MON-358 Hypertensive Crisis during CT-Guided Microwave Ablation for Adrenal Metastasis

Introduction We present a previously normotensive patient with history of metastatic esophageal adenocarcinoma to the adrenal gland who developed elevated blood pressure and tachycardia during a CT-guided microwave ablation. Clinical Case 67-year-old male with history of stage IV esophageal adenocarcinoma diagnosed in 2015. He was not a surgical candidate and therefore treated with chemotherapy and radiation. In 1/2017, abdominal magnetic resonance imaging (MRI) was done and revealed a left 3.8 x 4 x 4.7 cm adrenal mass. He had a biopsy of the lesion which was negative for adrenocortical cancer but suspected metastasis from the esophageal cancer. He underwent CT-guided microwave ablation of the adrenal mass and during the procedure developed high blood pressure (160/90) and tachycardia (122 bpm). Post-procedure work up for pheochromocytoma or primary hyperaldosteronism were negative. In 3/2017, he had a PET/CT scan which revealed an increase in size of adrenal mass. CT-guided microwave ablation was planned and pre-procedure, he was treated with Doxazosin titrated to 4 mg daily and then Metoprolol 12.5 mg daily. The ablation was successful without complication. Discussion Microwave ablation is a thermal-based therapeutic intervention used for eradication of tumor or reduce tumor burden. It can be an effective treatment option in various malignancies especially for individuals who are poor surgical candidate. Since it is a targeted procedure, it does carry risk of affecting surrounding tissue which may result in potential adverse event. There are few reports of ablation-induced hypertensive crisis in adrenal mass. It was thought to be due to catecholamine release from the normal adrenal medulla tissue. Catecholamine release will result in heightened sympathetic effect as seen in our patient. If not identified early, there may be a detrimental adverse event including death. It has been shown that pre-treatment with alpha-1-adrenergic antagonist followed by a beta-adrenergic antagonist can decrease catecholamine effect during the procedure. Conclusion CT-guided microwave ablation is an effective treatment in non-functioning adrenal tumor but with a risk for hemodynamic instability which may be prevented with prophylactic alpha-1-adrenergic antagonist before the procedure.