Hemodynamic instability during percutaneous ablation of extra-adrenal metastases of pheochromocytoma and paragangliomas: a case series

Abstract

BackgroundSurgical manipulation of pheochromocytomas and paragangliomas (PPGLs) may induce large hemodynamic oscillations due to catecholamine release. Little is known regarding hemodynamic instability during percutaneous ablation of PPGLs. We examined intraprocedural hemodynamic variability and postoperative complications related to percutaneous ablation of extra-adrenal metastases of PPGL.MethodsFrom institutional PPGL registry we identified patients undergoing ablation of extra-adrenal PPGL metastases from January 1, 2000, through December 31, 2016. We reviewed medical records for clinical characteristics and hospital outcomes. Tumors were categorized as functional or nonfunctional based on preprocedural fractionated catecholamine and metanephrine profiles.ResultsTwenty-one patients (14 female [67%]) underwent 38 ablations. Twenty-four ablations were performed in patients with functional metastatic lesions, and 14 were in nonfunctional lesions. Intraprocedural use of potent vasodilators for hypertension was higher for patients with functional tumors (P = 0.02); use of vasopressors for hypotension was similar for functional and nonfunctional tumors (P = 0.74). Mean (±SD) intraprocedural blood pressure range (maximum–minimum blood pressure) during 38 procedures was greater for functional than nonfunctional tumors [systolic: 106 (±48) vs 64 (±30) mm Hg, P = 0.005; diastolic: 58 (±22) vs 35 (±14) mm Hg, P = 0.002; mean arterial: 84 (±43) vs 47 (±29) mm Hg, P = 0.007]. Complications included 5 unplanned intensive care unit admissions (3 for precautionary monitoring, 1 for recalcitrant hypotension, and 1 for hypertensive crisis), 1 case of postoperative bleeding, and 1 death.ConclusionsSubstantial hemodynamic instability may develop during ablation of functional and nonfunctional PPGL metastases. When anesthesia is provided for ablation of metastatic PPGLs in radiology suites, preparation for hemodynamic management should match standards used for surgical resection.

Thermal ablation in adrenal disorders: a discussion of the technology, the clinical evidence and the future

“…Its indications are additionally broadened to those unwilling or unfit for adrenalectomy due to co-morbidity [ 49 ]. It is in this regard that thermal therapy has been trialed amongst small cohorts as a (i) minimally invasive alternative to definitive management of benign adrenal adenomas [ 39 , 50 – 56 ], (ii) adrenal metastases in patients unsuitable for surgery and [ 3 , 10 , 48 ▪▪ , 57 – 59 ] (iii) for local management of metastatic adrenal cancers [ 60 ▪▪ , 61 ▪▪ , 62 , 63 ▪▪ ].…”

“…Adrenal thermal ablation of phaeochromocytoma has had variable success. Hypertensive crisis (HTC) arising from tumoral degranulation of stored catecholamine remains a high risk and adrenalectomy remains the unquestionable treatment of choice [ 62 , 63 ▪▪ , 70 ].…”

“…Single case studies have demonstrated efficacy of this approach for spinal metastasis from ACC [ 60 ▪▪ ]. Similarly, localised therapy has been used to treat metastatic deposits from phaeochromocytoma/paraganglioma (PGGL), not fully controlled with chemotherapy or Peptide Receptor Radionuclide Therapy alone [ 62 , 63 ▪▪ ]. A recent case series described the outcomes of 31 patients with metastatic PGGL all of whom were alpha blocked for 7–14 days prior to ablation and treated with a combination of RFA, cryoablation or ethanol injection.…”

“…Tumour progression was reported in 6–26% (median time to progression 16 months). Symptoms related to catecholamine excess also improved in patients treated using this modality and procedural HTC was reported in 14% [ 62 , 63 ▪▪ ].…”

Percutaneous Adrenal Radiofrequency Ablation: A Short Review for Endocrinologists

“…Hypertensive crisis is frequently encountered during RFA procedures due to excessive excretion of catecholamines from the ablated adrenal medulla [41][42][43][44][45]. Theoretically, this complication is more severe in patients with pheochromocytomas producing epinephrine and norepinephrine [46][47][48][49]. Two or three weeks prior to RFA, these patients should undergo preoperative blockade to prevent peri-procedural (or intra-procedural) cardiovascular complications and blood pressure (BP) control.…”