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Kumar S, Melek M, Rohl P. Case Report: Hypoglycemia Due to Metastatic Insulinoma in Insulin-Dependent Type 2 Diabetes Successfully Treated With 177 Lu-DOTATATE. Front Endocrinol (Lausanne) 2022; 13:906012. [PMID: 35685218 PMCID: PMC9171402 DOI: 10.3389/fendo.2022.906012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/19/2022] [Indexed: 12/03/2022] Open
Abstract
We describe a 96-year-old man with insulin-dependent type 2 diabetes mellitus who, despite insulin cessation, presented with recurrent hypoglycemia associated with confirmed inappropriate endogenous hyperinsulinemia. 68Ga-DOTATATE-PET/CT scans demonstrated increased uptake in the pancreatic tail with multiple large intensely active liver metastases. Liver biopsy confirmed the diagnosis of well-differentiated metastatic neuroendocrine tumor. He was unsuitable for surgical resection and long-acting somatostatin analog therapy was ineffective. Subsequent management with four cycles of Lutate [177-Lutetium-DOTA0-Tyr3-octreotate (177Lu-DOTATATE)] resulted in resolution of hypoglycemia and ongoing clinical, biochemical, and radiological response 6 years after. This case is unique due to not only the paradoxical entity of insulinoma in insulin-dependent diabetes but also the positive sustained outcome after 177Lu-DOTATATE, given that unresectable metastatic insulinoma carries a poor prognosis. We review published cases of metastatic insulinoma in patients with diabetes mellitus as well as the literature to-date investigating efficacy and safety of Lutate therapy in metastatic insulinoma.
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Malignant Insulinoma with Multiple Liver Metastases and Hypercalcitoninemia in a Patient with Type 2 Diabetes Mellitus Presenting as Recurrent Episodes of Diaphoresis due to Severe Hypoglycemia. Case Rep Endocrinol 2020; 2020:4239679. [PMID: 32082648 PMCID: PMC7019204 DOI: 10.1155/2020/4239679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/18/2019] [Accepted: 01/04/2020] [Indexed: 11/17/2022] Open
Abstract
Insulinoma is an insulin-producing pancreatic neuroendocrine tumor that can be malignant in about 10% of cases. Locoregional invasion, lymph node metastases, or remote metastases are the main criteria of malignant insulinoma. Its incidence in patients with pre-existing diabetes mellitus (DM) is exceptionally rare. In this report, we describe a 66-year-old man with long-standing type 2 DM who presented with recurrent episodes of diaphoresis due to severe hypoglycemia despite the withdrawal of insulin therapy, hypercalcitoninemia, and biochemical and radiological findings suggestive of metastatic malignant insulinoma. Unfortunately, after few days of diazoxide treatment, edema, hypotension, oliguria, and water retention were observed, patient's clinical status deteriorated rapidly, and he died in our department from acute renal failure.
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Nastos C, Giannoulopoulos D, Dellaportas D, Mizamtsidi M, Dafnios N, Klonaris N, Kalogeris N, Vryonidou A. Sudden 'cure' of type two diabetes due to pancreatic insulinoma: A case report. Mol Clin Oncol 2020; 12:174-178. [PMID: 31929890 DOI: 10.3892/mco.2019.1957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 07/05/2019] [Indexed: 01/16/2023] Open
Abstract
Insulinomas are rare tumors of the islet cells of the pancreas and are the most common cause of endogenous hyperinsulinism. Although they usually present with symptoms of hypoglycemia, sometimes they can have vague symptoms. We present the case of a 62-year-old diabetic female who was diagnosed with a large insulinoma after being investigated for the 'cure' of her diabetes. We also review the literature regarding insulinomas in patients with diabetic. A 62-year-old, obese woman with type 2 diabetes mellitus was initially investigated for an unexplained normalization of her blood glucose levels after the cessation of antidiabetic medication due to an episode of severe hypoglycemia. She remained without antidiabetics for three months maintaining normoglycemia, and thereafter, she started experiencing frequent but less severe hypoglycemic episodes. She did not change her diet habits or level of activity and did not lose any weight. The patient underwent further investigation with a supervised 72 h fasting test, which resulted in the biochemical diagnosis of endogenous hyperinsulinism. Imaging studies revealed the presence of a large insulinoma in the head of the pancreas. Finally, the patient underwent a pylorus preserving Whipple procedure, which reversed the aforementioned 'normalization' of glucose levels and the underlying diabetes mellitus reappeared. Insulinomas are rare tumors causing hypoglycemia. Even more rarely are found in diabetic patients, making the diagnosis more challenging and probably delayed, as the symptoms are masked by the presence of diabetes, thereby leading to a more advanced disease diagnosis.
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Affiliation(s)
- Constantinos Nastos
- Second Department of Surgery, Endocrine Surgery Unit, National and Kapodistrian University of Athens, School of Medicine, Aretaieion University Hospital, 11528 Athens, Greece
| | - Dimitrios Giannoulopoulos
- Second Department of Surgery, Endocrine Surgery Unit, National and Kapodistrian University of Athens, School of Medicine, Aretaieion University Hospital, 11528 Athens, Greece
| | - Dionysios Dellaportas
- Second Department of Surgery, Endocrine Surgery Unit, National and Kapodistrian University of Athens, School of Medicine, Aretaieion University Hospital, 11528 Athens, Greece
| | - Maria Mizamtsidi
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, 11526 Athens, Greece
| | - Nikolaos Dafnios
- Second Department of Surgery, Endocrine Surgery Unit, National and Kapodistrian University of Athens, School of Medicine, Aretaieion University Hospital, 11528 Athens, Greece
| | - Nikolaos Klonaris
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, 11526 Athens, Greece
| | - Nikolaos Kalogeris
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, 11526 Athens, Greece
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, 11526 Athens, Greece
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Duvillié B, Kourdoughli R, Druillennec S, Eychène A, Pouponnot C. Interplay Between Diabetes and Pancreatic Ductal Adenocarcinoma and Insulinoma: The Role of Aging, Genetic Factors, and Obesity. Front Endocrinol (Lausanne) 2020; 11:563267. [PMID: 33101198 PMCID: PMC7556217 DOI: 10.3389/fendo.2020.563267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/14/2020] [Indexed: 12/11/2022] Open
Abstract
Epidemiologic analyses have shed light on an association between type 2 diabetes (T2D) and pancreatic ductal adenocarcinoma (PDAC). Recent data also suggest a potential relationship between T2D and insulinoma. Under rare circumstances, type 1 diabetes (T1D) can also be implicated in tumorigenesis. The biological mechanisms underlying such relationships are extremely complex. Some genetic factors contributing to the development of T2D are shared with pancreatic exocrine and endocrine tumors. Obesity and overweight can also contribute to the initiation and severity of T2D, while aging may influence both endocrine and exocrine tumors. Finally, pharmacological treatments of T2D may have an impact on PDAC. On the other hand, some treatments for insulinoma can trigger diabetes. In the present minireview, we discuss the cellular and molecular mechanisms that could explain these interactions. This analysis may help to define new potential therapeutic strategies.
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Affiliation(s)
- Bertrand Duvillié
- Department of Signaling, Radiobiology and Cancer, Institut Curie, Orsay, France
- INSERM U1021, Centre Universitaire, Orsay, France
- CNRS UMR 3347, Centre Universitaire, Orsay, France
- Université Paris-Saclay, Orsay, France
- PSL Research University, Paris, France
- *Correspondence: Bertrand Duvillié,
| | - Rayane Kourdoughli
- Department of Signaling, Radiobiology and Cancer, Institut Curie, Orsay, France
- INSERM U1021, Centre Universitaire, Orsay, France
- CNRS UMR 3347, Centre Universitaire, Orsay, France
- Université Paris-Saclay, Orsay, France
- PSL Research University, Paris, France
| | - Sabine Druillennec
- Department of Signaling, Radiobiology and Cancer, Institut Curie, Orsay, France
- INSERM U1021, Centre Universitaire, Orsay, France
- CNRS UMR 3347, Centre Universitaire, Orsay, France
- Université Paris-Saclay, Orsay, France
- PSL Research University, Paris, France
| | - Alain Eychène
- Department of Signaling, Radiobiology and Cancer, Institut Curie, Orsay, France
- INSERM U1021, Centre Universitaire, Orsay, France
- CNRS UMR 3347, Centre Universitaire, Orsay, France
- Université Paris-Saclay, Orsay, France
- PSL Research University, Paris, France
| | - Celio Pouponnot
- Department of Signaling, Radiobiology and Cancer, Institut Curie, Orsay, France
- INSERM U1021, Centre Universitaire, Orsay, France
- CNRS UMR 3347, Centre Universitaire, Orsay, France
- Université Paris-Saclay, Orsay, France
- PSL Research University, Paris, France
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Gjelberg HK, Hoem D, Verbeke CS, Eide J, Cooper JG, Molven A. Hypoglycemia and decreased insulin requirement caused by malignant insulinoma in a type 1 diabetic patient: when the hoof beats are from a zebra, not a horse. Clin Case Rep 2017; 5:761-768. [PMID: 28588806 PMCID: PMC5457997 DOI: 10.1002/ccr3.927] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 03/05/2017] [Indexed: 12/30/2022] Open
Abstract
Insulinomas are uncommon tumors, and in patients with diabetes mellitus they are extremely rare. We describe a patient with type 1 diabetes who developed malignant insulinoma. When hypoglycemic episodes persist in a patient with diabetes and treatment‐induced and other causes of hypoglycemia have been ruled out, an insulin‐producing tumor should be considered.
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Affiliation(s)
- Hilde K Gjelberg
- Department of Pathology Haukeland University Hospital Bergen Norway
| | - Dag Hoem
- Department of Gastrointestinal Surgery Haukeland University Hospital Bergen Norway
| | - Caroline S Verbeke
- Institute of Clinical Medicine University of Oslo Oslo Norway.,Department of Pathology Oslo University Hospital, Rikshospitalet Oslo Norway
| | - Johan Eide
- Department of Pathology Haukeland University Hospital Bergen Norway
| | - John G Cooper
- Department of Medicine Stavanger University Hospital Stavanger Norway
| | - Anders Molven
- Department of Pathology Haukeland University Hospital Bergen Norway.,Gade Laboratory for Pathology Department of Clinical Medicine University of Bergen Bergen Norway.,KG Jebsen Center for Diabetes Research Faculty of Medicine and Dentistry University of Bergen Bergen Norway
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Joshi T, Caswell A, Acharya S. A difficult case of recurrent hypoglycaemia: role of insulin assays in establishing the diagnosis. Diabet Med 2016; 33:e36-e39. [PMID: 27135190 DOI: 10.1111/dme.13146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Insulin assays are designed to detect endogenous insulin, however, insulin assays produced by different manufacturers may detect exogenous recombinant insulin, with varying degrees of cross-reactivity between different assays. We report a fascinating and difficult case of recurrent hypoglycaemia, where the final diagnosis was established with the help of insulin assays using different platforms. CASE REPORT A 24-year-old female presented with recurrent hypoglycaemic episodes on a background of Type 1 diabetes mellitus and a completely resected synovial sarcoma of the right hip several years previously. She reported significant physical, sexual and emotional abuse leading to reduced appetite and weight loss. Despite withdrawing insulin therapy, she experienced profound hypoglycaemic episodes with detectable C-peptide and inappropriately elevated insulin levels, suggesting endogenous hyperinsulinaemic hypoglycaemia; however, localization studies were negative and finally she was found to have exogenous hyperinsulinaemia after discordant insulin levels were detected using two different insulin assays. The C-peptide level was elevated as a result of stimulation by parenteral dextrose and was suppressed after dextrose was ceased. Her Type 1 diabetes mellitus was fabricated and she had factitious hypoglycaemia. CONCLUSIONS Factitious hypoglycemia is difficult to diagnose and treat. A low blood glucose level, suppressed C-peptide level and an inappropriately elevated insulin level is the classic finding. We were able to make a diagnosis in the present case after discordant insulin levels were detected on the two different insulin assays, signifying cross-reactivities of the recombinant insulin with the assays. A multidisciplinary team approach with psychiatric input is needed to treat such cases.
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Affiliation(s)
- T Joshi
- Department of Endocrinology, John Hunter Hospital, Newcastle, NSW, Australia
| | - A Caswell
- Department of Biochemistry, John Hunter Hospital, Newcastle, NSW, Australia
| | - S Acharya
- Department of Endocrinology, John Hunter Hospital, Newcastle, NSW, Australia
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Type 2 diabetes and insulinoma: An unusual association. DIABETES & METABOLISM 2015; 41:432-3. [PMID: 26386553 DOI: 10.1016/j.diabet.2015.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 08/07/2015] [Accepted: 08/12/2015] [Indexed: 11/21/2022]
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