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Preston CA, Sachithanandan N, Sim IW, van Heerden J, Farrell S. Insulinoma: Metastatic Recurrence 38 Years Following Initial Diagnosis in Pregnancy. JCEM CASE REPORTS 2024; 2:luad168. [PMID: 38196815 PMCID: PMC10773549 DOI: 10.1210/jcemcr/luad168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Indexed: 01/11/2024]
Abstract
A case of recurrent insulinoma spanning 4 decades is described. Following a delayed diagnosis, hyperinsulinemic hypoglycemia was confirmed in a 24-year-old woman during early pregnancy. Initial surgery, culminating in subtotal pancreatectomy, was noncurative. A 1-cm insulinoma was subsequently resected from the head of the pancreas postpartum, with postoperative resolution of hypoglycemia. However, 32 years later, the patient experienced a recurrence of hypoglycemic symptoms. Eventually, a subcentimeter extrapancreatic lesion was identified anterior to the pancreatic head on gallium-68 DOTA-Exendin-4 positron emission tomography/computed tomography. In 2022, a third operation was performed, with excision of a 4 × 3 mm tumor adjacent to the pancreatic head, and histology confirming insulinoma. She was again cured of symptoms.
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Affiliation(s)
- Christopher A Preston
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Fitzroy, Victoria 3065, Australia
- Department of Endocrinology & Diabetes, Western Health, Melbourne, Victoria 3021, Australia
| | - Nirupa Sachithanandan
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Fitzroy, Victoria 3065, Australia
- Department of Medicine, The University of Melbourne, Fitzroy, Victoria 3065, Australia
| | - Ie-Wen Sim
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Fitzroy, Victoria 3065, Australia
- Department of Endocrinology & Diabetes, Western Health, Melbourne, Victoria 3021, Australia
- Department of Medicine, The University of Melbourne, Fitzroy, Victoria 3065, Australia
- Department of Endocrinology & Diabetes, Monash Health and Eastern Health, Melbourne, Victoria 3168, Australia
- Department of Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Jon van Heerden
- Department of Surgery, Mayo Medical School, Rochester, MN 55905, USA
- Department of Surgery, Mayo Medical School, Mayo Clinic, Rochester, MN 55905, USA
- Department of Surgery, Medical University of South Carolina, Charleston 29425, USA
| | - Stephen Farrell
- Department of Surgery, St Vincent’s Hospital Melbourne, Fitzroy, Victoria 3065, Australia
- Department of Surgery, Austin Health, Heidelberg, Victoria 3084, Australia
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Elghobashy M, Gama R, Sulaiman RA. Investigation and Causes of Spontaneous (Non-Diabetic) Hypoglycaemia in Adults: Pitfalls to Avoid. Diagnostics (Basel) 2023; 13:3275. [PMID: 37892096 PMCID: PMC10606153 DOI: 10.3390/diagnostics13203275] [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: 09/07/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
Although adult spontaneous (non-diabetic) hypoglycaemia is rare, its recognition is important for the preventative or curative treatment of the underlying cause. Establishing Whipple's triad-low blood glucose, neuroglycopaenia and resolution of neuroglycopaenia on increasing blood glucose levels to normal or above-is essential to verify hypoglycaemia. Awareness that hypoglycaemia may occur in severely ill patients is important for its prevention. Further investigation in such cases is unnecessary unless another cause of hypoglycaemia is suspected. Patients are often asymptomatic and normoglycaemic at review. Their history of medication, self-medication, access to hypoglycaemic drugs, alcohol use and comorbidity may provide aetiological clues. The investigation involves obtaining blood samples during symptoms for laboratory glucose measurement or provoking fasting or postprandial hypoglycaemia as directed by symptoms. If confirmed, insulin, c-peptide, proinsulin and beta-hydroxybutyrate are analysed in hypoglycaemic samples. These will classify hypoglycaemia due to non-ketotic hyperinsulinaemia, non-ketotic hypoinsulinaemia and ketotic hypoinsulinaemia, and direct investigations to identify the underlying cause. There are, however, many pitfalls that may mislabel healthy individuals as "hypoglycaemic" or misdiagnose treatable or preventable causes of spontaneous hypoglycaemia. Clinical acumen and appropriate investigations will mostly identify hypoglycaemia and its cause.
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Affiliation(s)
- Maiar Elghobashy
- Clinical Chemistry, Black Country Pathology Services, Royal Wolverhampton Trust, Wolverhampton WV10 0QP, UK; (M.E.); (R.G.)
| | - Rousseau Gama
- Clinical Chemistry, Black Country Pathology Services, Royal Wolverhampton Trust, Wolverhampton WV10 0QP, UK; (M.E.); (R.G.)
- School of Medicine and Clinical Practice, Wolverhampton University, Wolverhampton WV1 1LY, UK
| | - Raashda Ainuddin Sulaiman
- Department of Medical Genomics, Center for Genomic Medicine, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
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Avari P, Eng PC, Hu M, Chen R, Popovic N, Polychronakos C, Spalding D, Rutter GA, Oliver N, Wernig F. A Novel Somatic Mutation Implicates ATP6V0D1 in Proinsulin Processing. J Endocr Soc 2023; 7:bvac196. [PMID: 36694809 PMCID: PMC9856271 DOI: 10.1210/jendso/bvac196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Indexed: 12/31/2022] Open
Abstract
Context Prohormone convertase 1/3 (PC1/3), encoded by protein convertase subtilisin kexin type 1 (PCSK1), converts inactive prohormones into biologically active peptides. Somatic mutations of insulinomas are associated with genetic defects interfering with control of insulin secretion from pancreatic beta cells. However, somatic mutations in proinsulinomas have not been described. Objective We report a case of a proinsulinoma, with suppressed insulin and C-peptide levels. Methods A 70-year-old woman presented with a 20-year history of "blackouts." During a 72-hour fast, blood glucose level dropped to 1.9 mmol/L with suppressed plasma insulin and C-peptide levels, but proinsulin levels were raised at 37 pmol/L (<10 pmol/L). Results Imaging revealed 3 distinct DOTATATE-avid pancreatic lesions. Laparoscopic spleen-preserving distal pancreatomy was performed. In view of discordant insulin, C-peptide, and proinsulin levels, whole exome sequencing analysis was performed on the tumor. In the somatic exome of the tumor, we found mutations in PCSK expression regulators, as well as a novel truncating somatic mutation in ATP6V0D1, a subunit of the ion pump that acidifies the β-cell compartments where the PCSKs act. Conclusion Appropriately suppressed insulin levels in the context of hypoglycemia do not always indicate the absence of a neuroendocrine islet cell tumor and proinsulin levels may be indicated to solidify the diagnosis. In the context of elevated proinsulin levels, low insulin and C-peptide levels might be explained by somatic mutations that likely implicate proinsulin processing within the tumor. Furthermore, we propose several mechanistic candidates, including ATP6V0D1. Experimental validation using cellular approaches may in future confirm pathomechanisms involved in this rare condition.
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Affiliation(s)
- Parizad Avari
- Correspondence: Parizad Avari, PhD, Department of Endocrinology, Hammersmith Hospital, Du Cane Road, London W12 ONN, UK.
| | | | - Ming Hu
- Section of Cell Biology and Functional Genomics, Department of Metabolism, Diabetes and Reproduction, Imperial College London, London W120NN, UK
| | - Runzhi Chen
- Section of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust London, London W120HS, UK
| | - Natalija Popovic
- The Endocrine Genetics Laboratory, Research Institute of the McGill University Health Centre and the Montreal Children's Hospital, Montréal, QC H4A3J1, Canada
| | - Constantin Polychronakos
- The Endocrine Genetics Laboratory, Research Institute of the McGill University Health Centre and the Montreal Children's Hospital, Montréal, QC H4A3J1, Canada
- Department of Endocrinology, Zhejiang University Children's Hospital, Hangzhou 310006, People's Republic of China
| | - Duncan Spalding
- Department of Hepatobiliary Surgery, Hammersmith Hospital, Imperial College London Healthcare NHS Trust London, London H2X049, UK
| | - Guy A Rutter
- Section of Cell Biology and Functional Genomics, Department of Metabolism, Diabetes and Reproduction, Imperial College London, London W120NN, UK
- Faculty of Medicine, CHUM Research Center and University of Montreal, Montreal, QC 639798, Canada
- Lee Kong Chian School of Medicine, Nan Yang Technological University, Singapore 308232, Singapore
| | - Nick Oliver
- Section of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust London, London W120HS, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London W120NN, UK
- Section of Cell Biology and Functional Genomics, Department of Metabolism, Diabetes and Reproduction, Imperial College London, London W120NN, UK
| | - Florian Wernig
- Section of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust London, London W120HS, UK
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Sakamoto A, Ogawa K, Iwata M, Ito C, Shine M, Matsui T, Nishi Y, Uraoka M, Utsunomiya T, Nagaoka T, Tamura K, Funamizu N, Inoue H, Sakamoto K, Kurata M, Takada Y. Intraoperative selective arterial calcium injection test to confirm complete resection of a proinsulinoma. J Surg Case Rep 2022; 2022:rjac249. [PMID: 35919694 PMCID: PMC9341228 DOI: 10.1093/jscr/rjac249] [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: 04/25/2022] [Revised: 05/07/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Proinsulinoma is a subtype of insulinoma that is surgically curable, but localization can be difficult as these tumors are typically too small to be visualized by imaging. We report the case of a 53-year-old woman referred to our hospital with dizziness and headache. Her blood glucose level was 46 mg/dl and Whipple’s triad was present. Although her immunoreactive insulin level during hypoglycemia was in the normal range (5.0 μU/ml), the proinsulin level was elevated (408 pmol/l). Imaging examinations showed no evidence of pancreatic tumor. A preoperative selective arterial calcium injection (SACI) test showed excessive insulin secretion in the splenic artery region, which localized the proinsulinoma to the body or tail of the pancreas, and laparoscopic spleen-preserving distal pancreatectomy was performed. Intraoperative SACI test performed after tumor removal did not show excessive insulin secretion. The intraoperative SACI test appears to be useful for localization and for confirming complete resection of proinsulinoma.
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Affiliation(s)
- Akimasa Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Kohei Ogawa
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Miku Iwata
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Chihiro Ito
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Mikiya Shine
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Takashi Matsui
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Yusuke Nishi
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Mio Uraoka
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Takeshi Utsunomiya
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Tomoyuki Nagaoka
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Kei Tamura
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Naotake Funamizu
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Hitoshi Inoue
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Katsunori Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Mie Kurata
- Department of Pathology , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
| | - Yasutsugu Takada
- Department of Hepato-Biliary-Pancreatic and Breast Surgery , , Toon City, Ehime, Japan
- Ehime University Graduate School of Medicine , , Toon City, Ehime, Japan
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Maher MD, Desai DN, Bajaj M. Metastatic insulinoma presenting with post-prandial hypoglycemia. AACE Clin Case Rep 2022; 8:154-157. [PMID: 35959085 PMCID: PMC9363506 DOI: 10.1016/j.aace.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/10/2022] [Accepted: 03/17/2022] [Indexed: 11/29/2022] Open
Abstract
Background/Objective Patients with an insulinoma, a type of pancreatic neuroendocrine tumor, typically present with fasting hypoglycemia but can rarely present exclusively with postprandial hypoglycemia. Case Report A 69-year-old man presented with episodes of postprandial blurry vision, sweating, and confusion for the last 2 years that were becoming more frequent over the last several weeks. Home blood glucose measurements revealed postprandial hypoglycemia (glucose level, 45-70 mg/dL), and symptoms were consistent with the Whipple triad. Continuous glucose monitoring revealed only postprandial hypoglycemia within 2 hours following meals. An outpatient fast was conducted with detectable insulin (6 μIU/mL) and C-peptide (2.0 ng/mL) levels with an elevated proinsulin (20.8 pmol/L) level when the serum blood glucose level dropped to 47 mg/dL (21 hours after the initiation of the fast). A computed tomography scan of the abdomen and pelvis showed a 1.6-cm hyperenhancing lesion in the distal body of the pancreas. He underwent endoscopic ultrasonography with fine-needle aspiration. Pathology revealed a low-grade, well-differentiated, neuroendocrine tumor with lymphovascular invasion and regional lymph node metastases, confirming the diagnosis of a pancreatic neuroendocrine tumor. Discussion Exclusive postprandial hypoglycemia is estimated to occur in 6% of the insulinomas. Patients with postprandial hypoglycemia may be initially managed as those with reactive hypoglycemia; however, this case highlights the importance of evaluating for an insulinoma in a patient who has failed treatment for reactive hypoglycemia. This case also demonstrates the importance of including proinsulin levels in that evaluation. Conclusion Pancreatic neuroendocrine tumor should be considered in postprandial hypoglycemia, even in the absence of fasting hypoglycemia. Measuring proinsulin levels is essential in the diagnostic workup of insulinoma causing hypoglycemia.
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Adult Proinsulinomatosis Associated With a MAFA Germline Mutation as a Rare Cause of Recurrent Hypoglycemia. Pancreas 2021; 50:1450-1453. [PMID: 35041347 DOI: 10.1097/mpa.0000000000001933] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Sporadic adult insulinomatosis is an extremely rare clinical condition. Adult proinsulinomatosis has not yet been described. We report the case of a 48-year-old female patient with recurrent hypoglycemia caused by benign proinsulin-secreting pancreatic neuroendocrine neoplasias (pNENs) with no history of multiple endocrine neoplasia type 1. Initial workup revealed elevated serum proinsulin levels and a positive fasting test. Magnetic resonance imaging and endosonography visualized 2 pNENs in the pancreatic body and tail that were treated by robotic-assisted enucleation. After initial biochemical cure, the patient's hypoglycemia recurred 3 months after surgery. Imaging showed a new lesion in the pancreatic body, so that now a spleen-preserving subtotal distal pancreatectomy was performed. The pathological examination revealed 17 neuroendocrine microadenomas and 1 well-differentiated pNEN (Ki-67% 1%-2%) of 22-mm size as well as more than 200 (pro)insulin-producing β-cell precursor lesions, confirming the diagnosis of adult proinsulinomatosis. Mutation analysis of the germline DNA identified the in-frame deletion mutation (p.His207del) in the MAFA gene on chromosome 8. The patient was biochemically cured 16 months after the last surgical resection. Similarly to adult insulinomatosis, the presence of proinsulin-secreting tumors causes recurrent hypoglycemia and might be associated with germline mutations in the MAFA gene.
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Chen Q, Wang WJ, Jia YX, Yuan H, Wu PF, Ge WL, Meng LD, Huang XM, Shen P, Yang TY, Miao Y, Zhang JJ, Jiang KR. Effect of the transcription factor YY1 on the development of pancreatic endocrine and exocrine tumors: a narrative review. Cell Biosci 2021; 11:86. [PMID: 33985581 PMCID: PMC8120816 DOI: 10.1186/s13578-021-00602-8] [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] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/04/2021] [Indexed: 12/19/2022] Open
Abstract
Pancreatic tumors are classified into endocrine and exocrine types, and the clinical manifestations in patients are nonspecific. Most patients, especially those with pancreatic ductal adenocarcinoma (PDAC), have lost the opportunity to receive for the best treatment at the time of diagnosis. Although chemotherapy and radiotherapy have shown good therapeutic results in other tumors, their therapeutic effects on pancreatic tumors are minimal. A multifunctional transcription factor, Yin-Yang 1 (YY1) regulates the transcription of a variety of important genes and plays a significant role in diverse tumors. Studies have shown that targeting YY1 can improve the survival time of patients with tumors. In this review, we focused on the mechanism by which YY1 affects the occurrence and development of pancreatic tumors. We found that a YY1 mutation is specific for insulinomas and has a role in driving the degree of malignancy. In addition, changes in the circadian network are a key causative factor of PDAC. YY1 promotes pancreatic clock progression and induces malignant changes, but YY1 seems to act as a tumor suppressor in PDAC and affects many biological behaviors, such as proliferation, migration, apoptosis and metastasis. Our review summarizes the progress in understanding the role of YY1 in pancreatic endocrine and exocrine tumors and provides a reasonable assessment of the potential for therapeutic targeting of YY1 in pancreatic tumors.
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Affiliation(s)
- Qun Chen
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, People's Republic of China.,Nanjing Medical University, Nanjing, China
| | - Wu-Jun Wang
- Jiangsu Province Hospital on Integration of Chinese and Western Medicine, Nanjing, China
| | | | - Hao Yuan
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, People's Republic of China.,Nanjing Medical University, Nanjing, China
| | - Peng-Fei Wu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, People's Republic of China.,Nanjing Medical University, Nanjing, China
| | - Wan-Li Ge
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, People's Republic of China.,Nanjing Medical University, Nanjing, China
| | - Ling-Dong Meng
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, People's Republic of China.,Nanjing Medical University, Nanjing, China
| | - Xu-Min Huang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, People's Republic of China.,Nanjing Medical University, Nanjing, China
| | - Peng Shen
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, People's Republic of China.,Nanjing Medical University, Nanjing, China
| | - Tao-Yue Yang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, People's Republic of China.,Nanjing Medical University, Nanjing, China
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, People's Republic of China.,Nanjing Medical University, Nanjing, China
| | - Jing-Jing Zhang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, People's Republic of China. .,Nanjing Medical University, Nanjing, China.
| | - Kui-Rong Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, People's Republic of China. .,Nanjing Medical University, Nanjing, China.
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Kriger AG, Berelavichus SV, Gorin DS, Panteleev VI, Demidova VS, Davydenko PI, Varava AB, Kaldarov AR. [Pancreatic proinsulinoma]. Khirurgiia (Mosk) 2021:5-10. [PMID: 33710820 DOI: 10.17116/hirurgia20210315] [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: 06/12/2023]
Abstract
OBJECTIVE To report own experience in the treatment of patients with proinsulinoma. MATERIAL AND METHODS There were 10 patients with increased proinsulin production and normal insulin level since 2017. Most of them were young women. RESULTS Fasting hypoglycemia in all patients was severe (up to 0.7 mmol/l). Clinical picture consisted of typical symptoms similar to those in insulinoma. The main difference in the course of proinsulinoma was the absence of weight gain in 7 patients and rapid weight loss (from 210 to 90 kg within 9 months) in 1 patient. All patients with proinsulinoma underwent surgery. In most cases, minimally aggressive surgery was performed. CONCLUSION Proinsulinoma is an extremely rare endocrine-active neuroendocrine pancreatic tumor. Differential features of proinsulinoma are the absence of weight gain and normal insulin levels in the presence of hypoglycemia. Surgery is the only radical method of treatment.
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Affiliation(s)
- A G Kriger
- A.V. Vishnevsky National Research Center for Surgery, Moscow, Russia
| | - S V Berelavichus
- A.V. Vishnevsky National Research Center for Surgery, Moscow, Russia
| | - D S Gorin
- A.V. Vishnevsky National Research Center for Surgery, Moscow, Russia
| | - V I Panteleev
- A.V. Vishnevsky National Research Center for Surgery, Moscow, Russia
| | - V S Demidova
- A.V. Vishnevsky National Research Center for Surgery, Moscow, Russia
| | - P I Davydenko
- A.V. Vishnevsky National Research Center for Surgery, Moscow, Russia
| | - A B Varava
- A.V. Vishnevsky National Research Center for Surgery, Moscow, Russia
| | - A R Kaldarov
- A.V. Vishnevsky National Research Center for Surgery, Moscow, Russia
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Layman PF, Davis-Merritt D, Neff P. Primary Functioning Neuroendocrine Tumor of the Appendix with Hypoglycemia Syndrome: A Case Report and Review of Neuroendocrine Tumors. Perm J 2020; 24:19.142. [PMID: 32240090 DOI: 10.7812/tpp/19.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Primary neuroendocrine tumors (NETs) of the appendix are uncommon, but when present are usually not hyperfunctioning. This case represents an extraordinarily rare primary hyperfunctioning NET of the appendix with a clinical presentation of symptomatic hypoglycemia in an otherwise healthy man. CASE PRESENTATION A previously healthy 34-year-old man was found to be symptomatically hypoglycemic in early 2018. After the workup, the apparent explanation was a tumor in his midappendix, for which he was referred to our surgical oncology service for resection. The patient's clinical course is described in detail, including imaging, as well as surgical and pathologic descriptions of the appendiceal NET. DISCUSSION A literature review demonstrates no other case series or reports of a primary hyperfunctioning NET of the appendix presenting with hypoglycemic crisis. The symptoms of tumor-induced hypoglycemia more typically arise with islet cell tumors, such as pancreatic NETs or insulinomas. We believe this case represents a nonislet cell tumor-induced hypoglycemia. This patient's elevated serum proinsulin level preoperatively implies secretion of proinsulin by the tumor. However, tumor-induced hypoglycemia caused by proinsulin has been described previously only in pancreatic tumors. This unique case adds knowledge to the possible glycemic endocrine effects of nonpancreatic NETs, specifically those that arise primarily in the appendix.
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Affiliation(s)
| | | | - Phillip Neff
- Surgery Department, Saint Joseph Hospital, Denver, CO.,Surgery Department, Kaiser Permanente Colorado, Denver
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Insulin Resistance Modifies the Effects of Omega-3 Acid Ethyl Esters on Left Ventricular Remodeling After Acute Myocardial Infarction (from the OMEGA-REMODEL Randomized Clinical Trial). Am J Cardiol 2020; 125:678-684. [PMID: 31948661 DOI: 10.1016/j.amjcard.2019.11.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 12/31/2022]
Abstract
Insulin resistance early after acute myocardial infarction is associated with increased heart failure and mortality. OMEGA-REMODEL was a prospective double-blind 1:1 randomized control trial of patients with AMI. We reported that 6-month treatment with omega-3 fatty acid (O-3FA) 4 g/day attenuated cardiac remodeling accompanied by reduction in inflammation. We hypothesized that insulin resistance modifies the therapeutic effect of O-3FA on post-MI cardiac remodeling. The OMEGA-REMODEL study group was dichotomized according to cohort- and gender-specific median cutoff value of leptin-to-adiponectin ratio (LAR) at baseline (LAR-Hi vs LAR-Lo). Mixed model regression analyses were used to evaluate effect modification of O-3FA on reduction of left ventricular end-systolic volume index (LVESVI) by LAR status. Baseline LAR was evaluated on 325 patients (59 ± 11 years, 81% male). A total of 168 patients were categorized in LAR-Lo, and 157 in LAR-Hi. O-3FA treatment resulted in significant LVESVI reduction in patients with LAR-Lo but not with LAR-Hi (p = 0.0002 vs 0.66, respectively). Mixed model regression analysis showed significant modification of LAR on O-3FA's treatment effect in attenuating LVESVI (p = 0.021). In conclusion, this post-hoc efficacy analysis suggests that LAR status significantly modified O-3FA's treatment effect in attenuating cardiac remodeling. During the convalescent phase of acute infarct healing, patients with lower insulin resistance estimated by LAR appear to derive more therapeutic response from O-3FA toward improvement of LVESVI.
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Maggio I, Mollica V, Brighi N, Lamberti G, Manuzzi L, Ricci AD, Campana D. The functioning side of the pancreas: a review on insulinomas. J Endocrinol Invest 2020; 43:139-148. [PMID: 31368049 DOI: 10.1007/s40618-019-01091-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/24/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Insulinomas are a rare type of neuroendocrine tumors, originating in the pancreas, difficult to diagnose and to treat. Due to its rarity, insulinomas are a not well-known pathological entity; thus, the diagnostic process is frequently a medical challenge with many possible differential diagnoses. The diagnostic process varies between non-invasive procedures, such as the fasting test or imaging techniques, and invasive ones. Insulinomas are rarely malignant, but the glycemic imbalance correlated with this tumor can frequently alter the quality of life of the patients and the consequent hypoglycemia can be extremely dangerous. Moreover, insulinomas can be associated with different genetic syndromes, such as Multiple Endocrine Neoplasia 1, accompanied by other specific symptoms. There are many different treatment strategies, depending on the need to control symptoms or control diseases progression, the only curative one being surgery. METHODS AND RESULTS We reviewed the evidences present in the literature on insulinomas and reported its main clinical characteristics and management strategies. CONCLUSION The aim of this review of the literature is to present the current knowledge on insulinomas, exploring the main clinical characteristics, the diagnostic tools, and the therapeutic strategies.
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Affiliation(s)
- I Maggio
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - V Mollica
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - N Brighi
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- NET Team Bologna ENETS Center of Excellence, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - G Lamberti
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - L Manuzzi
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - A D Ricci
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - D Campana
- NET Team Bologna ENETS Center of Excellence, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
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Lyerla RC, Bajaj A, Shrestha RT. USE OF A CONTINUOUS GLUCOSE MONITOR FOR PREOPERATIVE MONITORING AND TREATMENT OF HYPOGLYCEMIA IN A CASE OF PANCREATIC NEUROENDOCRINE TUMOR. AACE Clin Case Rep 2020; 5:e255-e258. [PMID: 31967047 DOI: 10.4158/accr-2018-0590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/13/2019] [Indexed: 12/22/2022] Open
Abstract
Objective Pancreatic neuroendocrine tumors secreting proinsulin and insulin could lead to life-threatening hypoglycemia. We aim to show this can be avoided by utilizing continuous glucose monitoring. Methods We describe a case of a 55-year-old female with hypoglycemia unawareness and seizures diagnosed with proinsulinoma. She utilized an intermittently scanned continuous glucose monitor (isCGM) to monitor hypoglycemia preoperatively. Results The patient underwent biochemical and radiographic evaluation to confirm the diagnosis of proinsulinoma. Utilizing isCGM to monitor blood glucose, she was able to prevent hypoglycemia-related seizures prior to definitive surgery. Conclusion In the time leading up to a definitive surgery, patients with proinsulinomas are at risk of hypoglycemic events leading to falls, seizures, and even death. isCGMs can be utilized for preoperative monitoring and treatment of hypoglycemia in these patients.
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Edwards K, de La Portilla L, Mirza FS, Luthra P. PROINSULIN-PREDOMINANT PANCREATIC NEUROENDOCRINE TUMOR-INDUCED HYPOGLYCEMIA AFTER ROUX-EN-Y GASTRIC BYPASS SURGERY. AACE Clin Case Rep 2019; 5:e339-e343. [PMID: 31967066 DOI: 10.4158/accr-2019-0148] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/02/2019] [Indexed: 12/26/2022] Open
Abstract
Objective To present a case of recurrent hypoglycemia following Roux-en-Y gastric bypass (RYGB) surgery whose etiology was determined to be a proinsulin-predominant pancreatic neuroendocrine tumor (a proinsulinoma). Methods A case report along with a brief discussion and review of the pertinent literature is presented. Results The patient is a 62-year-old female who presented with symptomatic hypoglycemia 11 years after RYGB surgery. Initial workup revealed low insulin levels with elevated proinsulin levels. A 72-hour fast confirmed the presence of proinsulin-induced hypoglycemia secondary to a pancreatic neuroendocrine tumor (PNET). She underwent distal pancreatectomy with splenectomy and a PNET tumor was successfully removed with resolution of her symptoms. Conclusion Hypoglycemia after RYGB surgery is a well-established syndrome. While there are several etiologies for this, PNETs (including proinsulinomas) should be considered in the differential diagnosis in this population. Proinsulinomas are an increasingly recognized cause of hypoglycemia. Proinsulin levels must always be included as part of the workup of hypoglycemia in an adult.
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Kriger AG, Berelavichus SV, Kaldarov AR, Panteleev VI, Gorin DS, Dugarova RS, Yukina MY. Proinsulin-Secreting Neuroendocrine Tumors of the Pancreas: A Single-Centre Experience. Gastrointest Tumors 2019; 6:64-70. [PMID: 31768350 DOI: 10.1159/000501455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 06/09/2019] [Indexed: 11/19/2022] Open
Abstract
Background Proinsulinoma is a neuroendocrine tumor (NET) of the pancreas that produces prohormone proinsulin. These tumors are very rare. In the literature, they are most often presented in the form of case reports. Materials and Methods We studied 177 patients with NET of the pancreas who underwent surgical treatment in the A.V. Vishnevsky National Medical Research Centre of Surgery from January 2007 to December 2018. Results Of 81 patients with organic hyperinsulinism caused by functioning NETs of the pancreas during the study period, 3 (3.7%) had a proinsulinoma; 2 were female; and 1 was male. None of them admitted to weight gain during this period, and their BMI was normal. All patients presented with Whipple's triad during the 72-h fast. Tumor-enucleating surgery was performed: one robot assisted, two laparotomies. A normal glucose level after treatment was achieved in all cases. Conclusion In cases where clinical hypoglycemia is present, but the serum insulin level is within the normal range or even decreased, proinsulinoma should be suspected. For now, surgical resection remains the only effective method of treatment. Further investigation of pro-insulinomas is needed.
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Affiliation(s)
| | | | | | | | - David Semjonovich Gorin
- Abdominal Surgery, Department of A.V. Vishnevsky Centre of Surgery, Moscow, Russian Federation
| | | | - Marina Yur'evna Yukina
- Therapeutic Endocrinology Department, National Medical Research Centre of Endocrinology, Moscow, Russian Federation
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Abstract
OBJECTIVES Rare cases of pancreatic neuroendocrine tumors (PNETs) that produce only proinsulin (PI) and manifest with hypoglycemia have been reported. Proinsulin expression in PNET has not been systematically studied, and the clinicopathologic features of such tumors remain unknown. METHODS We studied expression of PI by immunohistochemistry (IHC) in 136 PNETs from 2 high-volume surgical oncology centers and assessed all available clinicopathologic data. RESULTS Thirty-six (26%) of PNETs were positive for PI by IHC, most (89%) of which coexpressed insulin IHC. Nine PI-positive tumors represented functional insulinomas. Patients with PI IHC-positive tumors demonstrated significantly lower mean preoperative serum glucose compared with PI-negative PNET patients, even when insulinomas were excluded. No differences in survival between PI IHC-positive and PI IHC-negative tumors were observed. We identified 2 PI-positive PNETs from hypoglycemic patients, which were not insulinomas or other functional variants and in which serum PI was never tested. These may have been undetected proinsulinomas. CONCLUSIONS Proinsulin-expressing PNETs (functional or non) are not uncommon. Patients who present with hypoglycemia and normal insulin levels should be screened for proinsulinoma. Proinsulin IHC could also be used to screen for proinsulinoma. To further elucidate the clinical significance of PI expressing PNETs, prospective studies are required.
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Cheah SK, Halsall D, Barker P, Grant J, Mathews A, Seshadri S, Krishnan S. Refractory spontaneous hypoglycaemia: a diagnostic conundrum. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM18-0049. [PMID: 30306788 PMCID: PMC6169541 DOI: 10.1530/edm-18-0049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A frail 79-year-old lady with dementia presented with a 2-year history of frequent falls. Recurrent hypoglycaemic episodes were diagnosed and treated with continuous glucose infusion in multiple hospital admissions. Hypoadrenalism and hypothyroidism were ruled out. Whilst hypoglycaemic (blood glucose 1.6 mmol/L), both plasma C-peptide and proinsulin concentrations, were inappropriately elevated at 4210 pmol/L (174–960) and >200 pmol/L (0–7) respectively with plasma insulin suppressed at 12 pmol/L (0–180). Whilst reported cases of proinsulinoma are typically pancreatic in origin, radiological investigations of the pancreas in this patient did not identify abnormalities. Unexpectedly contrast CT identified a heterogeneously enhancing mass (6.6 cm) at the lower pole of the left kidney consistent with renal cell carcinoma. Non-islet cell tumour-induced hypoglycaemia has been associated with renal malignancy; however, a serum IGF2:IGF1 ratio measured at <10 effectively excludes this diagnosis. Concomitantly on the CT, extensive peripherally enhancing heterogeneous mass lesions in the liver were identified, the largest measuring 12 cm. A palliative approach was taken due to multiple comorbidities. On post-mortem, the kidney lesion was confirmed as clear cell renal carcinoma, whilst the liver lesions were identified as proinsulin-secreting neuroendocrine tumours. In conclusion, the diagnosis of proinsulinoma can be missed if plasma proinsulin concentration is not measured at the time of hypoglycaemia. In this case, the plasma insulin:C-peptide ratio was too high to be accounted for by the faster relative clearance of insulin and was due to proinsulin cross-reactivity in the C-peptide assay. In addition, the concomitant malignancy proved to be a challenging red herring.
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Affiliation(s)
- Seong Keat Cheah
- Endocrinology Department, Hinchingbrooke Hospital, North West Anglia NHS Foundation Trust, Huntingdon, UK
| | - David Halsall
- Pathology Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter Barker
- Core Biochemical Assay Laboratory (CBAL), Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - John Grant
- Pathology Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Abraham Mathews
- Endocrinology Department, Hinchingbrooke Hospital, North West Anglia NHS Foundation Trust, Huntingdon, UK
| | - Shyam Seshadri
- Endocrinology Department, Hinchingbrooke Hospital, North West Anglia NHS Foundation Trust, Huntingdon, UK
| | - Singhan Krishnan
- Endocrinology Department, Hinchingbrooke Hospital, North West Anglia NHS Foundation Trust, Huntingdon, UK
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Recurrence of Metastatic Pro-insulinoma Nearly 50 Years After Subtotal Pancreatectomy. J Gastrointest Cancer 2017; 50:345-348. [DOI: 10.1007/s12029-017-0023-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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