CT-Guided RFA of Pheochromocytomas in Von Hippel-Lindau Disease: Treatment Safety and Imaging Features

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Materials and Methods : Between September 2012 and February 2025, eight pheochromocytomas in six patients with VHLD were treated in eight CT-guided RFA sessions. Treatment outcomes, hypertensive crisis, kidney attenuation, and radiation dose were assessed. The Wilcoxon matched-pairs signed-rank test and Friedman test with post-hoc tests were used for statistical analysis. Results : Of the eight pheochromocytomas, seven were completely ablated in one session, and no local tumor progression, tumor recurrence, or major complications were observed. Only one patient had a residual tumor when a low tube current (30 mA) was used. Of the eight RFA sessions, five resulted in markedly elevated blood pressure during the RFA cycles (p=0.0078). The hypertensive crises were managed with intravenous antihypertensive administration. During hypertensive crises, the kidneys became hyperattenuating (p<0.05)but renal function was not reduced. The median dose length product was 1185.8 mGycm (350.1–1690.9 mGycm). Conclusion : CT-guided RFA has potential to safely treat pheochromocytomas in patients with VHLD. Hypertensive crisis is frequent but well-controlled. It makes kidneyshyperattenuating, probably due to vasospasm resulting from the hyperexcretion of catecholamines. Figures Figure 1 Figure 2 Figure 3 Introduction Pheochromocytomas are catecholamine-secreting tumors arising from chromaffin cells of the adrenal medulla and are currently considered a subset of neuroendocrine neoplasms [ 1 – 3 ]. Approximately 10% of these tumors are locally recurrent or have the potential to metastasize [ 4 , 5 ]. Hence, the WHO Health Organization does not classify this tumor as benign or malignant neoplasm any longer, but only as cancer [ 1 – 3 ]. Pheochromocytomas associated with von Hippel-Lindau disease (VHLD) tend to be multifocal and recurrent [ 6 , 7 ]. Surgical resection is the first choice for this tumor; however, bilateral adrenalectomies results in adrenal insufficiency in patients with VHLD [ 8 , 9 ]. They undergo life-long hormone replacement and face a high risk of morbidities, such as cardiovascular diseases, malignant tumors, infectious diseases, diabetes mellitus, and respiratory diseases [ 10 ]. Consequently, adrenal insufficiency-induced mortality increases and life expectancy decreases [ 10 ]. Percutaneous thermal ablation has been accepted as an alternative treatment for adrenal tumors in patients who cannot undergo adrenalectomy due to high post-operative morbidity or mortality [ 11 , 12 ]. This treatment modality ablates adrenal tumors completely but also preserves adrenal tissue as much as possible. Besides, it can be repeatedly performed to treat recurrent adrenal tumors, whereas partial adrenalectomy is barely repeated due to adhesion. There are many original articles dealing with percutaneous ablation in treating adrenal masses such as aldosterone-producing adenoma [ 13 , 14 ], cortisol-producing adenoma [ 15 , 16 ], and metastasis [ 17 , 18 ]. So far, however, only a few case reports are available on ablating pheochromocytoma with radiofrequency ablation (RFA) [ 19 , 20 ]. Hypertensive crises are frequently encountered when pheochromocytoma is being ablated and thus pre-medication and intravenous administration with calcium-channel blockers are necessary to reduce blood pressure (BP) [ 11 , 12 , 19 , 20 ]. Recently, percutaneous radiofrequency ablation (RFA) has been performed in our institute to treat pheochromocytomas in patients with VHLD. We hypothesized that image-guided RFA is a safe and good option for treating pheochromocytomas. The purpose of this study was to retrospectively assess the RFA techniques, hemodynamic changes, CT features, radiation doses, and treatment outcomes for pheochromocytoma in VHLD. Materials and Methods This retrospective study was approved by our Institutional Review Board, which waived the requirement for informed patient consent. Subjects Between September 2012 and February 2025, 24 patients with 27 adrenal masses were treated in 27 image-guided RFA sessions (Fig. 1 ). Of these masses, eight were diagnosed as pheochromocytomas in six VHLD patients (Male:Female = 3:3; median age, 30.5; age range, 19–48 years) according to the clinical findings, family history, genetic analysis, biochemical tests, or radiological findings (Table 1 ) (Fig. 2 ). No histological diagnosis was made for any tumor on percutaneous biopsy. Of the six patients, five had one pheochromocytoma, and one had three pheochromocytomas. The sizes of pheochromocytomas ranged from 5.5 mm to 22.5 mm (median, 15.7 mm). Of the six patients, four had a surgical history of right total and left partial in two, right total in one, and right partial in one (Table 1 ). Table 1 Patient demographics. Case No. Age/Sex Genetic analysis Family His Surgical His CT findings Clinical manifestations Tumor size (mm) Tumor location Case 1 30y/M No Yes R total, L partial 22.5 L lateral limb HB, PHEO, PNET Case 2 33y/F No Yes R total, L partial 19.9 L lateral limb HB, PPLG, RCC, PNET Case 3 48y/F No No R partial 20.0 L body HB, RCC, PHEO Case 4 31y/M No No None 5.5 R lateral limb HB, RCC, PHEO Case 5 19y/M Yes No R total 15.0 L body HB, PPLG 19y/M No R total 10.0 L lateral limb HB, PPLG 19y/M No R total 16.3 L medial limb HB, PPLG Case 6 24y/F No Yes None 13.6 R body HB, PHEO y, year; His, history; R, right; L, left; Total, total adrenalectomy; Partial, partial adrenalectomy; HB, hemangioblastoma, PHEO, Pheochromocytoma; PNET, pancreas neuroendocrine tumor; PPLG, pheochromocytoma & paraganglioma; RCC, renal cell carcinoma The inclusion criteria were patients with VHLD aged 18 years or older, pheochromocytoma, and undergoing percutaneous RFA. The exclusion criteria were as follows: other adrenal tumors (n = 17), percutaneous cryoablation (n = 1), and age < 18 years (n = 1). All the patients underwent biochemical tests and/or imaging examinations at regular intervals after RFA was done. The follow-up period ranged from 1 to 134 months (median, 60.5 months). Of this population, 3 patients with 5 pheochromocytomas were also used to assess the safety of trans-renal RFA in the previous research [ 19 , 21 ]. RFA procedures All RFA procedures were guided by one of two large-bore CT scanners [Aquilion (n = 3) and Aquilion One (n = 5), Cannon Medical Systems, Otawara, Japan] and were performed under general anesthesia. The CT parameters included 120 kvp, 2 mm section thickness, and 0.6 sec rotation time. Tube current was applied to maintain as low as possible. The trachea of each patient was intubated using a ventilator to monitor respiration and saturation. The radial artery was catheterized to continuously monitor blood pressure. The patients were positioned decubitus on the ipsilateral side down in two, prone in one, and supine in one session. A 17-gauge 12 cm (n = 5) or 15 cm (n = 3) single electrode [Proteus (n = 7) or Viva (n = 1), STARmed, Goyang, Korea] was internally cooled with normal saline circulating with a pump (STARmed). The length of the uninsulated tip was not fixed but was controlled from 5 mm to 30 mm according to the tumor size. The electrical power started at 20 watts and was increased 5 or 10 watts. As soon as the systolic blood pressure was more than 150 mmHg, the electrical power was turned off, and an attending anesthesiologist was informed to be ready for antihypertensive management. Prior to beginning the RFA cycles, he/she was asked to fill syringes with beta- and calcium channel blockers for immediate injection in case of rapidly elevated BP. Of the eight pheochromocytomas, only two were directly targeted from the skin entry site, and the remaining six were targeted through the trans-renal (n = 5) or transhepatic (n = 1) route with an electrode. Data analysis The numbers of RFA cycles and electrode repositioning were recorded. The RF duration was defined as the time required to complete the ablation cycles. An uninsulated electrode was selected to ablate each pheochromocytoma. It was assessed to determine technical effectiveness, residual tumor, and local tumor progression. Biochemical and tumor recurrences were also assessed. Hypertensive crisis was defined as systolic BP > 180 mmHg or diastolic BP > 120 mmHg [ 22 , 23 ]. BPs and heart rates (HR) were continuously measured using an arterial line before and after RFA initiation. Peak systolic and diastolic BP values were compared before and after the RFA cycles. BPs and HRs were recorded to determine when they were elevated during the RFA phases, such as the localization, targeting, monitoring, and survey phases [ 24 ]. The attenuation values of the inferior vena cava (IVC), liver, and kidneys were measured on contrast-enhanced CT images for tumor localization, on CT images obtained just before the RFA cycles began, on CT images immediately after the RFA cycles began, and on survey CT images obtained to determine if complications occurred. Contrast-enhanced CT was performed for 80 s after 80 ml of iodine contrast material was intravenously injected at a rate of 3 ml using a power injector. The region of interest (ROI) was appropriately placed to avoid partial volume effects, calcifications, and cystic or necrotic areas. CT attenuation values were obtained from the renal cortex. Representative attenuation values were obtained after averaging three measurements. Renal function parameters such as serum creatinine (sCr) and estimated glomerular filtration rate (eGFR) were also compared before and after the hypertensive crisis. sCr and eGFR were measured before and after each RFA session. CT dose index volume (CTDIvol) and dose-length product (DLP) were recorded to assess the radiation dose. The range and number of CT scans were measured during the RFA phase. The radiation information was reviewed based on the radiation protocol added to the final RFA CT image. Major (grade 3 or higher) or minor (grade 2 or less) complications were checked according to the Cardiovascular and Interventional Radiological Society (CIRSE) classification for interventional radiology [ 25 ]. Statistical analysis The Wilcoxon matched-pairs signed-rank test was used to compare changes in BPs, heart rate, and renal function before and after the initiation of RFA cycles. The Friedman Test (nonparametric repeated-measures ANOVA) with post-test (Dunn's Multiple Comparisons Test) was used to compare the attenuation values measured on contrast-enhanced, before-RFA, after-RFA, and survey CT images. Commercially available software (PASW Statistics, version 17; SPSS, Inc., Chicago, IL, USA) was used for statistical analysis. A p value < 0.05 was considered statistically significant. Results Of the eight pheochromocytomas, seven were completely ablated, with a technical success rate of 87.5% (7/8) (Fig. 2 ). Only one had a residual tumor after the first session. The size of the pheochromocytoma was 5.5 mm and that of the residual tumor was 3.0 mm. An additional RFA session was scheduled only if the tumor grew more than 1.0 cm. The median number of RFA cycles and electrode repositioning was 6 (range, 4–10) and 0 (0–1), respectively. The median RFA duration was 9 min (5–15 min). The median length of the uninsulated electrode was 17.5 min (10–25 min). When the case of residual tumor was excluded, no local tumor progression was observed after the first RFA. No biochemical or tumor recurrence was detected during the follow-up period. Systolic/diastolic BPs and HRs were significantly elevated after the initiation of RFA cycles (p = 0.0078 and 0.0156, respectively). Hypertensive crisis developed in five out of eight sessions (Table 2 ). The median systolic/diastolic BPs before and after the hypertensive crisis were 95/51 mmHg and 210/102 mmHg, respectively. The median heart rates before and after the hypertensive crisis were 66 and 120 beats/min, respectively. Hypertensive crisis did not occur when the electrode touched or penetrated the pheochromocytoma. This occurred immediately after the RFA cycles. The frequencies ranged from 1 to 5 (median: 3). In the remaining 3 sessions, the median baseline systolic/diastolic BP was 95/60 mmHg, and the peak systolic/diastolic BP increased to 136/89 mmHg. The median baseline and peak HRs were 79 and 89 beats/min, respectively. Attending anesthesiologists appropriately controlled the BP and heart rate using alpha-and/or beta-blockers. Table 2 Hemodynamic changes before and after RFA cycles began. Case No. Premedication BP (mmHg) and HR (beats/min) before RFA BP (mmHg) and HR (beats/min) after RFA Systolic Diastolic HR Systolic Diastolic HR Case 1 No 104 51 58 245 105 120 Case 2 No 95 51 72 185 101 136 Case 3 No 96 54 54 210 102 124 Case 4 Yes 102 63 72 125 94 81 Case 5 No 95 61 85 135 84 85 No 81 58 89 136 68 93 Yes 77 45 66 244 173 69 Case 6 No 78 42 72 182 77 78 BP, blood pressure; HR, heart rate The median sCr and eGFR before RFA were 0.72 mg/dl (0.67–1.18 mg/dl) and 117.7 (72.0–139.3), respectively and those after RFA were 0.67 mg/dl (0.6–1.1 mg/dl) and 122.3 (77.3–145.8), respectively. The median attenuation values of the IVC, liver, and kidney were 107.5 HU (, 102.5, and 149 HU, respectively, when the iodine contrast material was administered (Table 3 ) (Fig. 3 ). The median attenuation values of these organs decreased to 68.5 HU, 78.5 HU, and 92.0 HU just before electrical current was delivered to the pheochromocytoma, respectively. Immediately after ablation cycles began, the median attenuation values of IVC and liver decreased to 62.5 HU and 63.0 HU, respectively, but that of kidney increased to 138.5 HU (Figs. 2 and 3 ). Therefore, there was no significant difference between CECT and after RFA in terms of kidney attenuation values (p > 0.05). The median attenuation values of IVC, liver, and kidney were 58.0 HU, 68.5 HU, and 98.0 HU on survey CT image. The attenuation values of the kidneys before initiating RFA cycles were lower than those after initiating RFA cycles (Figs. 2 and 3 ) (p < 0.05). Table 3 Attenuation values of IVC, liver, and kidney according to the RFA phases. Abdominal organs Median attenuation values (HU) during RFA procedures CECT Before RFA After RFA Survey IVC 107.5 (78.0–121.0) 63.5 (38.0–98.0) 62.5 (41.0–77.0) 58.0 (43.0–72.0) Liver 102.5 (92.0–120.0) 78.5 (49.0–91.0) 63.0 (57.0–92.0) 68.5 (44.0–96.0) Kidney 149.0 (134.0–228.0) 92.0 (74.0–123.0) 138.5 (97.0–218.0) 98.0 (83.0–206.0) IVC, inferior vena cava; CECT, contrast-enhanced CT; RFA, radio-frequency ablation; Numbers in parenthesis are range of attenuation values. VHLD, von Hippel-Lindau disease; RFA, radiofrequency ablation A. Pre-RFA CT axial image shows a right adrenal mass (white arrow) with strong enhancement. She had slightly high levels of plasma normetanephrine (0.99 nmol/L) and urine norepinephrine (84.6 µg/day). The median CTDIvol and DLP were 205.6 mGy (55.2–422.8 mGy) and 1185.8 mGycm (350.1–1690.9 mGycm). The median number of CT scans was 21 (12–37). The median scan range was 4.1 cm (2.2–5.0 cm). The tube current ranged from 30 mA to 158 mA (median, 60 mA). Adrenal insufficiency and cardiovascular, cerebrovascular, or other major complications were not detected clinically or biochemically after any session. Minor bleeding without requtransfusion or embolization was detected around the pheochromocytomas in all sessions. Discussion Our results showed that CT-guided RFA safely treated pheochromocytomas and preserved the adrenal tissue in patients with VHLD. Hypertensive crisis developed immediately after RFA cycles began in many cases but was well controlled. The attenuation values of the renal cortex increased during the RFA cycles, in contrast to those of the other organs. It is difficult to detect a small pheochromocytoma using a low tube current. A residual tumor was detected in one case of a small pheochromocytoma (5.5 mm) following CT-guided RFA with a low tube current (30 mAs). It was difficult to clearly depict or localize the tumor. The DLP (350.1 mGycm) was the lowest in all sessions; however, the pheochromocytoma was not completely ablated. The tube current should not decrease to keep the image quality acceptable for depicting and targeting a tumor even though radiation exposure increases in patients [ 26 ]. Therefore, the tube currents were maintained at relatively high levels in the other RFA cases and increased radiation doses. Therefore, tube current should increase until a tumor is visible on CT scan. Our study showed that BP was not elevated when the electrode touched or penetrated the pheochromocytoma [ 19 ]. Hypertensive crisis was detected only when a pheochromocytoma was ablated [ 11 , 12 , 19 , 20 ]. Catecholamines were likely hyperexcreted from the tumor during the RFA cycles, leading to rapid BP and HR elevation. This phenomenon was not observed in all RFA cycles but was detected on an average of three cycles. As soon as we saw a BP increase of more than 150 mmHg, the electrical power was switched off to withhold ablation, and an anesthesiologist was asked to prepare antihypertensive agents. Although RFA was withheld, BP increased to > 180 mmHg because catecholamines were already excreted. The rationale to stop ablation was to ensure that additional catecholamines were not excreted and to help control the hypertensive crisis. The frequency or degree of BP elevation decreased in the late RFA cycles. There was pre-medication with alpha-blockers before the two RFA sessions, but only hypertensive crisis only in one RFA session. Therefore, the degree or frequency of hypertensive is likely to be related the tumor size, degeneration, and/or vascularity. However, further investigations are necessary to predict hypertensive crisis. Hyper-attenuation of the renal parenchyma may result from interlobar artery vasospasms induced by catecholamines secreted by pheochromocytoma cells. The contrast material is filtered from the glomeruli and excreted into the urinary tract [ 27 ]. Vasospasm induces the delayed excretion of contrast material; thus, kidney attenuation increases during a hypertensive crisis. The kidney is well known to be one of the end organs damaged by long-standing hypertension [ 28 , 29 ]. Hypertensive crisis is a transient phenomenon that does not impair renal function. In contrast, our study showed that the attenuation values of the liver and other organs were not elevated during the hypertensive crisis and were not influenced by hyper-excreting catecholamines. CT-guided RFA is a safe procedure for the treatment of cortisol- or aldosterone-producing adenomas and metastasis [ 13 – 18 ]. They reported no major complications except adrenal insufficiency. Cortisol-producing adenomas result in a thin adrenal cortex; subsequently, adrenal insufficiency occurs in all cases regardless of the treatment modality [ 15 , 16 ]. Adrenal metastasis requires a large ablation area for local control, and adrenal insufficiency is frequent in patients with a history of unilateral adrenalectomy [ 17 , 18 ]. However, although there were many cases of total and/or partial adrenalectomy, none had adrenal insufficiency in our study. Therefore, we could minimize loss of normal adrenal tissue to be ablated with RFA. This study had several limitations. First, the number of patients with pheochromocytomas was relatively small. Almost all pheochromocytomas are currently treated by adrenalectomy; thus, the number of RFA procedures performed is limited. Second, premedication was not administered in most cases. This contributes to a reduction in BP elevation [ 9 , 11 , 12 , 18 ]. Third, CT-guided RFA has a steep learning curve for interventional radiologists. The trans-renal route is most commonly used to treat pheochromocytomas [ 19 ]. Fourth, this was a retrospective study. The likelihood of a selection bias cannot be completely excluded. In conclusion, CT-guided RFA has potential to treat pheochromocytoma in patients with VHLD without major complications or sequelae such as adrenal insufficiency. Hypertensive crisis develops only during RFA cycles and can be managed with intravenous antihypertensive agents. Renal parenchyma becomes hyperattenuating during hypertensive crisis, probably due to vasoconstriction, but does not influence renal function. A low tube current may be difficult to detect and target small pheochromocytomas. Declarations Author Contribution BKP, Conceptualization; BKP, Data curation; BKP, Formal analysis; None, Funding acquisition; BKP, Investigation; BKP, Methodology; BKP, Project administration; BKP, Resources; None, Software; BKP, Supervision; BKP, Validation; BKP, Visualization; BKP, Roles/Writing – original draft; BKP, Writing – review & editing. 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Cite Share Download PDF Status: Published Journal Publication published 24 Oct, 2025 Read the published version in Abdominal Radiology → Version 1 posted Editorial decision: Revision requested 12 Aug, 2025 Reviews received at journal 12 Aug, 2025 Reviews received at journal 10 Aug, 2025 Reviewers agreed at journal 04 Aug, 2025 Reviewers agreed at journal 04 Aug, 2025 Reviewers agreed at journal 03 Aug, 2025 Reviewers agreed at journal 03 Aug, 2025 Reviewers agreed at journal 03 Aug, 2025 Reviewers invited by journal 28 Jul, 2025 Editor assigned by journal 28 Jul, 2025 Submission checks completed at journal 28 Jul, 2025 First submitted to journal 27 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7224205","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":492204545,"identity":"54a86691-31c3-4133-a55d-7789c76484fb","order_by":0,"name":"Byung Kwan Park","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsElEQVRIiWNgGAWjYNCCAzYMEjwgBhvxWtJI13KYBC3m7WcPfq44c95esueMAcOHssOEtcicyUuWPHPjduJs3h4DxhnniNAiwZBjINnw4XaCHD+PATNvGzFa+N8Y/2z4cM4erOUvUVokcswkG24cYAQ5jJmROC3v0iwbziQnzuw5VnCw51w6MQ7LPXyz4ZidvcSZ5I0PfpRZE9bCwMCDYB4gRj2qllEwCkbBKBgFWAEA/dI6EjDfuMoAAAAASUVORK5CYII=","orcid":"","institution":"Samsung Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Byung","middleName":"Kwan","lastName":"Park","suffix":""}],"badges":[],"createdAt":"2025-07-27 05:23:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7224205/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7224205/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00261-025-05258-3","type":"published","date":"2025-10-24T16:16:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88004156,"identity":"7c08b63d-7331-4124-bb7e-473441febb5c","added_by":"auto","created_at":"2025-07-31 10:35:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":138042,"visible":true,"origin":"","legend":"\u003cp\u003eA flow diagram illustrating the number of sessions included.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eVHLD, von Hippel-Lindau disease; RFA, radiofrequency ablation\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7224205/v1/569fbc33decb61c838c108e0.png"},{"id":88005517,"identity":"07c7c165-a4cd-4ffd-80e8-102cd25ce35f","added_by":"auto","created_at":"2025-07-31 10:43:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1870101,"visible":true,"origin":"","legend":"\u003cp\u003eA 24-year-old woman with von Hippel-Lindau disease(Case 6).\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eA. Pre-RFA CT axial image shows a right adrenal mass (white arrow) with strong enhancement. She had slightly high levels of plasma normetanephrine (0.99 nmol/L) and urine norepinephrine (84.6 µg/day).\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eB. F-18 F-DOPA PETCT axial fusion image shows the right adrenal mass has a higher standard uptake value (SUVmax=11.3) compared to liver. This finding is consistent with pheochromocytoma.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eC. RFA CT axial image shows an electrode (white arrowheads) targeting the right pheochromocytoma (white arrow).\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eD. Three RFA axial images were obtained after intravenously injecting 80 ml of iodine contrast material for tumor localization (D1), when right pheochromocytoma was targeted with an electrode (D2), and when hypertensive crisis was detected during RFA cycles (D3). The attenuation values of inferior vena cava (I) and liver (L) decrease gradually from D1 to D3. Right kidney (K) enhancement decreases from D1 to D2 but increases from D2 to D3. Iodine contrast material (black arrowhead) is excreting to the collecting system on D2 image but is not on D3 image.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eE. One-month follow-up CT axial image shows no enhancement in the right pheochromocytoma (white arrow).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7224205/v1/d07626e26e79933dbc6e817a.png"},{"id":88004154,"identity":"f997bbb3-7c47-423d-a3e9-70849e6f7cd0","added_by":"auto","created_at":"2025-07-31 10:35:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":153634,"visible":true,"origin":"","legend":"\u003cp\u003eA broken-line graph illustrates the change of attenuation values in the IVC (black), liver (green), and kidney (red) according to the RFA phases.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eThe X- and Y-axes indicate the RFA phasesand attenuation values (HU), respectively.\u003c/p\u003e\n\u003cp\u003eCECT indicates CT images obtained when contrast material is intravenously administered.\u003c/p\u003e\n\u003cp\u003eBefore indicates CT images obtained just before RFA cycles.\u003c/p\u003e\n\u003cp\u003eAfter indicates CT images obtained after RFA cycles.\u003c/p\u003e\n\u003cp\u003eSurvey indicates the last RFA CT images obtained to determine the presence of complications.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7224205/v1/59ae898da5834af5cf493081.png"},{"id":94490404,"identity":"a51621e6-de9a-4551-9797-bfef2770b052","added_by":"auto","created_at":"2025-10-27 17:09:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2705952,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7224205/v1/29547df4-e290-421d-809a-7754d3d60b5f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"CT-Guided RFA of Pheochromocytomas in Von Hippel-Lindau Disease: Treatment Safety and Imaging Features","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePheochromocytomas are catecholamine-secreting tumors arising from chromaffin cells of the adrenal medulla and are currently considered a subset of neuroendocrine neoplasms [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Approximately 10% of these tumors are locally recurrent or have the potential to metastasize [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Hence, the WHO Health Organization does not classify this tumor as benign or malignant neoplasm any longer, but only as cancer [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Pheochromocytomas associated with von Hippel-Lindau disease (VHLD) tend to be multifocal and recurrent [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Surgical resection is the first choice for this tumor; however, bilateral adrenalectomies results in adrenal insufficiency in patients with VHLD [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. They undergo life-long hormone replacement and face a high risk of morbidities, such as cardiovascular diseases, malignant tumors, infectious diseases, diabetes mellitus, and respiratory diseases [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Consequently, adrenal insufficiency-induced mortality increases and life expectancy decreases [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePercutaneous thermal ablation has been accepted as an alternative treatment for adrenal tumors in patients who cannot undergo adrenalectomy due to high post-operative morbidity or mortality [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This treatment modality ablates adrenal tumors completely but also preserves adrenal tissue as much as possible. Besides, it can be repeatedly performed to treat recurrent adrenal tumors, whereas partial adrenalectomy is barely repeated due to adhesion. There are many original articles dealing with percutaneous ablation in treating adrenal masses such as aldosterone-producing adenoma [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], cortisol-producing adenoma [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], and metastasis [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. So far, however, only a few case reports are available on ablating pheochromocytoma with radiofrequency ablation (RFA) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Hypertensive crises are frequently encountered when pheochromocytoma is being ablated and thus pre-medication and intravenous administration with calcium-channel blockers are necessary to reduce blood pressure (BP) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Recently, percutaneous radiofrequency ablation (RFA) has been performed in our institute to treat pheochromocytomas in patients with VHLD. We hypothesized that image-guided RFA is a safe and good option for treating pheochromocytomas.\u003c/p\u003e\u003cp\u003eThe purpose of this study was to retrospectively assess the RFA techniques, hemodynamic changes, CT features, radiation doses, and treatment outcomes for pheochromocytoma in VHLD.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e This retrospective study was approved by our Institutional Review Board, which waived the requirement for informed patient consent.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubjects\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBetween September 2012 and February 2025, 24 patients with 27 adrenal masses were treated in 27 image-guided RFA sessions (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of these masses, eight were diagnosed as pheochromocytomas in six VHLD patients (Male:Female\u0026thinsp;=\u0026thinsp;3:3; median age, 30.5; age range, 19\u0026ndash;48 years) according to the clinical findings, family history, genetic analysis, biochemical tests, or radiological findings (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). No histological diagnosis was made for any tumor on percutaneous biopsy. Of the six patients, five had one pheochromocytoma, and one had three pheochromocytomas. The sizes of pheochromocytomas ranged from 5.5 mm to 22.5 mm (median, 15.7 mm). Of the six patients, four had a surgical history of right total and left partial in two, right total in one, and right partial in one (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient demographics.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCase No.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge/Sex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGenetic analysis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFamily His\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSurgical His\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eCT findings\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eClinical manifestations\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTumor size (mm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eTumor location\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30y/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eR total, L partial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e22.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eL lateral limb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHB, PHEO, PNET\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33y/F\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eR total, L partial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e19.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eL lateral limb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHB, PPLG, RCC, PNET\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48y/F\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eR partial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e20.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eL body\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHB, RCC, PHEO\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31y/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eR lateral limb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHB, RCC, PHEO\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19y/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eR total\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e15.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eL body\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHB, PPLG\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19y/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eR total\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eL lateral limb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHB, PPLG\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19y/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eR total\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e16.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eL medial limb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHB, PPLG\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24y/F\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e13.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eR body\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHB, PHEO\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003ey, year; His, history; R, right; L, left; Total, total adrenalectomy; Partial, partial adrenalectomy; HB, hemangioblastoma, PHEO, Pheochromocytoma; PNET, pancreas neuroendocrine tumor; PPLG, pheochromocytoma \u0026amp; paraganglioma; RCC, renal cell carcinoma\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe inclusion criteria were patients with VHLD aged 18 years or older, pheochromocytoma, and undergoing percutaneous RFA. The exclusion criteria were as follows: other adrenal tumors (n\u0026thinsp;=\u0026thinsp;17), percutaneous cryoablation (n\u0026thinsp;=\u0026thinsp;1), and age\u0026thinsp;\u0026lt;\u0026thinsp;18 years (n\u0026thinsp;=\u0026thinsp;1). All the patients underwent biochemical tests and/or imaging examinations at regular intervals after RFA was done. The follow-up period ranged from 1 to 134 months (median, 60.5 months). Of this population, 3 patients with 5 pheochromocytomas were also used to assess the safety of trans-renal RFA in the previous research [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eRFA procedures\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll RFA procedures were guided by one of two large-bore CT scanners [Aquilion (n\u0026thinsp;=\u0026thinsp;3) and Aquilion One (n\u0026thinsp;=\u0026thinsp;5), Cannon Medical Systems, Otawara, Japan] and were performed under general anesthesia. The CT parameters included 120 kvp, 2 mm section thickness, and 0.6 sec rotation time. Tube current was applied to maintain as low as possible. The trachea of each patient was intubated using a ventilator to monitor respiration and saturation. The radial artery was catheterized to continuously monitor blood pressure. The patients were positioned decubitus on the ipsilateral side down in two, prone in one, and supine in one session.\u003c/p\u003e\u003cp\u003eA 17-gauge 12 cm (n\u0026thinsp;=\u0026thinsp;5) or 15 cm (n\u0026thinsp;=\u0026thinsp;3) single electrode [Proteus (n\u0026thinsp;=\u0026thinsp;7) or Viva (n\u0026thinsp;=\u0026thinsp;1), STARmed, Goyang, Korea] was internally cooled with normal saline circulating with a pump (STARmed). The length of the uninsulated tip was not fixed but was controlled from 5 mm to 30 mm according to the tumor size. The electrical power started at 20 watts and was increased 5 or 10 watts. As soon as the systolic blood pressure was more than 150 mmHg, the electrical power was turned off, and an attending anesthesiologist was informed to be ready for antihypertensive management. Prior to beginning the RFA cycles, he/she was asked to fill syringes with beta- and calcium channel blockers for immediate injection in case of rapidly elevated BP. Of the eight pheochromocytomas, only two were directly targeted from the skin entry site, and the remaining six were targeted through the trans-renal (n\u0026thinsp;=\u0026thinsp;5) or transhepatic (n\u0026thinsp;=\u0026thinsp;1) route with an electrode.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eThe numbers of RFA cycles and electrode repositioning were recorded. The RF duration was defined as the time required to complete the ablation cycles. An uninsulated electrode was selected to ablate each pheochromocytoma. It was assessed to determine technical effectiveness, residual tumor, and local tumor progression. Biochemical and tumor recurrences were also assessed.\u003c/p\u003e\u003cp\u003eHypertensive crisis was defined as systolic BP\u0026thinsp;\u0026gt;\u0026thinsp;180 mmHg or diastolic BP\u0026thinsp;\u0026gt;\u0026thinsp;120 mmHg [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. BPs and heart rates (HR) were continuously measured using an arterial line before and after RFA initiation. Peak systolic and diastolic BP values were compared before and after the RFA cycles. BPs and HRs were recorded to determine when they were elevated during the RFA phases, such as the localization, targeting, monitoring, and survey phases [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe attenuation values of the inferior vena cava (IVC), liver, and kidneys were measured on contrast-enhanced CT images for tumor localization, on CT images obtained just before the RFA cycles began, on CT images immediately after the RFA cycles began, and on survey CT images obtained to determine if complications occurred. Contrast-enhanced CT was performed for 80 s after 80 ml of iodine contrast material was intravenously injected at a rate of 3 ml using a power injector. The region of interest (ROI) was appropriately placed to avoid partial volume effects, calcifications, and cystic or necrotic areas. CT attenuation values were obtained from the renal cortex. Representative attenuation values were obtained after averaging three measurements.\u003c/p\u003e\u003cp\u003eRenal function parameters such as serum creatinine (sCr) and estimated glomerular filtration rate (eGFR) were also compared before and after the hypertensive crisis. sCr and eGFR were measured before and after each RFA session.\u003c/p\u003e\u003cp\u003eCT dose index volume (CTDIvol) and dose-length product (DLP) were recorded to assess the radiation dose. The range and number of CT scans were measured during the RFA phase. The radiation information was reviewed based on the radiation protocol added to the final RFA CT image.\u003c/p\u003e\u003cp\u003eMajor (grade 3 or higher) or minor (grade 2 or less) complications were checked according to the Cardiovascular and Interventional Radiological Society (CIRSE) classification for interventional radiology [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe Wilcoxon matched-pairs signed-rank test was used to compare changes in BPs, heart rate, and renal function before and after the initiation of RFA cycles. The Friedman Test (nonparametric repeated-measures ANOVA) with post-test (Dunn's Multiple Comparisons Test) was used to compare the attenuation values measured on contrast-enhanced, before-RFA, after-RFA, and survey CT images. Commercially available software (PASW Statistics, version 17; SPSS, Inc., Chicago, IL, USA) was used for statistical analysis. A \u003cem\u003ep\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the eight pheochromocytomas, seven were completely ablated, with a technical success rate of 87.5% (7/8) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Only one had a residual tumor after the first session. The size of the pheochromocytoma was 5.5 mm and that of the residual tumor was 3.0 mm. An additional RFA session was scheduled only if the tumor grew more than 1.0 cm. The median number of RFA cycles and electrode repositioning was 6 (range, 4\u0026ndash;10) and 0 (0\u0026ndash;1), respectively. The median RFA duration was 9 min (5\u0026ndash;15 min). The median length of the uninsulated electrode was 17.5 min (10\u0026ndash;25 min). When the case of residual tumor was excluded, no local tumor progression was observed after the first RFA. No biochemical or tumor recurrence was detected during the follow-up period.\u003c/p\u003e\u003cp\u003eSystolic/diastolic BPs and HRs were significantly elevated after the initiation of RFA cycles (p\u0026thinsp;=\u0026thinsp;0.0078 and 0.0156, respectively). Hypertensive crisis developed in five out of eight sessions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The median systolic/diastolic BPs before and after the hypertensive crisis were 95/51 mmHg and 210/102 mmHg, respectively. The median heart rates before and after the hypertensive crisis were 66 and 120 beats/min, respectively. Hypertensive crisis did not occur when the electrode touched or penetrated the pheochromocytoma. This occurred immediately after the RFA cycles. The frequencies ranged from 1 to 5 (median: 3). In the remaining 3 sessions, the median baseline systolic/diastolic BP was 95/60 mmHg, and the peak systolic/diastolic BP increased to 136/89 mmHg. The median baseline and peak HRs were 79 and 89 beats/min, respectively. Attending anesthesiologists appropriately controlled the BP and heart rate using alpha-and/or beta-blockers.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHemodynamic changes before and after RFA cycles began.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCase No.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePremedication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003eBP (mmHg) and HR (beats/min) before RFA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eBP (mmHg) and HR (beats/min) after RFA\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSystolic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiastolic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSystolic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDiastolic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHR\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e245\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e105\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e120\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e185\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e136\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e210\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e135\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e136\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e173\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eBP, blood pressure; HR, heart rate\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe median sCr and eGFR before RFA were 0.72 mg/dl (0.67\u0026ndash;1.18 mg/dl) and 117.7 (72.0\u0026ndash;139.3), respectively and those after RFA were 0.67 mg/dl (0.6\u0026ndash;1.1 mg/dl) and 122.3 (77.3\u0026ndash;145.8), respectively.\u003c/p\u003e\u003cp\u003eThe median attenuation values of the IVC, liver, and kidney were 107.5 HU (, 102.5, and 149 HU, respectively, when the iodine contrast material was administered (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The median attenuation values of these organs decreased to 68.5 HU, 78.5 HU, and 92.0 HU just before electrical current was delivered to the pheochromocytoma, respectively. Immediately after ablation cycles began, the median attenuation values of IVC and liver decreased to 62.5 HU and 63.0 HU, respectively, but that of kidney increased to 138.5 HU (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Therefore, there was no significant difference between CECT and after RFA in terms of kidney attenuation values (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The median attenuation values of IVC, liver, and kidney were 58.0 HU, 68.5 HU, and 98.0 HU on survey CT image. The attenuation values of the kidneys before initiating RFA cycles were lower than those after initiating RFA cycles (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAttenuation values of IVC, liver, and kidney according to the RFA phases.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAbdominal organs\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eMedian attenuation values (HU) during RFA procedures\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCECT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBefore RFA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAfter RFA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSurvey\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIVC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e107.5 (78.0\u0026ndash;121.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e63.5 (38.0\u0026ndash;98.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e62.5 (41.0\u0026ndash;77.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e58.0 (43.0\u0026ndash;72.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e102.5 (92.0\u0026ndash;120.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e78.5 (49.0\u0026ndash;91.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e63.0 (57.0\u0026ndash;92.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e68.5 (44.0\u0026ndash;96.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKidney\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e149.0 (134.0\u0026ndash;228.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e92.0 (74.0\u0026ndash;123.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e138.5 (97.0\u0026ndash;218.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e98.0 (83.0\u0026ndash;206.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eIVC, inferior vena cava; CECT, contrast-enhanced CT; RFA, radio-frequency ablation; Numbers in parenthesis are range of attenuation values.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eVHLD, von Hippel-Lindau disease; RFA, radiofrequency ablation\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eA. Pre-RFA CT axial image shows a right adrenal mass (white arrow) with strong enhancement. She had slightly high levels of plasma normetanephrine (0.99 nmol/L) and urine norepinephrine (84.6 \u0026micro;g/day).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe median CTDIvol and DLP were 205.6 mGy (55.2\u0026ndash;422.8 mGy) and 1185.8 mGycm (350.1\u0026ndash;1690.9 mGycm). The median number of CT scans was 21 (12\u0026ndash;37). The median scan range was 4.1 cm (2.2\u0026ndash;5.0 cm). The tube current ranged from 30 mA to 158 mA (median, 60 mA).\u003c/p\u003e\u003cp\u003eAdrenal insufficiency and cardiovascular, cerebrovascular, or other major complications were not detected clinically or biochemically after any session. Minor bleeding without requtransfusion or embolization was detected around the pheochromocytomas in all sessions.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur results showed that CT-guided RFA safely treated pheochromocytomas and preserved the adrenal tissue in patients with VHLD. Hypertensive crisis developed immediately after RFA cycles began in many cases but was well controlled. The attenuation values of the renal cortex increased during the RFA cycles, in contrast to those of the other organs. It is difficult to detect a small pheochromocytoma using a low tube current.\u003c/p\u003e\u003cp\u003eA residual tumor was detected in one case of a small pheochromocytoma (5.5 mm) following CT-guided RFA with a low tube current (30 mAs). It was difficult to clearly depict or localize the tumor. The DLP (350.1 mGycm) was the lowest in all sessions; however, the pheochromocytoma was not completely ablated. The tube current should not decrease to keep the image quality acceptable for depicting and targeting a tumor even though radiation exposure increases in patients [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Therefore, the tube currents were maintained at relatively high levels in the other RFA cases and increased radiation doses. Therefore, tube current should increase until a tumor is visible on CT scan.\u003c/p\u003e\u003cp\u003eOur study showed that BP was not elevated when the electrode touched or penetrated the pheochromocytoma [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Hypertensive crisis was detected only when a pheochromocytoma was ablated [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Catecholamines were likely hyperexcreted from the tumor during the RFA cycles, leading to rapid BP and HR elevation. This phenomenon was not observed in all RFA cycles but was detected on an average of three cycles. As soon as we saw a BP increase of more than 150 mmHg, the electrical power was switched off to withhold ablation, and an anesthesiologist was asked to prepare antihypertensive agents. Although RFA was withheld, BP increased to \u0026gt;\u0026thinsp;180 mmHg because catecholamines were already excreted. The rationale to stop ablation was to ensure that additional catecholamines were not excreted and to help control the hypertensive crisis. The frequency or degree of BP elevation decreased in the late RFA cycles. There was pre-medication with alpha-blockers before the two RFA sessions, but only hypertensive crisis only in one RFA session. Therefore, the degree or frequency of hypertensive is likely to be related the tumor size, degeneration, and/or vascularity. However, further investigations are necessary to predict hypertensive crisis.\u003c/p\u003e\u003cp\u003eHyper-attenuation of the renal parenchyma may result from interlobar artery vasospasms induced by catecholamines secreted by pheochromocytoma cells. The contrast material is filtered from the glomeruli and excreted into the urinary tract [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Vasospasm induces the delayed excretion of contrast material; thus, kidney attenuation increases during a hypertensive crisis. The kidney is well known to be one of the end organs damaged by long-standing hypertension [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Hypertensive crisis is a transient phenomenon that does not impair renal function. In contrast, our study showed that the attenuation values of the liver and other organs were not elevated during the hypertensive crisis and were not influenced by hyper-excreting catecholamines.\u003c/p\u003e\u003cp\u003eCT-guided RFA is a safe procedure for the treatment of cortisol- or aldosterone-producing adenomas and metastasis [\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. They reported no major complications except adrenal insufficiency. Cortisol-producing adenomas result in a thin adrenal cortex; subsequently, adrenal insufficiency occurs in all cases regardless of the treatment modality [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Adrenal metastasis requires a large ablation area for local control, and adrenal insufficiency is frequent in patients with a history of unilateral adrenalectomy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, although there were many cases of total and/or partial adrenalectomy, none had adrenal insufficiency in our study. Therefore, we could minimize loss of normal adrenal tissue to be ablated with RFA.\u003c/p\u003e\u003cp\u003eThis study had several limitations. First, the number of patients with pheochromocytomas was relatively small. Almost all pheochromocytomas are currently treated by adrenalectomy; thus, the number of RFA procedures performed is limited. Second, premedication was not administered in most cases. This contributes to a reduction in BP elevation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Third, CT-guided RFA has a steep learning curve for interventional radiologists. The trans-renal route is most commonly used to treat pheochromocytomas [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Fourth, this was a retrospective study. The likelihood of a selection bias cannot be completely excluded.\u003c/p\u003e\u003cp\u003eIn conclusion, CT-guided RFA has potential to treat pheochromocytoma in patients with VHLD without major complications or sequelae such as adrenal insufficiency. Hypertensive crisis develops only during RFA cycles and can be managed with intravenous antihypertensive agents. Renal parenchyma becomes hyperattenuating during hypertensive crisis, probably due to vasoconstriction, but does not influence renal function. A low tube current may be difficult to detect and target small pheochromocytomas.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eBKP, Conceptualization; BKP, Data curation; BKP, Formal analysis; None, Funding acquisition; BKP, Investigation; BKP, Methodology; BKP, Project administration; BKP, Resources; None, Software; BKP, Supervision; BKP, Validation; BKP, Visualization; BKP, Roles/Writing \u0026ndash; original draft; BKP, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMete O, Asa SL, Gill AJ, Kimura N, de Krijger RR, Tischler A (2022) Overview of the 2022 WHO Classification of Paragangliomas and Pheochromocytomas. Endocr Pathol 33:90-114. \u003c/li\u003e\n\u003cli\u003eMete O, Juhlin CC (2024) Recent progress in the pathologic classification of pheochromocytomas and paragangliomas. Best Practice \u0026amp; Research Clinical Endocrinology \u0026amp; Metabolism 38:101958. \u003c/li\u003e\n\u003cli\u003eRindi G, Mete O, Uccella S, Basturk O, La Rosa S, Brosens LAA, Ezzat S, de Herder WW, Klimstra DS, Papotti M, Asa SL (2022) Overview of the 2022 WHO Classification of Neuroendocrine Neoplasms. Endocr Pathol 33:115-154. \u003c/li\u003e\n\u003cli\u003eBaudin E, Habra MA, Deschamps F, Cote G, Dumont F, Cabanillas M, Arfi-Roufe J, Berdelou A, Moon B, Al Ghuzlan A, Patel S, Leboulleux S, Jimenez C (2014) Therapy of endocrine disease: treatment of malignant pheochromocytoma and paraganglioma. Eur J Endocrinol 171:R111-122. \u003c/li\u003e\n\u003cli\u003eScholz T, Eisenhofer G, Pacak K, Dralle H, Lehnert H (2007) Clinical review: Current treatment of malignant pheochromocytoma. J Clin Endocrinol Metab 92:1217-1225. \u003c/li\u003e\n\u003cli\u003eHes FJ, Höppener JWM, Lips CJM (2003) Pheochromocytoma in Von Hippel-Lindau Disease. The Journal of Clinical Endocrinology \u0026amp; Metabolism 88:969-974. \u003c/li\u003e\n\u003cli\u003eRednam SP, Erez A, Druker H, Janeway KA, Kamihara J, Kohlmann WK, Nathanson KL, States LJ, Tomlinson GE, Villani A, Voss SD, Schiffman JD, Wasserman JD (2017) Von Hippel\u0026ndash;Lindau and Hereditary Pheochromocytoma/Paraganglioma Syndromes: Clinical Features, Genetics, and Surveillance Recommendations in Childhood. Clinical Cancer Research 23:e68-e75. \u003c/li\u003e\n\u003cli\u003eLenders JWM, Duh Q-Y, Eisenhofer G, Gimenez-Roqueplo A-P, Grebe SKG, Murad MH, Naruse M, Pacak K, Young WF, Jr (2014) Pheochromocytoma and Paraganglioma: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology \u0026amp; Metabolism 99:1915-1942. \u003c/li\u003e\n\u003cli\u003ePappachan JM, Raskauskiene D, Sriraman R, Edavalath M, Hanna FW (2014) Diagnosis and Management of Pheochromocytoma: A Practical Guide to Clinicians. Current Hypertension Reports 16:442. \u003c/li\u003e\n\u003cli\u003eJohannsson G, Falorni A, Skrtic S, Lennern\u0026auml;s H, Quinkler M, Monson JP, Stewart PM (2015) Adrenal insufficiency: review of clinical outcomes with current glucocorticoid replacement therapy. Clinical Endocrinology 82:2-11. https://doi.org/https://doi.org/10.1111/cen.12603\u003c/li\u003e\n\u003cli\u003eBlinded for peer review\u003c/li\u003e\n\u003cli\u003eBlinded for peer review\u003c/li\u003e\n\u003cli\u003eLiu SY, Ng EK, Lee PS, Wong SK, Chiu PW, Mui WL, So WY, Chow FC (2010) Radiofrequency ablation for benign aldosterone-producing adenoma: a scarless technique to an old disease. Ann Surg 252:1058-1064. \u003c/li\u003e\n\u003cli\u003eBouhanick B, Delchier MC, Lagarde S, Boulestreau R, Conil C, Gosse P, Rousseau H, Lepage B, Olivier P, Papadopoulos P, Trillaud H, Cremer A (2021) Radiofrequency ablation for adenoma in patients with primary aldosteronism and hypertension: ADERADHTA, a pilot study. J Hypertens 39:759-765. \u003c/li\u003e\n\u003cli\u003eArima K, Yamakado K, Suzuki R, Matsuura H, Nakatsuka A, Takeda K, Sugimura Y (2007) Image-Guided Radiofrequency Ablation for Adrenocortical Adenoma with Cushing Syndrome: Outcomes After Mean Follow-up of 33 Months. Urology 70:407-411. \u003c/li\u003e\n\u003cli\u003eRosiak G, Milczarek K, Konecki D, Otto M, Rowinski O, Zgliczynski W (2020) Percutaneous Bilateral Adrenal Radiofrequency Ablation in Severe Adrenocorticotropic Hormone-dependent Cushing Syndrome. J Clin Imaging Sci 10:60. \u003c/li\u003e\n\u003cli\u003eHasegawa T, Yamakado K, Nakatsuka A, Uraki J, Yamanaka T, Fujimori M, Miki M, Sasaki T, Sakuma H, Sugimura Y (2015) Unresectable Adrenal Metastases: Clinical Outcomes of Radiofrequency Ablation. Radiology 277:584-593. \u003c/li\u003e\n\u003cli\u003eEspinosa De Ycaza AE, Welch TL, Ospina NS, Rodriguez-Gutierrez R, Atwell TD, Erickson D, Bancos I (2017) Image-Guided Thermal Ablation of Adrenal Metastases: Hemodynamic and Endocrine Outcomes. Endocrine Practice 23:132-140. \u003c/li\u003e\n\u003cli\u003eBlinded peer review\u003c/li\u003e\n\u003cli\u003eKako Y, Ueki R, Yamamoto S, Takaki H, Aoki Y, Yokoyama O, Yamakado K (2021) Adrenal pheochromocytoma treated by combination of adrenal arterial embolization and radiofrequency ablation. Clinical Case Reports 9. \u003c/li\u003e\n\u003cli\u003ePark BK (2025) Safety of Transrenal CT-Guided Radiofrequency Ablation of Left Adrenal Masses. AJR Am J Roentgenol. \u003c/li\u003e\n\u003cli\u003eChobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jr., Jones DW, Materson BJ, Oparil S, Wright JT, Jr., Roccella EJ (2003) Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 42:1206-1252. \u003c/li\u003e\n\u003cli\u003eRodriguez MA, Kumar SK, De Caro M (2010) Hypertensive crisis. Cardiol Rev 18:102-107. \u003c/li\u003e\n\u003cli\u003eBlinded for peer review\u003c/li\u003e\n\u003cli\u003eFilippiadis DK, Binkert C, Pellerin O, Hoffmann RT, Krajina A, Pereira PL (2017) Cirse Quality Assurance Document and Standards for Classification of Complications: The Cirse Classification System. CardioVascular and Interventional Radiology 40:1141-1146. \u003c/li\u003e\n\u003cli\u003eLira D, Padole A, Kalra MK, Singh S (2015) Tube Potential and CT Radiation Dose Optimization. American Journal of Roentgenology 204:W4-W10. \u003c/li\u003e\n\u003cli\u003eAndreucci M, Faga T, Serra R, De Sarro G, Michael A (2017) Update on the renal toxicity of iodinated contrast drugs used in clinical medicine. Drug Healthc Patient Saf 9:25-37. \u003c/li\u003e\n\u003cli\u003eDe Bhailis \u0026Aacute; M, Kalra PA (2022) Hypertension and the kidneys. Br J Hosp Med (Lond) 83:1-11. \u003c/li\u003e\n\u003cli\u003eGriffin KA (2017) Hypertensive Kidney Injury and the Progression of Chronic Kidney Disease. Hypertension 70:687-694. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"abdominal-radiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aima","sideBox":"Learn more about [Abdominal Radiology](http://link.springer.com/journal/261)","snPcode":"261","submissionUrl":"https://submission.springernature.com/new-submission/261/3","title":"Abdominal Radiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7224205/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7224205/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: To retrospectively assess the percutaneous radiofrequency ablation (RFA) safety and imaging features of pheochromocytomas in von Hippel Lindau disease (VHLD).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods\u003c/strong\u003e: Between September 2012 and February 2025, eight pheochromocytomas in six patients with VHLD were treated in eight CT-guided RFA sessions. Treatment outcomes, hypertensive crisis, kidney attenuation, and radiation dose were assessed. The Wilcoxon matched-pairs signed-rank test and Friedman test with post-hoc tests were used for statistical analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Of the eight pheochromocytomas, seven were completely ablated in one session, and no local tumor progression, tumor recurrence, or major complications were observed. Only one patient had a residual tumor when a low tube current (30 mA) was used. Of the eight RFA sessions, five resulted in markedly elevated blood pressure during the RFA cycles (p=0.0078). The hypertensive crises were managed with intravenous antihypertensive administration. During hypertensive crises, the kidneys became hyperattenuating (p\u0026lt;0.05)but renal function was not reduced. The median dose length product was 1185.8 mGycm (350.1–1690.9 mGycm).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: CT-guided RFA has potential to safely treat pheochromocytomas in patients with VHLD. Hypertensive crisis is frequent but well-controlled. It makes kidneyshyperattenuating, probably due to vasospasm resulting from the hyperexcretion of catecholamines.\u003c/p\u003e","manuscriptTitle":"CT-Guided RFA of Pheochromocytomas in Von Hippel-Lindau Disease: Treatment Safety and Imaging Features","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-31 10:27:22","doi":"10.21203/rs.3.rs-7224205/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-12T17:27:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-12T10:50:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-10T18:59:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150745556800766915304797157755157562682","date":"2025-08-04T10:47:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232231011020577431833711374174239885417","date":"2025-08-04T07:39:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211164971211644926628585080915066664736","date":"2025-08-03T21:54:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"72235105425144683983212776045414429883","date":"2025-08-03T21:50:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317516341964142306617399874060290626698","date":"2025-08-03T21:40:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-28T15:54:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-28T07:42:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-28T07:39:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"Abdominal Radiology","date":"2025-07-27T05:09:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"abdominal-radiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aima","sideBox":"Learn more about [Abdominal Radiology](http://link.springer.com/journal/261)","snPcode":"261","submissionUrl":"https://submission.springernature.com/new-submission/261/3","title":"Abdominal Radiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d095f101-08c2-4972-b0d6-bd9ab25fbfc5","owner":[],"postedDate":"July 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T16:27:36+00:00","versionOfRecord":{"articleIdentity":"rs-7224205","link":"https://doi.org/10.1007/s00261-025-05258-3","journal":{"identity":"abdominal-radiology","isVorOnly":false,"title":"Abdominal Radiology"},"publishedOn":"2025-10-24 16:16:55","publishedOnDateReadable":"October 24th, 2025"},"versionCreatedAt":"2025-07-31 10:27:22","video":"","vorDoi":"10.1007/s00261-025-05258-3","vorDoiUrl":"https://doi.org/10.1007/s00261-025-05258-3","workflowStages":[]},"version":"v1","identity":"rs-7224205","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7224205","identity":"rs-7224205","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}