mineralocorticoids.21,31 Postablation management of aldosteronomas is variable. Some recommend total cessation of mineralocorticoid receptor antagonists, antihypertensives and potassium supplementation, and adding them back as needed,3,29 while others recommend continuing them in the
immediate postablation period.7,19 In cases of pheochromo- cytomas, antihypertensives can be discontinued after ablation.3
Complications
Adrenal ablation carries an approximate 1% major and 12% minor complication rate,33 which is comparable to the com- plication rates of adrenalectomy.36
Hypertensive Crisis
Hypertensive crisis, defined as a systolic blood pressure >180 mm Hg and/or a diastolic blood pressure of
120 mm Hg, reportedly occurs in approximately 20% of adrenal ablations and is not limited to pheochromocytoma.7,8,14,19,21,30,37-39 Risk factors for hyper- tensive crisis include pheochromocytoma, tumor size <4.5 cm, BMI < 24 kg/m2, and preprocedural systolic blood pressure ≥130 mm Hg.38 As a result, we believe it is manda- tory to have an arterial line for close hemodynamic monitor- ing and antihypertensives readily available throughout the procedure. Although usually transient, a hypertensive crisis often requires medical management. Hemodynamic altera- tions can arise at any time during the ablation, but are reported to occur most frequently shortly after the radiofre- quency or microwave energy is initiated or when the ice on the cryoprobe is thawed.9,20,23,27,31,40 Several agents have been used to control intraprocedural hypertension, including hydralazine,19 esmolol,9,20,40,41 labetalol hydrochloride,9,14,29 sodium nitroprusside,3,40 nicardipine,3,13,14,30 magnesium sulfate,9 nitroglycerin,3,14 phentolamine,3 or a combination thereof. We recommend attempting to control the blood pres- sure with pharmacotherapy first. If unsuccessful, the ablation should be temporarily stopped until the patient’s blood pres- sure returns to baseline. Once stabilized, the ablation can be reinitiated.
Other
Retroperitoneal hematoma after adrenal ablation can occur in up to 15% of patients, however these have been self-
limited.7,8,15,19,29 Pneumothorax has been reported in up to 9% of adrenal ablations.7,8,15,29,35 Most of these iatrogenic pneumothoraces were able to be treated conservatively, but few required thoracostomy tube placement.7,8,13,15,29 Posta- blation infection is rare, but has been reported at the ablation site22 and within a retroperitoneal hemorrhage.29 Some less commonly reported adverse effects and complications include pleural effusions,23,32 mild postablation syndrome (pain and fever),20,24 hemothorax,8 nontarget thermal injury to the liver and diaphragmatic crus,8 neuritis,35 renal fail- ure,30 stroke,30 heart failure,30 demand myocardial infarc- tion,19 arrhythmia,18,31,35,41 and cardiomyopathy.42
Follow-up
Long-term Management
Clinical, laboratory and imaging follow-up is critical to assess patient response to treatment. Most perform a follow-up con- trast-enhanced CT at 1 month, 3 months, and then at 3-6 month intervals for at least 1-2 years for benign lesions and more for malignant masses.7,13,14,19-23,31-34 Residual or recurrent tumor presents with nodular residual or enlarging enhancement at the ablation zone over time. For biopsy proven adrenal malignancies, follow-up imaging with PET- CT should also be considered to assess for local recurrence and metastasis.19,20 If the tumor was hormonally active, fol- low-up with an endocrinologist is recommended to monitor biochemical response and titrate medications appropriately. In general, follow-up biochemical markers should be per- formed in 1-6 month intervals. 7,8,13,14
Expected Outcomes
Outcome data on adrenal ablations are limited by heteroge- neity in treated adrenal lesions and equipment used. Most studies are also limited by small sample size, absent control group, and lack of long-term follow-up. A summary of out- comes are as follows:
Nonfunctional Adenomas
Nonfunctional cortical adenomas are treated only when ≥4 cm due to increased risk of malignancy,2,3 and therefore, not optimal candidates for ablation.24 Nevertheless, Xiao et al. reported size reduction after chemical ablation of 11 nonfunctional adenomas, most under 4 cm, with unchanged normal biochemical and hemodynamic parameters.33
Functional Adenomas
Patients with cortisol-secreting adenomas do well after RFA and chemical ablation. Arima et al. reported 100% resolution of symptoms and cortisol normalization after RFA of 4 corti- sol-secreting adenomas with a mean size of 2.7 cm, even though 1 had incomplete ablation on imaging, and persistent ACTH suppression.13 Two other RFA studies reported
resolution of biochemical and clinical abnormalities in 3 patients.8,43 Similarly, 5 patients who underwent chemical ablation of 6 cortisol-secreting adenomas (mean diameter of 2.7 cm) normalized their biochemical markers.33
Aldosteronoma ablation is the best studied with the most promising results. The majority of patients had biochemical normalization with lower blood pressure on fewer antihyper- tensives and improved hypokalemia as summarized in Table 2.8,9,29,33,43,44 A meta-analysis of 89 patients showed that ablation resulted in a statistically significant decrease in blood pressure and number of antihypertensives as well as normalization of biochemical markers.39 Of all, 75.3% patients had resolution or improvement of their hypertension following ablation.39 The long-term cure rates for hyperten- sion after adrenalectomy for primary aldosteronism ranges from 30% to 60%.1º Two studies, 1 retrospective and 1 pro- spective, have directly compared percutaneous RFA with lap- aroscopic adrenalectomy and demonstrated noninferiority.14,45 The RFA groups had shorter operations with less blood loss, less post-procedural pain and shorter hospital stays. 14,45
One study reports performing RFA on 1 patient with a tes- tosterone-secreting adenoma and the patient had resolution of symptoms related to hypertestosteronism at 1 year.8
Pheochromocytoma
RFA of primary pheochromocytomas has been reported in 4 patients, all had clinical resolution of symptoms and 3 of the 4 patients no longer required antihypertensives.8,19,21 MWA of pheochromocytomas has also been reported in 4 patients resulting in normalization of blood pressure in all patients and improved metanephrine levels.24 It has also been used for treatment of pheochromocytomas metastasis. 46
Adrenocortical Carcinoma
The largest study evaluated RFA of 15 ACC recurrences or metastases.22 The lesions ranged from 1.5 to 9 cm (mean 4.3 cm) and were located in the adrenal bed (n =5), the liver (n=5), the kidney (n =2), the paraspinal region (n =2), the retroperitoneum (n= 1), and the ribs/lung (n = 1).22 The authors achieved local control in 8 of 15 (53%) tumors after a mean follow-up period of 10.3 months, but it was better in tumors ≤5 cm (67%).22 Li et al. performed MWA in a patient with a 6 cm primary ACC in the adrenal gland which demon- strated local control after 2 treatment sessions, however the patient eventually developed metastatic disease (mean fol- low-up of the study was 11.3 months).31
Adrenal Metastasis
Targeted ablation of isolated adrenal metastasis and a well- controlled or eradicated primary tumor31,32 provides local control (Fig. 3) >70% of the time, but most patients will have eventual progression of disease. 18-21,23,24,30-33,47 Age (65 years or older), presence of extra-adrenal metastases and
| Aldosterone-Secreting Adenomas | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Study | Ablation Modality | Patient Number | Mean Tumor Size (cm) | Mean Follow-up (months) | Technical Success (%) (Single/ Second Session) | Biochemical Markers (% Normalization, SS Improvement) | Mean Blood Pressure (mm Hg) (Before, After, SS Improvement) | Mean Number of Antihypertensives (Before/After, SS Improvement) | Potassium (% Normokalemia, SS Improvement) | |
| Liu et al. | RFA | 36 | 1.6 | 74.4 | 92%/100% | 92%, SS | 158/94, 128/76, SS | 1.8/1.2, NA | 100%*, SS | |
| Yang et al. | RFA | 7 | 1.8 | 6 | 100% | 100%, SS | 153/92, 122/72, SS | 3.4/1.4, SS | NA, SS | |
| Szejnfeld et al. | RFA | 9 | 1.8 | 3 | 100% | 89%*, SS | 166/105, 133/92, SS | 3.2/1.3, SS | NA, NA | |
| Ren et al. | MWA | 3 | NA | NA | 100% | 100%, NA | NA, NA, NA | NA, NA | 100%, NA | |
| Sarwar et al. | RFA | 12 | 1.6 | 15.2 | NA | NA, NA | 145/94, 129/81, SS | 3.0/1.8, SS | 100%, SS | |
| Mendiratta-Lala | RFA | 10 | NA+ | 21.2 | 100% | 100%", NA | 149/90, 124/76, SS | 3.1/1.3, SS | 100% , NA | |
| et al. | (biochemical) | |||||||||
| & 41.4 (clinical)9 | ||||||||||
| Abbas et al. | Cryoablation | 5 | 1.8 | 12 | 100% | 60%, NA | 164/95, 131/73, NA | 3.4/1.6, NA | 80%, NA | |
| (4) & RFA (1) | ||||||||||
| Xiao et al. | Chemical | 7 | 2.8 | 24 | 2-5 | 100% | 155/107, 135/88 | NA | 100% | |
| ablation | (9 adenomas) | treatments | ||||||||
SS, statistically significant.
*2 patients remained on spironolactone.
“One patient without normalization of biochemical markers had an adrenal nodule in close proximity to IVC and was incompletely treated
“All adenomas were <3.2 cm.
Follow-up means include 3 patients with other functional adrenal masses.
Postablation aldosterone available for 9 (out of 10) patients.
Postablation potassium available for 7 (out of 10) patients.
A
B
C
D
E
F
a primary malignancy of nonsmall cell lung carcinoma may confer worse prognosis. 18,30 Of note, same-day RFA and che- moembolization of adrenal metastasis has also been reported. 48
References
1. Bovio S, Cataldi A, Reimondo G, et al: Prevalence of adrenal incidenta- loma in a contemporary computerized tomography series. J Endocrinol Invest 29:298-302, 2006
2. Fassnacht M, Arlt W, Bancos I, et al: Management of adrenal incidenta- lomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 175:G1-G34, 2016
3. Zeiger MA, Thompson GB, Duh QY, et al: American Association of Clin- ical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: executive summary of recommendations. Endocr Pract 15:450-453, 2009
4. Boland GW, Blake MA, Hahn PF, et al: Incidental adrenal lesions: Prin- ciples, techniques, and algorithms for imaging characterization. Radiol- ogy 249:756-775, 2008
5. Ng CS, Altinmakas E, Wei W, et al: Combining washout and noncon- trast data from adrenal protocol CT: Improving diagnostic performance. Acad Radiol 25:861-868, 2018
6. Carroll TB, Aron DC, Findling JW, et al: Glucocorticoids and adrenal androgens. In: Gardner DG, Shoback D (eds): Greenspan’s Basic & Clinical Endocrinology, 10e, New York, NY: McGraw-Hill Education, 2017
7. Liu SY, Ng EK, Lee PS, et al: Radiofrequency ablation for benign aldoste- rone-producing adenoma: A scarless technique to an old disease. Ann Surg 252:1058-1064, 2010
8. Mendiratta-Lala M, Brennan DD, Brook OR, et al: Efficacy of radiofre- quency ablation in the treatment of small functional adrenal neoplasms. Radiology 258:308-316, 2011
9. Abbas A, Idriz S, Railton NJ, et al: Image-guided ablation of Conn’s ade- nomas in the management of primary hyperaldosteronism. Clin Radiol 68:279-283, 2013
10. Young WF: Endocrine Hypertension. In: Gardner DG, Shoback D (eds): Greenspan’s Basic & Clinical Endocrinology, 10e, New York, NY: McGraw-Hill Education, 2017
11. Tong A, Jiang J, Wang F, et al: Pure androgen-producing adrenal tumor: Clinical features and pathogenesis. Endocr Pract 23:399-407, 2017
12. Fitzgerald PA: Adrenal medulla and paraganglia. In: Gardner DG, Shoback D (eds): Greenspan’s Basic & Clinical Endocrinology, 10e, New York, NY: McGraw-Hill Education, 2017
13. Arima K, Yamakado K, Suzuki R, et al: Image-guided radiofrequency ablation for adrenocortical adenoma with Cushing syndrome: Out- comes after mean follow-up of 33 months. Urology 70:407-411, 2007
14. Yang MH, Tyan YS, Huang YH, et al: Comparison of radiofrequency ablation versus laparoscopic adrenalectomy for benign aldosterone-pro- ducing adenoma. Radiol Med 121:811-819, 2016
15. Liu SY, Chu CM, Kong AP, et al: Radiofrequency ablation compared with laparoscopic adrenalectomy for aldosterone-producing adenoma. Br J Surg 103:1476-1486, 2016
16. Ethier MD, Beland MD, Mayo-Smith W: Image-guided ablation of adre- nal tumors. Tech Vasc Interv Radiol 16:262-268, 2013
17. Sharma KV, Venkatesan AM, Swerdlow D, et al: Image-guided adrenal and renal biopsy. Tech Vasc Interv Radiol 13:100-109, 2010
18. Frenk NE, Daye D, Tuncali K, et al: Local control and survival after image-guided percutaneous ablation of adrenal metastases. J Vasc Interv Radiol 29:276-284, 2018
19. Wolf FJ, Dupuy DE, Machan JT, et al: Adrenal neoplasms: Effectiveness and safety of CT-guided ablation of 23 tumors in 22 patients. Eur J Radiol 81:1717-1723, 2012
20. Carrafiello G, Lagana D, Recaldini C, et al: Imaging-guided percutane- ous radiofrequency ablation of adrenal metastases: Preliminary results at a single institution with a single device. Cardiovasc Intervent Radiol 31:762-767, 2008
21. Mayo-Smith WW, Dupuy DE: Adrenal neoplasms: CT-guided radiofre- quency ablation-preliminary results. Radiology 231:225-230, 2004
22. Wood BJ, Abraham J, Hvizda JL, et al: Radiofrequency ablation of adre- nal tumors and adrenocortical carcinoma metastases. Cancer 97:554- 560, 2003
23. Welch BT, Atwell TD, Nichols DA, et al: Percutaneous image-guided adrenal cryoablation: Procedural considerations and technical success. Radiology 258:301-307, 2011
24. Ren C, Liang P, Yu XL, et al: Percutaneous microwave ablation of adre- nal tumours under ultrasound guidance in 33 patients with 35 tumours: A single-centre experience. Int J Hyperthermia 32:517-523, 2016
25. Patel IJ, Davidson JC, Nikolic B, et al: Consensus guidelines for peripro- cedural management of coagulation status and hemostasis risk in percu- taneous image-guided interventions. J Vasc Interv Radiol 23:727-736, 2012
26. Lenders JW, Duh QY, Eisenhofer G, et al: Pheochromocytoma and para- ganglioma: An endocrine society clinical practice guideline. J Clin Endo- crinol Metab 99:1915-1942, 2014
27. Venkatesan AM, Locklin J, Lai EW, et al: Radiofrequency ablation of met- astatic pheochromocytoma. J Vasc Interv Radiol 20:1483-1490, 2009
28. Venkatesan AM, Kundu S, Sacks D, et al: Practice guidelines for adult antibi- otic prophylaxis during vascular and interventional radiology procedures. Written by the Standards of Practice Committee for the Society of Interven- tional Radiology and Endorsed by the Cardiovascular Interventional Radio- logical Society of Europe and Canadian Interventional Radiology Association [corrected]. J Vasc Interv Radiol 21:1611-1630, 2010 .. quiz 1631
29. Liu SY, Chu CC, Tsui TK, et al: Aldosterone-producing adenoma in pri- mary aldosteronism: CT-guided radiofrequency ablation-long-term results and recurrence rate. Radiology 281:625-634, 2016
30. Hasegawa T, Yamakado K, Nakatsuka A, et al: Unresectable adrenal metastases: Clinical outcomes of radiofrequency Ablation. Radiology 277:584-593, 2015
31. Li X, Fan W, Zhang L, et al: CT-guided percutaneous microwave abla- tion of adrenal malignant carcinoma: Preliminary results. Cancer 117:5182-5188, 2011
32. Wang Y, Liang P, Yu X, et al: Ultrasound-guided percutaneous micro- wave ablation of adrenal metastasis: preliminary results. Int J Hyperther- mia 25:455-461, 2009
33. Xiao YY, Tian JL, Li JK, et al: CT-guided percutaneous chemical ablation of adrenal neoplasms. AJR Am J Roentgenol 190:105-110, 2008
34. Ahmed M, Solbiati L, Brace CL, et al: Image-guided tumor ablation: Standardization of terminology and reporting criteria-a 10-year update. J Vasc Interv Radiol 25:1691-1705, 2014,
35. Nunes TF, Szejnfeld D, Xavier AC, et al: Percutaneous ablation of func- tioning adrenal adenoma: A report on 11 cases and a review of the liter- ature. Abdom Imaging 38:1130-1135, 2013
36. Park HS, Roman SA, Sosa JA: Outcomes from 3144 adrenalectomies in the United States: Which matters more, surgeon volume or specialty? Arch Surg 144:1060-1067, 2009
37. Whelton PK, Carey RM, Aronow WS, et al: 2017 ACC/AHA/AAPA/ABC/ ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Associ- ation Task Force on clinical practice guidelines. J Am Coll Cardiol 71: e127-e248, 2018
38. Zheng L, Zhou F, Yu X, et al: Hypertensive crisis during microwave ablation of adrenal neoplasms: A retrospective analysis of predictive fac- tors. J Vasc Interv Radiol 30:1343-1350, 2019
39. Liang KW, Jahangiri Y, Tsao TF, et al: Effectiveness of thermal ablation for aldosterone-producing adrenal adenoma: A systematic review and meta-analysis of clinical and biochemical parameters. J Vasc Interv Radiol 30:1335-1342, 2019,
40. Atwell TD, Wass CT, Charboneau JW, et al: Malignant hypertension during cryoablation of an adrenal gland tumor. J Vasc Interv Radiol 17:573-575, 2006
41. Chini EN, Brown MJ, Farrell MA, et al: Hypertensive crisis in a patient under- going percutaneous radiofrequency ablation of an adrenal mass under gen- eral anesthesia. Anesth Analg 99:1867-1869, 2004 .. table of contents
42. Tsoumakidou G, Buy X, Zickler P, et al: Life-threatening complication during percutaneous ablation of adrenal gland metastasis: Takotsubo syndrome. Cardiovasc Intervent Radiol 33:646-649, 2010
43. Szejnfeld D, Nunes TF, Giordano EE, et al: Radiofrequency ablation of functioning adrenal adenomas: Preliminary clinical and laboratory find- ings. J Vasc Interv Radiol 26:1459-1464, 2015
44. Liang HL, Pan HB, Lee YH, et al: Small functional adrenal cortical ade- noma: treatment with CT-guided percutaneous acetic acid injection-re- port of three cases. Radiology 213:612-615, 1999
45. Sarwar A, Brook OR, Vaidya A, et al: Clinical outcomes following percu- taneous radiofrequency ablation of unilateral aldosterone-producing adenoma: Comparison with adrenalectomy. J Vasc Interv Radiol 27:961-967, 2016
46. Pacak K, Fojo T, Goldstein DS, et al: Radiofrequency ablation: A novel approach for treatment of metastatic pheochromocytoma. J Natl Cancer Inst 93:648-649, 2001
47. Shibata T, Maetani Y, Ametani F, et al: Percutaneous ethanol injection for treatment of adrenal metastasis from hepatocellular carcinoma. AJR Am J Roentgenol 174:333-335, 2000
48. Yamakado K, Anai H, Takaki H, et al: Adrenal metastasis from hepato- cellular carcinoma: Radiofrequency ablation combined with adrenal arterial chemoembolization in six patients. AJR Am J Roentgenol 192, 2009. p. W300-5