GROUNDBREAKING research has demonstrated that endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is a safe and potentially curative alternative to total adrenalectomy for patients with unilateral aldosterone-producing adenomas (APAs).
Hypertension due to unilateral APAs affects approximately 5% of cases, yet current diagnostic and treatment options require invasive procedures such as adrenal vein sampling (AVS) and laparoscopic adrenalectomy, which many patients find undesirable. Molecular imaging combined with EUS-RFA offers a minimally invasive approach, targeting left-sided APAs located near the stomach. This study aimed to assess the feasibility and safety of EUS-RFA for the treatment of left-sided APAs without causing damage to surrounding tissues or organs.
A multicentre, prospective, proof-of-concept trial was conducted across three UK centres, enrolling 28 participants (21 men, 7 women; mean age 57.7 years) diagnosed with primary aldosteronism. Molecular imaging was used to confirm APA localisation before and after ablation. The ablation procedure involved a 19G catheter delivering targeted burns under continuous ultrasound guidance, with safety monitored by an independent Safety Committee. The primary endpoint was safety, determined by the absence of major complications such as perforation, haemorrhage, or infarction. Secondary outcomes included reductions in radiotracer uptake at three months and improvements in biochemical markers and blood pressure at six months. Across 35 procedures, all PET-CT-positive nodules were successfully targeted and ablated, with no major complications. At six months, 75% of participants (95% CI 55–91) achieved biochemical improvement, and 43% (95% CI 24–61) saw clinical improvement in hypertension, with four participants experiencing complete remission off antihypertensive medication.
EUS-RFA presents a promising, less invasive alternative to traditional surgical approaches, offering a potential cure for primary aldosteronism while preserving adrenal function. These findings support further investigation into the efficacy of thermal ablation compared to adrenalectomy in a larger trial. If validated, EUS-RFA could significantly enhance clinical practice by reducing the need for major surgery and improving patient outcomes in managing hypertension related to APAs.
Katrina Thornber, EMJ
Reference
Argentesi G et al. Endoscopic, ultrasound-guided, radiofrequency ablation of aldosterone-producing adenomas (FABULAS): a UK, multicentre, prospective, proof-of-concept trial. The Lancet. 2025;DOI: DOI:10.1016/S0140-6736(24)02755-7.
