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Mikovic N, Mazzilli R, Zamponi V, Russo F, Mancini C, Mori F, Bollanti L, Conti F, Motta C, Monti S, Pugliese G, Faggiano A. Short fasting test as a reliable and effective tool to diagnose insulinoma. Endocrine 2024; 84:1258-1263. [PMID: 38451386 PMCID: PMC11208248 DOI: 10.1007/s12020-024-03759-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE The diagnosis of insulinoma can be challenging, requiring documentation of hypoglycaemia associated with non-suppressed insulin and C-peptide, often achieved during a prolonged 72 h fast performed in inpatient setting. Our goal is to predict weather a shorter outpatient fasting test initiated overnight and prolonged up until 24 h could be a sensitive method for diagnosing insulinoma. METHODS We conducted a retrospective monocentric study on subjects admitted to our Unit of Endocrinology from 2019 to 2022 for clinical suspicion of insulinoma and underwent the short fasting test. A comparison between the short test group and the group of subjects who underwent the standard prolonged fasting test (from 2003 to 2018) has also been performed. The short fasting test was initiated by the patient overnight at home and proceeded the following day in outpatient setting (Day Hospital). As in the standard protocol, symptoms and capillary blood glucose (CBG) were strictly monitored. Venous blood was drawn for glycaemia, insulin and C-peptide at admission and at established intervals, in case of symptoms of hypoglycaemia or if CBG ≤ 45 mg/dl, when the fast would be suspended. RESULTS The final sample consisted of 37 patients, with mean age of 44.5 ± 12.6 years (17-74). Short and standard tests were performed in 15 and 22 subjects, respectively. Diagnostic values for insulinoma were observed in 12 patients: in 5/15 who underwent the short fasting test, in 6/22 who underwent the prolonged test and in 1 patient who was initially negative on the short test and subsequently showed diagnostic values during the prolonged test. The diagnosis of insulinoma was achieved in 11/12 cases within 24 h of the beginning of the fast (91.7%). CONCLUSIONS A short fasting test could be a valid, sensitive and reliable first-line workup in diagnosing insulinoma.
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Affiliation(s)
- Nevena Mikovic
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy.
| | - Rossella Mazzilli
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Virginia Zamponi
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Flaminia Russo
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Camilla Mancini
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Fedra Mori
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Lucilla Bollanti
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Francesco Conti
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Cecilia Motta
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Salvatore Monti
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Giuseppe Pugliese
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Antongiulio Faggiano
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
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Черных ТМ, Малюгин ДА, Хачатуров МВ, Шефер АА, Золоедов ВИ. [Current views on the treatment of insulinoma]. PROBLEMY ENDOKRINOLOGII 2024; 70:46-55. [PMID: 38433541 PMCID: PMC10926244 DOI: 10.14341/probl13281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/06/2023] [Accepted: 07/20/2023] [Indexed: 03/05/2024]
Abstract
RELEVANCE Insulinoma is the most common hormonally active neuroendocrine tumor (NET) of the pancreas. In recent years, there has been a trend towards an increase in the incidence of NET especially insulinoma. AIM Summarizing and analyzing current data on various approaches to the treatment of insulinoma. Our review includes a comprehensive assessment of the advantages and disadvantages of currently available insulinoma treatment methods in comparison with past experience, as well as a review of promising methods that are not currently widely used. MATERIALS AND METHODS Analysis of literature from such databases as scientific electronic library elibrary.ru, Pubmed, Google Scholar, MedLine, Scopus and Web of Science. RESULTS The most common treatment for insulinoma is surgery. For patients with high operative risk, alternative methods such as alcohol ablation, radiofrequency ablation, and tumor embolization may be used. Medications include the use of somatostatin analogues, diazoxide. The literature describes the potential benefit of the use of beta-blockers, phenytoin, glucagon, however, in clinical trials, these drugs have not demonstrated a significant effect. For the treatment of malignant and metastatically advanced insulinoma, targeted therapy (primarily Everolimus), chemotherapy, as well as embolization (including chemoembolization, radioembolization), radiofrequency ablation (RFA), microwave ablation and cryoablation, ultrasound ablation (HIFU), laser ablation, brachytherapy, irreversible electroporation are used. CONCLUSION The study of new drugs is an important task for scientists, among medications the most promising are new generations of somatostatin analogues, targeted drugs and chemotherapy drugs. The rare frequency of insulinoma makes it difficult to conduct randomized controlled trials and prospective studies. That is why physicians and scientists need to maintain close contacts with each other and take into account the experience of treating each patient with such disease, which will help develop effective treatment algorithms in the future.
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Affiliation(s)
- Т. М. Черных
- Воронежский государственный медицинский университет им. Н.Н. Бурденко
| | - Д. А. Малюгин
- Воронежский государственный медицинский университет им. Н.Н. Бурденко
| | - М. В. Хачатуров
- Первый московский государственный медицинский университет им. И.М. Сеченова
| | - А. А. Шефер
- Воронежский государственный медицинский университет им. Н.Н. Бурденко
| | - В. И. Золоедов
- Воронежский государственный медицинский университет им. Н.Н. Бурденко
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3
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Neyaz A, Crotty R, Rickelt S, Pankaj A, Stojanova M, Michelakos TP, Sekigami Y, Kontos F, Parrack PH, Patil DT, Heaphy CM, Ferrone CR, Deshpande V. Predicting recurrence in pancreatic neuroendocrine tumours: role of ARX and alternative lengthening of telomeres (ALT). Histopathology 2023; 83:546-558. [PMID: 37455385 DOI: 10.1111/his.14996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 05/11/2023] [Accepted: 06/04/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND While many pancreatic neuroendocrine tumours (PanNET) show indolent behaviour, predicting the biological behaviour of small nonfunctional PanNETs remains a challenge. Nonfunctional PanNETs with an epigenome and transcriptome that resemble islet alpha cells (ARX-positive) are more aggressive than neoplasms that resemble islet beta cells (PDX1-positive). In this study, we explore the ability of immunohistochemistry for ARX and PDX1 and telomere-specific fluorescence in situ hybridisation (FISH) for alternative lengthening of telomeres (ALT) to predict recurrence. METHODS Two hundred fifty-six patients with PanNETs were identified, and immunohistochemistry for ARX and PDX1 was performed. Positive staining was defined as strong nuclear staining in >5% of tumour cells. FISH for ALT was performed in a subset of cases. RESULTS ARX reactivity correlated with worse disease-free survival (DFS) (P = 0.011), while there was no correlation between PDX1 reactivity and DFS (P = 0.52). ALT-positive tumours (n = 63, 31.8%) showed a significantly lower DFS (P < 0.0001) than ALT-negative tumours (n = 135, 68.2%). ARX reactivity correlated with ALT positivity (P < 0.0001). Among nonfunctional tumours, recurrence was noted in 18.5% (30/162) of ARX-positive tumours and 7.5% (5/67) of ARX-negative tumours. Among WHO grade 1 and 2 PanNETs with ≤2 cm tumour size, 14% (6/43) of ARX-positive tumours recurred compared to 0 of 33 ARX-negative tumours and 33.3% (3/9) ALT-positive tumours showed recurrence versus 4.4% (2/45) ALT-negative tumours. CONCLUSION Immunohistochemistry for ARX and ALT FISH status may aid in distinguishing biologically indolent cases from aggressive small low-grade PanNETs, and help to identify patients who may preferentially benefit from surgical intervention.
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Affiliation(s)
- Azfar Neyaz
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Rory Crotty
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Steffen Rickelt
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Boston, MA, USA
| | - Amaya Pankaj
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | | | | | - Yurie Sekigami
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Filippos Kontos
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Paige H Parrack
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Deepa T Patil
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Christopher M Heaphy
- Department of Medicine, Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Vikram Deshpande
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Del Rivero J, Mailman J, Rabow MW, Chan JA, Creed S, Kennecke HF, Pasieka J, Zuar J, Singh S, Fishbein L. Practical considerations when providing palliative care to patients with neuroendocrine tumors in the context of routine disease management or hospice care. Endocr Relat Cancer 2023; 30:e220226. [PMID: 37017232 PMCID: PMC10326633 DOI: 10.1530/erc-22-0226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/20/2023] [Indexed: 04/06/2023]
Abstract
This serves as a white paper by the North American Neuroendocrine Tumor Society (NANETS) on the practical considerations when providing palliative care to patients with neuroendocrine tumors in the context of routine disease management or hospice care. The authors involved in the development of this manuscript represent a multidisciplinary team of patient advocacy, palliative care, and hospice care practitioners, endocrinologist, and oncologists who performed a literature review and provided expert opinion on a series of questions often asked by our patients and patient caregivers affected by this disease. We hope this document serves as a starting point for oncologists, palliative care teams, hospice medical teams, insurers, drug manufacturers, caregivers, and patients to have a frank, well-informed discussion of what a patient needs to maximize the quality of life during a routine, disease-directed care as well as at the end-of-life.
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Affiliation(s)
- Jaydira Del Rivero
- Developmental Therapeutics Branch, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Josh Mailman
- NorCal CarciNET Community, Oakland, California, USA
| | - Michael W Rabow
- Department of Internal Medicine, Division of Palliative Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer A Chan
- Harvard Medical School, Program in Carcinoid and Neuroendocrine Tumors, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Sarah Creed
- Good Shepherd Community Care, Harvard Kennedy School, Natick, Massachusetts, USA
| | - Hagen F Kennecke
- Providence Cancer Institute Franz Clinic, Portland Providence Medical Center, Portland, Oregon, USA
| | - Janice Pasieka
- Department of Surgery, Section of General Surgery, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - Jennifer Zuar
- Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, Alpert Medical School, Providence, Rhode Island, USA
| | - Simron Singh
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lauren Fishbein
- Department of Medicine, Division of Endocrinology, Metabolism and Diabetes, Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Tarris G, Rouland A, Guillen K, Loffroy R, Lariotte AC, Rat P, Bouillet B, Andrianiaina H, Petit JM, Martin L. Case Report: Giant insulinoma, a very rare tumor causing hypoglycemia. Front Endocrinol (Lausanne) 2023; 14:1125772. [PMID: 37234805 PMCID: PMC10206132 DOI: 10.3389/fendo.2023.1125772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/17/2023] [Indexed: 05/28/2023] Open
Abstract
Insulinomas, with an incidence of 4 cases per million individuals per year, remain amongst the most frequent functional neuroendocrine tumors. The usual diameter of insulinomas usually remains under 3 cm of major axis. However, 44 exceptional cases of "giant insulinomas", have been reported worldwide, generally exceeding 9 cm in major axis. In this article, we report the case of a 38-year-old woman whom suffered from chronic hypoglycemia despite treatment with diazoxide. Abdominal CT-scan revealed a 88 x 73 mm mass located at the tail of the pancreas. Following surgical excision, histopathological analysis confirmed G1 neuroendocrine tumor, with focal cytoplasmic expression of insulin in tumor cells. After a 16-month follow-up period, the patient didn't address any specific complaint, and no disease recurrence and/or metastasis were observed. A 68Ga-DOTATATE-PET scan was performed 6 months after surgery, which came back normal. Genetic evaluation has not been performed in our patient. The physiopathology of giant insulinomas remain unexplained, however with possible relationship with type 1 multiple endocrine neoplasia, sporadic somatic YY1 mutations and possible transformation of bulky non-functional pancreatic neuroendocrine tumors to a functional phenotype, with slow insulin secretion. While giant insulinomas remain rare in the literature, multicentric genetic analysis of tumor samples might reveal unique features of this rare subtype of neuroendocrine pancreatic tumors. Insulinomas of large size tend to have greater malignancy and higher rates of invasiveness. Careful follow-up, especially for liver and lymph node metastases, must be performed using functional imaging techniques to avoid disease relapse.
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Affiliation(s)
- Georges Tarris
- Department of Pathology, University Hospital of Dijon, Dijon, France
| | - Alexia Rouland
- Department of Endocrinology and Diabetology, University Hospital of Dijon, Dijon, France
| | - Kévin Guillen
- Department of Radiology, University Hospital of Dijon, Dijon, France
| | - Romaric Loffroy
- Department of Radiology, University Hospital of Dijon, Dijon, France
| | | | - Patrick Rat
- Department of Digestive and Bariatric Surgery, University Hospital of Dijon, Dijon, France
| | - Benjamin Bouillet
- Department of Endocrinology and Diabetology, University Hospital of Dijon, Dijon, France
| | | | - Jean-Michel Petit
- Department of Endocrinology and Diabetology, University Hospital of Dijon, Dijon, France
| | - Laurent Martin
- Department of Pathology, University Hospital of Dijon, Dijon, France
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Palani G, Stortz E, Moheet A. Clinical Presentation and Diagnostic Approach to Hypoglycemia in Adults Without Diabetes Mellitus. Endocr Pract 2023; 29:286-294. [PMID: 36464132 DOI: 10.1016/j.eprac.2022.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/24/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To review the clinical presentation, causes, and diagnostic approach to spontaneous hypoglycemia in adults without diabetes mellitus. METHODS A literature review was performed using the PubMed and Google Scholar databases. RESULTS Hypoglycemia is uncommon in people who are not on glucose-lowering medications. Under normal physiologic conditions, multiple neural and hormonal counterregulatory mechanisms prevent the development of abnormally low levels of plasma glucose. If spontaneous hypoglycemia is suspected, the Whipple triad should be used to confirm hypoglycemia before pursuing further diagnostic workup. The Whipple criteria include the following: (1) low levels of plasma glucose, (2) signs or symptoms that would be expected with low levels of plasma glucose, and (3) improvement in those signs or symptoms when the level of plasma glucose increases. Spontaneous hypoglycemia can be caused by conditions that cause endogenous hyperinsulinism, including insulinoma, postbariatric hypoglycemia, and noninsulinoma pancreatogenous hypoglycemia. Spontaneous hypoglycemia can also be seen with critical illness, hepatic or renal dysfunction, hormonal deficiency, non-diabetes-related medications, and non-islet cell tumors. The initial diagnostic approach should begin by obtaining a detailed history of the nature and timing of the patient's symptoms, medications, underlying comorbid conditions, and any acute illness. A laboratory evaluation should be conducted at the time of the spontaneous symptomatic episode. Supervised tests such as a 72-hour fast or mixed-meal test may be needed to recreate the situation under which the patient is likely to experience symptoms. CONCLUSION We provide an overview of the physiology of counterregulatory response to hypoglycemia, its causes, and diagnostic approaches to spontaneous hypoglycemia in adults.
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Affiliation(s)
- Gurunanthan Palani
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Ethan Stortz
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Amir Moheet
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
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Fayyaz F, Reardon MF, Byrne L. Insulinoma as a cause of seizure-like activity and spontaneous hypoglycaemia. BMJ Case Rep 2023; 16:e250799. [PMID: 36627134 PMCID: PMC9835887 DOI: 10.1136/bcr-2022-250799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
A woman in her 60s presented to our hospital with recurrent episodes of confusion and double vision with spontaneous recovery to baseline within 10 min. Her initial workup was unremarkable, and she was diagnosed with complex partial seizures and commenced on levetiracetam. The following week, she re-presented with a recurrence of her symptoms, associated with spontaneous hypoglycaemia, with blood glucose levels of 1.9 mmol/L. She was found to have endogenously elevated serum insulin and C peptide levels, which were concomitantly associated with hypoglycaemia. An initial diagnosis of insulinoma was made and she was commenced on diazoxide. MRI and endoscopic ultrasound revealed 16 mm insulinoma in her uncinate process. She underwent surgical resection and remained symptom free at follow-up. This case highlights the importance of blood glucose measurements in patients presenting with neuroglycopenic symptoms and outlines the workup and management of insulinoma.
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Affiliation(s)
- Fahd Fayyaz
- Medicine, Wexford General Hospital, Wexford, Ireland
| | | | - Luke Byrne
- Cardiology, Tallaght University Hospital, Dublin, Ireland
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8
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Poku C, Amjed H, Kazi F, Samarasinghe S. Metastatic insulinoma presenting after bariatric surgery in a patient diagnosed with MEN1. Clin Case Rep 2022; 10:e05419. [PMID: 35145695 PMCID: PMC8818282 DOI: 10.1002/ccr3.5419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/14/2022] [Indexed: 11/23/2022] Open
Abstract
Insulinomas are uncommon neuroendocrine tumors and metastatic disease is extremely rare. We report a patient with metastatic insulinoma associated with multiple endocrine neoplasia type 1 presenting with hypoglycemia following sleeve gastrectomy. Potential causes of hypoglycemia include dumping syndrome, noninsulinoma pancreatogenous hypoglycemia syndrome, and rarely insulinoma. MEN1‐associated insulinomas have a higher recurrence rate.
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Affiliation(s)
- Caroline Poku
- Department of Medicine Division of Endocrinology Loyola University Medical Center Maywood Illinois USA
| | - Hafsa Amjed
- Department of Medicine Division of Endocrinology Loyola University Medical Center Maywood Illinois USA
| | - Fatima Kazi
- Department of Medicine Division of Endocrinology Loyola University Medical Center Maywood Illinois USA
| | - Shanika Samarasinghe
- Department of Medicine Division of Endocrinology Loyola University Medical Center Maywood Illinois USA
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Linch F, Thompson S, Fleming C, Vella A, Andrews J. Hepatic Artery Embolization for Palliation of Symptomatic Hypoglycemia in Patients With Hepatic Insulinoma Metastases. J Endocr Soc 2021; 5:bvab149. [PMID: 34877442 PMCID: PMC8643969 DOI: 10.1210/jendso/bvab149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Indexed: 12/03/2022] Open
Abstract
Context Insulinoma is a pancreatic neuroendocrine tumor that causes hyperinsulinemic hypoglycemia. Symptomatic hypoglycemia related to hepatic insulinoma metastases may be addressed with liver-directed therapies such as hepatic artery embolization. Objective This work aimed to determine the safety and effectiveness of bland hepatic artery embolization (HAE) for palliation of symptomatic hypoglycemia in patients with hepatic insulinoma metastases refractory to medical management. Methods An institutional review board–approved retrospective review was undertaken of all patients with a tissue (n = 18) or imaging (n = 2) diagnosis of hepatic insulinoma metastases and symptomatic hyperinsulinemic hypoglycemia refractory to medical management who underwent bland HAE at a single center between January 1, 1998 and November 1, 2020. Twenty patients (10 women, 10 men; mean age, 56 years; range, 18-84 years) were identified who individually underwent 1 (n = 7), 2 (n = 5), 3 (n = 5), 4 (n = 2), or 5 (n = 1) HAEs, for an overall total of 45 HAEs. Post-HAE hypoglycemia recurrence was defined as onset of adrenergic symptoms (eg, sweating, weakness, tremor), neuroglycopenic symptoms (eg, confusion, loss of consciousness), and/or documented serum glucose of less than 50 mg/dL, in the absence of an alternative explanation. Median time to first hypoglycemia recurrence, hypoglycemia-free survival (HFS), and overall survival (OS) were calculated using Kaplan-Meier method. Results Before HAE, all patients experienced adrenergic or neuroglycopenic symptoms alleviated by glucose intake, and 60% (n = 12) of patients had documented serum glucose of less than 50 mg/dL within 1 week of the first treatment. Median post-HAE follow-up was 9.4 months (mean, 26 months; range, 0.1-190 months). Postprocedural hypoglycemic symptom relief after the first HAE was reported in 100% (n = 20) of patients before discharge or at follow-up. Post-HAE hypoglycemia recurrence occurred in 60% (n = 12) of patients with a median time to first hypoglycemia recurrence of 2 months (mean, 14 months; range, 0.2-60 months). After the first HAE, median HFS was 14.5 months, and median OS was 16 months. One patient experienced labile postprocedure blood glucose levels requiring intensive care unit admission for intravenous dextrose. Otherwise, no major procedure-related complications occurred. Conclusion Bland HAE is a safe, effective, and repeatable procedure for palliation of symptomatic hypoglycemia in patients with hepatic insulinoma metastases refractory to medical management.
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Affiliation(s)
- Forrest Linch
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott Thompson
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Chad Fleming
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Vella
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota, USA
| | - James Andrews
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Kurakawa KI, Okada A, Manaka K, Konishi T, Jo T, Ono S, Uda K, Michihata N, Matsui H, Fushimi K, Yamaguchi S, Yamauchi T, Nangaku M, Yasunaga H, Kadowaki T. Clinical Characteristics and Incidences of Benign and Malignant Insulinoma Using a National Inpatient Database in Japan. J Clin Endocrinol Metab 2021; 106:3477-3486. [PMID: 34343300 DOI: 10.1210/clinem/dgab559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Insulinoma is the most common pancreatic functional neuroendocrine neoplasm, yet little information on recent clinical practice in patients with insulinoma, especially malignant insulinoma, is available. OBJECTIVE This work aims to clarify the characteristics and practice patterns in patients with insulinoma using a national inpatient database. METHODS Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified patients with insulinoma admitted between 2010 and 2018. We compared background characteristics and therapeutic interventions between patients with benign and malignant insulinoma. We also estimated the incidence of insulinoma using the number of patients with newly diagnosed insulinoma in 2012. RESULTS We identified 844 patients with benign insulinoma and 102 patients with malignant insulinoma. Patients with malignant insulinoma were younger (median, 55.5 vs 66.0 years, P < .001) and less likely to be female (55.9% vs 65.3%, P = .061) than patients with benign insulinoma. Analysis of therapeutic interventions revealed that patients with malignant insulinoma more frequently received medications (71.6% vs 49.6%, P < .001) but less frequently underwent pancreatic surgery (57.8% vs 72.0%, P = .003). Older patients were a smaller proportion of those undergoing surgery and a larger proportion of those managed with medications without surgery (P < .001). The incidence of insulinoma was estimated to be 3.27 (95% CI, 2.93-3.61) individuals per million Japanese adult population per year. CONCLUSION The present study using a nationwide database had a larger sample size than previous studies and revealed definitive differences in patient characteristics and therapeutic patterns between benign and malignant insulinoma.
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Affiliation(s)
- Kayo Ikeda Kurakawa
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Katsunori Manaka
- Division of Nephrology and Endocrinology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Taisuke Jo
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Sachiko Ono
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Kazuaki Uda
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo 113-8510, Japan
| | - Satoko Yamaguchi
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Toshimasa Yamauchi
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
| | - Takashi Kadowaki
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
- Toranomon Hospital, Tokyo 105-8470, Japan
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11
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Singbo J, Locketz M, Ross IL. Challenge of coexisting type 2 diabetes mellitus and insulinoma: a case report. J Med Case Rep 2021; 15:479. [PMID: 34583764 PMCID: PMC8479877 DOI: 10.1186/s13256-021-03047-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background Insulinomas are rare clinical entities, but concurrent diabetes mellitus is even more uncommon, and the combination is easily missed. Recurrent hypoglycemia could be misconstrued as improved glycemic control. We present an unusual patient with type 2 diabetes and neuroglycopenia, with apparent improved glycemic control due to an insulinoma. Case presentation A 54-year-old mixed ancestry man with a positive family history of type 2 diabetes mellitus was diagnosed with type 2 diabetes mellitus and hypertension 8 years prior to admission. He presented with episodes of abnormal behavior and hypoglycemia. Inappropriately high insulin and C-peptide concentrations were identified at the time of hypoglycemia. Despite poor adherence to his diabetic treatment, he had no target organ damage relating to diabetes, and his hemoglobin A1c (HbA1c) was 5.3%. A diagnosis of insulinoma was made, and he was started on diazoxide, with endoscopic ultrasound revealing a possible lesion in the pancreatic tail measuring 12 mm × 12 mm. A fine-needle aspiration biopsy could not be performed due to overlying splenic arteries and the risk of vascular perforation. An intraoperative ultrasound confirmed a 15 mm × 10 mm tumor in the pancreatic tail, necessitating a partial pancreatectomy and splenectomy, which were curative. A well-differentiated intermediate grade 2 pancreatic neuroendocrine tumor producing insulin was confirmed on histopathology. Conclusions Recurrent, progressive hypoglycemia and improved glycemic control in a diabetic, without an alternative explanation, may suggest an insulinoma. Insulinomas that exist with type 1 diabetes mellitus, particularly malignant insulinomas, must have escaped autoimmune attack through lack of autoantigen expression. Computed tomography on its own may be insufficiently sensitive for diagnosis of insulinomas, whereas endoscopic and intraoperative ultrasonography may improve the identification of the culprit lesion.
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Affiliation(s)
- Joseph Singbo
- Department of Medicine J47 Old Main Building Division of Endocrinology and Diabetes, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7945, South Africa
| | - Michael Locketz
- Department of Histopathology, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa
| | - Ian Louis Ross
- Department of Medicine J47 Old Main Building Division of Endocrinology and Diabetes, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7945, South Africa.
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12
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Diaconescu S, Gîlcă-Blanariu GE, Poamaneagra S, Marginean O, Paduraru G, Stefanescu G. Could the burden of pancreatic cancer originate in childhood? World J Gastroenterol 2021; 27:5322-5340. [PMID: 34539135 PMCID: PMC8409163 DOI: 10.3748/wjg.v27.i32.5322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 06/08/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023] Open
Abstract
The presence of pancreatic cancer during childhood is extremely rare, and physicians may be tempted to overlook this diagnosis based on age criteria. However, there are primary malignant pancreatic tumors encountered in pediatric patients, such as pancreatoblastoma, and tumors considered benign in general but may present a malignant potential, such as the solid pseudo-papillary tumor, insulinoma, gastrinoma, and vasoactive intestinal peptide secreting tumor. Their early diagnosis and management are of paramount importance since the survival rates tend to differ for various types of these conditions. Many pediatric cancers may present pancreatic metastases, such as renal cell carcinoma, which may evolve with pancreatic metastatic disease even after two or more decades. Several childhood diseases may create a predisposition for the development of pancreatic cancer during adulthood; hence, there is a need for extensive screening strategies and complex programs to facilitate the transition from pediatric to adult healthcare. Nevertheless, genetic studies highlight the fact the specific gene mutations and family aggregations may be correlated with a special predisposition towards pancreatic cancer. This review aims to report the main pancreatic cancers diagnosed during childhood, the most important childhood diseases predisposing to the development of pancreatic malignancies, and the gene mutations associates with pancreatic malignant tumors.
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Affiliation(s)
- Smaranda Diaconescu
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- Department of Pediatric Gastroenterology, St Mary Emergency Children's Hospital, Iasi 700309, Romania
| | - Georgiana Emmanuela Gîlcă-Blanariu
- Department of Gastroenterology and Hepatology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi 700115, Romania
- Department of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
| | - Silvia Poamaneagra
- Department of Pediatric Gastroenterology, St Mary Emergency Children's Hospital, Iasi 700309, Romania
- Doctoral School, George Emil Palade University of Medicine, Pharmacy, Science and Technology, Targu Mures 540142, Romania
| | - Otilia Marginean
- Department of Pediatrics, Research Center of Disturbance of Growth and Development on Children-Belive, University of Medicine and Pharmacy “Victor Babes” Timisoara, Timisoara 300041, Romania
- First Clinic of Pediatrics, "Louis Turcanu" Emergency Childen's Hospital, Timisoara 300011, Romania
| | - Gabriela Paduraru
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
- Department of Pediatric Gastroenterology, St Mary Emergency Children's Hospital, Iasi 700309, Romania
| | - Gabriela Stefanescu
- Department of Gastroenterology and Hepatology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi 700115, Romania
- Department of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, Iasi 700111, Romania
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13
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Multiple Endocrine Neoplasia Type 1 with Concomitant Existence of Malignant Insulinoma: A Rare Finding. Case Rep Endocrinol 2021; 2021:8842667. [PMID: 34367700 PMCID: PMC8337156 DOI: 10.1155/2021/8842667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 06/11/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022] Open
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is a rare syndrome of autosomal dominant inheritance defined by co-occurrence of two or more tumors originating from the parathyroid gland, pancreatic islet cells, and/or anterior pituitary. Insulinoma which has an incidence of 0.4% is a rare pancreatic neuroendocrine tumor. Malignant insulinoma is extremely rare, while primary hyperparathyroidism is a common occurrence in MEN1. We present a case of MEN1 syndrome with 2.6 cm insulinoma in the pancreatic head and parathyroid adenoma in a 56-year-old female who presented with symptoms suggestive of hypoglycemia like multiple episodes of loss of consciousness for four years. Classical pancreaticoduodenectomy was carried out, and the postoperative period was uneventful. Later, subtotal parathyroidectomy was performed, which showed parathyroid adenoma. Patients presenting with features of hypoglycemia should be vigilantly assessed for the presence of a sinister pathology.
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14
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Gao LP, Kong GX, Wang X, Ma HM, Ding FF, Li TD. Pancreatic neuroendocrine carcinoma in a pregnant woman: A case report and review of the literature. World J Clin Cases 2021; 9:4327-4335. [PMID: 34141797 PMCID: PMC8173422 DOI: 10.12998/wjcc.v9.i17.4327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/23/2021] [Accepted: 04/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Portal venous thromboembolism caused by malignant pancreatic neuroendocrine tumor metastasis, as the initial presentation of portal hypertension and upper gastrointestinal bleeding, is a rare entity. To our knowledge, there are no reports of this entity in pregnant women. We describe a case of pancreatic neuroendocrine carcinoma during pregnancy with hematemesis and hematochezia as the initial presentation and review the literature to analyze the demographic, clinical, and pathological features to provide a reference for clinical diagnosis and treatment.
CASE SUMMARY A 40-year-old woman presented with hematemesis and hematochezia at 26-wk gestation; she had no other remarkable medical history. The physical examination revealed normal vital signs, an anemic appearance, and lower abdominal distension. Abdominal color Doppler ultrasonography showed portal vein thrombosis, splenomegaly, intrauterine pregnancy, and intrauterine fetal death. Esophagogastroduodenoscopy revealed esophageal and gastric varicose veins and portal hypertensive gastropathy. Contrast-enhanced computed tomography demonstrated multiple emboli formation in the portal and splenic veins, multiple round shadows in the liver with a slightly lower density, portal vein broadening, varicose veins in the lower esophagus and gastric fundus, splenomegaly, bilateral pleural effusion, ascites and pelvic effusion, broadening of the common bile duct, and increased uterine volume. According to the results of Positron emission tomography-computed tomography and immunohistochemical staining, the final diagnoses were that the primary lesion was a pancreatic neuroendocrine tumor and that there were secondary intrahepatic metastases and venous cancer thrombogenesis.
CONCLUSION Upper gastrointestinal bleeding in a pregnant woman may be caused by portal hypertension due to a malignant pancreatic neuroendocrine tumor.
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Affiliation(s)
- Li-Ping Gao
- Department of Gastroenterology, The Second Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Gui-Xiang Kong
- Department of Gastroenterology, The Second Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Xiang Wang
- Department of Gastroenterology, The Second Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Hui-Min Ma
- Department of Gastroenterology, The Second Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Fei-Fei Ding
- Department of Gastroenterology, The Second Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Ting-Dong Li
- Department of Musculoskeletal Tumor, Gansu Provincial Cancer Hospital, Lanzhou 730000, Gansu Province, China
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15
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Spada F, Rossi RE, Kara E, Laffi A, Massironi S, Rubino M, Grimaldi F, Bhoori S, Fazio N. Carcinoid Syndrome and Hyperinsulinemic Hypoglycemia Associated with Neuroendocrine Neoplasms: A Critical Review on Clinical and Pharmacological Management. Pharmaceuticals (Basel) 2021; 14:ph14060539. [PMID: 34199977 PMCID: PMC8228616 DOI: 10.3390/ph14060539] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 02/05/2023] Open
Abstract
The carcinoid syndrome (CS) and hyperinsulinemic hypoglycemia (HH) represent two of the most common clinical syndromes associated with neuroendocrine neoplasms (NENs). The former is mainly related to the serotonin secretion by a small bowel NEN, whereas the latter depends on an insulin hypersecretion by a pancreatic insulinoma. Both syndromes/conditions can affect prognosis and quality of life of patients with NENs. They are often diagnosed late when patients become strongly symptomatic. Therefore, their early detection and management are a critical step in the clinical management of NEN patients. A dedicated and experienced multidisciplinary team with appropriate therapeutic strategies is needed and should be encouraged to optimize clinical outcomes. This review aims to critically analyze clinical features, evidence and treatment options of CS and HH and therefore to improve their management.
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Affiliation(s)
- Francesca Spada
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology (IEO) IRCCS, via G. Ripamonti 435, 20141 Milano, Italy; (F.S.); (A.L.); (M.R.)
| | - Roberta E. Rossi
- Hepatology and Hepato-Pancreatic-Biliary Surgery and Liver Transplantation, Fondazione IRCCS, Istituto Nazionale Tumori (INT), via G. Venezian 1, 20133 Milano, Italy; (R.E.R.); (S.B.)
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, via Festa del Perdono 7, 20122 Milano, Italy
| | - Elda Kara
- Endocrinology and Metabolism Unit, University Hospital S. Maria della Misericordia, Piazzale Santa Maria della Misericordia, 15, 33100 Udine, Italy; (E.K.); (F.G.)
| | - Alice Laffi
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology (IEO) IRCCS, via G. Ripamonti 435, 20141 Milano, Italy; (F.S.); (A.L.); (M.R.)
| | - Sara Massironi
- Division of Gastroenterology, San Gerardo Hospital, Bicocca School of Medicine, University of Milano Bicocca, 20126 Milano, Italy;
| | - Manila Rubino
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology (IEO) IRCCS, via G. Ripamonti 435, 20141 Milano, Italy; (F.S.); (A.L.); (M.R.)
| | - Franco Grimaldi
- Endocrinology and Metabolism Unit, University Hospital S. Maria della Misericordia, Piazzale Santa Maria della Misericordia, 15, 33100 Udine, Italy; (E.K.); (F.G.)
| | - Sherrie Bhoori
- Hepatology and Hepato-Pancreatic-Biliary Surgery and Liver Transplantation, Fondazione IRCCS, Istituto Nazionale Tumori (INT), via G. Venezian 1, 20133 Milano, Italy; (R.E.R.); (S.B.)
| | - Nicola Fazio
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology (IEO) IRCCS, via G. Ripamonti 435, 20141 Milano, Italy; (F.S.); (A.L.); (M.R.)
- Correspondence: ; Tel.: +39-025-748-9258
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16
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Shiozaki H, Shirai Y, Horiuchi T, Yasuda J, Furukawa K, Onda S, Gocho T, Shiba H, Ikegami T. Feasible laparoscopic distal pancreatectomy for pancreatic neuroendocrine tumors. Mol Clin Oncol 2021; 14:111. [PMID: 33903817 DOI: 10.3892/mco.2021.2273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 02/15/2021] [Indexed: 11/05/2022] Open
Abstract
Pancreatic neuroendocrine tumor (PNET) cases are increasing; however, the treatment indication and procedure remain unestablished. The present study evaluated the indication, feasibility and safety of laparoscopic distal pancreatectomy (LDP) with our technique for PNET. A total of 13 patients with insulinoma and nonfunctional PNET <2 cm in diameter who underwent LDP and 13 patients with any size of PNET who underwent open distal pancreatectomy (ODP) between October 2009 and June 2019 were retrospectively reviewed and compared. The median age of patients was 45 (33-61) years, and 14 (54%) patients were male. The median follow-up periods were 70 months for the LDP group and 46 months for the ODP group. The tumor diameter of the patients who underwent LDP for PNET was 18±9 mm compared with 37±25 mm for those who underwent ODP. The operation time, estimated blood loss, and complication were 290.2±115 vs. 337±131 min (P=0.338), 122±172 vs. 649±693 ml (P=0.019) and 31 vs. 54% (P=0.234), respectively. Pancreatic fistula developed in 8% of patients who underwent LDP compared with 31% who underwent ODP (P=0.131). Notably, the postoperative hospitalization period was significantly shorter in the LDP group (11±7 vs. 21±13 days; P=0.022). Tumor grade of 2017 World Health Organization classification (G1/G2/G3/NEC/unknown) was 9/2/0/0/2 for the LDP group compared with 5/5/0/3/0 for the ODP group. Furthermore, lymph node metastasis was detected in only 1 patient who underwent ODP, for whom the maximum tumor diameter was 70 mm and was classified as G2. In addition, 2 patients in the ODP group developed postoperative lung and liver metastases. LDP for PNETs of <2 cm in selected patients can be safely performed; however, the extent of lymph node dissection needs to be clarified.
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Affiliation(s)
- Hironori Shiozaki
- Department of Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Yoshihiro Shirai
- Department of Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Takashi Horiuchi
- Department of Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Jungo Yasuda
- Department of Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Kenei Furukawa
- Department of Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Shinji Onda
- Department of Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Takeshi Gocho
- Department of Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Hiroaki Shiba
- Department of Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
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17
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Sada A, Glasgow AE, Vella A, Thompson GB, McKenzie TJ, Habermann EB. Malignant Insulinoma: A Rare Form of Neuroendocrine Tumor. World J Surg 2021; 44:2288-2294. [PMID: 32128613 DOI: 10.1007/s00268-020-05445-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Due to the rarity of malignant insulinoma, a lack of the literature describing factors affecting outcomes exists. Our aim was to review malignant insulinoma incidence, characteristics and survival trends. METHODS We identified all patients with malignant insulinoma in the SEER registries from 1973 to 2015. Incidence, neoplasm characteristics and factors affecting cancer-specific survival (CSS) were described. RESULTS A total of 121 patients were identified. The crude annual overall incidence was low (range 0.0-0.27 cases per million person years). The largest proportion had localized disease (40%), while 16% had regional disease, 39% distant metastatic disease, and stage was unreported in 5%. Most neoplasms were in the body/tail of the pancreas, followed by the head of the pancreas. Grade was reported in 40% of patients; only a single patient reported as having grade IV with the remainder all grades I/II. Surgical resection was performed in 64% of patients. Within surgical patients, the median primary neoplasm size was 1.8 cm. Regional lymph nodes were examined in 57.1% of surgical patients, while 34% of examined nodes were positive. The median CSS was 183 months. On multivariable analysis, surgical resection, male sex and absence of metastatic disease were associated with superior survival. CONCLUSION While the greatest proportion of patients with malignant insulinoma present with localized disease, regional lymph node involvement was found in 34% of whose nodes were tested. Further studies are needed to assess the role of lymph node dissection in improving survival and preventing recurrence given the observed frequency of lymph node involvement.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
- Surgical Outcomes Program, Robert D and Patricia E Kern Center for The Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Amy E Glasgow
- Surgical Outcomes Program, Robert D and Patricia E Kern Center for The Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Adrian Vella
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Elizabeth B Habermann
- Surgical Outcomes Program, Robert D and Patricia E Kern Center for The Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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18
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Lorenzo-Villalba N, Maouche Y, Alonso Ortiz MB, Zulfiqar AA. [Complexity of the management of an insulinoma in a nonagenarian patient]. Rev Esp Geriatr Gerontol 2020; 56:63-64. [PMID: 33303259 DOI: 10.1016/j.regg.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/03/2020] [Accepted: 09/18/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Noel Lorenzo-Villalba
- Service de Médecine Interne, Diabète et Maladies Métaboliques, Hôpitaux Universitaires de Strasbourg, Estrasburgo, Francia.
| | - Yasmine Maouche
- Service de Médecine Interne, Diabète et Maladies Métaboliques, Hôpitaux Universitaires de Strasbourg, Estrasburgo, Francia
| | - Maria Belén Alonso Ortiz
- Servicio de Medicina Interna, Hospital Universitario de Gran Canaria Dr Negrín, Las Palmas de Gran Canaria, España
| | - Abrar-Ahmad Zulfiqar
- Service de Médecine Interne, Diabète et Maladies Métaboliques, Hôpitaux Universitaires de Strasbourg, Estrasburgo, Francia
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19
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Sada A, Yamashita TS, Glasgow AE, Habermann EB, Thompson GB, Lyden ML, Dy BM, Halfdanarson TR, Vella A, McKenzie TJ. Comparison of benign and malignant insulinoma. Am J Surg 2020; 221:437-447. [PMID: 32873371 DOI: 10.1016/j.amjsurg.2020.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/21/2020] [Accepted: 08/05/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND How malignant insulinomas present relative to benign insulinomas is unknown. METHODS A single-institution retrospective study identified patients with insulinoma. Malignancy was defined by distant metastases, positive lymph node(s), T stage of 4, direct invasion into surrounding peripancreatic tissue, or presence of lymphovascular invasion. Wilcoxon Rank Sum tests and Kaplan-Meier analysis were used. RESULTS A total of 311 patients were identified: 51 malignant and 260 benign. Patients with malignant insulinoma presented with higher levels of insulin, proinsulin, and c-peptide. Malignant lesions were larger: 4.2 ± 3.2 vs 1.8 ± 0.8 cm in benign lesions, p < 0.01. Overall survival at 5 years was 66.8% vs 95.4% for malignant and benign insulinoma respectively, p < 0.01. CONCLUSIONS Larger size of insulinoma and increased serum β-cell polypeptide concentrations were associated with malignancy. Malignant insulinoma has poorer survival. Further work-up to rule out malignancy may be indicated for larger pancreatic lesions and for patients with higher pre-operative insulin and pro-insulin.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA; Department of Health Services Research, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | | | - Amy E Glasgow
- Department of Health Services Research, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA; Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, 200th 1st Street, Rochester MN, 55905, USA
| | - Elizabeth B Habermann
- Department of Health Services Research, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA; Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, 200th 1st Street, Rochester MN, 55905, USA
| | - Geoffrey B Thompson
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | - Melanie L Lyden
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | | | - Adrian Vella
- Division of Endocrinology, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA.
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20
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Case Report and Literature Review of Insulinoma in the Geriatric Population: An 86-Year-Old Female with Syncope of Unknown Origin. Case Rep Endocrinol 2020; 2020:8879776. [PMID: 32733714 PMCID: PMC7383333 DOI: 10.1155/2020/8879776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/22/2020] [Indexed: 11/30/2022] Open
Abstract
Insulinomas are extremely rare pancreatic endocrine tumors. The tumor is characterized by endogenous hypersecretion of insulin and ensuing development of symptoms of neuroglycopenia and the catecholaminergic response. Symptoms may not always be present, particularly in patients compensating appropriately with increased appetites and caloric intake due to low glucose levels. Early localization of the disease is essential to prevent lethal hypoglycemia and timely treatment. This case report and literature review depict the case of a pancreatic insulinoma in an 86-year-old female, an exceptionally rare presentation based on age and absence of clinical symptoms for one or more years prior to hospitalization. Despite its rarity, similar presentations have been reported in the literature and are further outlined with characteristics and treatment plans. This case highlights a unique presentation of insulinoma and suggests the need for clinical vigilance and further study. It also discusses diagnosis, localization, and management of this uncommon disease in patients above the age of seventy-five.
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21
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Shankar N, Linzay C, Rowe K. Vasoactive intestinal peptide-oma causing refractory diarrhea in a young woman. Proc (Bayl Univ Med Cent) 2020; 33:641-643. [PMID: 33100555 DOI: 10.1080/08998280.2020.1778963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Vasoactive intestinal peptide (VIP)-secreting neuroendocrine tumors are an exceptionally rare cause of chronic diarrhea. We describe a 36-year-old woman presenting with a 2-year history of severe diarrhea and electrolyte derangements ultimately diagnosed with VIPoma.
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Affiliation(s)
- Nagasri Shankar
- Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | - Catherine Linzay
- Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas
| | - Kyle Rowe
- Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas
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22
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Tachibana T, Kasajima A, Aoki T, Tabata T, McNamara K, Yazdani S, Satoko S, Fujishima F, Motoi F, Unno M, Sasano H. Progesteron receptor expression in insulin producing cells of neuroendocrine neoplasms. J Steroid Biochem Mol Biol 2020; 201:105694. [PMID: 32437964 DOI: 10.1016/j.jsbmb.2020.105694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 05/02/2020] [Accepted: 05/04/2020] [Indexed: 12/15/2022]
Abstract
Progesterone receptor (PgR) inhibits cell proliferation in pancreatic neuroendocrine neoplasms (PanNEN). In non-neoplastic pancreas, loss of PgR induces β-cell proliferation and insulin production. However, detailed association between PgR and insulin producing PanNENs is poorly understood. Insulin, proinsulin, and PgR were immunolocalized in 82 PanNENs (54 non-functioning PanNENs: NF-PanNENs and 28 insulinomas). The status of immunoreactivity was compared to the clinicopathological factors of the patients. Immunoreactivity was also confirmed by employing the double-immunohistochemistry. These results were also compared with those in non-neoplastic Langerhans islets. PgR immunoreactivity was significantly higher in insulinomas than that in NF-PanNENs (p < 0.001). Insulin and proinsulin immunoreactivity was also detected in 20 (37 %) of (single cell) insulin positive NFs (Inspos-NF-PanNEN), in which PgR expression was higher than in insulin negative NF-PanNENs (Insneg-NF-PanNEN, p = 0.03). The ratio of PgR-insulin double positive cells to overall insulin positive cells, as well as PgR-proinsulin double positive cells to proinsulin positive cells, was detected to the same degree in insulinoma (PgR-insulin 70 %, PgR-proinsulin 66 %), Inspos-NF-PanNENs (PgR-insulin 65 %, PgR-proinsulin 68 %) and normal islet (PgR-insulin 80 %, PgR-proinsulin 72 %). PgR and insulin expressing cells colocalize in tumor cells of the PanNENs regardless of the hormone-related symptoms of the patients. Inhibitory effect of PgR on tumor cells might be associated with the favourable clinical outcome of insulinoma patients.
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Affiliation(s)
- Tomoyoshi Tachibana
- Department of Pathology, Tohoku University Graduate School of Medicine, Miyagi, Japan; Department of Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Atsuko Kasajima
- Department of Pathology, Tohoku University Graduate School of Medicine, Miyagi, Japan; Technical University Munich, School of Medicine, Klinikum rechts der Isar, Department of Pathology, Munich, Germany; Member of the German Cancer Consortium (DKTK), Germany.
| | - Takeshi Aoki
- Department of Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Tomoaki Tabata
- Department of Pathology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Keely McNamara
- Department of Pathology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Samaneh Yazdani
- Department of Pathology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Sato Satoko
- Department of Pathology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Fumiyoshi Fujishima
- Department of Pathology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Fuyuhiko Motoi
- Department of Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Miyagi, Japan
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23
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Hackeng WM, Schelhaas W, Morsink FHM, Heidsma CM, van Eeden S, Valk GD, Vriens MR, Heaphy CM, Nieveen van Dijkum EJM, Offerhaus GJA, Dreijerink KMA, Brosens LAA. Alternative Lengthening of Telomeres and Differential Expression of Endocrine Transcription Factors Distinguish Metastatic and Non-metastatic Insulinomas. Endocr Pathol 2020; 31:108-118. [PMID: 32103422 PMCID: PMC7250793 DOI: 10.1007/s12022-020-09611-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Insulin-producing pancreatic neuroendocrine tumors (PanNETs)/insulinomas are generally considered to be indolent tumors with an excellent prognosis after complete resection. However, some insulinomas have a poor prognosis due to relapses and metastatic disease. Recently, studies in non-functional PanNETs indicated that behavior can be stratified according to alpha- and beta-cell differentiation, as defined by expression of the transcription factors ARX and PDX1, respectively. It is unknown whether similar mechanisms play a role in insulinomas. Therefore, we determined ARX and PDX1 expression in a cohort of 35 sporadic primary insulinomas and two liver metastases of inoperable primary insulinomas. In addition, WHO grade and loss of ATRX or DAXX were determined by immunohistochemistry, and alternative lengthening of telomeres (ALT) and CDKN2A status by fluorescence in situ hybridization. These findings were correlated with tumor characteristics and clinical follow-up data. In total, five out of 37 insulinoma patients developed metastatic disease. Metastatic insulinomas were all larger than 3 cm, whereas the indolent insulinomas were smaller (p value < 0.05). All three primary insulinomas that metastasized showed ARX expression, 2/3 showed ALT, and 1/3 had a homozygous deletion of CDKN2A as opposed to absence of ARX expression, ALT, or CDKN2A deletions in the 32 non-metastatic cases. The two liver metastases also showed ARX expression and ALT (2/2). The presence of ARX expression, which is usually absent in beta-cells, and genetic alterations not seen in indolent insulinomas strongly suggest a distinct tumorigenic mechanism in malignant insulinomas, with similarities to non-functional PanNETs. These observations may inform future follow-up strategies after insulinoma surgery.
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Affiliation(s)
- Wenzel M Hackeng
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Willemien Schelhaas
- Department of Pathology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Folkert H M Morsink
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Charlotte M Heidsma
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Susanne van Eeden
- Department of Pathology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gerlof D Valk
- Department of Endocrinology and Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Menno R Vriens
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | - G Johan A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Koen M A Dreijerink
- Department of Endocrinology and Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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24
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Malignant Insulinoma with Multiple Liver Metastases and Hypercalcitoninemia in a Patient with Type 2 Diabetes Mellitus Presenting as Recurrent Episodes of Diaphoresis due to Severe Hypoglycemia. Case Rep Endocrinol 2020; 2020:4239679. [PMID: 32082648 PMCID: PMC7019204 DOI: 10.1155/2020/4239679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/18/2019] [Accepted: 01/04/2020] [Indexed: 11/17/2022] Open
Abstract
Insulinoma is an insulin-producing pancreatic neuroendocrine tumor that can be malignant in about 10% of cases. Locoregional invasion, lymph node metastases, or remote metastases are the main criteria of malignant insulinoma. Its incidence in patients with pre-existing diabetes mellitus (DM) is exceptionally rare. In this report, we describe a 66-year-old man with long-standing type 2 DM who presented with recurrent episodes of diaphoresis due to severe hypoglycemia despite the withdrawal of insulin therapy, hypercalcitoninemia, and biochemical and radiological findings suggestive of metastatic malignant insulinoma. Unfortunately, after few days of diazoxide treatment, edema, hypotension, oliguria, and water retention were observed, patient's clinical status deteriorated rapidly, and he died in our department from acute renal failure.
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25
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Nastos C, Giannoulopoulos D, Dellaportas D, Mizamtsidi M, Dafnios N, Klonaris N, Kalogeris N, Vryonidou A. Sudden 'cure' of type two diabetes due to pancreatic insulinoma: A case report. Mol Clin Oncol 2020; 12:174-178. [PMID: 31929890 DOI: 10.3892/mco.2019.1957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 07/05/2019] [Indexed: 01/16/2023] Open
Abstract
Insulinomas are rare tumors of the islet cells of the pancreas and are the most common cause of endogenous hyperinsulinism. Although they usually present with symptoms of hypoglycemia, sometimes they can have vague symptoms. We present the case of a 62-year-old diabetic female who was diagnosed with a large insulinoma after being investigated for the 'cure' of her diabetes. We also review the literature regarding insulinomas in patients with diabetic. A 62-year-old, obese woman with type 2 diabetes mellitus was initially investigated for an unexplained normalization of her blood glucose levels after the cessation of antidiabetic medication due to an episode of severe hypoglycemia. She remained without antidiabetics for three months maintaining normoglycemia, and thereafter, she started experiencing frequent but less severe hypoglycemic episodes. She did not change her diet habits or level of activity and did not lose any weight. The patient underwent further investigation with a supervised 72 h fasting test, which resulted in the biochemical diagnosis of endogenous hyperinsulinism. Imaging studies revealed the presence of a large insulinoma in the head of the pancreas. Finally, the patient underwent a pylorus preserving Whipple procedure, which reversed the aforementioned 'normalization' of glucose levels and the underlying diabetes mellitus reappeared. Insulinomas are rare tumors causing hypoglycemia. Even more rarely are found in diabetic patients, making the diagnosis more challenging and probably delayed, as the symptoms are masked by the presence of diabetes, thereby leading to a more advanced disease diagnosis.
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Affiliation(s)
- Constantinos Nastos
- Second Department of Surgery, Endocrine Surgery Unit, National and Kapodistrian University of Athens, School of Medicine, Aretaieion University Hospital, 11528 Athens, Greece
| | - Dimitrios Giannoulopoulos
- Second Department of Surgery, Endocrine Surgery Unit, National and Kapodistrian University of Athens, School of Medicine, Aretaieion University Hospital, 11528 Athens, Greece
| | - Dionysios Dellaportas
- Second Department of Surgery, Endocrine Surgery Unit, National and Kapodistrian University of Athens, School of Medicine, Aretaieion University Hospital, 11528 Athens, Greece
| | - Maria Mizamtsidi
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, 11526 Athens, Greece
| | - Nikolaos Dafnios
- Second Department of Surgery, Endocrine Surgery Unit, National and Kapodistrian University of Athens, School of Medicine, Aretaieion University Hospital, 11528 Athens, Greece
| | - Nikolaos Klonaris
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, 11526 Athens, Greece
| | - Nikolaos Kalogeris
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, 11526 Athens, Greece
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, 11526 Athens, Greece
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Abstract
Neuroendocrine tumors (NETs) represent a group of biologically and clinically heterogeneous neoplasms arising from the diffuse neuroendocrine system. Although NETs may develop in almost any organ, they commonly arise in the gastrointestinal tract and pancreas and are referred to as gastroenteropancreatic (GEP)-NETs when they arise from these sites. In recent years, advances in understanding of the biology of NETs have resulted in an expansion in treatment options and improved survival for patients. This review focuses on treatment of GEP-NETS and highlights factors that govern the therapeutic approach.
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Affiliation(s)
- Kimberly Perez
- Program in Carcinoid and Neuroendocrine Tumors, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA.
| | - Jennifer Chan
- Program in Carcinoid and Neuroendocrine Tumors, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA
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Dudum R, Murthy VK. Keeping a Low Profile: Insulinoma. Am J Med 2019; 132:1160-1162. [PMID: 31054830 DOI: 10.1016/j.amjmed.2019.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Ramzi Dudum
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Vivek K Murthy
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
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Briganti V, Cuccurullo V, Di Stasio GD, Mansi L. Gamma Emitters in Pancreatic Endocrine Tumors Imaging in the PET Era: Is there a Clinical Space for 99mTc-peptides? Curr Radiopharm 2019; 12:156-170. [DOI: 10.2174/1874471012666190301122524] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/15/2018] [Accepted: 10/19/2018] [Indexed: 12/18/2022]
Abstract
Background:
Pancreatic Neuroendocrine Tumors (PNETs) are rare neoplasms, sporadic or
familial, even being part of a syndrome. Their diagnosis is based on symptoms, hormonal disorders or
may be fortuitous. The role of Nuclear Medicine is important, mainly because of the possibility of a
theranostic strategy. This approach is allowed by the availability of biochemical agents, which may be
labeled with radionuclides suitable for diagnostic or therapeutic purposes, showing almost identical
pharmacokinetics. The major role for radiopharmaceuticals is connected with radiolabeled Somatostatin
Analogues (SSA), since somatostatin receptors are highly expressed on some of the neoplastic
cell types.
Discussion:
Nowadays, in the category of radiolabeled SSA, although 111In-pentetreotide, firstly
commercially proposed, is still used, the best choice for diagnosis is related to the so called DOTAPET
radiotracers labeled with 68-Gallium (Ga), such as 68Ga-DOTATATE, 68Ga-DOTANOC, and
68Ga-DOTATOC. More recently, labeling with 64-Copper (Cu) (64Cu-DOTATATE) has also been
proposed. In this review, we discuss the clinical interest of a SAA (Tektrotyd©) radiolabeled with
99mTc, a gamma emitter with better characteristics, with respect to 111Indium, radiolabeling Octreoscan
©. By comparing both pharmacokinetics and pharmacodynamics of Octreoscan©, Tektrotyd©
and PET DOTA-peptides, on the basis of literature data and of our own experience, we tried to highlight
these topics to stimulate further studies, individuating actual clinical indications for all of these
radiotracers.
Conclusion:
In our opinion, Tektrotyd© could already find its applicative dimension in the daily practice
of NETs, either pancreatic or not, at least in centers without a PET/CT or a 68Ga generator. Because
of wider availability, a lower cost, and a longer decay, compared with respect to peptides labeled
with 68Ga, it could be also proposed, in a theranostic context, for a dosimetry evaluation of patients
undergoing Peptide Receptor Radionuclide Therapy (PRRT), and for non-oncologic indications
of radiolabelled SSA. In this direction, and for a more rigorous cost/effective evaluation, more precisely
individuating its clinical role, further studies are needed.
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Affiliation(s)
- Vittorio Briganti
- Nuclear Medicine Unit - Azienda Ospedaliero Universitaria Careggi Firenze, Italy
| | - Vincenzo Cuccurullo
- Nuclear Medicine Unit, Department of Clinical and Experimental Medicine "F.Magrassi, A.Lanzara" – Università della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Giuseppe Danilo Di Stasio
- Nuclear Medicine Unit, Department of Clinical and Experimental Medicine "F.Magrassi, A.Lanzara" – Università della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Luigi Mansi
- Health and Development Section, Interuniversitary Research Center for Sustainable Development, Napoli-Roma, Italy
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29
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Ames A, Lago-Hernandez CA, Grunvald E. Hypoglycemia After Gastric Bypass Successfully Treated With Calcium Channel Blockers: Two Case Reports. J Endocr Soc 2019; 3:1417-1422. [PMID: 31286108 PMCID: PMC6608552 DOI: 10.1210/js.2019-00097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/22/2019] [Indexed: 12/14/2022] Open
Abstract
Postprandial hyperinsulinemic hypoglycemia is an uncommon yet well-established complication of Roux-en-Y gastric bypass (RYGB) that can result in serious morbidity and adversely affect quality of life. It is often unrecognized and may be difficult to diagnose. Management is challenging. As the number of bariatric procedures increases in parallel with the obesity epidemic, clinicians will be tasked to offer effective medical therapies for this complication. Two patients presented several years after RYGB with severe postprandial hypoglycemia. In one of the patients, we were able to document simultaneous postprandial hypoglycemia and hyperinsulinemia. Conventional treatment approaches, including medical nutrition therapy, acarbose, diazoxide, and octreotide, were either ineffective or limited by poor tolerance. Nifedipine and verapamil were used adjunctively with dietary modification, resulting in resolution of symptomatic hypoglycemic episodes. These agents are therapeutic options that can be used for some patients refractory to more traditional treatments. They should be tried before surgical procedures are considered for affected patients. These two cases demonstrate that calcium channel blockers may be efficacious and appropriate for select patients refractory to dietary interventions alone.
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Affiliation(s)
- Angharad Ames
- School of Medicine, University of California, San Diego, California.,Department of Psychiatry, University of California, Riverside, California
| | | | - Eduardo Grunvald
- School of Medicine, University of California, San Diego, California.,Bariatric and Metabolic Institute, Division of Minimally Invasive Surgery, Department of Surgery, University of California, San Diego, California.,Division of General Internal Medicine, Department of Medicine, University of California, San Diego, California
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30
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Gaballa D, Abendroth CS, Moyer MT. Alcohol-free EUS-guided chemoablation of multiple pancreatic insulinomas. Endosc Int Open 2019; 7:E186-E188. [PMID: 30705951 PMCID: PMC6338548 DOI: 10.1055/a-0764-4736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/25/2018] [Indexed: 10/27/2022] Open
Abstract
Background and study aims Endoscopic ultrasound (EUS)-guided chemoablation with ethanol lavage, followed by infusion with paclitaxel, has been found to be effective for treatment of mucinous pancreatic cysts. However, there are notable adverse events (AEs) associated with ethanol and its undesirable inflammatory effects on local tissue and vessels. The recent ChARM trial demonstrated that removing ethanol from the cyst ablation process resulted in equivalent efficacy while significantly reducing associated AEs. Encouraged by these results, we speculated that alcohol-free chemoablation can be applied to treatment of solid tumors, as described in our case with a patient with severe and symptomatic recurrent hypoglycemia in the setting of multifocal insulinomas. As a result, the patient saw a significant reduction in symptoms. EUS-guided alcohol-free chemoablation may represent a new alternative to previously established therapies that will ultimately reduce risk of AEs.
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Affiliation(s)
- Daniel Gaballa
- Department of Internal Medicine, Division of Gastroenterology, Penn State University Hospital, Hershey Medical Center, Hershey, Pennsylvania, United States,Corresponding author Daniel Gaballa, MD Department of Internal MedicinePenn State University HospitalHershey Medical CenterHershey, PA 17033+1-717-531-5831
| | - Catherine S. Abendroth
- Department of Pathology, Division of Anatomic Pathology, Penn State University Hospital, Hershey Medical Center, Hershey, Pennsylvania, United States
| | - Matthew T. Moyer
- Department of Internal Medicine, Division of Gastroenterology, Penn State University Hospital, Hershey Medical Center, Hershey, Pennsylvania, United States
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31
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Caliri M, Verdiani V, Mannucci E, Briganti V, Landoni L, Esposito A, Burato G, Rotella CM, Mannelli M, Peri A. A case of malignant insulinoma responsive to somatostatin analogs treatment. BMC Endocr Disord 2018; 18:98. [PMID: 30591061 PMCID: PMC6307122 DOI: 10.1186/s12902-018-0325-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 12/13/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Insulinoma is a rare tumour representing 1-2% of all pancreatic neoplasms and it is malignant in only 10% of cases. Locoregional invasion or metastases define malignancy, whereas the dimension (> 2 cm), CK19 status, the tumor staging and grading (Ki67 > 2%), and the age of onset (> 50 years) can be considered elements of suspect. CASE PRESENTATION We describe the case of a 68-year-old man presenting symptoms compatible with hypoglycemia. The symptoms regressed with food intake. These episodes initially occurred during physical activity, later also during fasting. The fasting test was performed and the laboratory results showed endogenous hyperinsulinemia compatible with insulinoma. The patient appeared responsive to somatostatin analogs and so he was treated with short acting octreotide, obtaining a good control of glycemia. Imaging investigations showed the presence of a lesion of the uncinate pancreatic process of about 4 cm with a high sst2 receptor density. The patient underwent exploratory laparotomy and duodenocephalopancreasectomy after one month. The definitive histological examination revealed an insulinoma (T3N1MO, AGCC VII G1) with a low replicative index (Ki67: 2%). CONCLUSIONS This report describes a case of malignant insulinoma responsive to octreotide analogs administered pre-operatively in order to try to prevent hypoglycemia. The response to octreotide analogs is not predictable and should be initially assessed under strict clinical surveillance.
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Affiliation(s)
- Mariasmeralda Caliri
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Careggi University Hospital, Florence, Italy
| | - Valentina Verdiani
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Careggi University Hospital, Florence, Italy
| | - Edoardo Mannucci
- Diabetology Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Careggi University Hospital, Florence, Italy
| | - Vittorio Briganti
- Division of Nuclear Medicine, Careggi University Hospital, Florence, Italy
| | - Luca Landoni
- General and Pancreatic Surgery Department, The Pancreas Institute-University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- General and Pancreatic Surgery Department, The Pancreas Institute-University of Verona Hospital Trust, Verona, Italy
| | - Giulia Burato
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Carlo Maria Rotella
- Diabetology Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Careggi University Hospital, Florence, Italy
| | - Massimo Mannelli
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Careggi University Hospital, Florence, Italy
| | - Alessandro Peri
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Careggi University Hospital, Florence, Italy
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32
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Yu J, Ping F, Zhang H, Li W, Yuan T, Fu Y, Feng K, Xia W, Xu L, Li Y. Clinical Management of Malignant Insulinoma: a single Institution's experience over three decades. BMC Endocr Disord 2018; 18:92. [PMID: 30522468 PMCID: PMC6282250 DOI: 10.1186/s12902-018-0321-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 11/27/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Malignant insulinoma is extremely rare and accounts for only 10% of total insulinoma cases. The goal of this study is to retrospectively analyze clinical data from 15 patients with malignant insulinoma treated at Peking Union Medical College Hospital (PUMCH) from 1984 to April 2017. METHODS "Malignant insulinoma" was used as the keywords in the PUMCH medical record retrieval system to search and obtain patients' clinical information. We identified subjects diagnosed with malignant insulinoma based on clinical or surgical pathological signs and subsequently analyzed their clinical data. RESULTS Eight males and seven females with a median age at diagnosis of 40 years (38-54 years) were included. Eight patients (53%) had developed metastases at diagnosis, while the others (46.67%) developed metastases during the follow-up visits. The major sites of metastasis were the liver (86.7%), local tissues and blood vessels (33%) and abdominal lymph nodes (13%). All patients displayed neuroglycopenic (100%) and/or autonomic (60%) symptoms, mostly during fasting periods (73.3%), with an average blood glucose level of 1.66 ± 0.51 mmol/L. A total of 93% of the patients had one primary pancreatic lesion, 53% had a lesion in the head of the pancreas, and 47% had a lesion in the tail of the pancreas, with diameters ranging between 0.9 and 6.0 cm. Most liver metastases were multiple lesions. Selective celiac arteriography yielded 100% sensitivity for both primary pancreatic lesions and liver metastases. Most patients received synthetical treatments, including surgery, chemoembolization, and octreotide. CONCLUSIONS Malignant insulinomas have a similar diagnostic process to that of benign insulinomas but require far more comprehensive therapies to alleviate hypoglycemic symptoms and extend patients' survival.
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Affiliation(s)
- Jie Yu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Fan Ping
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Huabing Zhang
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Wei Li
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Tao Yuan
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yong Fu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Kai Feng
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Weibo Xia
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Lingling Xu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yuxiu Li
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
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33
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Miranda G. Malignant insulinoma chemotherapy resistant, pancreatic neuroendocrine tumor of uncertain prognosis. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2018. [DOI: 10.1016/j.jecr.2018.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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34
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Zhou W, Gong L, Li X, Wan Y, Wang X, Li H, Jiang B. Screening key candidate genes and pathways involved in insulinoma by microarray analysis. Medicine (Baltimore) 2018; 97:e10826. [PMID: 29851790 PMCID: PMC6392920 DOI: 10.1097/md.0000000000010826] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Insulinoma is a rare type tumor and its genetic features remain largely unknown. This study aimed to search for potential key genes and relevant enriched pathways of insulinoma.The gene expression data from GSE73338 were downloaded from Gene Expression Omnibus database. Differentially expressed genes (DEGs) were identified between insulinoma tissues and normal pancreas tissues, followed by pathway enrichment analysis, protein-protein interaction (PPI) network construction, and module analysis. The expressions of candidate key genes were validated by quantitative real-time polymerase chain reaction (RT-PCR) in insulinoma tissues.A total of 1632 DEGs were obtained, including 1117 upregulated genes and 514 downregulated genes. Pathway enrichment results showed that upregulated DEGs were significantly implicated in insulin secretion, and downregulated DEGs were mainly enriched in pancreatic secretion. PPI network analysis revealed 7 hub genes with degrees more than 10, including GCG (glucagon), GCGR (glucagon receptor), PLCB1 (phospholipase C, beta 1), CASR (calcium sensing receptor), F2R (coagulation factor II thrombin receptor), GRM1 (glutamate metabotropic receptor 1), and GRM5 (glutamate metabotropic receptor 5). DEGs involved in the significant modules were enriched in calcium signaling pathway, protein ubiquitination, and platelet degranulation. Quantitative RT-PCR data confirmed that the expression trends of these hub genes were similar to the results of bioinformatic analysis.The present study demonstrated that candidate DEGs and enriched pathways were the potential critical molecule events involved in the development of insulinoma, and these findings were useful for better understanding of insulinoma genesis.
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Affiliation(s)
- Wuhua Zhou
- Department of Hepatobiliary Pancreatic Surgery, Taihe Hospital
| | - Li Gong
- Department of Endocrinology, Taihe Hospital, Shiyan City, Hubei Province, China
| | - Xuefeng Li
- Department of Endocrinology, Taihe Hospital, Shiyan City, Hubei Province, China
| | - Yunyan Wan
- Department of Hepatobiliary Pancreatic Surgery, Taihe Hospital
| | - Xiangfei Wang
- Department of Hepatobiliary Pancreatic Surgery, Taihe Hospital
| | - Huili Li
- Department of Hepatobiliary Pancreatic Surgery, Taihe Hospital
| | - Bin Jiang
- Department of Hepatobiliary Pancreatic Surgery, Taihe Hospital
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Câmara-de-Souza AB, Toyoshima MTK, Giannella ML, Freire DS, Camacho CP, Lourenço DM, Rocha MS, Bacchella T, Jureidini R, Machado MCC, Almeida MQ, Pereira MAA. Insulinoma: A retrospective study analyzing the differences between benign and malignant tumors. Pancreatology 2018; 18:298-303. [PMID: 29452754 DOI: 10.1016/j.pan.2018.01.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 01/28/2018] [Accepted: 01/30/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Insulinoma is a rare pancreatic tumor and, usually, a benign disease but can be a malignant one and, sometimes, a highly aggressive disease. The aim of this study was to determine differences between benign and malignant tumors. METHODS Retrospective study of 103 patients with insulinoma treated in a tertiary center. It was analyzed demographic, clinical, laboratory, localization and histologic analysis of tumor and follow up data of subjects in order to identify differences between individuals benign and malignant disease. RESULTS Almost all patients (87%) had a benign tumor and survival rates of 100% following pancreatic tumor surgery. Those with malignant tumors (13%) have a poor prognosis, 77% insulinoma-related deaths over a period of 1-300 months after the diagnosis with a survival rate of 24% in five years. The following factors are associated with an increased risk of malignant disease: duration of symptoms < 24 months, fasting time for the occurrence of hypoglycemia < 8 h, blood plasma insulin concentration ≥ 28 μU/mL and C-peptide ≥ 4.0 ng/mL at the glycemic nadir and tumor size ≥ 2.5 cm. CONCLUSIONS Our data help to base the literature about these tumors, reinforcing that although insulinoma is usually a single benign and surgically treated neoplasia, the malignant one is difficult to treat. We highlight the data that help predict a malignancy behavior of tumor and suggest a long follow up after diagnosis in these cases.
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Affiliation(s)
- A B Câmara-de-Souza
- Unidade de Endocrinologia Geral, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil.
| | - M T K Toyoshima
- Serviço de Endocrinologia e Metabologia, Instituto do Câncer do Estado de São Paulo (ICESP), Brazil
| | - M L Giannella
- Unidade de Diabetes, Serviço de Endocrinologia e Metabologia, HCFMUSP, Brazil
| | - D S Freire
- Unidade de Endocrinologia Geral, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil
| | - C P Camacho
- Serviço de Endocrinologia e Metabologia, Universidade 9 de Julho, Brazil
| | - D M Lourenço
- Unidade de Genética, Serviço de Endocrinologia e Metabologia, HCFMUSP, Brazil
| | - M S Rocha
- Serviço de Radiologia, HCFMUSP, Brazil
| | - T Bacchella
- Serviço de Cirurgia do Aparelho digestivo, HCFMUSP, Brazil
| | - R Jureidini
- Serviço de Cirurgia do Aparelho digestivo, HCFMUSP, Brazil
| | - M C C Machado
- Serviço de Cirurgia do Aparelho digestivo, HCFMUSP, Brazil
| | - M Q Almeida
- Serviço de Endocrinologia e Metabologia, Instituto do Câncer do Estado de São Paulo (ICESP), Brazil; Unidade de Suprarrenal, Serviço de Endocrinologia e Metabologia, HCFMUSP, Brazil
| | - M A A Pereira
- Unidade de Endocrinologia Geral, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil
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Corrias G, Monti S, Horvat N, Tang L, Basturk O, Saba L, Mannelli L. Imaging features of malignant abdominal neuroendocrine tumors with rare presentation. Clin Imaging 2018; 51:59-64. [PMID: 29448120 DOI: 10.1016/j.clinimag.2018.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/30/2018] [Accepted: 02/02/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Gastroenteropancreatic neuroendocrine tumors (NETs) are rare entities arising from neuroendocrine cells in the gastroenteric tract and pancreas. The purpose of this article is to present four cases of gastroenteropancreatic NETs that featured a challenging diagnosis. CASE PRESENTATION We report a case series of four NETs, each with different features. All NETs were suspected based on clinical and biochemical data. The workup of the abnormalities was performed with CT, PET or MRI. CONCLUSION The diagnosis of NETs is challenging and generally based on clinical manifestations, blood biochemical tests, imaging techniques, and pathology.
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Affiliation(s)
- Giuseppe Corrias
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Department of Radiology, University of Cagliari, Via Università, 40, 09124 Cagliari, CA, Italy
| | | | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Department of Radiology, Hospital Sírio-Libanês, São Paulo, SP, Brazil; Department of Radiology, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Laura Tang
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Luca Saba
- Department of Radiology, University of Cagliari, Via Università, 40, 09124 Cagliari, CA, Italy
| | - Lorenzo Mannelli
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Furnica RM, Istasse L, Maiter D. A severe but reversible reduction in insulin sensitivity is observed in patients with insulinoma. ANNALES D'ENDOCRINOLOGIE 2017; 79:30-36. [PMID: 29241949 DOI: 10.1016/j.ando.2017.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/24/2017] [Accepted: 08/24/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hypoglycemic manifestations are highly variable in patients with an insulinoma and largely independent of tumour size and severity of insulin hypersecretion. OBJECTIVES We investigated the clinical, biological and tumoral characteristics of insulinomas in a large monocentric series of patients and we evaluated their insulin sensitivity before and after successful pancreatic surgery. PATIENTS AND METHODS This was a retrospective analysis of 40 patients treated for an insulinoma between 1982 and 2012 in our academic hospital. Insulin sensitivity and beta cell function were evaluated by a HOMA test outside hypoglycaemic episodes in a large subset of these patients. RESULTS The mean age at onset of symptoms was 48.8±20.1 years and the mean age at diagnosis was 50.7±19.9 years. Neuroglycopenic symptoms were observed in 90% of patients. The most effective preoperative imaging technique to localize the tumour was endoscopic ultrasound. Insulin sensitivity was greatly reduced in patients with insulinoma (38.9%±22.3%), while beta cells function was increased (359.0±171.5%), but to a variable extent (range: 110.6-678.6%). After complete resection of the tumour and remission of hypoglycemic episodes, insulin sensitivity increased in all evaluated subjects (72.8±36.7%) and normalized in the majority. CONCLUSION Although neuroglycopenic symptoms are present in most patients, diagnosis of insulinoma is often delayed. Endoscopic ultrasound remains the most sensitive preoperative technique to localize the tumour. We also show that in response to chronic hyperinsulinemia, patients with insulinoma develop protective mechanisms responsible for a marked insulin resistance, which is reversible after complete resection of the tumour.
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Affiliation(s)
- Raluca Maria Furnica
- Department of Endocrinology, Université catholique de Louvain, Cliniques Universitaires Saint-Luc, avenue Hippocrate 10, 1200 Brussels, Belgium.
| | - Laure Istasse
- Department of Endocrinology, Université catholique de Louvain, Cliniques Universitaires Saint-Luc, avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Dominique Maiter
- Department of Endocrinology, Université catholique de Louvain, Cliniques Universitaires Saint-Luc, avenue Hippocrate 10, 1200 Brussels, Belgium
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Zandee WT, Kamp K, van Adrichem RC, Feelders RA, de Herder WW. Effect of hormone secretory syndromes on neuroendocrine tumor prognosis. Endocr Relat Cancer 2017; 24:R261-R274. [PMID: 28483790 DOI: 10.1530/erc-16-0538] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 05/08/2017] [Indexed: 12/12/2022]
Abstract
The treatment of hormone hypersecretory syndromes caused by neuroendocrine tumors (NETs) can be a major challenge. NETs originating from the small intestine often secrete serotonin causing flushing, diarrhea and valve fibrosis, leading to dehydration or heart failure in severe cases. NETs from the pancreas can secrete a wider variety of hormones, like insulin, glucagon and gastrin leading to distinct clinical syndromes. Historically mortality in patients with functioning NETs was high due to the complications caused by the hypersecretion of hormones. This has been reduced with several drugs: proton-pump inhibitors decrease acid secretion caused by gastrinomas. Somatostatin analogs can inhibit the secretion of multiple hormones and these are now the cornerstone for treating patients with a gastroenteropancreatic NET. However, peptide receptor radionuclide therapy (PRRT) with radiolabeled somatostatin analogs and everolimus can also decrease symptoms of hypersecretion and increase progression-free survival. Several factors affect the survival in patients with a functioning NET. Complications of hypersecretion negatively impact survival; however, secretion of hormones is also often a sign of a well-differentiated NET and due to the symptoms, functioning NETs can be detected in an earlier stage suggesting a positive effect on prognosis. The effect on survival is also dependent on the type of hormone being secreted. This review aims to study the effect of hormone secretion on the prognosis of NETs with the contemporary treatments options available today.
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Affiliation(s)
- Wouter T Zandee
- Department of Internal MedicineSector Endocrinology, ENETS Centre of Excellence, Erasmus MC, Rotterdam, the Netherlands
| | - Kimberly Kamp
- Department of Internal MedicineSector Endocrinology, ENETS Centre of Excellence, Erasmus MC, Rotterdam, the Netherlands
| | - Roxanne C van Adrichem
- Department of Internal MedicineSector Endocrinology, ENETS Centre of Excellence, Erasmus MC, Rotterdam, the Netherlands
| | - Richard A Feelders
- Department of Internal MedicineSector Endocrinology, ENETS Centre of Excellence, Erasmus MC, Rotterdam, the Netherlands
| | - Wouter W de Herder
- Department of Internal MedicineSector Endocrinology, ENETS Centre of Excellence, Erasmus MC, Rotterdam, the Netherlands
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Gu W, Liu Y, Liu H, Yang G, Guo Q, Du J, Jin N, Zang L, Lv Z, Ba J, Mu Y, Dou J. Characteristics of glucose metabolism indexes and continuous glucose monitoring system (CGMS) in patients with insulinoma. Diabetol Metab Syndr 2017; 9:17. [PMID: 28293303 PMCID: PMC5348912 DOI: 10.1186/s13098-017-0215-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 03/02/2017] [Indexed: 01/10/2023] Open
Abstract
AIMS Analyze the clinical applicability of glucose metabolism indexes and continuous glucose monitoring data on the qualitative diagnosis of insulinoma. METHODS Involve 22 patients with insulinoma (insulinoma group), 11 patients with hypoglycemia (hypoglycemia group) and 31 people with normal glucose tolerance (control group). HbA1c, fasting blood glucose (FBG), insulin (FINS) and C-peptide (FCP) was tested. Using CGMS to monitor the blood glucose for three consecutive days and selecting the monitoring data of 24 h thereof, figuring out, with the aid of EasyGV Version 9.0, the mean glucose (MG), the standard deviation (SD) of blood glucose, CONGA (continuous overall net glycemic action), J-Index, LI (Lability Index), LBGI (Low Blood Glucose Index), HBGI (High Blood Glucose Index), GRADE (glycaemic risk assessment diabetes equation), MAGE (mean aplitude of glycaemic excursions), M value, MAG (mean absolute glucose). RESULTS (1) FBG and LBG of insulinoma group are lower than those of control group and those of hypoglycemia group while FINS and FCP of insulinoma group are markedly higher than those of the other two groups; (2) the MG and CONGA of insulinoma group are lower than those of control group and its indexes like ST, LI, LBGI, GRADE, MAGE, M value and MAG are higher than those of control group; there are differences between the indexes of insulinoma group and those of hypoglycemia group in CONGA (lower than that of hypoglycemia group), LBGI (higher than that of hypoglycemia group), and M value (higher than that of hypoglycemia group). By drawing the ROC curve and calculating Youden index, the cut-off values of LBGI, M value, CONGA are respectively as 4.06, 7.79, 4.38, and the best index of differential diagnosis is LBGI. CONCLUSION Continuous glucose monitoring data can be used to diagnose insulinoma and blood glucose fluctuation indicators such as LBGI, M value, CONGA might be useful to identify insulinoma.
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Affiliation(s)
- Weijun Gu
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Yixin Liu
- Department of Internal Medicine, The Affiliated Hospital of Institute of Aviation Medicine, Beijing, 100089 People’s Republic of China
| | - Hongyan Liu
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Guoqing Yang
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Qinghua Guo
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Jin Du
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Nan Jin
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Li Zang
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Zhaohui Lv
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Jianming Ba
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Yiming Mu
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Jingtao Dou
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
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Davi MV, Pia A, Guarnotta V, Pizza G, Colao A, Faggiano A. The treatment of hyperinsulinemic hypoglycaemia in adults: an update. J Endocrinol Invest 2017; 40:9-20. [PMID: 27624297 DOI: 10.1007/s40618-016-0536-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/17/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Treatment of hyperinsulinemic hypoglycaemia (HH) is challenging due to the rarity of this condition and the difficulty of differential diagnosis. The aim of this article is to give an overview of the recent literature on the management of adult HH. METHODS A search for reviews, original articles, original case reports between 1995 and 2016 in PubMed using the following keywords: hyperinsulinemic hypoglycaemia, insulinoma, nesidioblastosis, gastric bypass, autoimmune hypoglycaemia, hyperinsulinism, treatment was performed. RESULTS One hundred and forty articles were selected and analysed focusing on the most recent treatments of HH. CONCLUSIONS New approaches to treatment of HH are available including mini-invasive surgical techniques and alternative local-regional ablative therapy for benign insulinoma and everolimus for malignant insulinoma. A correct differential diagnosis is of paramount importance to avoid unnecessary surgical operations and to implement the appropriate treatment mainly in the uncommon forms of HH, such as nesidioblastosis and autoimmune hypoglycaemia.
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Affiliation(s)
- M V Davi
- Section of Endocrinology, Medicina Generale e Malattie Aterotrombotiche e Degenerative, Department of Medicine, University of Verona, Piazzale LA Scuro, Policlinico G.B. Rossi, 37134, Verona, Italy.
| | - A Pia
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - V Guarnotta
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - G Pizza
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Colao
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Faggiano
- Thyroid and Parathyroid Surgery Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione G. Pascale" IRCCS, Naples, Italy
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Abstract
OBJECTIVE The aim of the study was to address the origin and natural history of malignant insulinoma. METHODS Retrospective review of medical records of patients diagnosed with insulinoma at Cedars-Sinai Medical Center between 2000 and 2015 was conducted. Hormonal expression in tumor specimens was examined by immunostaining. RESULTS All the 9 patients with malignant insulinoma (35% of 26 patients with insulinoma) already had liver metastasis at hypoglycemia presentation with bulky cumulative tumor burden. Six patients had de novo diagnosis, 2 had known metastatic nonfunctioning pancreatic neuroendocrine tumor, and 1 had a known pancreatic mass. Tumor grade at presentation was G1 in 4 patients, G2 in 4, and unknown in 1. Four patients died 2 to 32 months after presentation, all with extensive liver tumor involvement. Tumor expression of proinsulin and insulin was heterogeneous and overall infrequent. The proinsulin levels and proinsulin/insulin molar ratio in patients with malignant versus benign insulinoma were 334 versus 44 pmol/L and 2.1 versus 0.9, respectively. CONCLUSIONS Malignant insulinoma seems to arise from and behave like nonfunctioning pancreatic neuroendocrine tumor oncologically but with metachronous hyperinsulinemic hypoglycemia. High proinsulin levels and proinsulin/insulin molar ratio may suggest malignant insulinoma.
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Luu AM, Herzog T, Uhl W, Braumann C. Liver Metastases 10 Years after Resection of a “Benign” Insulinoma. Am Surg 2016. [DOI: 10.1177/000313481608201114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andreas Minh Luu
- Katholisches Klinikum Bochum—St. Josef Hospital Klinik für Allgemein- und Viszeralchirurgie Bochum, Germany
| | - Torsten Herzog
- Katholisches Klinikum Bochum—St. Josef Hospital Klinik für Allgemein- und Viszeralchirurgie Bochum, Germany
| | - Waldemar Uhl
- Katholisches Klinikum Bochum—St. Josef Hospital Klinik für Allgemein- und Viszeralchirurgie Bochum, Germany
| | - Chris Braumann
- Katholisches Klinikum Bochum—St. Josef Hospital Klinik für Allgemein- und Viszeralchirurgie Bochum, Germany
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Johannessen LE, Panagopoulos I, Haugvik SP, Gladhaug IP, Heim S, Micci F. Upregulation of INS-IGF2 read-through expression and identification of a novel INS-IGF2 splice variant in insulinomas. Oncol Rep 2016; 36:2653-2662. [PMID: 27667266 DOI: 10.3892/or.2016.5132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 06/30/2016] [Indexed: 11/06/2022] Open
Abstract
Fusion transcripts arising from the combination of exons residing on neighboring genes on the same chromosome may give rise to chimeric or novel proteins. Such read-through transcripts have been detected in different cancers where they may be of pathogenetic interest. In this study, we describe for the first time the expression of a read-through transcript in insulinomas, a functioning neuroendocrine pancreatic neoplasm. The read-through transcript INS-IGF2, composed of exons from the two genes proinsulin precursor (INS) and insulin‑like growth factor 2 (IGF2), both mapping to chromosomal subband 11p15.5, was highly expressed in the two insulinomas analyzed. More precisely, version 2 of the INS-IGF2 transcript was expressed, indicating possible expression of the chimeric INS-IGF2 protein. We further identified a novel splice variant of the INS-IGF2 read-through transcript in one of the insulinomas, composed of exon 1 of INS3 and exons of IGF2. In the same tumor, we found high expression of INS3 and the presence of the A allele at SNP rs689. SNP rs689 has been previously described to regulate splicing of the INS transcript, indicating that this regulatory mechanism also affects splicing of INS-IGF2. The identification of the INS-IGF2 read-through transcript specifically in tumor tissue but not in normal pancreatic tissue suggests that high expression of INS-IGF2 could be neoplasia‑specific. These results may have potential clinical applications given that the read-through transcript could be used as a biomarker in insulinoma patients.
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Affiliation(s)
- Lene E Johannessen
- Section for Cancer Cytogenetics, Institute for Cancer Genetics and Informatics, The Norwegian Radium Hospital, Oslo University Hospital, 0310 Oslo, Norway
| | - Ioannis Panagopoulos
- Section for Cancer Cytogenetics, Institute for Cancer Genetics and Informatics, The Norwegian Radium Hospital, Oslo University Hospital, 0310 Oslo, Norway
| | - Sven-Petter Haugvik
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, 0372 Oslo, Norway
| | - Ivar Prydz Gladhaug
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, 0372 Oslo, Norway
| | - Sverre Heim
- Section for Cancer Cytogenetics, Institute for Cancer Genetics and Informatics, The Norwegian Radium Hospital, Oslo University Hospital, 0310 Oslo, Norway
| | - Francesca Micci
- Section for Cancer Cytogenetics, Institute for Cancer Genetics and Informatics, The Norwegian Radium Hospital, Oslo University Hospital, 0310 Oslo, Norway
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Sacco Casamassima MG, Gause CD, Goldstein SD, Abdullah F, Meoded A, Lukish JR, Wolfgang CL, Cameron J, Hackam DJ, Hruban RH, Colombani PM. Pancreatic surgery for tumors in children and adolescents. Pediatr Surg Int 2016; 32:779-88. [PMID: 27364750 DOI: 10.1007/s00383-016-3925-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2016] [Indexed: 12/11/2022]
Abstract
PURPOSE Pancreatic neoplasms are uncommon in children. This study sought to analyze the clinical and pathological features of surgically resected pancreatic tumors in children and discuss management strategies. METHODS We conducted a retrospective review of patients ≤21 years with pancreatic neoplasms who underwent surgery at a single institution between 1995 and 2015. RESULTS Nineteen patients were identified with a median age at operation of 16.6 years (IQR 13.5-18.9). The most common histology was solid pseudopapillary neoplasm (SPN) (n = 13), followed by pancreatic neuroendocrine tumor (n = 3), serous cystadenoma (n = 2) and pancreatoblastoma (n = 1). Operative procedures included formal pancreatectomy (n = 17), enucleation (n = 1) and central pancreatectomy (n = 1). SPNs were noninvasive in all but one case with perineural, vascular and lymph node involvement. Seventeen patients (89.5 %) are currently alive and disease free at a median follow-up of 5.7 (IQR 3.7-10.9) years. Two patients died: one with metastatic insulinoma and another with SPN who developed peritoneal carcinomatosis secondary to a concurrent rectal adenocarcinoma. CONCLUSIONS Pediatric pancreatic tumors are a heterogeneous group of neoplastic lesions for which surgery can be curative. SPN is the most common histology, is characterized by low malignant potential and in selected cases can be safely and effectively treated with a tissue-sparing resection and minimally invasive approach.
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Affiliation(s)
| | - Colin D Gause
- Division of Pediatric Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Seth D Goldstein
- Division of Pediatric Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Avner Meoded
- Division of Pediatric Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
| | - Jeffrey R Lukish
- Division of Pediatric Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Research Center, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - John Cameron
- Department of Surgery, The Sol Goldman Pancreatic Research Center, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - David J Hackam
- Division of Pediatric Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul M Colombani
- Department of Surgery, Johns Hopkins All Children's Hospital, 601 5th Street South, Suite 501, Saint Petersburg, FL, 33701, USA.
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Di Martino M, García Sanz I, Delgado Valdueza J, Martín-Pérez E. Giant Malignant Insulinoma. J Gastrointest Surg 2016; 20:1530-1. [PMID: 26969167 DOI: 10.1007/s11605-016-3118-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/22/2016] [Indexed: 01/31/2023]
Abstract
The role of debulking resections in giant malignant insulinoma is still controversial. Here, we report the case of a 49-year-old patient woman with a giant malignant symptomatic insulinoma, who underwent debulking surgery, realizing a total pancreatectomy, splenectomy, partial gastrectomy and cholecystectomy.
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Cemeroglu AP, Racine MS, Kleis L, Borders H, Kurt BA. Metastatic Insulinoma in a 16-Year-Old Adolescent Male With Men-1: A Case Report and Review of the Literature. AACE Clin Case Rep 2016. [DOI: 10.4158/ep15980.cr] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Jerraya H, Zidi-Mouaffek Y, Dokmak S, Dziri C. Insulinoma with focal hepatic lesions: malignant insulinoma? BMJ Case Rep 2015; 2015:bcr-2015-212811. [PMID: 26670896 DOI: 10.1136/bcr-2015-212811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Insulinoma is a rare tumour that is malignant in only 10% of cases. We report a case of insulinoma in a 59-year-old woman, associated with focal liver lesions, which raised the suspicion of malignancy of a pancreatic tumour. Enucleation of the insulinoma was performed with wedge resection of one hepatic nodule. Pathological examination indicated that the pancreatic tumour was compatible with insulinoma whereas the hepatic lesion was related to focal nodular hyperplasia. This clinical case highlights the need for histopathological proof of malignancy before selecting therapeutic strategies for insulinomas.
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Affiliation(s)
- Hichem Jerraya
- Faculty of Medicine, Department of Surgery, Tunis El Manar University, Tunis, Tunisia
| | - Yossra Zidi-Mouaffek
- Department of Pathology, Charles Nicolle Hospital, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Paris, Texas, USA
| | - Chadli Dziri
- Department "B" of General Surgery, Charles Nicolle Hospital, Faculty of Medicine of Tunis, Tunis, Tunisia
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Antonakis PT, Ashrafian H, Martinez-Isla A. Pancreatic insulinomas: Laparoscopic management. World J Gastrointest Endosc 2015; 7:1197-1207. [PMID: 26566426 PMCID: PMC4639741 DOI: 10.4253/wjge.v7.i16.1197] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/22/2015] [Accepted: 09/07/2015] [Indexed: 02/05/2023] Open
Abstract
Insulinomas are rare pancreatic neuroendocrine tumors that are most commonly benign, solitary, and intrapancreatic. Uncontrolled insulin overproduction from the tumor produces neurological and adrenergic symptoms of hypoglycemia. Biochemical diagnosis is confirmed by the presence of Whipple’s triad, along with corroborating measurements of blood glucose, insulin, proinsulin, C-peptide, β-hydroxybutyrate, and negative tests for hypoglycemic agents during a supervised fasting period. This is accompanied by accurate preoperative localization using both invasive and non-invasive imaging modalities. Following this, careful preoperative planning is required, with the ensuing procedure being preferably carried out laparoscopically. An integral part of the laparoscopic approach is the application of laparoscopic intraoperative ultrasound, which is indispensable for accurate intraoperative localization of the lesion in the pancreatic region. The extent of laparoscopic resection is dependent on preoperative and intraoperative findings, but most commonly involves tumor enucleation or distal pancreatectomy. When performed in an experienced surgical unit, laparoscopic resection is associated with minimal mortality and excellent long-term cure rates. Furthermore, this approach confers equivalent safety and efficacy rates to open resection, while improving cosmesis and reducing hospital stay. As such, laparoscopic resection should be considered in all cases of benign insulinoma where adequate surgical expertise is available.
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Jyotsna VP, Malik E, Birla S, Sharma A. Novel MEN 1 gene findings in rare sporadic insulinoma--a case control study. BMC Endocr Disord 2015; 15:44. [PMID: 26307114 PMCID: PMC4549893 DOI: 10.1186/s12902-015-0041-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 08/21/2015] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Insulinomas, which are rare tumors causing hyperinsulinemic hypoglycemia are usually sporadic but may also occur in association with multiple endocrine neoplasia type 1 (MEN-1) syndrome an autosomal dominant disorder caused by MEN1 gene mutations. MEN1 encodes a nuclear protein Menin, a tumor suppressor which acts as an adapter and interacts with partner proteins involved in crucial activities like transcriptional regulation, cell division, proliferation and genome stability. This study reports on clinical findings and mutation screening in sporadic insulinoma patients. METHODS Seventeen patients diagnosed with insulinoma were recruited along with 30 healthy volunteers who acted as controls for the present study. The patients presented with symptoms of sweating, tremors, drowsiness, palpitations, loss of consciousness, abnormal behavior, seizures and weight gain. Detailed clinical and family history was collected from all the participants along with 5 ml of blood sample after taking informed consent. Genomic DNA isolated from blood was subjected to MEN1 gene amplification followed by direct sequencing. Nucleotide sequences obtained were compared with published MEN1 cDNA sequences. Prediction of functional effects of novel changes was done using various bioinformatics algorithms. RESULTS Molecular analysis revealed presence of three novel exonic mutations (M561K, Q192K and Q261Q), two novel intronic variations c.445-44G → A and c.913-42G → C in introns two and six respectively and three reported exon SNPs; H433H (rs540012), D418D (rs2071313), A541T (rs2959656) and one intronic SNP (rs669976). CONCLUSIONS The study identified presence of novel pathogenic MEN1 mutations in sporadic cases of insulinoma. The new mutations identified were in regions involved in defective binding of menin to proteins implicated in genetic and epigenetic mechanisms. The outcome of the study extends the growing list of MEN1 pathogenic mutations even in sporadic cases providing consequential insight into phenotypic heterogeneity and in the expression of individual mutations.
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Affiliation(s)
- Viveka P Jyotsna
- Department of Endocrinology and metabolism, All India Institute of Medical Sciences, Room No. 305, Third Floor, Biotechnology Building, New Delhi, India.
| | - Ekta Malik
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India.
| | - Shweta Birla
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India.
| | - Arundhati Sharma
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India.
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Bilici A. Advances in the management of unresectable or metastatic pancreatic neuroendocrine tumors: chemotherapy, targeted therapy, hormonal treatment, and future directions. Asian Pac J Cancer Prev 2015; 16:2151-9. [PMID: 25824731 DOI: 10.7314/apjcp.2015.16.6.2151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Pancreatic neuroendocrine tumors (pNETs) are rare and heterogenous tumors and surgery to remove the primary tumor is the mainstay of treatment for resectable disease. However, curative surgery is often not feasible, because half of patients with pNET have metastases at the time of diagnosis. Palliative dubulking surgery and liver-directed therapies are appropriate options for these patients. Streptozocin-based regimens are standard, although temozolamide-based treatments are rapidly gaining wide clinical application. Somatostatin analogs are mainly indicated in hormonally active tumors to ameliorate symptoms. In addition, anti-tumoral activity has been proven in well-differentiated NETs. Recently, there has been tremendous progress in the molecular biology of pNETs; thereby, the efficacy of sunitinib and everolimus in the treatment of patients with metastatic pNETs has been proven by large placebo-controlled phase III trials. Currently, there are no definitively proven predictive biomarkers to evaluate response to medical therapies in patients with pNET. Therefore, further studies are needed to individualize and optimize their management. This article reviews systemic chemotherapy, targeted therapies, and anti-secretory treatments for the management of patients with unresectable or metastatic pNETs, summarized in the light of recent advances.
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Affiliation(s)
- Ahmet Bilici
- Department of Medical Oncology, Istanbul Medipol University, Medical Faculty, Istanbul, Turkey E-mail :
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