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Modestino MR, Iacono O, Ferrentino L, Lombardi A, De Fortuna U, Verdoliva R, De Luca M, Guardasole V. How should we differentiate hypoglycaemia in non-diabetic patients? J Basic Clin Physiol Pharmacol 2024; 35:111-119. [PMID: 38619602 DOI: 10.1515/jbcpp-2024-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 03/10/2024] [Indexed: 04/16/2024]
Abstract
Hypoglycaemic syndromes are rare in apparently healthy individuals and their diagnosis can be a difficult challenge for clinicians as there are no shared guidelines that suggest how to approach patients with a suspect hypoglycaemic disorder. Since hypoglycaemia symptoms are common and nonspecific, it's necessary to document the Whipple Triad (signs and/or symptoms compatible with hypoglycaemia; relief of symptoms following glucose administration; low plasma glucose levels) before starting any procedure. Once the triad is documented, a meticulous anamnesis and laboratory tests (blood glucose, insulin, proinsulin, C-peptide, β-hydroxybutyrate and anti-insulin antibodies) should be performed. Results can guide the physician towards further specific tests, concerning the suspected disease. In this review, we consider all current causes of hypoglycaemia, including rare diseases such as nesidioblastosis and Hirata's syndrome, describe appropriate tests for diagnosis and suggest strategies to differentiate hypoglycaemia aetiology.
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Affiliation(s)
- Michele R Modestino
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Olimpia Iacono
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Laura Ferrentino
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Anna Lombardi
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Umberto De Fortuna
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Rita Verdoliva
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Mariarosaria De Luca
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Vincenzo Guardasole
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
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Skarbek A, Fouriez-Lablée V, Dirrig H, Llabres-Diaz F. Confirmed and presumed canine insulinomas and their presumed metastases are most conspicuous in the late arterial phase in a triple arterial phase CT protocol. Vet Radiol Ultrasound 2023; 64:834-843. [PMID: 37496364 DOI: 10.1111/vru.13278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 06/07/2023] [Accepted: 06/07/2023] [Indexed: 07/28/2023] Open
Abstract
Arterial enhancement is the commonly described characteristic of canine insulinomas in contrast-enhanced computed tomography (CECT). However, this finding is also reported as inconsistent. The main aim of this single-center retrospective observational study was to describe the contrast enhancement (CE) pattern of canine presumed and confirmed insulinomas and presumed metastases in three consecutive (early, mid, and late) arterial phases. Included dogs had a medical-record-based clinical or cytological/histopathological diagnosis of insulinoma and quadruple-phase CECT. The arterial phases were identified according to published literature. The arterial enhancement of confirmed and presumed lesions was assessed using a visual grading score. Twelve dogs with a total of 17 pancreatic nodules were analyzed. Three dogs had multiple pancreatic nodules and nine had solitary findings. Four insulinomas were histopathologically confirmed. Late arterial phase (LAP) images demonstrated the largest number of pancreatic nodules reaching the highest enhancement scores (n = 13, 76%). All analyzed dogs had CT evidence of arterially enhancing nodules in the liver (n = 12), seven in the hepatic, splenic, or colic lymph nodes, and three in the spleen. Three out of five sampled livers and three lymph nodes were metastatic. All sampled spleens were benign. Avid arterial enhancement was the most dominant feature of canine presumed and confirmed insulinomas and presumed metastases in quadruple-phase CECT. The highest enhancement scores were observed primarily in LAP, followed by MAP. Authors, therefore, recommend including LAP in the standard CT protocol for dogs with suspected pancreatic insulinomas.
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Affiliation(s)
- Adrianna Skarbek
- The Department of Small Animal Diagnostic Imaging, Queen Mother Hospital for Animals, Hawkshead Lane, Hertfordshire, Hatfield, United Kingdom
| | - Virginie Fouriez-Lablée
- The Department of Small Animal Diagnostic Imaging, Queen Mother Hospital for Animals, Hawkshead Lane, Hertfordshire, Hatfield, United Kingdom
| | - Helen Dirrig
- The Department of Small Animal Diagnostic Imaging, Queen Mother Hospital for Animals, Hawkshead Lane, Hertfordshire, Hatfield, United Kingdom
| | - Francisco Llabres-Diaz
- The Department of Small Animal Diagnostic Imaging, Queen Mother Hospital for Animals, Hawkshead Lane, Hertfordshire, Hatfield, United Kingdom
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Awan MJ, Mohd Rahim MS, Salim N, Nobanee H, Asif AA, Attiq MO. MGACA-Net: a novel deep learning based multi-scale guided attention and context aggregation for localization of knee anterior cruciate ligament tears region in MRI images. PeerJ Comput Sci 2023; 9:e1483. [PMID: 37547408 PMCID: PMC10403161 DOI: 10.7717/peerj-cs.1483] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/16/2023] [Indexed: 08/08/2023]
Abstract
Anterior cruciate ligament (ACL) tears are a common knee injury that can have serious consequences and require medical intervention. Magnetic resonance imaging (MRI) is the preferred method for ACL tear diagnosis. However, manual segmentation of the ACL in MRI images is prone to human error and can be time-consuming. This study presents a new approach that uses deep learning technique for localizing the ACL tear region in MRI images. The proposed multi-scale guided attention-based context aggregation (MGACA) method applies attention mechanisms at different scales within the DeepLabv3+ architecture to aggregate context information and achieve enhanced localization results. The model was trained and evaluated on a dataset of 917 knee MRI images, resulting in 15265 slices, obtaining state-of-the-art results with accuracy scores of 98.63%, intersection over union (IOU) scores of 95.39%, Dice coefficient scores (DCS) of 97.64%, recall scores of 97.5%, precision scores of 98.21%, and F1 Scores of 97.86% on validation set data. Moreover, our method performed well in terms of loss values, with binary cross entropy combined with Dice loss (BCE_Dice_loss) and Dice_loss values of 0.0564 and 0.0236, respectively, on the validation set. The findings suggest that MGACA provides an accurate and efficient solution for automating the localization of ACL in knee MRI images, surpassing other state-of-the-art models in terms of accuracy and loss values. However, in order to improve robustness of the approach and assess its performance on larger data sets, further research is needed.
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Affiliation(s)
- Mazhar Javed Awan
- Faculty of Computing, Universiti Teknologi Malaysia, Johar Bahru, JOHOR, Malaysia
- Department of Software Engineering, University of Management & Technology, Lahore, Punjab, Pakistan
| | | | - Naomie Salim
- Faculty of Computing, Universiti Teknologi Malaysia, Johar Bahru, JOHOR, Malaysia
| | - Haitham Nobanee
- College of Business, Abu Dhabi University, Abu Dhabi, United Arab Emirates
- Oxford Centre for Islamic Studies, University of Oxford, Oxford, United Kingdom
- School of Histories, Languages and Cultures, University of Liverpool, Liverpool, United Kingdom
| | - Ahsen Ali Asif
- Department of Software Engineering, University of Management & Technology, Lahore, Punjab, Pakistan
| | - Muhammad Ozair Attiq
- Department of Software Engineering, University of Management & Technology, Lahore, Punjab, Pakistan
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Winczura A, Saggi B, Savage-Lobeck D. Gastrinoma With Relatively Low Gastrin Levels: A Case Report. Cureus 2023; 15:e41686. [PMID: 37575785 PMCID: PMC10413305 DOI: 10.7759/cureus.41686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/15/2023] Open
Abstract
Gastrinomas can often be cured with surgical removal if detected early enough. We present a case report where a patient was diagnosed with gastrinoma with relatively low serum gastrin levels after subsequent duodenojejunostomy, gastrojejunostomy, total gastrectomy, and cholecystectomy. With this case report, we hope to promote a higher level of awareness of pancreatic neuroendocrine (NE) tumors and educate clinicians on the full effects of proton pump inhibitor (PPI) use on patient workup, diagnostics, and care.
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Affiliation(s)
| | - Bob Saggi
- General Surgery, South Texas Health System, McAllen, USA
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Palani G, Stortz E, Moheet A. Clinical Presentation and Diagnostic Approach to Hypoglycemia in Adults Without Diabetes Mellitus. Endocr Pract 2023; 29:286-294. [PMID: 36464132 DOI: 10.1016/j.eprac.2022.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/24/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To review the clinical presentation, causes, and diagnostic approach to spontaneous hypoglycemia in adults without diabetes mellitus. METHODS A literature review was performed using the PubMed and Google Scholar databases. RESULTS Hypoglycemia is uncommon in people who are not on glucose-lowering medications. Under normal physiologic conditions, multiple neural and hormonal counterregulatory mechanisms prevent the development of abnormally low levels of plasma glucose. If spontaneous hypoglycemia is suspected, the Whipple triad should be used to confirm hypoglycemia before pursuing further diagnostic workup. The Whipple criteria include the following: (1) low levels of plasma glucose, (2) signs or symptoms that would be expected with low levels of plasma glucose, and (3) improvement in those signs or symptoms when the level of plasma glucose increases. Spontaneous hypoglycemia can be caused by conditions that cause endogenous hyperinsulinism, including insulinoma, postbariatric hypoglycemia, and noninsulinoma pancreatogenous hypoglycemia. Spontaneous hypoglycemia can also be seen with critical illness, hepatic or renal dysfunction, hormonal deficiency, non-diabetes-related medications, and non-islet cell tumors. The initial diagnostic approach should begin by obtaining a detailed history of the nature and timing of the patient's symptoms, medications, underlying comorbid conditions, and any acute illness. A laboratory evaluation should be conducted at the time of the spontaneous symptomatic episode. Supervised tests such as a 72-hour fast or mixed-meal test may be needed to recreate the situation under which the patient is likely to experience symptoms. CONCLUSION We provide an overview of the physiology of counterregulatory response to hypoglycemia, its causes, and diagnostic approaches to spontaneous hypoglycemia in adults.
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Affiliation(s)
- Gurunanthan Palani
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Ethan Stortz
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Amir Moheet
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
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Muacevic A, Adler JR, Deshpande S, Buragamadagu BC, Khanam A, Paravathaneni M, Mulla S, Bedi V, Thota V, Baralo R, Jain A, Choi E, Thirumaran R. Review of Hematology-Oncology Emergencies for Internal Medicine Residents. Cureus 2023; 15:e33563. [PMID: 36779153 PMCID: PMC9908426 DOI: 10.7759/cureus.33563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2023] [Indexed: 01/11/2023] Open
Abstract
The prevalence of cancer continues to grow globally every year. With therapeutic advances over the recent decades, the prevalence of individuals living with cancer continues to increase. Internal medicine residents can see patients admitted to the hospital for cancer-related emergencies. Early identification and appropriate management of these emergencies have been shown to improve mortality and morbidity. In this article, we aim to review the recent updates in the management of commonly encountered oncologic emergencies in the practice of internal medicine residents. This review will cover spinal cord compression, superior vena cava syndrome, tumor lysis syndrome, hypercalcemia, pericardial tamponade, hypoglycemia, hyponatremia, bowel obstruction, increased intracranial pressure, leukostasis, hyperviscosity syndrome, neutropenic fever, and hypersensitivity reactions.
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Deshpande SS, Joshi AR, Mankar D. Pancreatic Neoplasms: CT Evaluation of the Uncommon Presentations of Common Lesions and Common Presentations of the Uncommon Lesions! Indian J Radiol Imaging 2022; 32:531-539. [DOI: 10.1055/s-0042-1754359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
AbstractPancreatic masses are commonly encountered entities in radiology practice. Pancreatic ductal adenocarcinomas (PDAC) are the commonest pancreatic malignancies that typically present as infiltrative hypodense focal masses in the pancreatic head, which are hypoattenuating to the pancreatic parenchyma on pancreatic parenchymal and venous phases. However, there are various atypical imaging features of PDACs that create a diagnostic dilemma like tumor in body or tail, diffuse glandular involvement, isoattenuating tumors, cystic changes, or calcifications. Also, few relatively uncommon pancreatic malignancies like pancreatic neuroendocrine tumors, cystic pancreatic tumors, pancreatic lymphoma, and pancreatic metastases present with overlapping features. Accurate radiological characterization of pancreatic masses is important for optimal management and prognostication. Thus, it is imperative for radiologists to be aware of all the uncommon presentations of common pancreatic lesions and common presentations of uncommon pancreatic lesions to avoid erroneous interpretations and establishing the correct diagnosis.
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Affiliation(s)
- Sneha Satish Deshpande
- Department of Radiology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
| | - Anagha Rajeev Joshi
- Department of Radiology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
| | - Diksha Mankar
- Department of Radiology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
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Sharma A, Varshney P, Kasliwal R, Nagar A, Venkatatelikicherla K, Sarin S, Choubey RP, Kapoor VK. Insulinoma—Accurate Preoperative Localization Is the Key to Management: An Initial Experience. Indian J Surg Oncol 2022; 13:403-411. [DOI: 10.1007/s13193-022-01534-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 04/19/2022] [Indexed: 11/30/2022] Open
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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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Doi S, Yamada T, Kito Y, Obara S, Fujii Y, Nishimura T, Kato T, Nakayama H, Tsutsumi M, Okamura R. Adult-Onset Focal Nesidioblastosis With Nodular Formation Mimicking Insulinoma. J Endocr Soc 2022; 6:bvab185. [PMID: 35024540 PMCID: PMC8743044 DOI: 10.1210/jendso/bvab185] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Indexed: 11/21/2022] Open
Abstract
Nesidioblastosis is defined as the neoformation of the islets of Langerhans from the pancreatic ductal epithelium and is recognized as the most common cause of hyperinsulinemic hypoglycemia in infants. We herein report an extremely rare case of adult-onset focal nesidioblastosis with the unusual feature of hyperplastic nodular formation. A 55-year-old woman was admitted to our hospital for a tumor detected in the body of the pancreas by magnetic resonance imaging screening. Laboratory examinations showed a high insulin level in the blood. Contrast-enhanced computed tomography and the selective arterial calcium injection test suggested the presence of multiple insulinomas in the body and tail of the pancreas, and, thus, the patient underwent distal pancreatectomy. A histopathological examination of the tumor in the body of the pancreas showed the nodular hyperplasia of islet-like cell clusters. In addition, many small intralobular ductules and islet cells appeared to be budding from the proliferating ductal epithelium, forming “ductuloinsular complexes”. No other abnormal lesion was detected in the remainder of the pancreas. The histopathological diagnosis was focal nesidioblastosis. The patient has remained free of the recurrence of hypoglycemic episodes for more than 31 months. The present case of rare adult-onset focal nesidioblastosis with hyperplastic nodular formation was preoperatively identified as an apparent pancreatic tumor mimicking insulinoma. Nesidioblastosis and insulinoma need to be considered in cases of hyperinsulinemic hypoglycemia, even in adult patients.
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Affiliation(s)
- Shunsuke Doi
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Takatsugu Yamada
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Yoshinori Kito
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Shinsaku Obara
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Yusuke Fujii
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Takao Nishimura
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Tatsushi Kato
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Hiroyuki Nakayama
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Masahiro Tsutsumi
- Department of Pathology, Saiseikai Chuwa Hospital, Nara 633-0054, Japan
| | - Ryuji Okamura
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
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Laks S, van Leeuwaarde R, Patel D, Keutgen XM, Hammel P, Nilubol N, Links TP, Halfdanarson TR, Daniels AB, Tirosh A. Management recommendations for pancreatic manifestations of von Hippel-Lindau disease. Cancer 2021; 128:435-446. [PMID: 34735022 DOI: 10.1002/cncr.33978] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 12/26/2022]
Abstract
Von Hippel-Lindau disease (VHL) is a multineoplasm inherited disease manifesting with hemangioblastoma of the central nervous system and retina, adrenal pheochromocytoma, renal cell carcinoma, pancreatic neuroendocrine tumors and cysts, and neoplasms/cysts of the ear, broad ligament, and testicles. During 2018-2020, the VHL Alliance gathered several committees of experts in the various clinical manifestations of VHL to review the literature, gather the available evidence on VHL, and develop recommendations for patient management. The current report details the results of the discussion of a group of experts in the pancreatic manifestations of VHL along with their proposed recommendations for the clinical surveillance and management of patients with VHL. The recommendations subcommittee performed a comprehensive systematic review of the literature and conducted panel discussions to reach the current recommendations. The level of evidence was defined according to the Shekelle variation of the Grading of Recommendations, Assessment, Development, and Evaluation grading system. The National Comprehensive Cancer Network Categories of Evidence and Consensus defined the committee members' interpretation of the evidence and degree of consensus. The recommendations encompass the main aspects of VHL-related pancreatic manifestations and their clinical management. They are presented in a clinical orientation, including general planning of screening and surveillance for pancreatic neuroendocrine tumors, utility of biochemical biomarkers, the optimal choice for imaging modality, indirect risk stratification, indications for tissue sampling of VHL-related pancreatic neuroendocrine tumors, and interventions. These recommendations are designed to serve as the reference for all aspects of the screening, surveillance, and management of VHL-related pancreatic manifestations.
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Affiliation(s)
- Shachar Laks
- Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rachel van Leeuwaarde
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dhaval Patel
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Xavier M Keutgen
- Division of Endocrine Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Pascal Hammel
- Department of Digestive and Medical Oncology, Paul Brousse Hospital, Villejuif, France
| | - Naris Nilubol
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Thera P Links
- Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Anthony B Daniels
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, Vanderbilt Eye Institute and Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amit Tirosh
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Neuroendocrine Tumors Service, VHL Clinical Care Center, Endocrine Oncology Genomics Laboratory, Chaim Sheba Medical Center, Tel Hashomer, Israel
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12
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Coss P, Gilman O, Warren-Smith C, Major AC. The appearance of canine insulinoma on dual phase computed tomographic angiography. J Small Anim Pract 2021; 62:540-546. [PMID: 33769568 DOI: 10.1111/jsap.13336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To further evaluate the appearance of insulinoma in dogs on dual-phase CT angiography, given the disparity of findings in recent publications. To establish whether CT angiographic localisation of insulinoma correlates with surgical findings. MATERIALS AND METHODS Single centre study of dogs with a final diagnosis of insulinoma which underwent abdominal CT angiography. Scans were retrospectively re-evaluated for specific features by two board-certified veterinary radiologists. These findings were also subsequently compared to surgical and histopathological reports to determine the accuracy of lesion localisation on CT. RESULTS Thirty-five cases were included in final analysis, with pancreatic nodules identified in 33. Twenty-one were confirmed as insulinoma with histopathology. Jack Russell Terriers were over-represented. Twenty of 21 cases with confirmed insulinoma and 27 of 33 overall showed hyperattenuation in the arterial phase. The mean size of pancreatic insulinoma on CT was 15.1 mm, and 18.2% were larger than 20 mm. Eighteen of 21 confirmed and eight of 12 suspected insulinomas caused a deformation of the pancreatic shape, with two only identified as a result of this feature as these lesions were isoattenuating throughout the study. Pancreatic insulinoma location at surgery matched that described on the CT images in 17 of 19 cases where location was described in the surgical report. CLINICAL SIGNIFICANCE In contrast to recent publications, this study suggests hyperattenuation of insulinomas in the arterial phase is a predominant feature, and that hypoattenuation or isoattenuation are much less common. CT angiography is accurate in prediction of lesion location before surgery in most cases.
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Affiliation(s)
- P Coss
- Langford Vets/University of Bristol, Langford Vets, Langford House, Langford, Bristol, BS40 5DU, UK
| | - O Gilman
- Highcroft Veterinary Referrals, 615 Wells Road, Whitchurch, Bristol, BS14 9BE, UK
| | - C Warren-Smith
- Langford Vets/University of Bristol, Langford Vets, Langford House, Langford, Bristol, BS40 5DU, UK
| | - A C Major
- Langford Vets/University of Bristol, Langford Vets, Langford House, Langford, Bristol, BS40 5DU, UK
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Atypical CT and MR imaging of insulinoma: A case report. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.jecr.2020.100075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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14
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Niederle B, Selberherr A, Bartsch DK, Brandi ML, Doherty GM, Falconi M, Goudet P, Halfdanarson TR, Ito T, Jensen RT, Larghi A, Lee L, Öberg K, Pavel M, Perren A, Sadowski SM, Tonelli F, Triponez F, Valk GD, O'Toole D, Scott-Coombes D, Thakker RV, Thompson GB, Treglia G, Wiedenmann B. Multiple Endocrine Neoplasia Type 1 and the Pancreas: Diagnosis and Treatment of Functioning and Non-Functioning Pancreatic and Duodenal Neuroendocrine Neoplasia within the MEN1 Syndrome - An International Consensus Statement. Neuroendocrinology 2021; 111:609-630. [PMID: 32971521 DOI: 10.1159/000511791] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/18/2020] [Indexed: 11/19/2022]
Abstract
The better understanding of the biological behavior of multiple endocrine neoplasia type 1 (MEN1) organ manifestations and the increase in clinical experience warrant a revision of previously published guidelines. Duodenopancreatic neuroendocrine neoplasias (DP-NENs) are still the second most common manifestation in MEN1 and, besides NENs of the thymus, remain a leading cause of death. DP-NENs are thus of main interest in the effort to reevaluate recommendations for their diagnosis and treatment. Especially over the last 2 years, more clinical experience has documented the follow-up of treated and untreated (natural-course) DP-NENs. It was the aim of the international consortium of experts in endocrinology, genetics, radiology, surgery, gastroenterology, and oncology to systematically review the literature and to present a consensus statement based on the highest levels of evidence. Reviewing the literature published over the past decade, the focus was on the diagnosis of F- and NF-DP-NENs within the MEN1 syndrome in an effort to further standardize and improve treatment and follow-up, as well as to establish a "logbook" for the diagnosis and treatment of DP-NENs. This shall help further reduce complications and improve long-term treatment results in these rare tumors. The following international consensus statement builds upon the previously published guidelines of 2001 and 2012 and attempts to supplement the recommendations issued by various national and international societies.
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Affiliation(s)
- Bruno Niederle
- Department of Surgery, Medical University of Vienna, Vienna, Austria,
| | | | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Maria L Brandi
- Firmo Lab, Fondazione F.I.R.M.O. and University Florence, Florence, Italy
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Massimo Falconi
- Pancreatic Surgery, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Pierre Goudet
- Service de Chirurgie Viscérale et Endocrinienne, Centre Hospitalier Universitaire François Mitterand, Dijon, France
| | | | - Tetsuhide Ito
- Neuroendocrine Tumor Centre, Fukuoka Sanno Hospital and Department of Gastroenterology, Graduate School of Medical Sciences, International University of Health and Welfare, Sawara-ku, Fukuoka, Japan
| | - Robert T Jensen
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS and Center for Endoscopic Research, Therapeutics and Training, Catholic University, Rome, Italy
| | - Lingaku Lee
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Kjell Öberg
- Endocrine Oncology, Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Marianne Pavel
- Endocrinology and Diabetology, Department of Medicine 1, University Clinic of Erlangen, Erlangen, Germany
| | - Aurel Perren
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Samira M Sadowski
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Francesco Tonelli
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Frédéric Triponez
- Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Dermot O'Toole
- Department of Clinical Medicine, St. James's Hospital and St Vincent's University Hospital and Trinity College, Dublin, Ireland
| | - David Scott-Coombes
- Department of Endocrine Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Rajesh V Thakker
- Academic Endocrine Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Geoffrey B Thompson
- Section of Endocrine Surgery, Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giorgio Treglia
- Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Bertram Wiedenmann
- Department of Gastroenterology and Hepatology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
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15
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Fu J, Zhang J, Wang Y, Yan J, Yuan K, Wang M. Comparison of angio-CT versus multidetector CT in the detection and location for insulinomas. Clin Radiol 2020; 75:796.e11-796.e16. [DOI: 10.1016/j.crad.2020.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/07/2020] [Indexed: 10/23/2022]
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Abstract
OBJECTIVE. Multiple endocrine neoplasia (MEN) syndromes are autosomal-dominant genetic disorders that predispose two or more organs of the endocrine system to tumor development. Although the diagnosis relies on clinical and serologic findings, imaging provides critical information for surgical management with the ultimate goal of complete tumor resection. CONCLUSION. This article reviews abdominal neoplasms associated with the various subtypes of MEN syndromes, with a focus on clinical presentation and characteristic imaging features.
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Abstract
Vasoactive intestinal peptide-secreting tumors (VIPomas) are a group of rare neuroendocrine tumors, which cause a typical syndrome of watery diarrhea. Most of these tumors are found in the pancreas and are usually detected at a later stage. Although curative resection is not possible in most of these tumors, both symptom and tumor control can be achieved by a multidimensional approach, to enable a long survival of most patients. There are no clear-cut guidelines for the management of VIPomas because of the rarity of this neoplasm and lack of prospective data. In this review, we discuss the available evidence on the clinical features and management of these rare tumors.
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Dudum R, Murthy VK. Keeping a Low Profile: Insulinoma. Am J Med 2019; 132:1160-1162. [PMID: 31054830 DOI: 10.1016/j.amjmed.2019.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Ramzi Dudum
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Vivek K Murthy
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
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Kaeppeli SAM, Schibli R, Mindt TL, Behe M. Comparison of desferrioxamine and NODAGA for the gallium-68 labeling of exendin-4. EJNMMI Radiopharm Chem 2019; 4:9. [PMID: 31659487 PMCID: PMC6522624 DOI: 10.1186/s41181-019-0060-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/02/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Radiolabeled exendin-4 (Ex4) derivatives are used to target the glucagon-like peptide-1 receptor (GLP-1R) for the clinical diagnosis of insulinomas, a rare type of neuroendocrine tumor. Gallium-68 is an ideal diagnostic nuclide for this application and a study evaluating an exendin-4-NODAGA conjugate is currently underway. However, in complexion with the chelator DFO, its in vivo stability has been a matter of dispute. The aim of this work was to directly compare [68Ga]Ga-Ex4NOD with [68Ga]Ga-Ex4DFO in vitro and in vivo. METHODS In our approach, we directly compared N'-[5-(acetyl-hydroxy-amino)pentyl]-N-[5-[3-(5-aminopentyl-hydroxy-carbamoyl)propanoylamino]pentyl]-N-hydroxy-butane diamide (desferriox-amine B, DFO) and 2-(4,7-bis (carboxymethyl)-1,4,7-triazonan-1-yl) pentanedioic acid (NODAGA) conjugated to exendin-4 in vitro and in vivo. We radiolabeled the peptides with gallium-68, followed by HPLC quality control. In vitro characterization was performed in CHL cells overexpressing the GLP-1R and in vivo studies were conducted with CD1 nu/nu mice carrying tumors derived from these cells. RESULTS We found that both peptides could be radiolabeled with a molar activity of about 9.33 MBq/nmol without further purification. They internalized equally well into GLP-1R-expressing cells and their IC50 was similar with 15.6 ± 7.8 nM and 18.4 ± 3.0 nM for [natGa]Ga-Ex4NOD and [natGa]Ga-Ex4DFO, respectively. In vivo, [68Ga]Ga-Ex4NOD accumulated more in all tissue, while [68Ga]Ga-Ex4DFO exhibited a more favorable target-to-kidney ratio. CONCLUSION AND RELEVANCE DFO is a suitable chelator for the radiolabeling of exendin-4 derivatives with gallium-68 for in vitro and preclinical in vivo studies. DFO performed better in vivo due to its significantly lower kidney accumulation (p < 0.0001). It was also found to be stable in vivo in mice, contrary to earlier reports. Based on our results, the DFO chelating system in combination with exendin-4 would be an interesting option for clinical imaging of insulinomas.
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Affiliation(s)
- Simon A M Kaeppeli
- Center for Radiopharmaceutical Sciences ETH-PSI-USZ, Paul Scherrer Institute, OIPA/102, Forschungsstrasse 111, 5232, Villigen-PSI, Switzerland
| | - Roger Schibli
- Center for Radiopharmaceutical Sciences ETH-PSI-USZ, Paul Scherrer Institute, OIPA/102, Forschungsstrasse 111, 5232, Villigen-PSI, Switzerland.,Department of Chemistry and Applied Biosciences, ETH Zurich, Vladimir-Prelog-Weg 4, 8093, Zurich, Switzerland
| | - Thomas L Mindt
- Ludwig Boltzmann Institute Applied Diagnostics, General Hospital Vienna (AKH), c/o Sekretariat Nuklearmedizin Währinger Gürtel 18-20, Vienna, Austria.,Department of Biomedical Imaging and Image Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Martin Behe
- Center for Radiopharmaceutical Sciences ETH-PSI-USZ, Paul Scherrer Institute, OIPA/102, Forschungsstrasse 111, 5232, Villigen-PSI, Switzerland.
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Ren S, Chen X, Wang Z, Zhao R, Wang J, Cui W, Wang Z. Differentiation of hypovascular pancreatic neuroendocrine tumors from pancreatic ductal adenocarcinoma using contrast-enhanced computed tomography. PLoS One 2019; 14:e0211566. [PMID: 30707733 PMCID: PMC6358067 DOI: 10.1371/journal.pone.0211566] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 01/16/2019] [Indexed: 12/14/2022] Open
Abstract
Hypovascular pancreatic neuroendocrine tumors (hypo-PNETs) are often misdiagnosed as pancreatic ductal adenocarcinoma (PDAC). However, the treatment options and prognosis of PNETs and PDAC are substantially different. This retrospective study differentiated hypo-PNETs from PDAC using contrast-enhanced CT (CE-CT). Clinical data and CE-CT findings, including tumor location, size, boundary, pancreatic duct dilatation, local invasion or metastases, tumor contrast enhancement, and tumor-to-pancreas enhancement ratio, were compared between 39 PDACs and 18 hypo-PNETs. At CT imaging, hypo-PNETs showed a higher frequency of a well-defined margin and lower frequencies of pancreatic duct dilatation and local invasion or metastasis when compared with PDAC (p < 0.05 for all). The mean attenuation of hypo-PNETs at the arterial and portal venous phase was significantly higher than that of PDAC (p < 0.001, p = 0.003, respectively). Similar results were observed in tumor-to-pancreas enhancement ratio. Tumor attenuation and tumor-to-pancreas enhancement ratio at the arterial phase showed the largest area under the curve (AUC) of 0.888 and 0.812 with 83.3–88.9% of sensitivity and 61.6–77.0% of specificity. Pancreatic duct dilatation, local invasion or metastasis, and tumor attenuation at the portal venous phase also showed acceptable AUC (0.703–0.748). Thus CE-CT features, especially the enhancement degree at the arterial phases, may be useful for differentiating hypo-PNETs from PDAC using CE-CT.
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Affiliation(s)
- Shuai Ren
- Department of Radiology, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Xiao Chen
- Department of Radiology, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhonglan Wang
- Department of Radiology, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Rui Zhao
- Department of Radiology, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Jianhua Wang
- Department of Radiology, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Wenjing Cui
- Department of Radiology, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhongqiu Wang
- Department of Radiology, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- * E-mail:
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Walczak R, Paek M, Uzzle M, Taylor J, Specchi S. Canine insulinomas appear hyperintense on MRI T2-weighted images and isointense on T1-weighted images. Vet Radiol Ultrasound 2019; 60:330-337. [PMID: 30654407 DOI: 10.1111/vru.12715] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 11/27/2022] Open
Abstract
Clinical and imaging diagnosis of canine insulinomas has proven difficult due to nonspecific clinical signs and the small size of these tumors. The aim of this retrospective case series study was to describe MRI findings in a group of dogs with pancreatic insulinomas. Included dogs were presented for suspected pancreatic insulinoma, MRI was used to assist with localization of the primary lesion, and the diagnosis was confirmed with surgical exploratory laparotomy and histopathology. The MRI studies for each dog were retrieved and the following data were recorded: T1-weighted and T2-weighted signal intensities, type of contrast enhancement, size and location of the primary lesion, and characteristics of metastatic lesions (if present). A total of four dogs were sampled. In all patients, the insulinoma displayed high-intensity signal on T2-weighted fat saturation images, similar to human studies. On postcontrast T1-weighted fat saturation images, the tumors were primarily isointense to normal pancreatic tissue, in contrast to human studies where a low-intensity signal is typically identified. Abnormal islet tissue was detected with MRI in all four dogs and metastases were identified in three dogs. Variations in the MRI appearance of primary and metastatic lesions were identified and could have been related to the variation of tissue composition, including the presence of neoplastic cells, hemorrhage, and fibrovascular stroma, and to the transformation of this tissue throughout the disease process.
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Affiliation(s)
- Raelyn Walczak
- Diagnostic Imaging, Gulf Coast Veterinary Specialists, Houston, TX, 77027
| | - Matthew Paek
- Department of Radiology, Synergy Veterinary Imaging Partners, Columbia, MD, 20129
| | - Matthew Uzzle
- Bush Advanced Veterinary Imaging, The Life Centre, Leesburg, VA, 20176
| | - Jim Taylor
- Veterinary Surgical Centers, The Life Centre, Leesburg, VA, 20176
| | - Swan Specchi
- Department of Clinical Sciences, Istituto Veterinario di Novara, Novara, 28060, Italy
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A case of hyperinsulinemic hypoglycemia related with a calcimimetic agent. Diabetol Int 2019; 9:196-200. [PMID: 30603367 DOI: 10.1007/s13340-018-0350-6] [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: 11/19/2017] [Accepted: 02/14/2018] [Indexed: 10/18/2022]
Abstract
We herein report a case of a 60-year-old female receiving hemodialysis who developed severe hyperinsulinemic hypoglycemia and lost her consciousness. A calcimimetic agent had been administered for the secondary hyperparathyroidism. The calcimimetic agent, mimicking the elevation of the extracellular calcium ion concentration, activates calcium-sensing receptors (CaSR) of the parathyroid cells and inhibits the parathyroid hormone secretions. The previous study suggested that the CaSR are also expressed in both human β cells and insulinoma cells, but the reactivity to change in the extracellular calcium ion concentration is different between normal β cells and insulinoma cells. After cessation of the calcimimetic agent, hypoglycemic symptoms disappeared and endogenous insulin secretion dropped to normal levels. However, the result of a prolonged fasting test indicated that she remained hyperinsulinemic even after its cessation, suggesting that she had insulinoma which could not be detected by the imaging examinations. The previous autopsy data showed that there were many cases of the insulinoma without the symptoms of hypoglycemia. We considered the possibility that she had the insulinoma and the pancreatic tumor was too small to promote the insulin secretion and cause hypoglycemia without activation by the calcimimetic agent. We should know that the calcimimetic agent could cause hyperinsulinemic hypoglycemia with the unidentified insulinoma.
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Shi Z, Li X, You R, Li Y, Zheng X, Ramen K, Loosa VS, Cao D, Chen Q. Homogenously isoattenuating insulinoma on biphasic contrast-enhanced computed tomography: Little benefits of diffusion-weighted imaging for lesion detection. Oncol Lett 2018; 16:3117-3125. [PMID: 30127903 PMCID: PMC6096136 DOI: 10.3892/ol.2018.9037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/30/2018] [Indexed: 12/15/2022] Open
Abstract
The aim of the present study was to evaluate the diagnostic benefit of diffusion-weighted imaging (DWI) in the detection of homogenous isoattenuating insulinoma on biphasic contrast-enhanced computed tomography (CT) preoperatively and to determine which magnetic resonance (MR) sequences exhibited the best diagnostic performance. A total of 44 consecutive patients who underwent biphasic contrast-enhanced CT and conventional MR imaging (MRI), including DWI on a 3T scanner, were identified retrospectively. Apparent diffusion coefficient (ADC) values of insulinomas and the surrounding pancreatic parenchyma were compared using a Wilcoxon signed-rank test. Receiver operating characteristic analysis was used to compare the diagnostic accuracy of four randomized image sets [T2-weighted image (WI), axial T1WI, DWI and T2WI + DWI] for each reader. Axial T1-weighted MRI exhibited the highest relative sensitivity for each reader; DWI alone exhibited the lowest relative sensitivity and the lower inter-reader agreement. There was no significant difference in lesion detection between T2WI and T2WI + DWI image sets for each reader. The ADC values of the insulinoma were significantly lower compared with those of the surrounding parenchyma. In conclusion, DWI does not benefit the detection of homogenous isoattenuating insulinoma. Axial T1WI is the optimal pulse sequence. Quantitative assessment of the tumor ADC values may be a useful tool to characterize identified pancreatic neoplasms.
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Affiliation(s)
- Zhenshan Shi
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Xiumei Li
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Ruixiong You
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Yueming Li
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Xianying Zheng
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Kamisha Ramen
- Department of Radiology, Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Vikash Sahadeo Loosa
- Department of Radiology, Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Dairong Cao
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Qunlin Chen
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
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Qin S, Liu Y, Ning H, Tao L, Luo W, Lu D, Luo Z, Qin Y, Zhou J, Chen J, Jiang H. EUS-guided lauromacrogol ablation of insulinomas: a novel treatment. Scand J Gastroenterol 2018; 53:616-620. [PMID: 29141488 DOI: 10.1080/00365521.2017.1402206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS EUS-guided ablation with ethanol has been used to treat insulinoma since 2006 as a minimally invasive alternative for those who are unwilling or unsuitable for surgeries. However, pancreatic fistula, pancreatitis and other adverse effects were found after the procedure in these patients. Herein, we aimed to find a novel feasible injection. METHODS Seven patients with different chief complaints were diagnosed with insulinoma by symptoms, lab results and pathology results from EUS fine needle aspiration. All the patients refused to have surgeries and were treated by EUS-guided ablation with lauromacrogol. The injection volume was calculated by tumor size. All the patients were followed up by at least 1 month to see if there is any adverse effect. Blood glucose (BG), insulin and C-peptide levels were monitored before and after the procedure. RESULTS Insulinoma size ranged from 0.76 cm ×0.84 cm to 3.39 cm ×1.84 cm. With a mean injection volume of 1.9 ml (range from 0.9 to 3.9 ml), all the patients showed relief in symptoms after the procedure. During the follow up, their BG, insulin and C-peptide levels went back to normal. None of the patients had any adverse effect. CONCLUSIONS EUS-guided ablation with lauromacrogol showed good treatment results and received no adverse effect after the procedure. Hence, we consider it as an effective and safe method to treat insulinoma.
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Affiliation(s)
- Shanyu Qin
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Yongru Liu
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Hongjian Ning
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Lin Tao
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Wei Luo
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Donghong Lu
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Zuojie Luo
- b Endocrinology Department , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Yingfen Qin
- b Endocrinology Department , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Jia Zhou
- b Endocrinology Department , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Junqiang Chen
- c Department of Gastrointestinal Surgery , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Haixing Jiang
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
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Dialer LO, Jodal A, Schibli R, Ametamey SM, Béhé M. Radiosynthesis and evaluation of an 18F-labeled silicon containing exendin-4 peptide as a PET probe for imaging insulinoma. EJNMMI Radiopharm Chem 2018; 3:1. [PMID: 29503858 PMCID: PMC5824708 DOI: 10.1186/s41181-017-0036-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 12/14/2017] [Indexed: 12/05/2022] Open
Abstract
Background Analogues of exendin-4 have been radiolabeled for imaging the glucagon-like peptide type 1 receptors (GLP-1R) which are overexpressed in insulinoma. The aim of this research was to synthesize an 18F–labeled silicon containing exendin-4 peptide (18F-2) and to evaluate its in vitro and in vivo behavior in CHL-GLP-1 receptor positive tumor-bearing mice. 18F–labeled silicon containing exendin-4 peptide (18F-2) was prepared via one-step nucleophilic substitution of a silane precursor with 18F–fluoride in the presence of acetic acid and K222. 18F-2 was then administered to tumor-bearing mice for PET imaging and ex vivo biodistribution experiments. Results 18F-2 was produced in a radiochemical yield (decay corrected) of 1.5% and a molar activity of max. 16 GBq/μmol. The GLP-1R positive tumors were clearly visualized by PET imaging. Biodistribution studies showed reduced uptake of 18F-2 in the kidneys compared to radiometal labeled exendin-4 derivatives. The radiotracer showed specific tumour uptake which remained steady over 2 h. Conclusions This exendin-4 analogue, 18F-2, is a potential probe for imaging GLP-1R positive tumors.
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Affiliation(s)
- Lukas O Dialer
- 1Center for Radiopharmaceutical Sciences (CRS) of ETH, PSI and USZ, Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Hönggerberg, ETH Zurich, Zurich, Switzerland
| | - Andreas Jodal
- 2Center for Radiopharmaceutical Sciences (CRS), Research Department Biology and Chemistry, Paul Scherrer Institut, CH-5232 Villigen, Switzerland
| | - Roger Schibli
- 1Center for Radiopharmaceutical Sciences (CRS) of ETH, PSI and USZ, Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Hönggerberg, ETH Zurich, Zurich, Switzerland.,2Center for Radiopharmaceutical Sciences (CRS), Research Department Biology and Chemistry, Paul Scherrer Institut, CH-5232 Villigen, Switzerland
| | - Simon M Ametamey
- 1Center for Radiopharmaceutical Sciences (CRS) of ETH, PSI and USZ, Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Hönggerberg, ETH Zurich, Zurich, Switzerland
| | - Martin Béhé
- 2Center for Radiopharmaceutical Sciences (CRS), Research Department Biology and Chemistry, Paul Scherrer Institut, CH-5232 Villigen, Switzerland
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Manjunath PR, George B, Mathew V, Bantwal G, Ayyar V. "Riding High on Low Fuel" - Our Experience with Endogenous Hyperinsulinemic Hypoglycemia. Indian J Endocrinol Metab 2017; 21:655-659. [PMID: 28989869 PMCID: PMC5628531 DOI: 10.4103/ijem.ijem_174_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Endogenous hyperinsulinemic hypoglycemia (EHH) is a condition in which the insulin levels are inappropriately high in the presence of low plasma glucose. MATERIALS AND METHODS We did a retrospective analysis of case records of those patients admitted and evaluated for EHH from June 2004 to June 2016 in our center, excluding those that were diagnosed with reactive hypoglycemia. We collected data regarding demographics, clinical presentation, laboratory results, localization techniques, and treatment administered. RESULTS Sixteen patients who were admitted for evaluation based on history suggestive of repeated hypoglycemic episodes were included in the study. All but one pregnant patient was subjected to a supervised fast in the hospital. All patients developed hypoglycemia (defined using Whipple's triad) within the first 24 h. Three patients had autoimmune hypoglycemia which differed significantly from insulinoma-mediated hypoglycemia in certain clinical and laboratory parameters. They were older in age with marked fluctuations in the 24 h glucose profile ranging from frank hypoglycemia to frank hyperglycemia. The insulin levels were markedly elevated in this group of patients along with a significantly elevated insulin C peptide molar ratio (ICMR) when compared with patients with insulinoma-mediated hypoglycemia. CONCLUSIONS Although insulinoma is the most common cause of EHH, autoimmune hypoglycemia should be considered as a differential diagnosis, particularly in older individuals with plasma glucose values increasing to the hyperglycemic range. Degree of elevation of insulin levels and ICMR may provide additional clues. Overall, the survival and prognosis of patients with EHH are excellent.
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Affiliation(s)
- P. R. Manjunath
- Department of Endocrinology, St. John's Medical College, Bengaluru, Karnataka, India
| | - Belinda George
- Department of Endocrinology, St. John's Medical College, Bengaluru, Karnataka, India
| | - Vivek Mathew
- Department of Endocrinology, St. John's Medical College, Bengaluru, Karnataka, India
| | - Ganapathi Bantwal
- Department of Endocrinology, St. John's Medical College, Bengaluru, Karnataka, India
| | - Vageesh Ayyar
- Department of Endocrinology, St. John's Medical College, Bengaluru, Karnataka, India
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Abstract
Imaging of the endocrine pancreas is dominated by neuroendocrine tumors, a diverse category of neoplasms that may or may not cause symptoms from hormone hypersecretion. These tumors may also be evidence of several different genetic syndromes. Understanding the usefulness of different imaging modalities and entities that simulate neuroendocrine tumors is key for both radiologists and referring physicians.
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Affiliation(s)
- Mark Masciocchi
- Department of Radiology, UMass Memorial Medical Center, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA.
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Kittah NE, Vella A. MANAGEMENT OF ENDOCRINE DISEASE: Pathogenesis and management of hypoglycemia. Eur J Endocrinol 2017; 177:R37-R47. [PMID: 28381450 DOI: 10.1530/eje-16-1062] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/15/2017] [Accepted: 04/05/2017] [Indexed: 01/03/2023]
Abstract
Glucose is the main substrate utilized by the brain and as such multiple regulatory mechanisms exist to maintain glucose concentrations. When these mechanisms fail or are defective, hypoglycemia ensues. Due to these robust mechanisms, hypoglycemia is uncommon and usually occurs in the setting of the treatment of diabetes using glucose-lowering agents such as sulfonylureas or insulin. The symptoms of hypoglycemia are non-specific and as such it is important to confirm hypoglycemia by establishing the presence of Whipple's triad before embarking on an evaluation for hypoglycemia. When possible, evaluation of hypoglycemia should be carried out at the time of spontaneous occurrence of symptoms. If this is not possible then one would want to create the circumstances under which symptoms occur. In cases where symptoms occur in the post absorptive state, a 72-h fast should be performed. Likewise, if symptoms occur after a meal then a mixed meal study may be the test of choice. The causes of endogenous hyperinsulinemic hypoglycemia include insulinoma, post-bariatric hypoglycemia and noninsulinoma pancreatogenous hypoglycemia syndrome. Autoimmune hypoglycemia syndrome is clinically and biochemically similar to insulinoma but associated with high levels of insulin antibodies and plasma insulin. Other important causes of hypoglycemia include medications, non-islet cell tumors, hormonal deficiencies, critical illness and factitious hypoglycemia. We provide an overview of the pathogenesis and management of hypoglycemia in these situations.
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Affiliation(s)
- Nana Esi Kittah
- Division of EndocrinologyDiabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Vella
- Division of EndocrinologyDiabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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Sade R, Ogul H, Eren S, Levent A, Kantarci M. Comparison of Ultrasonography and Low-Dose Computed Tomography for the Diagnosis of Pediatric Urolithiasis in the Emergency Department. Eurasian J Med 2017. [PMID: 28638256 DOI: 10.5152/eurasianjmed.2017.17083] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE This study aimed to compare ultrasonography (US) and low-dose computed tomography (LDCT) for diagnosing pediatric urolithiasis in the emergency department. MATERIALS AND METHODS This retrospective study was approved by our institutional ethics committee, and informed consent was waived. From March 2016 to March 2017, 100 consecutive patients met the selection criteria and were enrolled in the study. Patients were randomly selected in a 1:1 ratio and were allocated to one of the following two imaging groups: US or abdominal LDCT. LDCT examinations were performed using a 320-detector row CT. Radiation dose analysis was performed using Radimetrics. US examinations were performed using the Aplio 500 ultrasound system. The presence of urolithiasis, anatomical location of urolithiasis, and measurements of renal stones were evaluated and recorded. RESULTS There were statistically significant differences between US and standard-dose CT (SDCT) with respect to the diagnosis of urolithiasis, anatomical location of urolithiasis, and measurements of renal stones (p<0.001, p=0.005, and p=0.03, respectively). The mean effective radiation dose of LDCT was 1.44±0.34 mSv and that of SDCT was calculated to be 4.36±1.33 mSv. There was no statistically significant difference between LDCT and SDCT with regard to the diagnosis of urolithiasis, anatomical location of urolithiasis and measurements of renal stones (p=1 for all). The diagnostic accuracy of US and LDCT was 0.68 and 1.0, respectively. CONCLUSION Low-dose computed tomography had 1/3 SDCT radiation dose, and LDCT and SDCT accurately diagnosed pediatric urolithiasis in the emergency department. US had a lower accuracy than SDCT and LDCT for diagnosing pediatric urolithiasis in the emergency department. LDCT can be an alternative for SDCT for diagnosing pediatric urolithiasis.
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Affiliation(s)
- Recep Sade
- Department of Radiology, Atatürk University School of Medicine, Erzurum, Turkey
| | - Hayri Ogul
- Department of Radiology, Atatürk University School of Medicine, Erzurum, Turkey
| | - Suat Eren
- Department of Radiology, Atatürk University School of Medicine, Erzurum, Turkey
| | - Akin Levent
- Department of Radiology, Atatürk University School of Medicine, Erzurum, Turkey
| | - Mecit Kantarci
- Department of Radiology, Atatürk University School of Medicine, Erzurum, Turkey
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Hu J, Hu Q, Hu H. Characterization of single lesion nonfunctioning pancreatic neuroendocrine carcinoma via computed tomography. Oncol Lett 2017; 13:2186-2190. [PMID: 28454379 PMCID: PMC5403290 DOI: 10.3892/ol.2017.5729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 10/24/2016] [Indexed: 11/17/2022] Open
Abstract
Nonfunctioning pancreatic neuroendocrine carcinoma (NPNEC) is a poorly differentiated neuroendocrine carcinoma and a rare type of pancreatic cancer. Computed tomography (CT)-based imaging is currently the most effective method for diagnosing and classifying NPNEC. The present study investigated the clinical features and CT manifestations of this disease. The CT manifestations and clinical data of 13 patients with NPNEC, confirmed by surgery or needle biopsy, were retrospectively analyzed. None of the 13 patients exhibited endocrine-related symptoms and a single lesion with a variable position in the pancreatic was observed in all patients. The tumors were generally round or irregular, with inhomogeneous density and an average diameter of 7.45±3.92 cm (range, 4.0–16.0 cm). Cystic necrosis zones were observed in 5 patients and calcification was observed in 2. A total of 4 patients exhibited intrahepatic metastases, and 2 patients demonstrated spleen and colon invasion. Enhanced scanning indicated that tumors were markedly enhanced. There were 11 cases of middle or high-grade enhancement (84.6%) and 2 cases of mild enhancement (15.4%). Marked envelope enhancement was observed in 3/11 patients with high-grade enhancement. In conclusion, the majority of patients with NPNEC lacked characteristic manifestations. While the CT examination revealed certain characteristics, histological analysis was necessary to confirm diagnoses.
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Affiliation(s)
- Jibo Hu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
| | - Qunhui Hu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
| | - Hongjie Hu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
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Zhu L, Xue H, Sun Z, Li P, Qian T, Xing X, Li N, Zhao Y, Wu W, Jin Z. Prospective comparison of biphasic contrast-enhanced CT, volume perfusion CT, and 3 Tesla MRI with diffusion-weighted imaging for insulinoma detection. J Magn Reson Imaging 2017; 46:1648-1655. [PMID: 28419614 DOI: 10.1002/jmri.25709] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 03/06/2017] [Indexed: 01/17/2023] Open
Abstract
PURPOSE To evaluate the diagnostic performance of biphasic contrast-enhanced CT (CECT), volume perfusion CT (VPCT) and 3 Tesla MRI with diffusion-weighted imaging (DWI), in patients with clinically suspected insulinomas. MATERIALS AND METHODS This prospective study was approved by the institutional review board. Sixty-four patients with clinically suspected insulinomas underwent biphasic CECT, VPCT, and 3T MR with DWI. Two radiologists independently determined the presence/absence of tumor using a 5-scale confidence level. Conspicuity of the lesion and clarity of tumor-to-pancreatic duct distance were graded. Receiver operating characteristic analysis was performed to compare diagnostic performance. RESULTS Forty-seven patients were tumor positive, with 51 tumors. The differences between the areas under the curve values for tumor detection were as follows: 0.715 (CECT), 0.903 (VPCT), 0.832 (MRI without DWI) and 0.955 (MRI with DWI) for reader 1, and 0.738 (CECT), 0.895 (VPCT), 0.841 (MRI without DWI), and 0.956 (MRI with DWI) for reader 2. MRI with DWI and VPCT were significantly more accurate than CECT for insulinoma detection (P = 0.01 and 0.02 for reader 1, and P = 0.01 and 0.03 for reader 2). Lesion conspicuity was better on MRI compared with VPCT (P = 0.01), and both were better than CECT (both P < 0.01). Tumor-to-pancreatic duct distance was better appreciated on MRI, compared with CECT and VPCT (both P < 0.01). The weighted k values indicate good to excellent agreement between observers for determining tumor presence/absence (k = 0.64-0.84). CONCLUSION The 3T MRI with DWI and VPCT are significantly more accurate than CECT for insulinoma detection. MRI demonstrates higher tumor conspicuity and is superior in depicting the tumor-to-duct distance. LEVEL OF EVIDENCE 1 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017;46:1648-1655.
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Affiliation(s)
- Liang Zhu
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Huadan Xue
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Zhaoyong Sun
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Ping Li
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Tianyi Qian
- MR collaborations NE Asia, Siemens Healthcare, Beijing, China
| | - Xiaoping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, The National Health and Family Planning Commission, Beijing, China
| | - Naishi Li
- Department of Endocrinology, Key Laboratory of Endocrinology, The National Health and Family Planning Commission, Beijing, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Wenming Wu
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Zhengyu Jin
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
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Yamamoto Y, Okamura Y, Uemura S, Sugiura T, Ito T, Ashida R, Kato Y, Ohgi K, Yamada M, Sasaki K, Aramaki T, Uesaka K. Vascularity and Tumor Size are Significant Predictors for Recurrence after Resection of a Pancreatic Neuroendocrine Tumor. Ann Surg Oncol 2017; 24:2363-2370. [PMID: 28271173 DOI: 10.1245/s10434-017-5823-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND It is difficult to identify patients at high risk of recurrence after pancreatectomy for pancreatic neuroendocrine tumor (PNET) using only the grading classification, especially the G2 category, which includes both benign and low- and high-grade malignant tumors. METHODS Forty-one patients with PNET who underwent pancreatectomy were enrolled in this study. We defined the computed tomography (CT) ratio as the CT value of the tumor divided by that of non-tumorous pancreatic parenchyma using the late arterial phase dynamic CT. The optimal cut-off values for CT ratio and tumor size were determined using p-values that were calculated using the log-rank test. RESULTS The optimal cut-off values of CT ratio and tumor size for dividing patients into groups according to the greatest difference in disease-free survival (DFS) were 0.85 (p < 0.001) and 3.0 cm (p < 0.001), respectively. In analysis using Spearman's correlation coefficient, CT ratio (p = 0.007) and tumor size (p = 0.003) were individually associated with the Ki-67 proliferative index. Cox proportional hazard analysis identified that a CT ratio <0.85 (n = 10, p = 0.006) and tumor size ≥3.0 cm (n = 13, p = 0.023) were independent prognostic factors associated with DFS. All patients in the CT ratio ≥0.85 and tumor size <3.0 cm group (n = 23, including seven patients with G2 disease) did not develop recurrence after surgery. On the other hand, 5-year DFS in the CT ratio <0.85 and tumor size ≥3.0 cm group (n = 5, including three patients with G2 disease) was zero. CONCLUSIONS PNETs with a CT ratio <0.85 and tumor size ≥3.0 cm should be considered as having a high risk of recurrence after pancreatectomy.
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Affiliation(s)
- Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan.
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Sunao Uemura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Yoshiyasu Kato
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Mihoko Yamada
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Keiko Sasaki
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takeshi Aramaki
- Division of Radiology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
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Abstract
Insulinomas are rare neuroendocrine tumors which occur predominantly in the pancreas. Although majority of the insulinomas are benign, over-secretion of insulin by the tumor leads to debilitating hypoglycemic symptoms. The diagnosis is based on clinical and biochemical findings. After the diagnosis is made, the principal challenge lies in locating the tumor because most tumors are solitary and small in size. Locating the tumor is of paramount importance as complete surgical excision is the only curative treatment, and incomplete resection leads to persistence of symptoms. Different preoperative and intraoperative imaging techniques have been used with varying success rates for the insulinoma imaging. Besides localizing the tumor, imaging also helps to guide biopsy, detect metastatic lesions, and perform image-guided therapeutic procedures. This review will discuss the role of different Cross sectional and nuclear medicine imaging modalities in insulinomas.
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Zhu L, Wu WM, Xue HD, Liu W, Wang X, Sun H, Li P, Zhao YP, Jin ZY. Sporadic insulinomas on volume perfusion CT: dynamic enhancement patterns and timing of optimal tumour–parenchyma contrast. Eur Radiol 2017; 27:3491-3498. [DOI: 10.1007/s00330-016-4709-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 11/30/2016] [Accepted: 12/15/2016] [Indexed: 12/13/2022]
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Ouleghzal H, Ziadi T, Menfaa M, Safi S. Association of Insulinoma and Type 2 Diabetes Mellitus. Int J Endocrinol Metab 2017; 15:e39439. [PMID: 28835758 PMCID: PMC5554613 DOI: 10.5812/ijem.39439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/20/2016] [Accepted: 10/24/2016] [Indexed: 12/22/2022] Open
Abstract
The association of diabetes mellitus and insulinoma is unusual. We are reporting the case of a 58 years old patient having diabetes mellitus type 2 for several years. This patient was well balanced with oral anti-diabetic treatment. However, the diagnosis of insulinoma was discussed due to recent episodes of hypoglycemia that persisted even after stopping the treatment. Abdominal CT allowed the topographic diagnosis. The patient underwent a caudal pancreatectomy. Furthermore, the postoperative period shows that the diabetes mellitus requires the oral anti-diabetic treatment and basal insulin have to be stable. Then, the occurrence of hypoglycemia in the diabetic mellitus type 2 and, especially the persistence after discontinuation of therapy, suggest the unusual diagnosis of insulinoma as illustrated in our observation.
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Affiliation(s)
- Hassan Ouleghzal
- Endocrinology Department, Military Hospital Moulay Ismail, Meknes, Morocco
- Corresponding author: Hassan Ouleghzal, Endocrinology Department, Military Hospital Moulay Ismail, Meknes, Morocco. Tel: +212-0661099517, E-mail:
| | - Tarik Ziadi
- Radiology Department, Military Hospital Moulay Ismail, Meknes, Morocco
| | - Mohammed Menfaa
- Visceral Surgery Department, Military Hospital Moulay Ismail, Meknes, Morocco
| | - Soumia Safi
- Endocrinology Department, Military Hospital Moulay Ismail, Meknes, Morocco
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Abstract
Neuroendocrine tumors are increasingly diagnosed, either incidentally as part of screening processes, or for symptoms, which have commonly been mistaken for other disorders initially. The diagnostic workup to characterize tumor behaviour and prognosis focuses on histologic, anatomic, and functional imaging assessments. Several therapeutic options exist for patients ranging from curative and debulking surgery through to liver-directed therapies and systemic treatments. Multimodal therapies are often required over the patient's disease history. The management paradigm can be complex but should be focused on curative resections and then on controlling symptoms and limiting disease progression. There are several new systemic therapies that have completed phase 3 studies with new compounds being studied in phase 2. Genetic and epigenetic markers may lead to a new era of personalised therapy in the future.
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Affiliation(s)
- Ron Basuroy
- Neuroendocrine Tumour Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Raj Srirajaskanthan
- Neuroendocrine Tumour Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London SE5 9RS, UK
| | - John K Ramage
- Neuroendocrine Tumour Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London SE5 9RS, UK.
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99mTc Labeled Glucagon-Like Peptide-1-Analogue (99mTc-GLP1) Scintigraphy in the Management of Patients with Occult Insulinoma. PLoS One 2016; 11:e0160714. [PMID: 27526057 PMCID: PMC4985165 DOI: 10.1371/journal.pone.0160714] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 07/22/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The aim of this study was to assess the utility of [Lys40(Ahx-HYNIC-99mTc/EDDA)NH2]-exendin-4 scintigraphy in the management of patients with hypoglycemia, particularly in the detection of occult insulinoma. MATERIALS AND METHODS Forty patients with hypoglycemia and increased/confusing results of serum insulin and C-peptide concentration and negative/inconclusive results of other imaging examinations were enrolled in the study. In all patients GLP-1 receptor imaging was performed to localise potential pancreatic lesions. RESULTS Positive results of GLP-1 scintigraphy were observed in 28 patients. In 18 patients postsurgical histopathological examination confirmed diagnosis of insulinoma. Two patients had contraindications to the surgery, one patient did not want to be operated. One patient, who presented with postprandial hypoglycemia, with positive result of GLP-1 imaging was not qualified for surgery and is in the observational group. Eight patients were lost for follow up, among them 6 patients with positive GLP-1 scintigraphy result. One patient with negative scintigraphy was diagnosed with malignant insulinoma. In two patients with negative scintigraphy Munchausen syndrome was diagnosed (patients were taking insulin). Other seven patients with negative results of 99mTcGLP-1 scintigraphy and postprandial hypoglycemia with C-peptide and insulin levels within the limits of normal ranges are in the observational group. We would like to mention that 99mTc-GLP1-SPECT/CT was also performed in 3 pts with nesidioblastosis (revealing diffuse tracer uptake in two and a focal lesion in one case) and in two patients with malignant insulinoma (with the a focal uptake in the localization of a removed pancreatic headin one case and negative GLP-1 1 scintigraphy in the other patient). CONCLUSIONS 99mTc-GLP1-SPECT/CT could be helpful examination in the management of patients with hypoglycemia enabling proper localization of the pancreatic lesion and effective surgical treatment. This imaging technique may eliminate the need to perform invasive procedures in case of occult insulinoma.
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Morera J, Guillaume A, Courtheoux P, Palazzo L, Rod A, Joubert M, Reznik Y. Preoperative localization of an insulinoma: selective arterial calcium stimulation test performance. J Endocrinol Invest 2016; 39:455-63. [PMID: 26577133 DOI: 10.1007/s40618-015-0406-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 10/29/2015] [Indexed: 12/24/2022]
Abstract
PURPOSE Preoperative localization of an insulinoma is recommended to improve the cure rate, but non-invasive procedures can fail to detect the tumour. The objective of the study was to assess the performance of a selective arterial calcium stimulation test in the preoperative localization of insulinomas that were not detected by conventional imaging procedures. METHODS We conducted a monocenter retrospective case review of 13 patients who had endogenous hyperinsulinism and were treated between 1994 and 2013. Patients were selected on the basis of negative or doubtful non-invasive preoperative imaging. A selective arterial calcium stimulation test was performed by pancreatic and hepatic arteriography with selective intra-arterial calcium stimulation and hepatic venous sampling in order to obtain the plasma insulin measurement. We evaluated the efficacy of the test by comparing the results with an endoscopic ultrasound. RESULTS Twelve of the 13 patients underwent surgery, and the presence of an insulinoma was proven in 11 patients by pathological analysis of the tumour. An endoscopic ultrasound was consistent with surgery in 71.4 % of cases, while selective arterial calcium stimulation was consistent with surgery in 90.9 % and allowed detection of an insulinoma in two additional patients with a negative endoscopic ultrasound. One false-negative and one false-positive arterial calcium test were observed. No adverse events were recorded except transient skin flush following calcium injection in one patient. CONCLUSION The selective arterial calcium stimulation test is a sensitive diagnostic procedure for localizing insulinomas and may be considered when non-invasive radiological imaging does not allow the detection of an occult insulinoma.
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Affiliation(s)
- J Morera
- Endocrinology Unit, Centre Hospitalo-Universitaire de Caen, Avenue de la côte de Nacre, CS 30001, 14033, Caen Cedex 9, France
| | - A Guillaume
- Endocrinology Unit, Centre Hospitalo-Universitaire de Caen, Avenue de la côte de Nacre, CS 30001, 14033, Caen Cedex 9, France
| | - P Courtheoux
- Diagnostic Radiology Unit, Centre Hospitalo-Universitaire de Caen, Avenue de la côte de nacre, CS 30001, 14033, Caen Cedex 9, France
| | - L Palazzo
- Endoscopic Ultrasound Unit, Trocadero Clinic, 75016, Paris, France
| | - A Rod
- Endocrinology Unit, Centre Hospitalo-Universitaire de Caen, Avenue de la côte de Nacre, CS 30001, 14033, Caen Cedex 9, France
| | - M Joubert
- Endocrinology Unit, Centre Hospitalo-Universitaire de Caen, Avenue de la côte de Nacre, CS 30001, 14033, Caen Cedex 9, France
| | - Y Reznik
- Endocrinology Unit, Centre Hospitalo-Universitaire de Caen, Avenue de la côte de Nacre, CS 30001, 14033, Caen Cedex 9, France.
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Chiruvella A, Kooby DA. Surgical Management of Pancreatic Neuroendocrine Tumors. Surg Oncol Clin N Am 2016; 25:401-21. [DOI: 10.1016/j.soc.2015.12.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Evaluation and management of pancreatic lesions in patients with von Hippel–Lindau disease. Nat Rev Clin Oncol 2016; 13:537-49. [DOI: 10.1038/nrclinonc.2016.37] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Prasad V, Sainz-Esteban A, Arsenic R, Plöckinger U, Denecke T, Pape UF, Pascher A, Kühnen P, Pavel M, Blankenstein O. Role of (68)Ga somatostatin receptor PET/CT in the detection of endogenous hyperinsulinaemic focus: an explorative study. Eur J Nucl Med Mol Imaging 2016; 43:1593-600. [PMID: 26923247 DOI: 10.1007/s00259-016-3331-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 02/07/2016] [Indexed: 01/29/2023]
Abstract
PURPOSE To explore the role of (68)Ga-DOTATATE/DOTATOC PET/CT (SR PET/CT) in patients with suspicion of or histopathologically proven pancreatogenic hyperinsulinaemic hypoglycaemia. METHODS We included 13 patients with histopathologically proven or a high clinical suspicion of pancreatogenic hyperinsulinaemia. All the patients underwent a SR PET/CT scan. The results were correlated with histopathological findings. Normalization of blood glucose levels after resection of the pancreatic lesion, as well as a cytological and/or pathological diagnosis of insulinoma, was considered the diagnostic gold standard for insulinoma. The diagnosis of nesidioblastosis was based on exclusion of an insulinoma and conclusive pathological examination of a segment of the pancreas. Malignant insulinoma was defined as the presence of locoregional or distant metastases. RESULTS Based on histopathology, 13 patients were found to have pancreatic hyperinsulinaemia: two patients had malignant insulinoma, eight had nonmetastasized insulinoma, and three had nesidioblastosis. SR PET was positive in 11 of the 13 patients (84.6 %) with a final diagnosis of endogenous pancreatic hypoglycaemia. Histopathological staining confirmed 16 foci of hyperinsulinism (insulin positivity). SR PET detected 14 of the 16 lesions, resulting in a sensitivity of 87 %. One intrapancreatic spleen was falsely diagnosed as insulinoma focus on SR PET, resulting in positive predictive value of 93.3 %. Immunohistochemical staining of somatostatin receptor (SSR) subtype 2a was available in ten specimens: two nesidioblastosis, and seven benign and one malignant insulinoma. Eight out of the ten specimens (80 %) stained strongly to moderately positive. Seven of the eight SSR2a-positive lesions were picked up on SR PET. Based on the results of SR PET/CT, nine patients achieved complete remission of the hypoglycaemic events during follow-up. CONCLUSION This explorative study suggests that SR PET in combination with CT may play a significant role in the detection and management of patients with pancreatogenic hyperinsulinaemic hypoglycaemia. A large proportion of insulinomas express SSR2a, and a larger study is needed to fully assess the diagnostic accuracy of SR PET in patients with insulinoma and nesidioblastosis compared with current localizing studies used in clinical practice.
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Affiliation(s)
- Vikas Prasad
- Department of Nuclear Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Aurora Sainz-Esteban
- Department of Nuclear Medicine, Hospital Clínico Universitario Valladolid, Valladolid, Spain
| | - Ruza Arsenic
- Institute of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ursula Plöckinger
- Interdisziplinären Stoffwechsel-Centrum, Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Timm Denecke
- Department of Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrich-Frank Pape
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Kühnen
- Institute for Experimental Paediatric Endocrinology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Marianne Pavel
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Oliver Blankenstein
- Institute for Experimental Paediatric Endocrinology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
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Ende AR, Sedarat A, Shah P, Jhala N, Fraker DL, Drebin JA, Metz DC, Kochman ML. Risk factors for aggressive nonfunctional pancreatic neuroendocrine tumors and the role of endoscopic ultrasound guided fine-needle aspiration. Endosc Ultrasound 2016; 5:49-54. [PMID: 26879167 PMCID: PMC4770623 DOI: 10.4103/2303-9027.175897] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Nonfunctional pancreatic neuroendocrine tumors (NF-pNETs) are increasingly being diagnosed but management, especially of small tumors, remains a clinical dilemma. Endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) is now routinely used for diagnosis of pancreatic neuroendocrine tumors (pNETs) but has not been well studied as a tool for identifying aggressive disease. Materials and Methods: A systematic search of the cytology database identified all patients at our center who underwent EUS-FNA from 1999 through 2011 and were diagnosed with NF-pNET. Results: A total of 50 patients were identified. Though patients with metastatic disease had a mean tumor size of 40 mm compared to 25 mm in patients without metastatic disease (P = 0.04), we also identified several patients with tumors <20 mm who presented with metastatic disease. Furthermore, we found no statistically significant difference in metastatic disease between tumors <20 mm and >20 mm (P = 0.13). Using receiver operating characteristic (ROC) analysis, we found that using a cutoff point of 20 mm only led to a sensitivity of 85% in screening for metastases, while lowering the cutoff point to 18 mm allowed for a sensitivity of 95%. Conclusion: Currently, guidelines suggest that only patients with tumors greater than 20 mm undergo surgical resection, as tumors less than this size are thought to have low risk of metastases. Our analysis suggests that these recommendations could lead to undertreating patients with small tumors. Tumor size alone may be inadequate as a marker for aggressive NF-pNETs. Given this, other risk factors for aggressive pNETs should be studied to help identify the patients most likely to benefit from surgery.
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Affiliation(s)
- Alexander R Ende
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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Isoattenuating insulinomas at biphasic contrast-enhanced CT: frequency, clinicopathologic features and perfusion characteristics. Eur Radiol 2016; 26:3697-705. [PMID: 26815370 DOI: 10.1007/s00330-016-4216-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 12/30/2015] [Accepted: 01/13/2016] [Indexed: 01/26/2023]
Abstract
OBJECTIVES We aimed to determine the frequency of isoattenuating insulinomas, to investigate their clinicopathological features and to assess their regional pancreatic perfusion characteristics. METHODS Institutional review board approval was obtained, and patient informed consent was waived. From July 2010 to June 2014, 170 patients (66 male, 104 female) with endogenous hyperinsulinemic hypoglycemia underwent biphasic contrast-enhanced CT before surgery, and 129 of those patients also received preoperative whole-pancreas CT perfusion. A total of 181 tumours were proved histopathologically after surgery. Enhancement pattern and regional pancreatic perfusion characteristics were analyzed. Clinical features, tumour size and pathological grading were investigated. RESULTS The frequency of isoattenuating tumours was 24.9 %. Tumour size and WHO grading was not significantly different between isoattenuating and hyperattenuating tumours. Tumour-free regions had identical blood flow (BF) regardless of their location (p = 0.35). Isoattenuating tumour-harbouring regions had lower BF compared with hyperattenuating tumour-harbouring regions; both showed higher BF compared with tumour-free neighbourhood regions (all p < 0.01). For patients with isoattenuating tumours, the overall hospital stay was longer (p < 0.01). CONCLUSIONS A substantial subset of insulinomas were isoattenuating on biphasic CT. CT perfusion showed higher BF in tumour-harbouring regions compared to tumour-free regions, providing a clue for tumour regionalization. KEY POINTS • About a quarter of all insulinomas were isoattenuating on biphasic contrast-enhanced CT. • CT perfusion finds tumour-harbouring regions have higher blood-flow compared to tumour-free regions. • CT perfusion provides important information for tumour regionalization, for isoattenuating tumours.
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Abstract
Currently, ultrasound (US), computed tomography (CT) and Magnetic Resonance imaging (MRI) represent the mainstay in the evaluation of pancreatic solid and cystic tumors affecting pancreas in 80-85% and 10-15% of the cases respectively. Integration of US, CT or MR imaging is essential for an accurate assessment of pancreatic parenchyma, ducts and adjacent soft tissues in order to detect and to stage the tumor, to differentiate solid from cystic lesions and to establish an appropriate treatment. The purpose of this review is to provide an overview of pancreatic tumors and the role of imaging in their diagnosis and management. In order to a prompt and accurate diagnosis and appropriate management of pancreatic lesions, it is crucial for radiologists to know the key findings of the most frequent tumors of the pancreas and the current role of imaging modalities. A multimodality approach is often helpful. If multidetector-row CT (MDCT) is the preferred initial imaging modality in patients with clinical suspicion for pancreatic cancer, multiparametric MRI provides essential information for the detection and characterization of a wide variety of pancreatic lesions and can be used as a problem-solving tool at diagnosis and during follow-up.
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45
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Moreno-Moreno P, Alhambra-Expósito MR, Herrera-Martínez AD, Palomares-Ortega R, Zurera-Tendero L, Espejo Herrero JJ, Gálvez-Moreno MA. Arterial Calcium Stimulation with Hepatic Venous Sampling in the Localization Diagnosis of Endogenous Hyperinsulinism. Int J Endocrinol 2016; 2016:4581094. [PMID: 27795707 PMCID: PMC5066019 DOI: 10.1155/2016/4581094] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 06/25/2016] [Accepted: 08/04/2016] [Indexed: 01/01/2023] Open
Abstract
Objective. The aim of this study was to assess the utility of arterial calcium stimulation with hepatic venous sampling (ASVS) in the localization diagnosis of endogenous hyperinsulinism. Patients and Methods. A retrospective descriptive study was performed including patients with endogenous hyperinsulinism who underwent ASVS. The histopathological diagnosis in patients who underwent a surgical procedure was used as the reference for the statistical study of the accuracy of this technique. Results. 30 patients were included with endogenous hyperinsulinism and nonconclusive imaging diagnosis was included. ASVS was performed in all cases. Surgery was performed in 20 cases. Insulinoma was removed in 19 patients; the location of all cases was detected in the ASVS. All cases of endogenous hyperinsulinism had a positive result for the ASVS, with this association being statistically significant (χ2 = 15.771; p < 0.001). A good and statistically significant agreement was obtained between histopathologic diagnosis and ASVS results (K = 0.518, p < 0.001). Conclusions. ASVS is a useful procedure in the localization diagnosis of endogenous hyperinsulinism undetected by other imaging tests. This technique allows the localization of intrapancreatic insulinomas and represents useful tool for the diagnosis and surgical management of these tumors.
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Affiliation(s)
- Paloma Moreno-Moreno
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Córdoba, Spain
- Endocrinology and Nutrition Service, Reina Sofia University Hospital, Córdoba, Spain
| | - María Rosa Alhambra-Expósito
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Córdoba, Spain
- Endocrinology and Nutrition Service, Reina Sofia University Hospital, Córdoba, Spain
| | - Aura Dulcinea Herrera-Martínez
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Córdoba, Spain
- Endocrinology and Nutrition Service, Reina Sofia University Hospital, Córdoba, Spain
- *Aura Dulcinea Herrera-Martínez:
| | | | | | | | - María Angeles Gálvez-Moreno
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Córdoba, Spain
- Endocrinology and Nutrition Service, Reina Sofia University Hospital, Córdoba, Spain
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Sheybani A, Menias CO, Luna A, Fowler KJ, Hara AK, Silva AC, Yano M, Sandrasegaran K. MRI of the stomach: a pictorial review with a focus on oncological applications and gastric motility. ACTA ACUST UNITED AC 2015; 40:907-30. [PMID: 25261256 DOI: 10.1007/s00261-014-0251-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The purpose of this pictorial review is to demonstrate gastric pathology seen on magnetic resonance imaging (MRI) and discuss the essential MRI sequences for the evaluation of benign and malignant gastric pathologies. Common tumors of the stomach, polyposis syndromes, iatrogenic conditions, as well as other conditions of the stomach will be reviewed. The utility of MRI in the evaluation of patients with gastric malignancies and disorders of gastric motility will also be discussed.
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Affiliation(s)
- Arman Sheybani
- Department of Radiology, University of Illinois Hospital and Health Sciences System, University of Illinois at Chicago, 1740 W Taylor Street, Suite 2511, Chicago, IL, 60612, USA,
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Battocchio M, Zatelli MC, Chiarelli S, Trento M, Ambrosio MR, Pasquali C, De Carlo E, Dassie F, Mioni R, Rebellato A, Fallo F, Degli Uberti E, Martini C, Vettor R, Maffei P. Ovarian tumors secreting insulin. Endocrine 2015; 49:611-9. [PMID: 25896552 DOI: 10.1007/s12020-015-0605-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 04/13/2015] [Indexed: 10/23/2022]
Abstract
Combined ovarian germ cell and neuroendocrine tumors are rare. Only few cases of hyperinsulinism due to ovarian ectopic secretion have been hypothesized in the literature. An ovarian tumor was diagnosed in a 76-year-old woman, referred to our department for recurrent hypoglycemia with hyperinsulinism. In vivo tests, in particular fasting test, rapid calcium infusion test, and Octreotide test were performed. Ectopic hyperinsulinemic hypoglycemia was demonstrated in vivo and hypoglycemia disappeared after hysteroadnexectomy. Histological exam revealed an ovarian germ cell tumor with neuroendocrine and Yolk sac differentiation, while immunostaining showed insulin positivity in neuroendocrine cells. A cell culture was obtained by tumoral cells, testing Everolimus, and Pasireotide. Insulin was detected in cell culture medium and Everolimus and Pasireotide demonstrated their potentiality in reducing insulin secretion, more than controlling cell viability. Nine cases of hyperinsulinism due to ovarian ectopic secretion reported in literature have been reviewed. These data confirm the ovarian tissue potentiality to induce hyperinsulinemic hypoglycemic syndrome after neoplastic transformation.
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Affiliation(s)
- Marialberta Battocchio
- Internal Medicine 3, Department of Medicine, University of Padua, Via Giustiniani 2, 35100, Padua, Italy,
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Jang SK, Kim JH, Joo I, Jeon JH, Shin KS, Han JK, Choi BI. Differential diagnosis of pancreatic cancer from other solid tumours arising from the periampullary area on MDCT. Eur Radiol 2015; 25:2880-8. [PMID: 25916385 DOI: 10.1007/s00330-015-3721-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 03/17/2015] [Accepted: 03/18/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE To investigate CT features and differential diagnosis of pancreatic adenocarcinoma compared to other solid tumours arising in the periampullary area. MATERIALS AND METHODS One hundred and ninety-five patients with pathologically proven, solid periampullary tumours, including pancreatic adenocarcinoma (n = 98), neuroendocrine tumours (n = 52), gastrointestinal stromal tumours (n = 31), and solid pseudopapillary neoplasms (n = 14), underwent preoperative CT. Two radiologists reviewed CT features and rated the possibility of pancreatic adenocarcinoma. RESULTS Statistically common findings for pancreatic adenocarcinoma included: patient age >50 years; ill-defined margin; completely solid mass; homogeneous enhancement; hypoenhancement on arterial and venous phases; atrophy; and duct dilatation. Statistically common findings for GIST included: heterogeneous enhancement; hyperenhancement on arterial and venous phases; rim enhancement; and prominent feeding arteries. The hyperenhancement on arterial and venous phases is statistically common in NET, and heterogeneous enhancement, hypoenhancement on the arterial and venous phases are statistically common in SPN. Diagnostic performance of CT for differentiating pancreatic adenocarcinomas from other solid periampullary tumours was 0.962 and 0.977 with excellent interobserver agreement (κ = 0.824). CONCLUSION CT is useful not only for differentiating pancreatic adenocarcinoma form other solid tumours but also for differentiating between other solid tumours, including NET, SPN, and GIST, arising in the periampullary area. KEY POINTS • Periampullary tumours arise within 2 cm of major duodenal papilla. • Many mass-forming periampullary tumours can be completely removed by minimal surgery. • Accurate differentiation of pancreatic adenocarcinoma from other solid tumours is important. • CT is useful for differentiating pancreatic adenocarcinoma from other solid tumours. • CT is useful for characterization of periampullary tumours other than adenocarcinomas.
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Affiliation(s)
- Suk Ki Jang
- Departments of Radiology, Daejin Medical Center, Bundang Jesaeng General Hospital, 20, Seohyeon-ro 180beon-gil, Bundang-gu, Seognam-si, Gyeonggi-do, 463-774, Korea
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Kim DW, Kim HJ, Kim KW, Byun JH, Song KB, Kim JH, Hong SM. Neuroendocrine neoplasms of the pancreas at dynamic enhanced CT: comparison between grade 3 neuroendocrine carcinoma and grade 1/2 neuroendocrine tumour. Eur Radiol 2014; 25:1375-83. [PMID: 25465713 DOI: 10.1007/s00330-014-3532-z] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/03/2014] [Accepted: 11/20/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To identify the CT features in differentiating grade 3 neuroendocrine carcinomas from grade 1/2 neuroendocrine tumours. METHODS This study included 161 patients with surgically confirmed pancreatic neuroendocrine neoplasms. Pathology slides were reviewed to determine the tumour grade. CT image analysis included size, pattern, calcification, margin, pancreatic duct dilatation, bile duct dilatation, vascular invasion, arterial enhancement ratio, and portal enhancement ratio. We used 2 cm, 3 cm, and 4 cm as cutoff values of tumour size and 0.9 and 1.1 of enhancement ratio to determine the sensitivity and specificity. RESULTS Pathology analysis identified 167 lesions in 161 patients. 154 lesions (92 %) were grade 1/2 and 13 (8 %) were grade 3. Portal enhancement ratio (< 1.1) showed high sensitivity and specificity 92.3 % and 80.5 %, respectively in differentiating grade 3 from grade 1/2. It showed the highest odds ratio (49.60), followed by poorly defined margin, size (> 3 cm), bile duct dilatation, and vascular invasion. When at least two of these five criteria were used in combination, the sensitivity and specificity for diagnosing grade 3 were 92.3 % (12/13) and 87.7 % (135/154), respectively. CONCLUSIONS By using specific CT findings, grade 3 can be differentiated from grade 1/2 with a high diagnostic accuracy leading to an appropriate imaging staging. KEY POINTS • Neuroendocrine carcinomas should be differentiated from neuroendocrine tumours. • Neuroendocrine carcinomas can be differentiated from neuroendocrine tumours on dynamic CT. • Neuroendocrine carcinomas show iso- or hypo-enhancement on portal venous phase CT.
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Affiliation(s)
- Dong Wook Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-gil, Songpa-gu, Seoul, 138-736, Korea
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Singh S, Dey C, Kennecke H, Kocha W, Maroun J, Metrakos P, Mukhtar T, Pasieka J, Rayson D, Rowsell C, Sideris L, Wong R, Law C. Consensus Recommendations for the Diagnosis and Management of Pancreatic Neuroendocrine Tumors: Guidelines from a Canadian National Expert Group. Ann Surg Oncol 2014; 22:2685-99. [PMID: 25366583 DOI: 10.1245/s10434-014-4145-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Indexed: 12/29/2022]
Abstract
Pancreatic neuroendocrine tumors (pNETs) are rare heterogeneous tumors that have been steadily increasing in both incidence and prevalence during the past few decades. Pancreatic NETs are categorized as functional (F) or nonfunctional (NF) based on their ability to secrete hormones that elicit clinically relevant symptoms. Specialized diagnostic tests are required for diagnosis. Treatment options are diverse and include surgical resection, intraarterial hepatic therapy, and peptide receptor radionuclide therapy (PRRT). Systemic therapy options include targeted agents as well as chemotherapy when indicated. Diagnosis and management should occur through a collaborative team of health care practitioners well-experienced in managing pNETs. Recent advances in pNET treatment options have led to the development of the Canadian consensus document described in this report. The discussion includes the epidemiology, classification, pathology, clinical presentation and prognosis, imaging and laboratory testing, medical and surgical management, and recommended treatment algorithms for pancreatic neuroendocrine cancers.
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Affiliation(s)
- Simron Singh
- Department of Medicine, Odette Cancer Centre - Sunnybrook Hospital, University of Toronto, Toronto, ON, Canada,
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