Cushing’s syndrome managed by endoscopic ultrasound-guided radiofrequency ablation of adrenal gland adenoma

A 38-year-old woman presented with “moon face,” “buffalo hump,” and weight gain of 9 kg in 12 months. Overnight, 1 mg dexamethasone failed to suppress the morning level of cortisol, and the 24-hour urine cortisol level was elevated to 101 μg/day (normal range 0 – 50). Initial contrast-enhanced abdominal computed tomography (CT) showed a 2.8-cm left adrenal mass enhanced in arterial phase, and the patient was diagnosed with Cushing’s syndrome due to left adrenal adenoma ([Fig. 1 a]). She refused surgical treatment but agreed to undergo endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA; STARmed, Koyang, Korea) ([Video 1]).

Fig. 1 Computed tomography scan showing a 2.8-cm left adrenal adenoma with arterial enhancement in the coronal view (arrows). a Before endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA). b After EUS-RFA.

Video 1: Endoscopic ultrasound-guided radiofrequency ablation performed on a left adrenal adenoma for the management of Cushing’s syndrome.

Prior to RFA, contrast-enhanced EUS with SonoVue (Bracco, Inc., Milan, Italy) was performed. Findings of early enhancement and delayed washout were compatible with adrenal adenoma ([Fig. 2 a]).

Fig. 2 Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) of the left adrenal adenoma. a Contrast-enhanced EUS with early enhancement. b The EUS-RFA needle positioned inside the adenoma.

A 19-guage needle electrode was positioned inside the adenoma. Using real-time EUS imaging, RFA (50 W) was performed at five different sites ([Fig. 2 b]).

Four days later contrast-enhanced EUS revealed viable tissue remaining at the marginal edge of the previously ablated portion of the adenoma ([Fig. 3 a]). EUS-RFA was repeated at five more sites in the remaining viable tissue ([Fig. 3 b]).

Fig. 3 Contrast-enhanced endoscopic ultrasound (EUS) 4 days after the first EUS-guided radiofrequency ablation (RFA) treatment. a Central hypo-echogenicity with enhancement remained at the marginal edge of the adenoma. b Repeat EUS-RFA was performed.

Follow-up CT at 1 week showed the adrenal mass almost completely replaced with necrotic tissue, without complications ([Fig. 1 b]). Serum and urine cortisol levels returned to normal the following day and remained normal for the next 2 months, with no adverse events related to RFA. However after the third month, the cortisol levels were re-elevated and this time the patient agreed to surgery.

Until recently, there were only a few case reports of RFA for the treatment of Cushing’s syndrome; all of them were treated via the CT-guided percutaneous method [1] [2]. The present case is the first in which EUS-RFA was used to manage Cushing’s syndrome caused by adrenal adenoma. This case report supports EUS-RFA as a safe and feasible alternative method that should be considered in patients who refuse surgical treatment. Further evidence and experiences are required.

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• References

• 1 Nishi N, Tanaka J, Minagawa A. Cushing syndrome treated by radiofrequency ablation of adrenal gland adenoma. Jpn J Radiol 2012; 30: 274-276
• 2 Nunes TF, Szejnfeld D, Xavier AC. et al. Percutaneous ablation of functioning adrenal adenoma: a report on 11 cases and a review of the literature. Abdom Imaging 2013; 38: 1130-1135