Cushing's syndrome managed by endoscopic ultrasound-guided radiofrequency ablation of adrenal gland adenoma.

A 38-year-old woman presented with “moon face,” “buffalo hump,” and weight gain of 9 kg in 12 months. Overnight, 1mg dexamethasone failed to suppress the morning level of cortisol, and the 24-hour urine cortisol level was elevated to 101μg/day (normal range 0–50). Initial contrast-enhanced abdominal computed tomography (CT) showed a 2.8-cm left adrenal mass enhanced in arterial phase, and the patient was diagnosed with Cushing’s syndrome due to left adrenal adenoma (▶Fig. 1 a). She refused surgical treatment but agreed to undergo endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA; STARmed, Koyang, Korea) (▶Video1). Prior to RFA, contrast-enhanced EUS with SonoVue (Bracco, Inc., Milan, Italy) was performed. Findings of early enhancement and delayed washout were compatible with adrenal adenoma (▶Fig. 2 a). A 19-guage needle electrode was positioned inside the adenoma. Using realtime EUS imaging, RFA (50W) was performed at five different sites (▶Fig. 2 b). Four days later contrast-enhanced EUS revealed viable tissue remaining at the marginal edge of the previously ablated portion of the adenoma (▶Fig. 3 a). EUS-RFA was repeated at five more sites in the remaining viable tissue (▶Fig. 3 b). Follow-up CT at 1 week showed the adrenal mass almost completely replaced with necrotic tissue, without complications (▶Fig. 1b). Serum and urine cortisol levels returned to normal the following day and remained normal for the next 2 months, with no adverse events related to RFA. However after the third month, the cortisol levels were re-elevated and this time the patient agreed to surgery. Until recently, there were only a few case reports of RFA for the treatment of Cushing’s syndrome; all of them were treated via the CT-guided percutaneous method [1, 2]. The present case is the first in which EUS-RFA was used to manage Cushing’s syndrome caused by adrenal adenoma. This case report supports EUS-RFA as a safe and feasible alternative method that should be considered in patients who refuse surgical treatment. Further evidence and experiences are required.