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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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Mansour JC, Chavin K, Morris-Stiff G, Warner SG, Cardona K, Fong ZV, Maker A, Libutti SK, Warren R, St Hill C, Celinski S, Newell P, Ly QP, Howe J, Coburn N. Management of asymptomatic, well-differentiated PNETs: results of the Delphi consensus process of the Americas Hepato-Pancreato-Biliary Association. HPB (Oxford) 2019; 21:515-523. [PMID: 30527517 DOI: 10.1016/j.hpb.2018.09.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/24/2018] [Accepted: 09/30/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Variation in the management of PNETs exist due to the limited high-level evidence to guide clinical practice. The aim of this work is to generate consensus guidelines with a Delphi process for managing PNETs. METHODS A panel of experts reviewed the surgical literature and scored a set of clinical case statements using a web-based survey to identify areas of agreement and disagreement. Results of the survey were discussed after each round of review. This cycle was repeated until no further likelihood of reaching consensus existed. RESULTS Twenty-two case statements related to surgical indications, preoperative biopsy, extent of resection, type of surgery, and tumor location were scored. Using a pre-defined definition of consensus, the panel achieved consensus on the following: i) resection is not recommended for <1 cm lesions; ii) resection is recommended for lesions greater than 2 cm; iii) lymph node dissection is recommended for radiographically-suspicious nodes with splenectomy for distal lesions; iv) tumor enucleation and central pancreatectomy are acceptable when technically feasible. No consensus was reached regarding issues of preoperative biopsy or 1-2 cm tumors. CONCLUSIONS Using a structured, validated system for identifying consensus, an expert panel identified areas of agreement regarding critical management decisions for patients with PNET. Issues without consensus warrant additional clinical investigation.
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Affiliation(s)
- John C Mansour
- Department of Surgery, UT Southwestern, Dallas, TX, USA.
| | - Kenneth Chavin
- Department of Surgery, University Hospitals, Cleveland, OH, USA
| | | | | | | | - Zhi V Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ajay Maker
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Steven K Libutti
- Department of Surgery, Rutgers Cancer Institute of New Jersey, NJ, USA
| | - Robert Warren
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Charles St Hill
- Department of Surgery, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Scott Celinski
- Department of Surgery, Baylor Scott and White, Dallas, TX, USA
| | - Philippa Newell
- Department of Surgery, Providence Portland Medical Center, Portland, OR, USA
| | - Quan P Ly
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - James Howe
- Department of Surgery, University of Iowa College of Medicine, Iowa City, IA, USA
| | - Natalie Coburn
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, USA
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Solomou S, Khan R, Propper D, Berney D, Druce M. A case of insulin and ACTH co-secretion by a neuroendocrine tumour. Endocrinol Diabetes Metab Case Rep 2014; 2014:130082. [PMID: 24683485 PMCID: PMC3965280 DOI: 10.1530/edm-13-0082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/23/2014] [Accepted: 02/04/2014] [Indexed: 11/08/2022] Open
Abstract
UNLABELLED A 33-year-old male was diagnosed with a metastatic neuroendocrine carcinoma of uncertain primary. He defaulted from follow-up without therapy and some months later developed episodic severe hypoglycaemia, which was found to be associated with inappropriately elevated insulin and C-peptide levels. It was considered likely that the neuroendocrine tumour was the source of the insulin secretion. Diazoxide and somatostatin analogue were used to control hypoglycaemia. Much later in the course of the disease, he developed metabolic derangement, increased skin pigmentation and psychological disturbance, without frankly Cushingoid physical findings. Investigations revealed highly elevated cortisol levels (the levels having previously been normal) with markedly raised ACTH levels, consistent with the co-secretion of ACTH and insulin by the tumour. Treatment with metyrapone improved his psychological state and electrolyte imbalance. Unfortunately, despite several cycles of first-, second- and third-line chemotherapy from the start of the first hormonal presentation onwards, imaging revealed widespread progressive metastatic disease and the patient eventually passed away. This case highlights the importance of keeping in mind the biochemical heterogeneity of endocrine tumours during their treatment. LEARNING POINTS The clinical presentation of insulin-secreting tumours includes symptoms of neuroglycopaenia and sympathetic overstimulation.Tumour-associated hypoglycaemia can be due to pancreatic insulinomas, and although ectopic hormone production occurs in a number of tumours, ectopic secretion of insulin is rare.A possible switch in the type of hormone produced can occur during the growth and progression of neuroendocrine tumours and, when treating neuroendocrine tumours, it is important to keep in mind their biochemical heterogeneity.
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Affiliation(s)
- S Solomou
- Department of Endocrinology Barts and the London School of Medicine, QMUL W SmithfieldEC1A 7BE, London UK
| | - R Khan
- Department of Endocrinology Barts and the London School of Medicine, QMUL W SmithfieldEC1A 7BE, London UK
| | - D Propper
- Department of Oncology Barts and the London School of Medicine, QMUL W SmithfieldEC1A 7BE, London UK
| | - D Berney
- Department of Histopathology Barts and the London School of Medicine, QMUL W SmithfieldEC1A 7BE, London UK
| | - M Druce
- Department of Endocrinology Barts and the London School of Medicine, QMUL W SmithfieldEC1A 7BE, London UK
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Toaiari M, Davì MV, Dalle Carbonare L, Boninsegna L, Castellani C, Falconi M, Francia G. Presentation, diagnostic features and glucose handling in a monocentric series of insulinomas. J Endocrinol Invest 2013; 36:753-8. [PMID: 23608735 DOI: 10.3275/8942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND New aspects have emerged in the clinical and diagnostic scenarios of insulinoma: current guidelines have lowered the diagnostic insulin threshold to 3 μU/ml in the presence of hypoglycemia (<55 mg/dl); post-prandial hypoglycemia has been reported as the only presenting symptom; preexisting diabetes mellitus (DM) was recognized in some patients. AIM To evaluate clinical features, diagnostic criteria and glucose metabolic profile in a monocentric series of patients affected by insulinomas including two subgroups: sporadic and multiple endocrine neoplasia type-1 syndrome (MEN-1). SUBJECTS AND METHODS Clinical, pathological and biochemical data regarding 33 patients were analyzed. RESULTS following the current guidelines the 72-h fasting test was initially positive in all cases but one. In this case the test, initially negative, became positive after a 2-yr follow-up. Nadir insulin level was ≥ 3 μU/ml but <6 μU/ml in 3 patients and ≥ 6 μU/ml in the remaining 30 cases. At presentation, 27 patients (82%) reported only fasting symptoms, 3 (9%) only post-prandial and 3 (9%) both. Seven cases (21%) had previously been affected by type 2 DM or impaired glucose metabolism. CONCLUSIONS In our series the new cut-off of insulin increased the sensitivity of the 72-h fasting test from 87% to 97%. The absence of hypoglycemia during the test cannot definitively rule out the diagnosis and the test should be repeated in every highly suspicious case. Post-prandial hypoglycemia can be the only presenting symptom. DM may be associated with the occurrence of insulinoma. So that a possible diagnosis of insulinoma must not be ignored if previous impaired glucose handling is evident.
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Affiliation(s)
- M Toaiari
- Department of Internal Medicine D, "G.B. Rossi" University Hospital, Verona, Italy
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