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Case Report |
1
Department of Radiology, One Silverstein Bldg., Hospital of the University of
Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104.
2
Present address: Division of Vascular and Interventional Radiology, MHB 4-100,
New York Presbyterian Hospital-Columbia, 177 Fort Washington Ave., New York,
NY 10032.
3
Department of Medicine, Hematology/Oncology Division, University of
Pennsylvania Medical Center, Philadelphia, PA 19104.
Received July 27, 1999;
accepted after revision September 14, 1999.
Address correspondence to Z. J. Haskal.
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A follow-up CT performed 6 months later revealed a substantial increase in the size of the mass, which at this time measured more than 11 cm (Fig. 1A). The mass had central hypoattenuation that likely represented necrosis. By this time, the patient had developed left-sided abdominal pain, and laboratory studies revealed an elevated serum cortisol level over a 24-hr period. Multiple passes from a CT-guided biopsy were nondiagnostic, revealing only scant cellular debris; however, the radiologic and laboratory findings were most consistent with functioning primary adrenal adenocarcinoma.
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The patient was referred for possible transcatheter chemoembolization of the mass. Aortography and selective left renal arteriography were performed, which revealed an almost entirely hypovascular 11-cm left adrenal mass. A 2-cm pseudoaneurysm arose from a small peripheral upper pole branch of the left renal artery associated with a tiny corkscrewlike vessel, which extended to the large adrenal mass, representing parasitized vascularity. This tumor vessel was too small to superselectively catheterize; therefore, tumor embolization could not be performed.
Because the patient was still a poor surgical candidate, it was decided to attempt percutaneous ablation of the tumor. Prednisone was administered to the patient in case an addisonian crisis followed tumor ablation.
Under sonographic guidance, a 22-gauge needle was advanced into the center of the mass, and approximately 30 ml of absolute ethanol was instilled. The patient tolerated the procedure well, requiring only minimal IV conscious sedation. She returned for three additional ethanol injections, for a cumulative dose of 120 ml of ethanol over a 4-month period, and tolerated each injection without difficulty.
Approximately 5 months after the first treatment, the patient returned for follow-up imaging of the tumor. Enhanced CT revealed a decrease in tumor size, which measured 7.8 cm at this time (Fig. 1B). The tumor had developed central gas formation; however, the patient was asymptomatic, without fever, pain, leukocytosis, or other evidence of infection. An FDG PET scan was obtained on an ADAC C-PET scanner (UGM Medical Systems, Philadelphia, PA) after IV injection of 2.99 mCi (110.63 MBq) of FDG. The scans revealed a large photopenic area in the tumor (Figs. 1C and 1D), indicating essentially absent metabolic activity in the tumor. The standardized uptake values were 0.41-0.49 in the photopenic center of the tumor and 1.21-1.58 at the thin tumor margin. The patient has remained on a low dose of oral corticosteriods since the initial treatment to prevent addisonian crisis; thus, serum cortisol levels have not been followed clinically. She remains well 8 months after initial referral to our service and has experienced no adverse effects from the treatment. Her flank pain has resolved.
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Percutaneous ethanol injection has been applied to a number of tumors of the liver [1, 2], and tumors of the kidneys [3]. Although the technique typically requires a larger number of treatments than radiofrequency ablation, ethanol ablation has been associated with fewer complications [4]. The technique carries potential morbidity; rare instances of fatal thrombotic disease, tumor seeding of the pleural or peritoneal spaces, and other complications have been reported [5].
Application of percutaneous ethanol ablation to the treatment of benign adrenocortical adenoma has been described [6]. In a case report, percutaneous ethanol ablation was reported to be an effective adjunct for treatment of an aldosterone-producing adenoma, and this was not associated with complications. The use of percutaneous ethanol ablation to treat adenocarcinoma of the adrenal gland has not, to our knowledge, been previously reported. We performed multiple cycles of percutaneous ethanol ablation in our patient, and over time the adrenal mass not only stopped growing, but also decreased in size and developed central necrosis and gas formation. We were unfortunately unable to obtain proof of cell type on our CT-guided biopsy, probably because of extensive necrosis of the tumor. However, the CT appearance of the mass, including the heterogeneous enhancement, central necrosis, growth rate, and size, were highly suggestive of malignancy. Adrenal masses larger than 6 cm have been considered to likely represent malignant lesions [7]. In our patient, a lack of identifiable malignancy elsewhere in the body and the presence of elevated serum cortisol levels strongly suggested that the tumor represented a hormonally active primary adenocarcinoma of the adrenal gland.
For more than a decade FDG PET has been increasingly applied to the staging and follow-up of patients with malignancies. Apart from its well-established use for staging a wide variety of primary malignant tumors [8], FDG PET has also been used for the evaluation of treatment response after surgery, chemotherapy, or radiation therapy [8]. The use of PET to follow the tumor response to transcatheter chemoembolization of liver tumors has been described [9]; however, the use of PET to assess tumor response to percutaneous ethanol ablation, particularly that of adrenal tumors, has not, to our knowledge, been described.
Although PET was not performed before treatment, the complete absence of FDG radiotracer activity in the adrenal tumor after treatment suggested an excellent response to the ablation therapy. Diffusion of alcohol throughout a tumor is variable, depending on a variety of factors, including the fibrous or scirrhous nature of the treated mass. PET findings, which suggested homogenous tumor destruction, confirmed that our multiple alcohol injections effectively addressed the entire mass. Based on our findings, we have ceased performing percutaneous ethanol ablation and will now follow her condition with periodic PET and CT. In retrospect, it would have been ideal to obtain a baseline PET examination before initiation of therapy. Nevertheless, even slowly growing tumors have low levels of FDG activity on PET; thus, the complete absence of uptake is suggestive of massive tumor cell death despite the lack of PET before treatment.
In summary, percutaneous ethanol ablation may provide a promising treatment option for malignant tumors of the adrenal gland for patients who are not candidates for surgical resection. Further studies are needed to determine the efficacy and safety of the technique with different cell types. FDG PET may play a role in evaluating the response to treatment in this unique patient population.
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Erratum Am. J. Roentgenol., June 1, 2000; 174(6): 1791 - 1791. [Full Text]
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