Dimethyltriazenoimidazole carboxamide therapy of islet cell carcinoma of the pancreas

Unsuccessful DTIC treatment of a patient with glucagonoma syndrome

Various chemotherapeutic modalities have been tried in the treatment of patients with malignant glucagonomas. Promising results have been reported after drug treatment with dimethyltriazenoimidazole carboxamide (DTIC). We present a patient with a metastasizing pancreatic glucagonoma, in whom treatment with neither DTIC nor with the combination of streptozotocin and 5-fluorouracil resulted in any noticeable improvement.

The glucagonoma syndrome: a review of its features and discussion of new perspectives

Glucagonoma syndrome is a paraneoplastic phenomenon characterized by an islet alpha-cell pancreatic tumor, necrolytic migratory erythema, diabetes mellitus, weight loss, anemia, stomatitis, thromboembolism, and gastrointestinal and neuropsychiatric disturbances. These clinical findings in association with hyperglucagonemia and demonstrable pancreatic tumor establish the diagnosis. Glucagon itself is responsible for most of the observed signs and symptoms, and its induction of hypoaminoacidemia is thought to lead to necrolytic migratory erythema. Liver disease and fatty acid and zinc deficiency states may also contribute to the pathogenesis of the eruption in some cases. Most patients are diagnosed too late in the clinical course for cure, but successful palliation of symptomatology can usually be achieved with surgical and medical intervention. This paper reviews the glucagonoma syndrome, paying particular attention to its cutaneous features, and provides new perspectives in our current understanding of this phenomenon.

Gastrointestinal endocrine tumours. Glucagonomas

Glucagonoma is an uncommon, challenging but treatable disease with varied manifestations. Despite its predominantly malignant nature, prolonged symptom-free survival can be achieved using a targeted combination of surgery, hepatic artery embolization and somatostatin analogues. Given the difficult management issues, an initial assessment in an experienced tertiary referral centre may also be of benefit. This chapter has looked at the long-term follow-up of 18 such patients over a 25-year period. Given the rarity of the tumour, the numbers are small, but valuable lessons can be learnt from the study in the clinical management of these patients.

Surgery and polychemotherapy of non-functional endocrine pancreatic tumors: a case report with a dramatic clinical response

Endocrine pancreatic tumors (EPT) are a rare clinical entity, representing 5% of all pancreatic tumors. Nonfunctional subtypes (NF-EPT) often present themselves at diagnosis in a locally advanced or metastatic stage. Therapeutic planning of these neoplasias is based on a multidisciplinary integration of surgery and medical treatments. The Authors describe a case of NF-EPT with massive metastatic spread after cytoreductive surgery, with impressive response to polychemotherapy with 5-fluorouracil, epirubicin and dacarbazine. The various options concerning chemotherapic treatment of these tumors are reviewed.

Anatomic distribution of pancreatic endocrine tumors

Pancreatic endocrine tumors are grouped together by their common histologic, cytochemical, and ultrastructural features. Although useful conceptually, this paradigm has been unable to predict the anatomic location of different tumor types. Successful surgical excision of these tumors would be facilitated by an improved understanding of their anatomic distribution. Based on the available data, a bimodal distribution of pancreatic endocrine tumors was identified. Cluster 1 (gastrinomas, pancreatic polypeptide (PP)-secreting tumors, somatostatinomas) had 75% of tumors to the right of the superior mesenteric artery, whereas cluster 2 (insulinoma, glucagonoma) had 75% of tumors to the left of the superior mesenteric artery (p less than 0.05). This distribution is similar to that distribution predicted based on the volume density of the corresponding islet cells for insulinoma, glucagonoma, and PP-secreting tumors, but not for somatostatinoma. These findings suggest that pancreatic endocrine tumors are derived from similar cytologic precursors as pancreatic islet cells, and their distribution may be a consequence of embryologic development from either the ventral (cluster 1) or dorsal (cluster 2) pancreatic buds.

Metastatic medullary thyroid carcinoma. Complete response to combination chemotherapy with dacarbazine and 5-fluorouracil

A 20-year-old woman had a sporadic case of medullary thyroid carcinoma (MTC) metastatic to the lungs. After a transient response to streptozotocin and doxorubicin, new subcutaneous lesions appeared on the left chest wall and there was progression of pulmonary disease. Because MTC is one of the amine precursor uptake and decarboxylation (APUD) tumors, treatment was undertaken with agents active in these diseases. Dacarbazine and 5-fluorouracil, given daily for 5 days every 4 weeks, resulted in complete resolution of pulmonary and subcutaneous lesions and a sharp decrease in tumor marker levels that lasted 10 months. Recurrence of the pulmonary disease lead to her death 21 months after presentation. Thus, the chemo-responsiveness of MTC may be akin to that of other APUD carcinomas (APUDomas) and treatment of metastatic MTC and other APUDomas with the combination of dacarbazine and 5-fluorouracil appears to merit further study.

Retrobulbar neuritis as the first sign of the glucagonoma syndrome

A 63-year-old man with a metastasising pancreatic glucagonoma is described, who presented with progressive deterioration of vision and bilateral central scotomata as the first symptom. This patient was treated with dacarbazine (DTIC) 250 mg/m2 IV daily for five consecutive days at 4-week intervals. The vision returned completely to normal, in a clinical and biochemical remission. Although there is no wide experience in treatment, the literature seems to indicate that DTIC should be the drug of choice in treating metastatic glucagonoma. Central scotomata may be a new 'paraneoplastic' symptom and a key to the earlier diagnosis of the glucagonoma syndrome by ophthalmologists, just as necrolytic migratory erythema has been for the dermatologists.

A glucagon-secreting pancreatic alpha islet cell tumor presenting as spinal cord compression

We describe a patient with a pancreatic islet carcinoma presenting with spinal cord compression owing to vertebral metastases. Subsequent studies demonstrated a typical islet cell carcinoma by light microscopy. By electron microscopy, the neurosecretory granules were morphologically suggestive of glucagon production. Radioimmunoassay studies revealed markedly elevated levels of serum glucagon. Notably, the patient did not exhibit the characteristic glucagonoma syndrome. This case exemplifies clearly that elevated levels of immunoreactive neuropeptide hormones are not necessarily associated with overt hormonal syndromes. Possible mechanisms for explaining this apparent discrepancy include the production of immunoreactive molecules with weak or absent systemic biological activity. Nevertheless, the determination of immunoreactive hormone levels in neuroendocrine neoplasms is an extremely effective adjunct method for their diagnosis and monitoring.

Successful treatment of glucagonoma-related necrolytic migratory erythema with dacarbazine

A 63-year-old man with a glucagonoma syndrome is described. The diagnosis was confirmed by necrolytic migratory erythema, which is the most distinctive feature of the clinical syndrome. There was no chance of operative resection of the tumor because of liver metastases at the time of diagnosis. The patient was treated with dacarbazine. During this treatment the skin lesions disappeared completely.

Glucagonoma and its angiographic diagnosis

Four patients with metastatic glucagonoma are described. Angiography demonstrated a small avascular primary tumor of the tail of the pancreas in one patient and large hypervascular tumors of the pancreatic head in the other three. Liver metastases, were hypervascular in all four. Including our 4 with 21 cases from the literature, glucagonomas show a 92% incidence of increased tumor vascularity--thus increasing the likelihood of successful angiographic diagnosis. The awareness of clinically subtle or atypical glucagonomas and use of plasma glucagon determination are important factors leading to early diagnosis of these neoplasms. Since angiography can localize the tumor, assess its extent, and detect hepatic metastases, it is essential to the detailed evaluation of glucagonomas.