819

ArterialEmbolization of Adrenal
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Tumors: Results in Nine Cases

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Francis N. O’Keeffe1 Adrenal arterial embolization was performed in nine patients, four with inoperable
C. Humberto Carrasco adrenal cortical carcinoma and five with metastatic adrenal tumors. Embolic agents
Chusilp Chamsangavej used were polyvinyl alcohol foam (Ivalon) In seven patients, stainless steel coils In four,
ethanol in three, and surgical gelatin (Gelfoam) in two. In eight patients, embolizatlon
Williarn R. Richli
was performed for palliation, either to decrease tumor bulk (all patients), suppress
Sidney Wallace
tumor hormonal function (three patients), or relieve pain (four patients). One patient had
an embolization to facilitate subsequent adrenalectomy. In four patients in whom It was
possible to assess the effect of embolization on tumor bulk by follow-up CT, a striking
reduction in size had occurred in one, the lesions remained stable In size for 12 months
in two, and the tumor continued to increase in size In the fourth. A striking reduction In
the production of the cortisol for 12 months was seen in two of three patients with
Cushing syndrome. This reduction was considered due at least in part to embolization.
Adrenal embolization resulted in effective palliation of pain in three of four patients and
may have contributed to palliation in the fourth. Apart from a hypertensive episode in
one patient, the cause of which was unclear, no serious side effects occurred.
Adrenal arterial embolization may play an effective role without serious side effects
In palliation of pain and reduction of hormone production in inoperable adrenal lesions.

Although arterial embolization has been widely used in the management of

tumors [1], it has been used rarely in adrenal neoplasms [2-4]. Although technically
readily accomplished, transcatheter venous adrenal ablation has been reported to
be neither effective nor safe [5]. In this presentation, nine cases are described in
which adrenal arterial embolization was performed as part of the treatment of
primary and secondary carcinomas of the adrenal glands.

Materials and Methods

We reviewed the records of the nine patients referred for adrenal arterial embolization
during a 4-year period (1 982-1 986). The five women and four men were 37-72 years old.
Four patients had inoperable adrenal cortical carcinoma; three of these had associated
Cushing syndrome. The other five patients had metastatic adrenal lesions (three had renal
cell carcinoma, two had melanoma). Indications included reduction of tumor bulk (all patients),
suppression of tumor hormonal function (three patients), pain relief (four patients), and
preoperative reduction of vascularity (one patient).

Technical Considerations
Received March 1 1 , 1988; accepted after revi-
sion May 16, 1988. The adrenal gland is supplied by three groups of arteries; the superior, middle, and inferior
1 All authors: Department of Diagnostic Radiol-
adrenals arise from the inferior phrenic, aorta, and renal arteries, respectively. Infrequently,
ogy, The University of Texas M. D. Anderson Can-
they originate elsewhere. The number of vessels in each group is quite variable. These
cer Center, 1515 HOIcOmbe Blvd., Houston, TX
77030. Address reprint requests to F. N. O’Keeffe. variations have been deScribed elsewhere [6J.
Embolic materials used were polyvinyl alcohol foam (Ivalon) in seven patients, stainless
AJR 151:819-822,October 1988
0361 -803X/88/1 51 4-0819 steel coils in four, ethanol in three, and surgical gelatin (Gelfoam) in two. The most frequently
0 American Roentgen Ray Society used occlusive agent was Ivalon suspended in radiopaque contrast material, iothalamate
 820 O’KEEFFE ET AL. AJA:151, October1988

meglumine (Conray 60, Mallinckrodt, St. Louis, MO), which was vascularity. Follow-up CT confirmed the reduction in tumor
stored on the shelf and ready for use without extra preparation [7]. size and revealed a decrease in tumor attenuation coefficient,
The particles ranged from 1 50 to 590 m in size, which provided for probably due to necrosis. Symptoms of excess cortisol re-
more peripheral arterial occlusion. Gelfoam was used as cubes (3
developed 1 year later, at which time CT showed progression
mm) for peripheral occlusion and as segments (3 x 3 x 20 mm) for
ofthe adrenal disease. Repeat angiography showed the blood
proximal occlusion.
To avoid reflux of embolic material into normal arteries, we used a supply to be predominantly from the right hepatic artery,
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flow-controlled technique [8] and nonoccluding catheters. Having which was embolized with Ivalon. The patient died about 20
ensured stable catheter position by test injection of contrast material, months after the first embolization.
we introduced the opacified embolic material (Gelfoam suspended in Of the five patients with adrenal metastases, three with
full-strength Conray 60, Ivalon as described earlier) while arterial painful metastatic lesions experienced effective relief after
runoff was monitored fluoroscopically. The injection rate was reduced embolization. In one of these patients with renal cell carcinoma
as runoff slowed. Complete stasis was avoided to prevent reflux and! and ipsilateral adrenal metastasis, pain relief was probably
or subsequent dislodgment of particles remaining in the catheter. mainly due to concomitant renal embolization for the control
Frequent small test injections of contrast material
performed to were
of hematuria. One of the other two patients with pain had
assess vessel patency. To minimize the injection force necessary,
received no relief from radiotherapy or chemotherapy. The
we injected Gelfoam one piece at a time. Stainless steel coils were
third patient with metastatic melanoma had severe left flank
used for proximal occlusion at the catheter tip. This technique has
been described [9]. pain not relieved by opiate analgesics. He had refused other
In one patient with metastatic melanoma, a 1-mm (0.038-in.) open- treatment. The adrenal tumor received its blood supply from
end infusion guidewire (USCI, Billerica, MA) in the inferior adrenal superior and inferior adrenal arteries, and these were embo-
artery was used to embolize with ethanol when a stable catheter lized with a combination of Ivalon, ethanol, and 3-mm stainless
position could not be attained in the conventional manner. steel coils (Fig. 2). The left adrenal vein was occluded with a
The inferior adrenal artery was occluded in six patients, the supe- latex occlusion balloon catheter, and 3 ml of ethanol were
rior adrenal in four (directly in one, indirectly via the inferior phrenic in injected slowly in a retrograde fashion to achieve satisfactory
three), and the middle adrenal in two. The hepatic arterial supply to
infarction. The patient had very good pain relief but died 3
the adrenal neoplasm was embolized in two patients. The left adrenal
months later (during his last 3 months, he had developed
vein was occluded with a latex occlusion balloon catheter (Medi-tech,
Watertown, MA), followed by the retrograde injection of ethanol in persistent hiccups for 4 weeks). There was no reduction in
one patient, in addition to embolizing the superior and inferior adrenal tumor size.
arteries (see Fig. 2). No deaths resulted from embolization. The most frequent
Patients were not treated with either alpha or beta-adrenergic complication of embolization was pain (four patients) lasting
antagonists before embolization. less than 48 hr. This was mild to moderate in intensity. Three
patients developed low-grade fever lasting 48 hr. One patient
who had previously been hypertensive and also had renal
Results
arterial embolization required a temporary postprocedure in-
Twelve adrenal arteries were embolized in nine patients. Of crease in his usual medication for hypertension.
four patients with inoperable adrenal cortical carcinoma, one
died at 20 months, one died at i 2 months, and two died at 2
months after initial embolization. Follow-up CT examinations Discussion
to assess the effect of embolization on tumor bulk were
performed in two patients. Tumor size was markedly reduced Inoperable adrenal neoplasms may present problems in
in one patient, but the adrenal tumor remained stable in size management because of tumor function or local symptoms.
for 1 year in the other patient. One patient with adrenal cortical Although palliation for metastatic adrenal lesions has received
carcinoma experienced effective pain relief after embolization. little attention, many different modes of therapy have been
Two of three patients with Cushing syndrome had dramatic used for inoperable adrenal cortical carcinomas. However,
and prolonged reduction of urine steroid levels with return to the effects of treatment are still dismal; only surgery may be
normal levels within 48 hr of embolization. Both patients associated with long-term survival [i 0, 1 1]. Most adrenal
received metyrapone (Metopirone [2-methyl-i ,2-Bis(3-pyri- cortical carcinomas, however, are unresectable at the time of
dyl)-i -propanone]), which inhibits cortisol production, for a diagnosis [i 2]. Mitotane has been widely used but has been
period of i month. One also received mitotane (o,p’-DDD; or largely ineffective except after resection of the primary tumor
2,2,4-chlorophenyl,2-chlorophenyl-i ,i -dichloroethane) inter- [1 0-i 2]. In addition, side effects frequently limit its use [12-
mittently as tolerated for 1 month. One patient, a 63-year-old 1 4]. Local radiotherapy also has been ineffective in most
woman, had a marked reduction in adrenal tumor size and series [i 0, 1 1 i 5], although palliation occasionally
, may be
correondingly good clinical and biochemical responses. CT achieved [16].
showed a 9-cm adrenal mass (Fig. 1) and evidence of tumor Despite the wide use of arterial embolization in the treat-
thrombus in the inferior vena cava (confirmed by cavography). ment of other tumors, adrenal arterial embolization has been
Angiography showed the vascular supply from the inferior reported infrequently. In part, this may be attributed to the
adrenal artery, inferior phrenic artery, and parasitic supply adrenal arterial supply, which may be complex [6], rendering
from right hepatic arterial branches. Angiography after Ivalon catheterization both time-consuming and difficult. Sometimes
embolization showed marked reduction in tumor size and this may be less of a problem, especially when adrenal lesions
 I ::‘
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A B C
Fig. 1.-Adrenal cortical carcinoma with as-
soclated Cushing syndrome.
A-C, Inferior phrenic anglogram (A), inferior
adrenal anglogram (B), and right hepatic anglo-
gram (C) show hypervascular adrenal mass with
simultaneous opacification of retrocrural ade-
nopathy.

D and E, Effects of embolization of Inferior

phrenlc artery, Inferior adrenal artery, and para-
sitic right hepatic arterial supply. Hepatic arterio-
grams before embolization (D) and after embo-
lization (E) show markedly reduced tumor size
and vascularlty. Inferior phrenlc and inferior ad-
renal arteries are occluded.

F and G, CT scans show effects of emboliza-

tion. CT scan before therapeutic embolization
(F) shows right adrenal mass and retrocrural
adenopathy. CT scan 7 months after emboliza-
tion (G) shows reduction in tumor size. Ivalon
particles are present in liver.

are hypervascular and there is hypertrophy of the feeding because of uncontrolled catecholamine release. Transvenous
vessels. In our series, there was difficulty in achieving a stable ablation of the adrenals in an experimental study with animals
catheter position in only one patient. resulted in massive release of catecholamines with severe
Several different occlusive agents were used. Of these, hypertension and tachycardia [5]. The limited evidence avail-
Ivalon in a radiopaque suspension [7] was used most often. able from embolization in man has been mainly with cases of
Embolization with this material resulted in more occlusion of functioning pheochromocytomas [2-4], in which catechol-
peripheral vessels and was probably most effective in delaying amine release after embolization required close monitoring
collateral reconstitution of the occluded vascular territory. but was effectively controlled by the use of alpha- and beta-
In addition to technical difficulties, embolization of the nor- adrenergic blockade. Our experience suggests that life-threat-
mal adrenal has been considered a life-threatening procedure ening catecholamine release is unlikely after embolization of
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t’_ ...‘

A B C
Fig. 2.-Metastatic melanoma of adrenal gland.
A, Inferior phrenlc arteriogram shows superior adrenal arterial supply that was embolized with Ivalon and a 3-mm coil.
B, Inferior adrenal arteriogram shows Inferior adrenal arterial tumor supply. A 3-mm coil used to occlude superior adrenal arterial blood supply is also
evident.
C, Balloon occlusion catheter in adrenal vein. Three ml of ethanol were injected retrograde into adrenal vein. Coils used to occlude both superior and
inferior adrenal arterial blood supply to adrenal tumor are shown.

other adrenal lesions. This hypothesis is supported by the We conclude that adrenal arterial embolization can be a
evidence available from reported complications of adrenal safe and effective procedure in the management of inoperable
angiography [1 7]. Although one patient did become hyperten- adrenal neoplasms when performed by using selective cath-
sive after embolization, the cause of this was unclear, as he eterization.
had been hypertensive previously. In addition, he had renal
arterial embolization. Catecholamine levels were not obtained.
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