ORIGINAL ARTICLE
Hiroshi YOKOYAMA . Ichiro KONOMI Tetsumasa MIYAJIMA · Shunzo TAMARU Masatoshi TANAKA
Interventional ultrasound for adrenal masses
Received: March 27, 2006 / Accepted: June 5, 2006
Abstract
Purpose. To determine the value of interventional ultra- sound (US) for adrenal masses, especially incidentally dis- covered adrenal masses.
Methods. Demographic, clinical, and pathological data were reviewed for eight patients who underwent percutane- ous US-guided puncture or biopsy for adrenal masses from September 1994 through March 2002 in our institute.
Results. US-guided intervention was successfully per- formed for seven patients: two with adrenal cysts, two with adrenocortical adenomas, and three with metastatic adrenal tumors (one from prostate cancer, one from lung cancer, and one from renal cell carcinoma). The remaining patient had bilateral adrenal masses, and a biopsy specimen could not be obtained because safe puncture was difficult. For all patients there was no postoperative hemorrhage or pain, and no major complications were observed during the procedure.
Conclusions. Interventional US using the color Doppler method for adrenal masses is a useful procedure for safe puncture to reveal the orientation of adjacent viscera and blood vessels at the puncture site and to avoid complica- tions including hemorrhage and pneumothorax. US, in- cluding color Doppler US, is also useful for detection of complications and follow-up studies because it is noninvasive and can be used for real-time examinations. In addition, pathological examination of specimens obtained by percutaneous biopsy or fine needle aspiration is useful for avoiding unnecessary surgery in patients with metastatic adrenal masses.
Keywords adrenal mass · interventional ultrasound
Department of Urology, Fukuoka University School of Medicine, 7-45-1 Nanakuma, Jonan, Fukuoka 814-0180, Japan
Tel. +81-92-801-1011; Fax +81-92-873-1109 e-mail: hyokoyam@fukuoka-u.ac.jp
Introduction
Since it was established in the 1970s by Holm et al.,1 ultra- sound (US)-guided puncture has been extensively used in the clinical setting. Its scope of application has been ex- panding since a color Doppler US-guided puncture tech- nique was reported by Saito et al. in the 1990s.2 At present, US-guided puncture is also used for various organs of the urogenital system at our facility. Following recent advances in diagnostic imaging and techniques for the clinical evalu- ation of diseases, the frequency of incidental detection of adrenal masses has been increasing.3-7 Despite various argu- ments made to date concerning how to deal with adrenal masses detected incidentally, no consensus has yet been reached on this issue.
We analyzed patients in whom US-guided puncture had been used to evaluate adrenal masses and examined the roles played by US-guided puncture in the diagnosis of adrenal masses, especially those detected incidentally. In the present article we report on the findings of this analysis.
Subjects and methods
The subjects of this study were eight patients who received US-guided puncture to evaluate incidentally detected adre- nal masses at the Department of Urology, Fukuoka Univer- sity Hospital, during the period from September 1994 to March 2002. We analyzed the background variables, mor- phology of the masses, affected side, presence/absence of endocrine activity of the masses, and histopathological fea- tures of these cases.
The ultrasonography systems used were the Aloka SSD- 2000 or SSD-5500 in combination with a 5-MHz convex probe, a 3.5-MHz microconvex probe, or a 5-MHz sector probe (Aloka, Tokyo, Japan). For cystic lesions, a 20G puncture needle was used. Biopsy was carried out using an automated biopsy device (Biopty; Bard, Covington, GA, USA), with an 18G biopsy needle.
| Patient | Age (years) | Sex | Side of mass | Size of mass (cm) | Diagnosis |
|---|---|---|---|---|---|
| 1 | 19 | Female | Right | 7 | Cyst |
| 2 | 68 | Male | Right | 3 | Cyst |
| 3 | 45 | Male | Right | 3 | Adrenocortical adenoma |
| 4 | 67 | Female | Bilateral | 3 | Not available |
| 5 | 50 | Female | Left | 3 | Adrenocortical adenoma |
| 6 | 79 | Male | Bilateral | 6 | Metastasis from carcinoma of the prostate |
| 7 | 81 | Male | Left | 4 | Metastasis from lung cancer |
| 8 | 52 | Male | Right | 7 | Metastasis from renal cell carcinoma |
Punctures were performed as follows. First, with the pa- tient in the prone position, the mass was observed by using two-dimensional gray-scale US. Then, a puncture line was designated, avoiding the blood vessels as visualized by color Doppler US. Puncture was then performed under the guid- ance of gray-scale US. As a rule, punctures can be carried out under local anesthesia alone. For two patients in the present study, however, epidural block was used at the request of the patient.
Results
Characteristics of the subjects and their adrenal masses are shown in Table 1. There were five men and three women, with ages ranging from 19 to 81 years (mean: 57.6 years). Puncture of the targeted mass was possible for seven of the eight patients. The mass was found to be an adrenal cyst in two patients, an adrenocortical adenoma in two patients, and a metastatic adrenal tumor in three patients (originat- ing from prostate cancer in one patient, lung cancer in one patient, and renal cell carcinoma in one patient). In one patient in whom an adrenal mass was visualized on both sides by an abdominal computed tomography (CT) scan, it was difficult to set a puncture line using a dorsal approach; therefore, it was not possible to carry out a biopsy. Postop- erative bleeding and pain were absent in all patients. No serious complications occurred in any patient after the procedure. Thus, unnecessary surgery was avoided in all of these patients. The courses three typical patients are described below.
Patient 1
Patient 1 was a 19-year-old woman with an adrenal cyst. The cyst had markedly compressed the inferior vena cava in the ventral direction and had been increasing in size (Fig. 1). When the cyst was punctured with a 20G puncture needle, a brown mud-like liquid flowed out. Because the cyst immediately closed after the first puncture, a 7-Fr pig- tail catheter was then inserted into the cyst, the contents were aspirated, and the inside was washed. The adrenal cyst almost completely disappeared after this treatment.
Patient 6
Patient 6 was a 79-year-old man. In 1990, he was diagnosed with well-differentiated prostate cancer. He subsequently underwent castration at a nearby hospital, but he stopped visiting the hospital for follow-up 3 years after treatment started. In 1996, he consulted a clinic because of back pain. At that time, bilateral adrenal masses were noted (Fig. 2). Furthermore, his serum prostate-specific antigen concentra- tion was high (396ng/ml) and his systemic condition was poor. He was thus referred to our department. At our de- partment, he was diagnosed with adrenal failure. Because metastatic adrenal tumor was suspected, we performed a needle biopsy to allow a definite diagnosis. Blood vessels surrounding the mass were identified by color Doppler US, and a puncture line was designated that avoided injury to the surrounding blood vessels. The left adrenal gland was then punctured (Fig. 3). The tumor was histopathologically rated as moderately differentiated to undifferentiated adenocarcinoma of the adrenal gland (metastatic from prostate cancer). Following the start of treatment with diethylstilbestrol diphosphate, the adrenal mass diminished markedly in size.
Patient 4 (unsuccessful puncture)
Patient 4 was a 50-year-old woman. Diagnostic imaging revealed masses in both adrenal glands (Fig. 4). When both adrenal glands were observed using gray-scale US, the right adrenal gland was not visible by scanning from the dorsal side; therefore, we planned to sample tissue from the left adrenal gland (Fig. 5). Because the patient had undergone valve replacement in the past to treat mitral stenosis and insufficiency, her heart function was compromised, and it was not possible for her to hold her breath for an extended period of time. Designating a puncture line from the dorsal side was therefore difficult, and tissue sampling was not possible. We considered puncturing the right adrenal gland via the liver, but we refrained from doing so because of her low endocrine activity. She was thus followed up without active treatment.
Discussion
US-guided puncture has been used for evaluation of the kidney, prostate, and other organs of the urogenital system.
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It is now an indispensable technique for urologists. The scope of its application has been expanding in recent years. When carrying out puncture, it should be possible to (1) confirm the anatomical relationship of the target organ to the surrounding organs, (2) avoid injury to blood vessels, and (3) take the shortest possible route for puncture. US- guided puncture is thus an optimal puncture method be- cause it satisfies these requirements. However, the adrenal glands are located at a high level within the retroperitoneal cavity, adjoining major organs (liver, kidneys, etc.) and large blood vessels, and incidentally detected adrenal masses are often small. For these reasons, physicians some- times hesitate to perform puncture guided solely by conven- tional gray-scale US. However, it has recently become possible to set a puncture line on the basis of the clearly defined locations of the surrounding organs and blood ves-
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sels by making use of color Doppler US. In the present study, this technique allowed us to perform US-guided puncture of the adrenal glands safely, without causing any complications (e.g. bleeding or pneumothorax). Two- dimensional ultrasonography (including color Doppler US) allows noninvasive observation on a real-time basis. It is also useful in checking for complications (e.g. bleeding) caused by puncture and for following the courses of indi- vidual patients. Although the locations and sizes of masses that can be punctured can vary depending on the skill of the surgeon, we think that, as a rule, masses that are clearly visible on two-dimensional ultrasound images can be
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punctured. However, when an automated biopsy device is used, it seems advisable to confine this technique to patients in whom the distance from the body surface to the mass is less than 15cm and the mass diameter is more than 2cm, with the aim of minimizing the biopsy needle stroke and the incidence of complications. Although puncture of inter-cos- tal areas and puncture via multiple organs are also possible, as a rule, to minimize the incidence of complications, it is advisable that puncture of inter-costal areas be confined to patients for whom a mass is clearly visible between the 11th and 12th ribs, and that puncture via the liver or kidney be performed with the shortest possible puncture line, avoid- ing blood vessels (as visualized by color Doppler US) as far as possible.
Although the frequency of incidental detection of adre- nal masses has been increasing following the widespread use of two-dimensional ultrasonography and CT scans,3-7 no consensus has yet been reached about how to deal with these masses. Three key points when diagnosing inciden- tally detected adrenal masses are: (1) checking for endo- crine activity of the tumor, (2) determining whether the tumor is solid or cystic, and (3) determining the tumor size. Surgical treatment is indicated for tumors with endocrine activity. For tumors without endocrine activity, adrenal puncture plays an important role in diagnosis of the tu- mors.3,7,8 In such cases, first the contents of the cystic mass must be checked by puncture and aspiration. Copeland re- ported that if the fluid collected from an adrenal cyst is transparent, the disease can be deemed benign and no addi- tional examination is needed. He added that even when the contents of the cyst are bloody, it does not inevitably imply malignancy, and that instead of immediate surgical resec- tion, the patient should be followed by diagnostic imaging
to check for changes in the morphological features of the mass.3 Second, a histopathological diagnosis is needed via biopsy of the solid tumor. Some investigators have ques- tioned the validity of this examination for adrenal tumors on the grounds that distinction between benign and malig- nant tumors of the adrenal gland is histologically difficult. However, Katz and Shirkhoda9 and Ochiai et al.1º have both reported results that refute this claim. Histological exami- nation of biopsy specimens is indicated particularly in cases where metastasis of a malignant tumor of some other organ to the adrenal gland is suspected.11,12 How best to distinguish between cases suitable for aspiration cytology and cases suitable for needle biopsy is still controversial. At our facil- ity, we make it a rule to perform needle biopsy for solid tumors to increase the amount of tissue collected for histo- pathological examination as much as possible, whereas we carry out aspiration cytology for cystic masses.
As illustrated above, diagnosis based on percutaneous puncture and aspiration of adrenal tumors allows unneces- sary surgery to be avoided. For this reason, US-guided puncture can be considered to be highly useful. However, because puncture can cause a fatal outcome in patients with pheochromocytoma, which accounts for about 10% of inci- dentally detected adrenal masses,13 it is essential to rule out pheochromocytoma by endocrinological screening before puncture is performed on adrenal masses, particularly cystic lesions. If the tumor is malignant, tumor seeding may occur. Ferrucci et al. reported that tumor seeding occurred in 1 out of 100 patients with adrenal masses.14 For this reason, as a rule, it is advisable to avoid biopsy in patients scheduled for radical surgery. Biopsy is clearly indicated for patients with metastatic adrenal tumors, like our patient 6, for whom histopathological examination can be expected to provide important information for determining the treatment strat- egy for the tumor.
In summary, we conclude the following from the present study:
1. In patients with adrenal masses, puncture guided by color Doppler US allows physicians to set a puncture line given clear information about the locations of the surrounding organs and blood vessels, and to perform puncture safely without causing any complications.
2. Two-dimensional ultrasonography, including color Dop- pler US, is useful in checking for puncture-related com- plications and following up individual patients because it allows noninvasive observation on a real-time basis.
3. In patients suspected of having a metastatic adrenal tu- mor, histopathological diagnosis based on percutaneous biopsy and aspiration is very useful because it allows unnecessary surgery to be avoided.
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