Anesthetic management of bilateral adrenal microwave ablation for ectopic Cushing's syndrome in a critically ill patient: A case report

Ectopic Cushing's syndrome is associated with severe morbidity and mortality, and management can be challenging in critically ill patients who are poor surgical candidates. We report a patient with ACTH-dependent Cushing's syndrome secondary to diffuse intrapulmonary neuroendocrine cell hyperplasia. Oral cortisol-lowering therapy was not feasible, prompting initiation of intravenous etomidate infusion and adjunct ketoconazole for temporary control of hypercortisolemia. Given rapid clinical deterioration and poor candidacy for surgical adrenalectomy, CT-guided bilateral adrenal microwave ablation (MWA) under general anesthesia was performed. During ablation of both adrenal glands, the patient experienced catecholamine-mediated hypertensive crises managed effectively with nicardipine. Anticipatory stress-dose glucocorticoids were administered to mitigate perioperative adrenal insufficiency. Post-ablation cortisol levels decreased substantially. This case highlights adrenal microwave ablation as a minimally invasive option for high-risk patients, requiring multidisciplinary coordination of preprocedural endocrine optimization, invasive hemodynamic monitoring, preparedness for catecholamine-mediated hypertensive crises, and careful perioperative steroid administration to address complex physiologic challenges.