Role of Adrenal Embolization in the management of Cushing s syndrome

Transcription

1 Role of Adrenal Embolization in the management of Cushing s syndrome Shazia Ahmad MD Fellow-Division of Endocrinology Albany Medical Center

2 Patient Case Summary 35 year old woman presented to outside hospital with 3 day history of progressive worsening nausea, vomiting, and altered mental status; she was found to be in severe sepsis of unclear origin, and transferred to Albany Medical Center (AMC) on November 28, 2015 for higher level of care. In AMC ER, patient progressed to septic shock, intubated, started on pressors, with MAP persistently <50. She was started to stress dose steroids- 100 mg hydrocortisone q8h. Admitted to ICU on broad spectrum antibiotics. Hospital course was complicated by multiple organ failure requiring CRRT, continued ventilator and pressor support. Endocrinology was consulted on hospital day 2 for the concern that patient has history of Cushing's syndrome. At that time patient was changed to dexamethasone 4mg q8 and slowly titrated off.

3 Background Progressive clinical deterioration: Complains of vague symptoms of low energy, weight gain, agitation, decreased appetite. Initially diagnosed with Chronic Lyme Disease and received months of antibiotic treatment via PICC line. Sustained a fall resulting in right femur mid shaft fracture. Failed ORIF x 3. Managed at different facilities in NYC and MA. While undergoing rehab to ambulate, dislocated her right shoulder - as such became wheelchair bound. CT abdomen in 2010, showed incidental 2.2 cm left adrenal massno work up done at that time. ~100 lb. weight gain developed stretch marks, swollen legs menses stopped loss of hair; thinning skin and nails recurrent infections Normal young college girl Continued to deteriorate

4 Workup for Cushing's begins Her mother was concerned of Cushingoid features after internet search and requested PCP for further work up Referred to Endocrinologist. Labs were repeated on multiple occasions. Biochemical findings did not fully correlate to the extent of clinical symptoms. OUTPATIENT WORK UP CT scan 3.5 cm Left adrenal tumor (previously 2.2cm in 2010) Random cortisol 26.1 ug/dl (upper limit of normal 22.4) ACTH less than 1.1 pg/ml 24-hour urine free cortisol 50.5 mcg/day (nl< 24) Repeat- 24-hour urine free cortisol is 25.8 mcg/day 1 am salivary cortisol ug/dl (nl<0.112) TSH 0.03 on Levothyroxine (dose decreased) Creatinine 1.2, calcium 9.8, potassium

5 Planned to start on Mifepristone Cardiac evaluation done for concerns of Cushing's related cardiomyopathy Scheduled for left adrenal laparoscopic surgery in October 2015 Referred to Endocrine surgery Patient sustained another fall, fractured her cervical spine and multiple ribs and surgery was delayed Patient had vomiting, fever abdominal pain and was taken to ED for further evaluation. August 2015 September 2015 October 2015 November 2015

6 Back to Hospital Course Work up of septic shock: Patient was found to have necrotic pancreatitis with peri-pancreatic abscess (pseudomonas + candida) and multiple colonic fistulas. She underwent multiple surgical drainages followed by an open abdominal exploration and lavage to manage her extensive infectious process. Endocrine surgery was consulted, but patient was not considered surgical candidate as such decision to treat medically was made. Pretreatment (while in ICU): Cortisol levels ranged between ug/dl ACTH ~ ug/dl

7 A 2.8 CM LEFT ADRENAL NODULE COMPATIBLE WITH A LIPID-POOR ADRENAL ADENOMA

8 Medical Management Date Ketoconazole Dose Cortisol level ug/dl 12/25/15 200mg daily /5/16 200mg TID 5.9 1/14/ mg TID 23.4 Date Metyrapone Dose Cortisol level ug/dl Good initial response Response faded due to decreased absorption with concomitant PPI administration 1/18/16 500mg TID /25/16 750mg TID /30/ mg TID 9.2 2/22/ mg TID 0.7 Lowest level achieved

9 Hospital Course continues 1/27/16 Underwent exploratory laparotomy, drainage of pancreatic abscesses, small bowel resection; Left adrenal gland was not successfully accessed due to extensive adhesions and bleeding. 2/24/16 Super selective embolization of the patient's left adrenal adenoma performed by interventional radiology; Metyrapone was stopped and patient was started on Hydrocortisone replacement on discharge. Weight trend while on medical management: 82 kg on admission 101 kg ( 1/4/16) 72 kg

10 SUPER SELECTIVE ADRENAL EMBOLIZATION OF LEFT ADRENAL GLAND

11 Arterial anatomy of adrenal gland

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15 ADRENAL ARTERY EMBOLIZATION Adrenal artery embolization is a minimally invasive procedure that can be used as an alternative or adjunct to surgery. Because multiple arteries can supply the adrenal gland, it is important to investigate all of the potential sources of bleeding or tumor vascularity for successful procedure. Fowler AM et al. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations. AJR :

16 Indications: Indications for adrenal artery embolization include: Oncologic applications for palliation, such as: pain relief reduction of tumor bulk preoperative reduction of tumor vascularity Emergency embolization for hemostasis of ruptured tumors with retroperitoneal hemorrhage Adrenal artery embolization can also be used to Suppress excess adrenal hormone production Treat traumatic adrenal artery injury Occlude adrenal artery aneurysms Fowler AM et al. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations. AJR :

17 ADRENAL EMBOLIZATION FOR HORMONE SUPRESSION IN CUSHING S SYNDROME Transarterial embolization has been used to treat corticotrophin-independent causes (adrenal adenoma, adrenal cortical carcinoma) and corticotrophin-dependent causes (ectopic corticotrophins syndrome from medullary thyroid carcinoma) of Cushing s Syndrome. Embolization was found effective in hormone and symptom control for two of the three patients with Cushing s syndrome due to inoperable adrenal cortical carcinoma reported by O Keeffe et al. and for the one patient reported by Uflacker et al. for at least 1 year. Fowler AM et al. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations.AJR :

18 Fowler AM et al. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations.AJR :

19 Fowler AM et al. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations. AJR :

20 Ueno K et al. Transcatheter adrenal arterial embolization of cortisol-producing tumors. Two cases of Cushing's syndrome.acta Radiol Jan.40(1):100-3

21 Ueno K et al. Transcatheter adrenal arterial embolization of cortisol-producing tumors. Two cases of Cushing's syndrome. Acta Radiol Jan. 40(1):100-3

22 O'Keeffe FN et al. Arterial embolization of adrenal tumors: results in nine cases. AJR Am J Roentgenl.1988 Oct.151(4):

23 O'Keeffe FN etal; Arterial embolization of adrenal tumors: results in nine cases.ajr Am J Roentgenl.1988 Oct.151(4):

24 Fowler AM etal. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations.AJR :

25 TECHNIQUE CONSIDERATION General Procedure: Moderate sedation and local anesthetic at the vascular access site. Access is achieved via common femoral artery puncture with an 18-gauge puncture needle ( Seldinger technique). A guidewire is passed centrally under fluoroscopic guidance, and a 6-French vascular sheath is placed and connected to a low pressure heparinized saline flush. Because of the variable anatomy, additional arteriograms of the inferior phrenic and renal arteries are obtained. Fowler AM et al. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations. AJR :

26 For super-selection, a 3-French micro-catheter system is used with coaxial technique. Digital subtraction angiography is performed to confirm appropriate catheter placement. The embolic agent is administered by flow-control technique. Post-embolization angiography is performed to evaluate for additional arteries that may be supplying the tumor. Fowler AM et al. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations.AJR :

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28 CHOICE OF EMBOLIC AGENT No reports in the literature showing superiority of one embolic agent over others. Considerations in choosing an embolic agent include the; clinical application and endpoint desired (permanent versus temporary occlusion), experience and preference of the radiologist, and cost and availability of the agent. Fowler AM et al. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations. AJR :

29 Permanent proximal vessel occlusion can be achieved with micro coils. (aneurysms). Temperory effects can be achieved with Gelatin sponge particles(gelfoam, Pfizer) which are the least expensive particulate embolic agent. (hemorrhagic adrenal masses and to suppress the hormonal function of pheochromocytoma). Semi permanent particulate agents include PVA and trisacryl gelatin microspheres. (tumor embolization and traumatic adrenal hemorrhage). Fowler AM et al. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations.AJR :

30 COMPLICATIONS Patients generally tolerate adrenal artery embolization well with typically selflimited symptoms that can be treated conservatively. Mild to moderate flank pain lasting less than 48 hours and low-grade fever are the most common complications. Transient pleural effusion has been observed transient ischemia of the diaphragm from embolization of the inferior phrenic artery. Persistent hiccups due to diaphragmatic irritation inferior phrenic artery embolization. Fowler AM et al. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations.AJR :

31 Transient hypertension: Ueno et al. No immediate deaths or serious complications have been reported. Precise micro-coil placement is important. The proximal end of platinum coil placed in a left middle adrenal artery for hemostasis due to vessel rupture in a 32-year-old pregnant woman was noted to project into the aortic lumen at the ostium of the adrenal artery, indicating a more proximal location of coil deployment than intended. The coil was thought to be a potential source of thrombus, it was removed without complication (Christie J etal: Adrenal artery rupture in pregnancy. BJOG 2004) Fowler AM et al. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations.AJR :190-22

32 Risk of reflux of embolic agents into normal arteries and risk for contrast extravasation from too forceful injection. Accidental non target embolization can lead to ischemia. Transverse palsy of the lower extremities occurred in a patient in whom inadvertent embolization of the anterior spinal artery occurred at adrenal artery embolization for adrenal metastasis from hepatocellular carcinoma (Kitagawa Y et al. Adrenal metastasis from hepatocellular carcinoma: report of a case. Hepato-gastroenterology;1996) The spinal artery can originate from the middle adrenal artery, and in one caser report, embolization was thus not performed in a patient with aldosteronoma to avoid possible spinal infarction (Hokotate H, etal: Aldosteronomas: experience with super-selective adrenal arterial embolization in 33 cases. Radiology 2003) Fowler AM et al. Adrenal Artery Embolization: Anatomy, Indications, and Technical Considerations.AJR :190-22

33 Back to our patient Patient underwent successful left sided super-selective adrenal embolization with elastic coils by interventional radiology at AMC in Feb Patient was discharged to rehabilitation facility on Hydrocortisone 10 mg QAM and 5 mg QPM.

34 Post-treatment follow up: Follow up on March 26, 2016: Patient was overall doing well Her appearance significantly improved Continued on Wheelchair, but plan for shoulder surgery once out of rehab Weight further improved to 63 kg (Admission weight of 82 Kg) LABS: Random cortisol am 12ug/dL, ACTH 13pg/dL, DHEAS <15 ==> given symptoms of low energy and low appetite, Hydrocortisone was increased to 15mg am and 10mg pm. LH 1.7, FSH 3.2, Progesterone 0.45, Estradiol 43 Vitamin D 39.2 (on Vitamin D 1000iu Daily) TSH 3.81 (on Levothyroxine 175mcg daily)

35 Follow up on June Discharged from rehab in May 2016 Energy level and Cushingoid features improved significantly Weight remained stable at 65kg Scheduled to see Orthopedic surgery on July 1, 2016 for shoulder surgery evaluation LABS: Cosyntropin Stim test: cortisol 5.5 (baseline) 11.9 (60 min post cosyntropin) continued on replacement. ACTH 13, progesterone 0.26, DHEAS undetectable Calcium: 9.2; vitamin D 38.7 LH is still low 0.2, FSH 1.6, Estradiol 28 Started on OCPs (Sprintec 0.25mg/35mcg daily)

36 4 months follow up CT scan

37 July : Father called Endocrine clinic stating that his daughter could not get out of bed last night; when tried to help her to her feet, patient fell to the floor with garbled speech; No head trauma She was found to have a hemorrhagic stroke and hospitalized at AMC She underwent decompressive craniotomy, started on dexamethasone 4mg q6hr July : Patient placed on comfort measures only and she died within 24 hours.

38 CT Head

39 Thank you