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Larsen AR, Brusgaard K, Christesen HT, Detlefsen S. Genotype-histotype-phenotype correlations in hyperinsulinemic hypoglycemia. Histol Histopathol 2024; 39:817-844. [PMID: 38305063 DOI: 10.14670/hh-18-709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Hyperinsulinemic hypoglycemia (HH) of pancreatic origin includes congenital hyperinsulinism (CHI), insulinoma, insulinomatosis, and adult-onset non-insulinoma persistent hyperinsulinemic hypoglycemia syndrome (NI-PHHS). In this review, we describe the genotype-histotype-phenotype correlations in HH and their therapeutic implications. CHI can occur from birth or later on in life. Histologically, diffuse CHI shows diffuse beta cell hypertrophy with a few giant nuclei per islet of Langerhans, most frequently caused by loss-of-function mutations in ABCC8 or KCNJ11. Focal CHI is histologically characterized by focal adenomatous hyperplasia consisting of confluent hyperplastic islets, caused by a paternal ABCC8/KCNJ11 mutation combined with paternal uniparental disomy of 11p15. CHI in Beckwith-Wiedemann syndrome is caused by mosaic changes in the imprinting region 11p15.4-11p15.5, leading to segmental or diffuse overgrowth of endocrine tissue in the pancreas. Morphological mosaicism of pancreatic islets is characterized by occurence of hyperplastic (type 1) islets in one or a few lobules and small (type 2) islets in the entire pancreas. Other rare genetic causes of CHI show less characteristic or unspecific histology. HH with a predominant adult onset includes insulinomas, which are pancreatic insulin-producing endocrine neoplasms, in some cases with metastatic potential. Insulinomas occur sporadically or as part of multiple endocrine neoplasia type 1 due to MEN1 mutations. MAFA mutations may histologically lead to insulinomatosis with insulin-producing neuroendocrine microadenomas or neuroendocrine neoplasms. NI-PHHS is mainly seen in adults and shows slight histological changes in some patients, which have been defined as major and minor criteria. The genetic cause is unknown in most cases. The diagnosis of HH, as defined by genetic, histological, and phenotypic features, has important implications for patient management and outcome.
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Affiliation(s)
- Annette Rønholt Larsen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center, Odense University Hospital, Odense, Denmark
| | - Henrik Thybo Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Steno Diabetes Center, Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark.
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Pizzoferro M, Masselli G, Maiorana A, Casciani E, Sollaku S, Dionisi-Vici C, Spada M, Altini C, Villani MF, Rufini V, Gualdi G, Garganese MC. PET/CT in congenital hyperinsulinism: transforming patient's lives by molecular hybrid imaging. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2022; 12:44-53. [PMID: 35535120 PMCID: PMC9077170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/13/2022] [Indexed: 06/14/2023]
Abstract
Congenital hyperinsulinism (HI) is a life-threatening condition characterized by severe and recurrent episodes of hypoglycaemia due to defects in key genes involved in regulating insulin secretion. The delay in diagnosis and inappropriate management of HI lead to high risk of permanent hypoglycemic brain injury. The management of HI is challenging as each form of HI (focal, diffuse, and atypical) requires its own therapeutic strategy. In HI diagnostic work-up, integrated PET/CT scan is currently the first-line imaging technique allowing to differentiate between diffuse and focal form and, in the latter case, to localize the focus within the pancreas with high precision. Only in focal HI partial pancreatectomy is the treatment of choice and a curative surgical treatment means a real chance of transforming patient's lives and HI patient's future. The aim of this review is to discuss the role of PET/CT imaging in HI scenario, its technical advantages and limitations and how successful surgery is strongly dependent on accurate preoperative assessment (genetic analysis and PET/CT scan). A multidisciplinary approach in HI diagnosis and treatment inside a single team (involving different expertise) allows to manage children safely and properly, supporting their families in an organized care network.
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Affiliation(s)
- Milena Pizzoferro
- Nuclear Medicine Unit/Imaging Department, IRCCS Bambino Gesù Children’s HospitalRome, Italy
| | - Gabriele Masselli
- Nuclear Medicine Section, Pio XI Private HospitalRome, Italy
- Radiology and Molecular Imaging Department, Umberto I Hospital, Sapienza UniversityRome, Italy
| | - Arianna Maiorana
- Division of Metabolic Diseases, Department of Pediatric Specialties, IRCCS Bambino Gesù Children’s HospitalRome, Italy
| | | | - Saadi Sollaku
- Nuclear Medicine Section, Pio XI Private HospitalRome, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolic Diseases, Department of Pediatric Specialties, IRCCS Bambino Gesù Children’s HospitalRome, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, IRCCS Bambino Gesù Children’s HospitalRome, Italy
| | - Claudio Altini
- Nuclear Medicine Unit/Imaging Department, IRCCS Bambino Gesù Children’s HospitalRome, Italy
| | - Maria Felicia Villani
- Nuclear Medicine Unit/Imaging Department, IRCCS Bambino Gesù Children’s HospitalRome, Italy
| | - Vittoria Rufini
- Institute of Nuclear Medicine, Policlinico Gemelli Foundation, Catholic University of The Sacred HeartRome, Italy
| | | | - Maria Carmen Garganese
- Nuclear Medicine Unit/Imaging Department, IRCCS Bambino Gesù Children’s HospitalRome, Italy
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Sagar S, Arora G, Damle N, Sharma R, Jain V, Jana M, Tripathi M, Bal C, Goel P. F-18 DOPA PET/CT in pediatric patients with hyperinsulinemic hypoglycemia: A correlation with genetic analysis. Nucl Med Commun 2022; 43:451-457. [PMID: 35045547 DOI: 10.1097/mnm.0000000000001526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM Persistent hyperinsulinemic hypoglycemia is a rare but life-threatening disease of infancy and childhood. 18F-DOPA PET/CT has been shown to be a useful modality in the localization of focal pancreatic lesions in these patients. We aimed to assess the role of 18F-DOPA PET/CT in such patients at our institution. MATERIALS AND METHODS In this prospective study, 18F-DOPA PET/CT scans and clinical details of 20 children with clinical diagnosis of hyperinsulinemic hypoglycemia were reviewed. Scans were acquired at 5 min postinjection of 2-3 mCi of 18F-DOPA on dedicated PET/CT scanners (Biograph mCT, Siemens Inc and Discovery PET/CT, GE). Abdominal spot images over 1-2 bed positions were acquired. Additionally, genetic mutation status, where available, was correlated to the scan findings. RESULTS Out of 20 children (7 female and 13 male), 13 were infants. The age of the children ranged from 3 months to 8 years. Fifteen children had undergone gene analysis, 12 were positive for mutation in ABCC8, 1 for GLUD-1, 1 for GCK mutations and 1 had not shown any mutation. 18F-DOPA PET/CT scan showed 5 focal pancreatic lesions in 5 children (1 in each), two focal lesions in 1 child and diffuse pancreatic uptake in 14 children. CONCLUSION 18F-DOPA PET/CT is a useful modality for localizing focal pancreatic lesions in children with persistent hyperinsulinemic hypoglycemia. The detection rate is significantly higher in patients with ABCC8 paternal monoallelic recessive gene mutation. 18F-DOPA PET/CT scan consequent to findings on genetic analysis appears to be useful in planning the management of children with hyperinsulinism.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Prabudh Goel
- Department of Pediatric Surgery, AIIMS, New Delhi, India
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Congenital hyperinsulinism: localization of a focal lesion with 18F-FDOPA positron emission tomography. Pediatr Radiol 2022; 52:693-701. [PMID: 34668049 DOI: 10.1007/s00247-021-05206-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/29/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
Hyperinsulinemic hypoglycemia of infancy, also known as congenital hyperinsulinism, is a group of disorders characterized by dysregulated insulin release. Neonates with severe, persistent hyperinsulinemic hypoglycemia who are unresponsive to medical therapy require pancreatectomy to prevent brain damage from hypoglycemia. To date, multiple genetic mutations and syndromes and several unique histopathological entities have been identified in children with hyperinsulinism. Histopathology is characterized as diffuse, focal or atypical. Surgical resection of a focal lesion results in a cure in up to 97% of these children. Imaging with 6-fluoro-(18F)-L-3,4-dihydroxyphenylalanine (18F-FDOPA) positron emission tomography (PET) is the test of choice for identifying and localizing a focal lesion and has proved to be an invaluable guide for surgical resection. Genetic evaluation is essential for determining who will benefit from PET imaging. This article provides an approach to determine who should be imaged, how to set up a protocol and how to interpret the imaging findings. The diagnosis and management of this disorder require a multidisciplinary approach to prevent brain damage from hypoglycemia.
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Giri D, Hawton K, Senniappan S. Congenital hyperinsulinism: recent updates on molecular mechanisms, diagnosis and management. J Pediatr Endocrinol Metab 2022; 35:279-296. [PMID: 34547194 DOI: 10.1515/jpem-2021-0369] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/30/2021] [Indexed: 12/20/2022]
Abstract
Congenital hyperinsulinism (CHI) is a rare disease characterized by an unregulated insulin release, leading to hypoglycaemia. It is the most frequent cause of persistent and severe hypoglycaemia in the neonatal period and early childhood. Mutations in 16 different key genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, KCNQ1, CACNA1D, FOXA2, EIF2S3, PGM1 and PMM2) that are involved in regulating the insulin secretion from pancreatic β-cells have been described to be responsible for the underlying molecular mechanisms of CHI. CHI can also be associated with specific syndromes and can be secondary to intrauterine growth restriction (IUGR), maternal diabetes, birth asphyxia, etc. It is important to diagnose and promptly initiate appropriate management as untreated hypoglycaemia can be associated with significant neurodisability. CHI can be histopathologically classified into diffuse, focal and atypical forms. Advances in molecular genetics, imaging techniques (18F-fluoro-l-dihydroxyphenylalanine positron emission tomography/computed tomography scanning), novel medical therapies and surgical advances (laparoscopic pancreatectomy) have changed the management and improved the outcome of patients with CHI. This review article provides an overview of the background, clinical presentation, diagnosis, molecular genetics and therapy for children with different forms of CHI.
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Affiliation(s)
- Dinesh Giri
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.,University of Bristol, Bristol, UK
| | - Katherine Hawton
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Diagnostic Value of Seven Different Imaging Modalities for Patients with Neuroblastic Tumors: A Network Meta-Analysis. CONTRAST MEDIA & MOLECULAR IMAGING 2021; 2021:5333366. [PMID: 34548851 PMCID: PMC8429030 DOI: 10.1155/2021/5333366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/18/2021] [Accepted: 08/20/2021] [Indexed: 11/25/2022]
Abstract
Objective We performed a systematic review and network meta-analysis (NMA) to compare the diagnostic value of seven different imaging modalities for the detection of neuroblastic tumors in diverse clinical settings. Methods PubMed, Embase, Medline, and the Cochrane Library were searched to identify eligible studies from inception to Sep 29, 2020. Quality assessment of included studies was appraised with Quality Assessment of Diagnostic Accuracy Studies. Firstly, direct pairwise meta-analysis was conducted to calculate the pooled estimates of odds ratio (OR) and 95% confidence interval (CI) of the sensitivity, specificity, NPV, PPV, and DR. Next, NMA using Bayesian methods was performed. The superiority index was assessed to quantify the rank probability of a diagnostic test. The studies performed SPECT/CT or SPECT were analyzed separately from the ones only performed planar imaging. Results A total of 1135 patients from 32 studies, including 7 different imaging modalities, were eligible for this NMA. In the pairwise meta-analysis, 18F-FDOPA PET/CT had a relatively high value of all the outcomes (sensitivity: 10.195 [5.332–19.493]; specificity: 17.906 [5.950–53.884]; NPV: 16.819 [7.033–40.218]; PPV: 11.154 [4.216–29.512]; and DR 5.616 [3.609–8.739]). In the NMA, 18F-FDOPA PET/CT exhibited relatively high sensitivity in all subgroups (all data: 0.94 [0.87–0.98]; primary tumor: 0.89 [0.53–1]; bone/bone marrow metastases: 0.96 [0.83–1]; and primary tumor and metastases (P + M): 0.92 [0.80–0.97]), the highest specificity in the subgroup of P + M (0.85 [0.61–0.97]), and achieved the highest superiority index in the subgroups of all data (8.57 [1–15]) and P + M (7.25 [1–13]). Conclusion 18F-FDOPA PET/CT exhibited the best diagnostic performance in the comprehensive detection of primary tumor and metastases for neuroblastic tumors, followed by 68Ga-somatostatin analogs, 123I-meta-iodobenzylguanidine (MIBG), 18F-FDG, and 131I-MIBG tomographic imaging.
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States LJ, Davis JC, Hamel SM, Becker SA, Zhuang H. 18F-6-Fluoro-l-Dopa PET/CT Imaging of Congenital Hyperinsulinism. J Nucl Med 2021; 62:51S-56S. [PMID: 34230074 DOI: 10.2967/jnumed.120.246033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 12/08/2020] [Indexed: 11/16/2022] Open
Abstract
Congenital hyperinsulinism is characterized by persistent hypoglycemia due to inappropriate excess secretion of insulin resulting in hyperinsulinemic hypoglycemia. The clinical course varies from mild to severe, with a significant risk for brain damage. Imaging plays a valuable role in the care of infants and children with severe hypoglycemia unresponsive to medical therapy. 18F-6-fluoro-l-dopa PET/CT is the method of choice for the detection and localization of a focal lesion of hyperinsulinism. Surgical resection of a focal lesion can lead to a cure with limited pancreatectomy. This article reviews the role of 18F-6-fluoro-l-dopa PET/CT in the management of this vulnerable population.
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Affiliation(s)
- Lisa J States
- Radiology Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, and
| | - J Christopher Davis
- Radiology Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, and
| | - Steven M Hamel
- Radiology Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Susan A Becker
- Radiology Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Hongming Zhuang
- Radiology Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, and
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Djekidel M. 18F-FDOPA and 68Ga-dotatate PET imaging in congenital hyperinsulinism. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2021; 11:188-195. [PMID: 34234997 PMCID: PMC8255214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/07/2021] [Indexed: 06/13/2023]
Abstract
Congenital hyperinsulinism (CHI) occurs most commonly in infants but may also be discovered in older children. It presents with recurrent episodes of hypoglycemia due to high endogenous insulin levels. There is a focal and diffuse form of the disease depending on the extent of pancreatic involvement. Hyperplasia of the islet cells results in hyperfunctioning pancreatic β cells and the ensuing clinical disease. Medical treatment fails in several patients and surgery has been shown to be very effective in improving prognosis and even resolution of disease in the focal form. Several genetic mutations have been uncovered and these may also be predictive of prognosis. Anatomical imaging alone including ultrasound, CT and MRI are rarely able to detect any abnormality in the pancreas. PET plays a major role in the distinction between the focal and diffuse forms of the disease. It also guides surgical intervention by providing information on the location of the focal hyperfunctioning islet cells. Imaging children and infants in this disease is quite challenging. We propose to show the benefit of using two PET tracers in this disease. 18F-FDOPA has been used quite successfully in the evaluation of CHI. 68Ga-DOTATATE has also been described to be helpful although inferior to 18F-FDOPA. We illustrate imaging of CHI patients in 3 different scans and briefly review the literature. 18F-FDOPA as described in the literature is superior but when unavailable 68Ga-DOTATATE may be a reasonable alternative.
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Affiliation(s)
- Mehdi Djekidel
- Division Lead Nuclear Medicine and Molecular Imaging, Department of Diagnostic Imaging, Sidra Medicine Al-Luqta Street, PO Box Number. 26999, Doha, Qatar
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Masselli G, Casciani E, De Angelis C, Sollaku S, Gualdi G. Clinical application of 18F-DOPA PET/TC in pediatric patients. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2021; 11:64-76. [PMID: 34079636 PMCID: PMC8165723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/14/2021] [Indexed: 06/12/2023]
Abstract
The use 18F-DOPA PET/CT for oncologic and non-oncologic pediatric diseases is well consolidated in clinical practice. The indications include brain tumors, neuroendocrine malignancies and congenital hyperinsulinism. The number of papers involving pediatric subjects is steadily growing. However, literature still lacks clinical trials and large multicentric studies in contrast with the extensive literature available for adult patients. The aim of this review is to discuss the main clinical indications of 18F-DOPA in pediatric oncologic and nononcologic diseases and to analyze its role in diagnosis, staging, biopsy and surgical planning. The high resolution of PET/CT tomographs in addition to the high sensitivity and specificity of 18F-DOPA imaging exceeds the downsides linked to this nuclear medicine imaging modality. In fact, few potential limitations could discourage the use of PET/CT imaging. For example, similarly to MRI studies the long acquisition time of a PET/CT scan often requires sedation especially in infants. Moreover, the radiation exposure of a PET/CT scan may be high, but the clinical benefit deriving from nuclear medicine imaging outruns the risk connected to the use of ionizing radiations.
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Affiliation(s)
- Gabriele Masselli
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, “Sapienza” University of RomeItaly
- PET/CT Section, Pio XI Private HospitalRome, Italy
| | | | - Cristina De Angelis
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, “Sapienza” University of RomeItaly
| | - Saadi Sollaku
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, “Sapienza” University of RomeItaly
- PET/CT Section, Pio XI Private HospitalRome, Italy
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Garegrat R, Patnaik S, Suryawanshi P, Datar C. Focal congenital hyperinsulinism resulting from biallelic loss of function of KCNJ11 gene. BMJ Case Rep 2021; 14:14/3/e240218. [PMID: 33762279 PMCID: PMC7993335 DOI: 10.1136/bcr-2020-240218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Congenital hyperinsulinism (CHI) characterised by inappropriate secretion of insulin despite low blood glucose can result in irreversible brain damage if not promptly treated. The most common genetic cause of hyperinsulinism is the pathogenic variants in ABCC8 and KCNJ11, causing dysregulated insulin secretion. Rapid testing is crucial for all patients because finding a mutation significantly impacts this condition's clinical management. We report a rare case of focal CHI after a homozygous KCNJ11 mutation who underwent a selective lesionectomy and required octreotide for euglycaemia.
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Affiliation(s)
- Reema Garegrat
- Department of Neonatology, Bharati Hospital and Research Centre, Pune, Maharashtra, India
| | - Suprabha Patnaik
- Department of Neonatology, Bharati Hospital and Research Centre, Pune, Maharashtra, India
| | | | - Chaitanya Datar
- Department of Neonatology, Bharati Hospital and Research Centre, Pune, Maharashtra, India
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Alhaidan Y, Christesen HT, Lundberg E, Balwi MAA, Brusgaard K. CRISPR/Cas9 ADCY7 Knockout Stimulates the Insulin Secretion Pathway Leading to Excessive Insulin Secretion. Front Endocrinol (Lausanne) 2021; 12:657873. [PMID: 34177802 PMCID: PMC8231291 DOI: 10.3389/fendo.2021.657873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/18/2021] [Indexed: 11/15/2022] Open
Abstract
AIM Despite the enormous efforts to understand Congenital hyperinsulinism (CHI), up to 50% of the patients are genetically unexplained. We aimed to functionally characterize a novel candidate gene in CHI. PATIENT A 4-month-old boy presented severe hyperinsulinemic hypoglycemia. A routine CHI genetic panel was negative. METHODS A trio-based whole-exome sequencing (WES) was performed. Gene knockout in the RIN-m cell line was established by CRISPR/Cas9. Gene expression was performed using real-time PCR. RESULTS Hyperinsulinemic hypoglycemia with diffuse beta-cell involvement was demonstrated in the patient, who was diazoxide-responsive. By WES, compound heterozygous variants were identified in the adenylyl cyclase 7, ADCY7 gene p.(Asp439Glu) and p.(Gly1045Arg). ADCY7 is calcium-sensitive, expressed in beta-cells and converts ATP to cAMP. The variants located in the cytoplasmic domains C1 and C2 in a highly conserved and functional amino acid region. RIN-m(-/-Adcy7) cells showed a significant increase in insulin secretion reaching 54% at low, and 49% at high glucose concentrations, compared to wild-type. In genetic expression analysis Adcy7 loss of function led to a 34.1-fold to 362.8-fold increase in mRNA levels of the insulin regulator genes Ins1 and Ins2 (p ≤ 0.0002), as well as increased glucose uptake and sensing indicated by higher mRNA levels of Scl2a2 and Gck via upregulation of Pdx1, and Foxa2 leading to the activation of the glucose stimulated-insulin secretion (GSIS) pathway. CONCLUSION This study identified a novel candidate gene, ADCY7, to cause CHI via activation of the GSIS pathway.
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Affiliation(s)
- Yazeid Alhaidan
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Medical Genomics Research, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- *Correspondence: Yazeid Alhaidan,
| | - Henrik Thybo Christesen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Odense Pancreas Center, Odense, Denmark
| | - Elena Lundberg
- Institute of Clinical Science, Pediatrics, Umea University, Umeå, Sweden
| | - Mohammed A. Al Balwi
- Department of Medical Genomics Research, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, NGHA, Riyadh, Saudi Arabia
| | - Klaus Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Near East University, Nicosia, Cyprus
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Bjarnesen AP, Dahlin P, Globa E, Petersen H, Brusgaard K, Rasmussen L, Melikian M, Detlefsen S, Christesen HT, Mortensen MB. Intraoperative ultrasound imaging in the surgical treatment of congenital hyperinsulinism: prospective, blinded study. BJS Open 2020; 5:5973900. [PMID: 33688939 PMCID: PMC7944853 DOI: 10.1093/bjsopen/zraa008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/04/2020] [Indexed: 11/24/2022] Open
Abstract
Background In congenital hyperinsulinism (CHI), preoperative prediction of the histological subtype (focal, diffuse, or atypical) relies on genetics and 6-[18F]fluoro-l-3,4-dihydroxyphenylalanine (18F-DOPA) PET–CT. The scan also guides the localization of a potential focal lesion along with perioperative frozen sections. Intraoperative decision-making is still challenging. This study aimed to describe the characteristics and potential clinical impact of intraoperative ultrasound imaging (IOUS) during CHI surgery. Methods This was a prospective, observational study undertaken at an expert centre over a 2-year interval. IOUS was performed blinded to preoperative diagnostic test results (genetics and 18F-DOPA PET–CT), followed by unblinding and continued IOUS during pancreatic resection. Characteristics and clinical impact were assessed using predefined criteria. Results Eighteen consecutive, surgically treated patients with CHI, with a median age of 5.5 months, were included (focal 12, diffuse 3, atypical 3). Focal lesions presented as predominantly hypoechoic, oval lesions with demarcated or blurred margins. Patients with diffuse and atypical disease had varying echogenicity featuring stranding and non-shadowing hyperechoic foci in three of six, whereas these characteristics were absent from those with focal lesions. The blinded IOUS-based subclassification was correct in 17 of 18 patients; one diffuse lesion was misclassified as focal. IOUS had an impact on the surgical approach in most patients with focal lesions (9 of 12), and in those with diffuse (2 of 3) and atypical (2 of 3) disease when the resection site was close to the bile or pancreatic duct. Conclusion Uniform IOUS characteristics made all focal lesions identifiable. IOUS had a clinical impact in 13 of 18 patients by being a useful real-time supplementary modality in terms of localizing focal lesions, reducing the need for frozen sections, and preserving healthy tissue and delicate structures.
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Affiliation(s)
- A P Bjarnesen
- Upper Gastrointestinal and Hepato-Pancreato-Biliary Section, Department of Surgery, Odense University Hospital, Odense, Denmark
- Odense Pancreas Centre, OPAC, Odense University Hospital, Odense, Denmark
| | - P Dahlin
- Upper Gastrointestinal and Hepato-Pancreato-Biliary Section, Department of Surgery, Odense University Hospital, Odense, Denmark
- Odense Pancreas Centre, OPAC, Odense University Hospital, Odense, Denmark
| | - E Globa
- Ukrainian Research Centre of Endocrine Surgery, Endocrine Organs and Tissue Transplantation, Paediatric Endocrinology Department, Ministry of Health of Ukraine, Kiev, Ukraine
| | - H Petersen
- PET and Cyclotron Unit, Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - K Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - L Rasmussen
- Odense Pancreas Centre, OPAC, Odense University Hospital, Odense, Denmark
- Paediatric Surgery Section, Department of Surgery, Odense University Hospital, Odense, Denmark
| | - M Melikian
- Endocrine Research Centre, Department of Paediatric Endocrinology, Moscow, Russia
| | - S Detlefsen
- Odense Pancreas Centre, OPAC, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - H T Christesen
- Odense Pancreas Centre, OPAC, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
| | - M B Mortensen
- Correspondence to: Department of Surgery, Odense University Hospital, J. B. Winsløvs Vej 4, 5000 Odense C, Denmark (e-mail: )
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Garg PK, Putegnat B, Truong L, Reynolds C, Sanchez I, Nedrelow JK, Uffman J, Lokitz SJ, Nazih R, Garg S, Thornton PS. Visual interpretation, not SUV ratios, is the ideal method to interpret 18F-DOPA PET scans to aid in the cure of patients with focal congenital hyperinsulinism. PLoS One 2020; 15:e0241243. [PMID: 33108363 PMCID: PMC7591017 DOI: 10.1371/journal.pone.0241243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/11/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Congenital hyperinsulinism is characterized by abnormal regulation of insulin secretion from the pancreas causing profound hypoketotic hypoglycemia and is the leading cause of persistent hypoglycemia in infants and children. The main objective of this study is to highlight the different mechanisms to interpret the 18F-DOPA PET scans and how this can influence outcomes. MATERIALS AND METHODS After 18F-Fluoro-L-DOPA was injected intravenously into 50 subjects' arm at a dose of 2.96-5.92 MBq/kg, three to four single-bed position PET scans were acquired at 20, 30, 40 and 50-minute post injection. The radiologist interpreted the scans for focal and diffuse hyperinsulinism using a visual interpretation method, as well as determining the Standard Uptake Value ratios with varying cut-offs. RESULTS Visual interpretation had the combination of the best sensitivity and positive prediction values. CONCLUSIONS In patients with focal disease, SUV ratios are not as accurate in identifying the focal lesion as visual inspection, and cases of focal disease may be missed by those relying on SUV ratios, thereby denying the patients a chance of cure. We recommend treating patients with diazoxide-resistant hyperinsulinism in centers with dedicated multidisciplinary team comprising of at least a pediatric endocrinologist with a special interest in hyperinsulinism, a radiologist experienced in interpretation of 18F-Fluoro-L-DOPA PET/CT scans, a histopathologist with experience in frozen section analysis of the pancreas and a pancreatic surgeon experienced in partial pancreatectomies in patients with hyperinsulinism.
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Affiliation(s)
- Pradeep K. Garg
- Center for Molecular Imaging and Therapy, Biomedical Research Foundation, Shreveport, Louisiana, United States of America
- * E-mail:
| | - Burton Putegnat
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | - Lisa Truong
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | - Courtney Reynolds
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | - Irene Sanchez
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | | | - John Uffman
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | - Stephen J. Lokitz
- Center for Molecular Imaging and Therapy, Biomedical Research Foundation, Shreveport, Louisiana, United States of America
| | - Rachid Nazih
- Center for Molecular Imaging and Therapy, Biomedical Research Foundation, Shreveport, Louisiana, United States of America
| | - Sudha Garg
- Center for Molecular Imaging and Therapy, Biomedical Research Foundation, Shreveport, Louisiana, United States of America
| | - Paul S. Thornton
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
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Papel de la PET/TC con 18F-DOPA en el diagnóstico de la forma congénita focal del hiperinsulinismo en niños. Rev Esp Med Nucl Imagen Mol 2020. [DOI: 10.1016/j.remnie.2020.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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15
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The role of 18F-DOPA PET/CT in the diagnosis of the congenital focal form of hyperinsulinism in children. Rev Esp Med Nucl Imagen Mol 2020; 39:279-283. [PMID: 32448747 DOI: 10.1016/j.remn.2020.02.005] [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: 10/01/2019] [Revised: 01/15/2020] [Accepted: 02/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Congenital hyperinsulinism (CHI) is a neuroendocrine disease with focal or diffuse abnormalities in pancreas. While drug-resistant diffuse forms require near-total pancreatectomy or prolonged pharmacotherapy, focal CHI may be treated by targeted surgical resection. We evaluated the usefulness of 18F-DOPA PET/CT to identify the focal pancreatic form. SUBJECTS AND METHODS Nineteen children (11 boys, 8 girls, aged 2-54 months) with clinical signs of neonatal CHI and positive genetic examinations were enrolled in the study. After i.v. administration of 18F-DOPA, early PET and late PET/CT acquisition covering one-bed length over thoraco-abdominal region were performed. Both acquisitions were done in dynamic mode to allow exclusion of frames with motion artefacts. Standardized uptake values were adjusted to bodyweight (SUVbw). The finding was considered as focal when the ratio of SUVbwmax between the suspicious region and the rest of pancreas was greater than 1.2. RESULTS Focal forms were recorded in 10/19 children and 4 of them underwent surgical resection with complete recovery. Focal uptake was significantly higher than the uptake in the normal pancreatic tissue (p=0.0059). Focal and diffuse forms of CHI did not differ significantly in normal pancreatic tissue uptake. We found no advantage in the measurement of SUVbwmean ratio compared to SUVbwmax ratio (p=0.50). CONCLUSION 18F-DOPA PET/CT is a useful tool for the localization of focal CHI and planning of surgical treatment.
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Rasmussen AG, Melikian M, Globa E, Detlefsen S, Rasmussen L, Petersen H, Brusgaard K, Rasmussen AH, Mortensen MB, Christesen HT. The difficult management of persistent, non-focal congenital hyperinsulinism: A retrospective review from a single, tertiary center. Pediatr Diabetes 2020; 21:441-455. [PMID: 31997554 DOI: 10.1111/pedi.12989] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 11/14/2019] [Accepted: 01/13/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Congenital hyperinsulinism (CHI) is a rare, heterogeneous disease with transient or persistent hypoglycemia. Histologically, focal, diffuse, and atypical forms of CHI exist, and at least 11 disease-causing genes have been identified. METHODS We retrospectively evaluated the treatment and outcome of a cohort of 40 patients with non-focal, persistent CHI admitted to the International Hyperinsulinism Center, Denmark, from January 2000 to May 2017. RESULTS Twenty-two patients (55%) could not be managed with medical monotherapy (diazoxide or octreotide) and six (15%) patients developed severe potential side effects to medication. Surgery was performed in 17 (43%) patients with resection of 66% to 98% of the pancreas. Surgically treated patients had more frequently KATP -channel gene mutations (surgical treatment 12/17 vs conservative treatment 6/23, P = .013), highly severe disease (15/17 vs 13/23, P = .025) and clinical onset <30 days of age (15/17 vs 10/23, P = .004). At last follow-up at median 5.3 (range: 0.3-31.3) years of age, 31/40 (78%) patients still received medical treatment, including 12/17 (71%) after surgery. One patient developed diabetes after a 98% pancreatic resection. Problematic treatment status was seen in 7/40 (18%). Only 8 (20%) had clinical remission (three spontaneous, five after pancreatic surgery). Neurodevelopmental impairment (n = 12, 30%) was marginally associated with disease severity (P = .059). CONCLUSIONS Persistent, non-focal CHI remains difficult to manage. Neurological impairment in 30% suggests a frequent failure of prompt and adequate treatment. A high rate of problematic treatment status at follow-up demonstrates an urgent need for new medical treatment modalities.
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Affiliation(s)
- Amalie G Rasmussen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maria Melikian
- Department of Pediatric Endocrinology, Endrocrine Research Center, Moscow, Russia
| | - Evgenia Globa
- Department of Pediatric Endocrinology, Ukrainian Research Center of Endocrine Surgery, Kyiv, Ukraine
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Lars Rasmussen
- OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Henrik Petersen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Annett H Rasmussen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Michael B Mortensen
- OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Henrik T Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark
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Christesen HT, Christensen LG, Löfgren ÅM, Brøndum-Nielsen K, Svensson J, Brusgaard K, Samuelsson S, Elfving M, Jonson T, Grønskov K, Rasmussen L, Backman T, Hansen LK, Larsen AR, Petersen H, Detlefsen S. Tissue variations of mosaic genome-wide paternal uniparental disomy and phenotype of multi-syndromal congenital hyperinsulinism. Eur J Med Genet 2020; 63:103632. [DOI: 10.1016/j.ejmg.2019.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/11/2019] [Accepted: 02/17/2019] [Indexed: 01/12/2023]
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Xu ZR, Zhu XY, Lu W, Sun WH, Cheng RQ, Ni JW, Xi L, Hussain K, Luo FH, Zhang MY. Altered Serum Amino Acid and Acylcarnitine Profiles in Hyperinsulinemic Hypoglycemia and Ketotic Hypoglycemia. Front Endocrinol (Lausanne) 2020; 11:577373. [PMID: 33133020 PMCID: PMC7579424 DOI: 10.3389/fendo.2020.577373] [Citation(s) in RCA: 2] [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: 06/29/2020] [Accepted: 09/22/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In addition to inborn metabolic disorders, altered metabolic profiles were reported to be associated with the risk and prognosis of some non-metabolic diseases, while as a rare metabolic disease, the overall secondary metabolic spectrum in congenital hyperinsulinemic hypoglycemia (HH) is largely undetermined. Therefore, we investigated metabolic profiles in HH patients and used ketotic hypoglycemia (KH) patients as a control cohort to unveil their distinct metabolic features. METHODS A total of 97 hypoglycemia children, including 74 with hyperinsulinemic hypoglycemia and 23 with ketotic hypoglycemia, and 170 euglycemia control subjects were studied retrospectively. Clinical and biochemical data were collected. The normoglycemic spectra of amino acids and acylcarnitines were determined by liquid chromatography tandem mass spectrometry. The serum insulin and fatty acid concentrations during standardized fasting tests in hypoglycemia patients were also collected. Receiver operating characteristic curve analysis was performed to screen potential biomarkers. RESULTS Among the normoglycemic spectra of amino acids, blood valine (p < 0.001), arginine (p < 0.001), threonine (p = 0.001), glutamate (p = 0.002), methionine (p = 0.005), ornithine (p = 0.008), leucine (p = 0.014), alanine (p = 0.017), proline (p = 0.031), citrulline (p = 0.042), aspartate (p = 0.046), and glycine (p = 0.048) levels differed significantly among the three groups. Significantly decreased levels of long- (C14:1, p < 0.001; C18, p < 0.001), medium- (C8, p < 0.001; C10, p < 0.001; C10:1, p < 0.001), and short-chain (C4-OH, p < 0.001; C5OH, p < 0.001) acylcarnitines were found in the hyperinsulinemic hypoglycemia group. Hyperinsulinemic hypoglycemia children with focal lesions and diffuse lesions had similar amino acid and acylcarnitine spectra. C10:1 < 0.09 μmol/L, threonine > 35 μmol/L, and threonine/C10:1 > 440 showed sensitivities of 81.1, 66.2, and 81.1% and specificities of 72.7, 78.3, and 81.8%, respectively, in distinguishing HH from KH. CONCLUSIONS We found significantly different altered serum amino acid and acylcarnitine profiles at normoglycemia, especially decreased C10:1 and increased threonine levels, between HH and KH children, which may reflect the insulin ketogenesis inhibition effect in HH patients; however, the detailed mechanisms and physiological roles remain to be studied in the future.
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Affiliation(s)
- Zhen-Ran Xu
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Xiao-Yi Zhu
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Wei Lu
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Wei-Hua Sun
- Pediatric Research Institute, Children's Hospital of Fudan University, Shanghai, China
| | - Ruo-Qian Cheng
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Jin-Wen Ni
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Li Xi
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Khalid Hussain
- Department of Pediatric Medicine, Weill Cornell Medicine, Division of Endocrinology, Doha, Qatar
| | - Fei-Hong Luo
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Miao-Ying Zhang
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
- *Correspondence: Miao-Ying Zhang,
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Siersbæk J, Larsen AR, Nybo M, Christesen HT. A Sensitive Plasma Insulin Immunoassay to Establish the Diagnosis of Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2020; 11:614993. [PMID: 33679602 PMCID: PMC7935514 DOI: 10.3389/fendo.2020.614993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/31/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The diagnosis of congenital hyperinsulinism (CHI) may be hampered by a plasma (p-) insulin detection limit of 12-18 pmol/L (2-3 mU/L). OBJECTIVE To evaluate the diagnostic performance of a sensitive insulin immunoassay and to find the optimal p-insulin cut-off for the diagnosis of CHI. METHODS Diagnostic fasting tests, performed without medication or i.v.-glucose, were investigated in children with a clinical diagnosis of CHI, or idiopathic ketotic hypoglycemia (IKH). The CHI diagnosis was either clinical or by the alternative, p-insulin-free criteria; hypoglycemia plus disease-causing genetic mutations and/or CHI-compatible pancreatic histopathology. We included diagnostic p-insulin samples with simultaneous p-glucose <3.2 mmol/L and used a sensitive insulin assay (Cobas e411 immunoassay analyzer; lower detection limit 1.2 pmol/L; normal range 15.1-147.1 pmol/L). Receiver operating characteristics area under the curve (ROC AUC) values and optimal cut-offs were analyzed for the performance of p-insulin to diagnose CHI. RESULTS In 61 CHI patients, the median (range) p-insulin was 76.5 (17-644) pmol/L compared to 1.5 (1.5-7.7) pmol/L in IKH patients (n=15). The ROC AUC was 1.0 for the diagnosis of CHI defined both by the clinical diagnosis (n=61) and by alternative criteria (n=57). The optimal p-insulin cut-offs were 12.3 pmol/L, and 10.6 pmol/L, at p-glucose <3.2 mmol/L (n=61), and <3.0 mmol/L (n=49), respectively. CONCLUSIONS The sensitive insulin assay performed excellent in diagnosing CHI with optimal p-insulin cut-offs at 12.3 pmol/L (2.0 mU/L), and 10.6 pmol/L (1.8 mU/L), at p-glucose <3.2 mmol/L, and <3.0 mmol/L, respectively. A sensitive insulin assay may serve to simplify the diagnosis of CHI.
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Affiliation(s)
- Julie Siersbæk
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Annette Rønholt Larsen
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Henrik Thybo Christesen
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- *Correspondence: Henrik Thybo Christesen,
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Giovannini E, Giovacchini G, Borsò E, Lazzeri P, Riondato M, Leoncini R, Duce V, Ciarmiello A. [68Ga]-Dota Peptide PET/CT in Neuroendocrine Tumors: Main Clinical Applications. Curr Radiopharm 2019; 12:11-22. [DOI: 10.2174/1874471012666181212101244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 12/14/2022]
Abstract
Objective:
Neuroendocrine Neoplasms (NENs) are generally defined as rare and heterogeneous
tumors. The gastrointestinal system is the most frequent site of NENs localization, however they
can be found in other anatomical regions, such as pancreas, lungs, ovaries, thyroid, pituitary, and adrenal
glands. Neuroendocrine neoplasms have significant clinical manifestations depending on the
production of active peptide.
Methods:
Imaging modalities play a fundamental role in initial diagnosis as well as in staging and
treatment monitoring of NENs, in particular they vastly enhance the understanding of the physiopathology
and diagnosis of NENs through the use of somatostatin analogue tracers labeled with appropriate
radioisotopes. Additionally, the use of somatostatin analogues provides the ability to in-vivo measure
the expression of somatostatin receptors on NEN cells, a process that might have important therapeutic
implications.
Results:
A large body of evidences showed improved accuracy of molecular imaging based on PET/CT
radiotracer with SST analogues (e.g. [68Ga]-DOTA peptide) for the detection of NEN lesions in comparison
to morphological imaging modalities. So far, the role of imaging technologies in assessing
treatment response is still under debate.
Conclusion:
This review offers the systems of classification and grading of NENs and summarizes the
more useful recommendations based on data recently published for the management of patients with
NENs, with special focus on the role of imaging modalities based on SST targeting with PET / CT
radiotracers.
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Affiliation(s)
| | | | - Elisa Borsò
- Department of Nuclear Medicine, S. Andrea Hospital, La Spezia, Italy
| | - Patrizia Lazzeri
- Department of Nuclear Medicine, S. Andrea Hospital, La Spezia, Italy
| | - Mattia Riondato
- Department of Nuclear Medicine, S. Andrea Hospital, La Spezia, Italy
| | - Rossella Leoncini
- Department of Nuclear Medicine, S. Andrea Hospital, La Spezia, Italy
| | - Valerio Duce
- Department of Nuclear Medicine, S. Andrea Hospital, La Spezia, Italy
| | - Andrea Ciarmiello
- Department of Nuclear Medicine, S. Andrea Hospital, La Spezia, Italy
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Banerjee I, Salomon‐Estebanez M, Shah P, Nicholson J, Cosgrove KE, Dunne MJ. Therapies and outcomes of congenital hyperinsulinism-induced hypoglycaemia. Diabet Med 2019; 36:9-21. [PMID: 30246418 PMCID: PMC6585719 DOI: 10.1111/dme.13823] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2018] [Indexed: 12/01/2022]
Abstract
Congenital hyperinsulinism is a rare disease, but is the most frequent cause of persistent and severe hypoglycaemia in early childhood. Hypoglycaemia caused by excessive and dysregulated insulin secretion (hyperinsulinism) from disordered pancreatic β cells can often lead to irreversible brain damage with lifelong neurodisability. Although congenital hyperinsulinism has a genetic cause in a significant proportion (40%) of children, often being the result of mutations in the genes encoding the KATP channel (ABCC8 and KCNJ11), not all children have severe and persistent forms of the disease. In approximately half of those without a genetic mutation, hyperinsulinism may resolve, although timescales are unpredictable. From a histopathology perspective, congenital hyperinsulinism is broadly grouped into diffuse and focal forms, with surgical lesionectomy being the preferred choice of treatment in the latter. In contrast, in diffuse congenital hyperinsulinism, medical treatment is the best option if conservative management is safe and effective. In such cases, children receiving treatment with drugs, such as diazoxide and octreotide, should be monitored for side effects and for signs of reduction in disease severity. If hypoglycaemia is not safely managed by medical therapy, subtotal pancreatectomy may be required; however, persistent hypoglycaemia may continue after surgery and diabetes is an inevitable consequence in later life. It is important to recognize the negative cognitive impact of early-life hypoglycaemia which affects half of all children with congenital hyperinsulinism. Treatment options should be individualized to the child/young person with congenital hyperinsulinism, with full discussion regarding efficacy, side effects, outcomes and later life impact.
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Affiliation(s)
- I. Banerjee
- Department of Paediatric EndocrinologyRoyal Manchester Children's HospitalManchester University NHS Foundation TrustManchesterUK
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - M. Salomon‐Estebanez
- Department of Paediatric EndocrinologyRoyal Manchester Children's HospitalManchester University NHS Foundation TrustManchesterUK
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - P. Shah
- Endocrinology DepartmentGreat Ormond Street Hospital for ChildrenNHS Foundation TrustLondonUK
| | - J. Nicholson
- Paediatric Psychosocial DepartmentRoyal Manchester Children's HospitalManchester University NHS Foundation TrustManchesterUK
| | - K. E. Cosgrove
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - M. J. Dunne
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
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Bendix J, Laursen MG, Mortensen MB, Melikian M, Globa E, Detlefsen S, Rasmussen L, Petersen H, Brusgaard K, Christesen HT. Intraoperative Ultrasound: A Tool to Support Tissue-Sparing Curative Pancreatic Resection in Focal Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2018; 9:478. [PMID: 30186238 PMCID: PMC6113400 DOI: 10.3389/fendo.2018.00478] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/02/2018] [Indexed: 12/11/2022] Open
Abstract
Background: Focal congenital hyperinsulinism (CHI) may be cured by resection of the focal, but often non-palpable, pancreatic lesion. The surgical challenge is to minimize removal of normal pancreatic tissue. Aim: To evaluate the results of intraoperative ultrasound-guided, tissue-sparing pancreatic resection in CHI patients at an international expert center. Methods: Retrospective study of CHI patients treated at Odense University Hospital, Denmark, between January 2010 and March 2017. Results: Of 62 consecutive patients with persistent CHI, 24 (39%) had focal CHI by histology after surgery. All patients had a paternal ABCC8 or KCNJ11 mutation and a focal lesion by 18F-DOPA-PET/CT. Intraoperative ultrasound localized the focal lesion in 16/20 patients (sensitivity 0.80), including one ectopic lesion in the duodenal wall. Intraoperative ultrasound showed no focal lesion in 11/11 patients with diffuse CH (specificity 1.0). The positive predictive value for focal histology was 1.0, negative predictive value 0.73. Tissue-sparing pancreatic resection (focal lesion enucleation, local resection of tail or uncinate process) was performed in 67% (n = 16). In 11/12 having tissue-sparing resection and intraoperative ultrasound, the location of the focal lesion was exactly identified. Eight patients had resection of the pancreatic head or head/body, four with Roux-en-Y, three with pancreatico-gastrostomy and one without reconstruction. None had severe complications to surgery. Cure of hypoglycaemia was seen in all patients after one (n = 21) or two (n = 3) pancreatic resections. Conclusion: In focal CHI, tissue-sparing pancreatic resection was possible in 67%. Intraoperative ultrasound was a helpful supplement to the mandatory use of genetics, preoperative 18F-DOPA-PET/CT and intraoperative frozen sections.
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Affiliation(s)
- Julie Bendix
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mette G. Laursen
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Michael B. Mortensen
- Department of Surgery, Odense University Hospital, Odense, Denmark
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
| | - Maria Melikian
- Department of Paediatric Endocrinology, Endocrine Research Centre, Moscow, Russia
| | - Evgenia Globa
- Department of Paediatric Endocrinology, Ukrainian Centre of Endocrine Surgery, Kiev, Ukraine
| | - Sönke Detlefsen
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Lars Rasmussen
- Department of Surgery, Odense University Hospital, Odense, Denmark
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
| | - Henrik Petersen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Henrik T. Christesen
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
- *Correspondence: Henrik T. Christesen
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Abstract
Pancreatic β-cells are finely tuned to secrete insulin so that plasma glucose levels are maintained within a narrow physiological range (3.5-5.5 mmol/L). Hyperinsulinaemic hypoglycaemia (HH) is the inappropriate secretion of insulin in the presence of low plasma glucose levels and leads to severe and persistent hypoglycaemia in neonates and children. Mutations in 12 different key genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, PGM1 and PMM2) that are involved in the regulation of insulin secretion from pancreatic β-cells have been described to be responsible for the underlying molecular mechanisms leading to congenital HH. In HH due to the inhibitory effect of insulin on lipolysis and ketogenesis there is suppressed ketone body formation in the presence of hypoglycaemia thus leading to increased risk of hypoglycaemic brain injury. Therefore, a prompt diagnosis and immediate management of HH is essential to avoid hypoglycaemic brain injury and long-term neurological complications in children. Advances in molecular genetics, imaging techniques (18F-DOPA positron emission tomography/computed tomography scanning), medical therapy and surgical advances (laparoscopic and open pancreatectomy) have changed the management and improved the outcome of patients with HH. This review article provides an overview to the background, clinical presentation, diagnosis, molecular genetics and therapy in children with different forms of HH.
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Affiliation(s)
- Hüseyin Demirbilek
- Hacettepe University Faculty of Medicine, Department of Paediatric Endocrinology, Ankara, Turkey
| | - Khalid Hussain
- Sidra Medical and Research Center, Clinic of Paediatric Medicine, Doha, Qatar
,* Address for Correspondence: Sidra Medical and Research Center, Clinic of Paediatric Medicine, Doha, Qatar Phone: +974-30322007 E-mail:
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Could 68Ga-somatostatin analogues be an important alternative to 18F-DOPA PET/CT in pediatrics? Eur J Nucl Med Mol Imaging 2017; 45:247-249. [PMID: 29181566 DOI: 10.1007/s00259-017-3894-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022]
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