Background: Adrenal metastases are relatively common in patients with known malignancy. In patients who are not candidates for adrenalectomy, percutaneous radiofrequency ablation can offer an alternative management strategy. There is evidence to suggest adrenergic blockade can reduce the risk of hypertensive crisis.
Case: A 67-year-old gentleman with metastatic hepatocellular carcinoma (HCC) with a left adrenal gland metastasis unsuccessfully treated with radiotherapy in May 2023, underwent an interventional radiology guided ablation of the adrenal metastasis in April 2024. The patient required pre-operative alpha blockade with an up-titrated dose of phenoxybenzamine 30mg TDS with IV normal saline for intravascular volume expansion. The patient tolerated the procedure well with no intraoperative hypertension.
Discussion: The prevalence of adrenal metastases in HCC has been reported between 8.0-19.1% [1]. Adrenalectomy for adrenal metastases may not be appropriate depending on the burden of metastatic disease and other comorbidities [2]. Imaging-guided percutaneous ablation can be safe for selected adrenal tumours, offering an alternative therapy for non-surgical candidates [3]. Hypertensive crisis is a potential complication due to excessive catecholamine excretion from ablated adrenal medulla [4] which can be managed by periprocedural adrenergic blockade. In a meta-analysis of 15 studies of percutaneous adrenal metastases ablation [2], the overall pooled rate of hypertensive crisis in 11 studies was 6%, with a rate of 10% in the 3 studies of patients with primary HCC. Adrenal insufficiency is a rare complication of adrenal ablation in the setting of unilateral disease. In one study, adrenal insufficiency occurred in 13/58 (22%) of patients following ablation, of whom 10 had a history of contralateral adrenalectomy or metastases [5]. Whilst numbers are limited, with appropriate adrenergic-blockade, adrenal ablation can be a safe option for adrenal metastases management in certain patients.