Cushing's syndrome due to a bronchial ACTH-secreting carcinoid successfully treated with radio frequency ablation (RFA)

Context: The ectopic production of ACTH is responsible for approximately 10% of cases of Cushing's syndrome. Whenever possible, once hypercortisolemia is under control with medical therapy, the final treatment consists of surgical excision of the tumor. We report a case of a patient with high surgical risk and poor response to medical therapy in which hypercortisolemia has been successfully treated with radio frequency ablation of the bronchial carcinoid tumor. Case presentation: A 43 old woman came to our hospital because of severe and rapidly worsening signs and symptoms of hypercortisolism over the previous three months. Hormonal tests suggested the presence of Cushing's syndrome due to ectopic ACTH-production. Imaging studies detected an 8 mm pulmonary nodule with fluorine- 18-fluorodeoxyglucose (FDG) uptake localized in the middle right lobe. The patient started therapy with ketoconazole with poor response. Middle right lobectomy was indicated but, due to the patient's very high surgical risk, a thermal ablation with radiofrequency of the bronchial nodule was performed. Outcomes and results: After the procedure, ACTH and cortisol levels dropped and FDG positron emission tomography (PET) showed complete response to treatment. Clinical conditions progressively improved and, six weeks later, the patient underwent middle lobectomy without complications. Histology showed a 0.7 cm ACTH-producing typical bronchial carcinoid tumor. Conclusions: Thermal ablation with radiofrequency allows to achieve a rapid control of hypercortisolism with subsequent improvement of symptoms. This procedure should, therefore, be considered as viable therapeutic option in those cases of bronchial ACTH-secreting tumors in which the surgical approach is initially contraindicated.