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Henquin JC, Pattou F, Nenquin M. Insulin secretion in response to high extracellular calcium is not a pathognomonic feature of insulinoma cells. DIABETES & METABOLISM 2017; 45:76-78. [PMID: 29097005 DOI: 10.1016/j.diabet.2017.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 07/17/2017] [Accepted: 07/22/2017] [Indexed: 10/18/2022]
Affiliation(s)
- J-C Henquin
- Unit of Endocrinology and Metabolism, Faculty of Medicine, University of Louvain, 1200 Brussels, Belgium.
| | - F Pattou
- Institut National de la Santé et de la Recherche Médicale U1190, Translational Research for Diabetes, University of Lille, 59000 Lille, France
| | - M Nenquin
- Unit of Endocrinology and Metabolism, Faculty of Medicine, University of Louvain, 1200 Brussels, Belgium
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Davi MV, Pia A, Guarnotta V, Pizza G, Colao A, Faggiano A. The treatment of hyperinsulinemic hypoglycaemia in adults: an update. J Endocrinol Invest 2017; 40:9-20. [PMID: 27624297 DOI: 10.1007/s40618-016-0536-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/17/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Treatment of hyperinsulinemic hypoglycaemia (HH) is challenging due to the rarity of this condition and the difficulty of differential diagnosis. The aim of this article is to give an overview of the recent literature on the management of adult HH. METHODS A search for reviews, original articles, original case reports between 1995 and 2016 in PubMed using the following keywords: hyperinsulinemic hypoglycaemia, insulinoma, nesidioblastosis, gastric bypass, autoimmune hypoglycaemia, hyperinsulinism, treatment was performed. RESULTS One hundred and forty articles were selected and analysed focusing on the most recent treatments of HH. CONCLUSIONS New approaches to treatment of HH are available including mini-invasive surgical techniques and alternative local-regional ablative therapy for benign insulinoma and everolimus for malignant insulinoma. A correct differential diagnosis is of paramount importance to avoid unnecessary surgical operations and to implement the appropriate treatment mainly in the uncommon forms of HH, such as nesidioblastosis and autoimmune hypoglycaemia.
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Affiliation(s)
- M V Davi
- Section of Endocrinology, Medicina Generale e Malattie Aterotrombotiche e Degenerative, Department of Medicine, University of Verona, Piazzale LA Scuro, Policlinico G.B. Rossi, 37134, Verona, Italy.
| | - A Pia
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - V Guarnotta
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - G Pizza
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Colao
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Faggiano
- Thyroid and Parathyroid Surgery Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione G. Pascale" IRCCS, Naples, Italy
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Thompson SM, Vella A, Service FJ, Grant CS, Thompson GB, Andrews JC. Impact of variant pancreatic arterial anatomy and overlap in regional perfusion on the interpretation of selective arterial calcium stimulation with hepatic venous sampling for preoperative localization of occult insulinoma. Surgery 2015; 158:162-72. [PMID: 25873534 DOI: 10.1016/j.surg.2015.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 02/25/2015] [Accepted: 03/07/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND To determine the impact of variant pancreatic arterial anatomy and overlap in regional perfusion on the interpretation of selective arterial calcium stimulation (SACST) with hepatic venous sampling for preoperative localization of occult insulinoma. METHODS An institutional review board-approved retrospective review was undertaken of 42 patients with surgically confirmed, occult insulinoma who underwent SACST from January 1996 to March 2014. Location of the insulinoma was predicted initially based on the biochemical results of SACST alone according to Doppman's criteria. Pancreatic arteriograms were reviewed blinded to the biochemical results and the regional perfusion of each artery assessed. The anatomic and perfusion data were combined with the biochemical results to make a second prediction and compared with the surgical findings. RESULTS The biochemical results were positive in 1, 2, and 3 arterial distributions in 73.8%, 21.4%, and 4.8% of patients, respectively. The celiac trunk and superior mesenteric artery (SMA) anatomy were aberrant in 38.1% and 35.7% of patients, respectively. Clinically significant variations included dorsal pancreatic artery replaced to SMA (21.4%) and celiac stenosis (4.8%). Significant variation and overlap in regional pancreatic perfusion was observed, particularly for the SMA. Sensitivity for insulinoma localization was 54.8% (diagnostic arteriography), 73.8% (biochemical data), 88.1% (biochemical, anatomic, perfusion data), and 92.8% (arteriographic, biochemical, anatomic, perfusion data). CONCLUSION Careful review of the pancreatic arterial anatomy and regional perfusion is critical for correct interpretation of the biochemical results of SACST and improves the sensitivity of localization for occult insulinoma, particularly in the presence of pancreatic arterial variants or overlap in regional perfusion.
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Krampitz GW, Norton JA. WITHDRAWN: Current Problems in Surgery: Pancreatic Neuroendocrine Tumors. Curr Probl Surg 2014. [DOI: 10.1067/j.cpsurg.2013.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Insulinoma is a rare neuroendocrine tumor that causes oversecretion of insulin and, as a result, patients present with symptoms of hypoglycemia. Fortunately, insulinomas are usually benign and solitary, and surgical cure rates are highly favorable. Most of these tumors occur sporadically, but they can also be associated with multiple endocrine neoplasia type-1 syndrome. The diagnosis is confirmed by a supervised fast, and early detection is important. Several preoperative and intraoperative techniques with various success rates have been employed in order to localize the lesion. When technically feasible, tumor enucleation is the procedure of choice; however, a more formal resection may be necessary for certain tumors. In the age of laparoscopy, the role of laparoscopic surgery in the management of insulinomas is continuing to attract attention. This review will discuss the historical background, pathogenesis, diagnosis, localization and management of insulinomas.
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Affiliation(s)
- Joyce J Shin
- Montefiore Medical Center/Albert Einstein, College of Medicine, Greene Medical Arts, Pavilion 4th Floor, 3400 Bainbridge Avenue, Bronx, NY 10467, USA
| | - Phillip Gorden
- NIDDK, National Institutes of Health, Building 10-CRC, Room 6-5952, 10 Center Dr., Bethesda, MD, USA, Tel.: +1 301 402 7340, Fax: +1 301 435 5873
| | - Steven K Libutti
- Montefiore-Einstein Center for Cancer Care, NY, USA and Department of Surgery, Montefiore, Medical Center/Albert Einstein College of Medicine, Greene Medical Arts Pavilion, 4th Floor, 3400 Bainbridge Avenue, Bronx, NY 10467, USA, Tel.: +1 718 920 4231, Fax: +1 718 798 0309
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Guettier JM, Kam A, Chang R, Skarulis MC, Cochran C, Alexander HR, Libutti SK, Pingpank JF, Gorden P. Localization of insulinomas to regions of the pancreas by intraarterial calcium stimulation: the NIH experience. J Clin Endocrinol Metab 2009; 94:1074-80. [PMID: 19190102 PMCID: PMC2682461 DOI: 10.1210/jc.2008-1986] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
CONTEXT Selective intraarterial calcium injection of the major pancreatic arteries with hepatic venous sampling [calcium arterial stimulation (CaStim)] has been used as a localizing tool for insulinomas at the National Institutes of Health (NIH) since 1989. The accuracy of this technique for localizing insulinomas was reported for all cases until 1996. OBJECTIVES The aim of the study was to assess the accuracy and track record of the CaStim over time and in the context of evolving technology and to review issues related to result interpretation and procedure complications. CaStim was the only invasive preoperative localization modality used at our center. Endoscopic ultrasound (US) was not studied. DESIGN AND SETTING We conducted a retrospective case review at a referral center. PATIENTS Twenty-nine women and 16 men (mean age, 47 yr; range, 13-78) were diagnosed with an insulinoma from 1996-2008. INTERVENTION A supervised fast was conducted to confirm the diagnosis of insulinoma. US, computed tomography (CT), magnetic resonance imaging (MRI), and CaStim were used as preoperative localization studies. Localization predicted by each preoperative test was compared to surgical localization for accuracy. MAIN OUTCOME We measured the accuracy of US, CT, MRI, and CaStim for localization of insulinomas preoperatively. RESULTS All 45 patients had surgically proven insulinomas. Thirty-eight of 45 (84%) localized to the correct anatomical region by CaStim. In five of 45 (11%) patients, the CaStim was falsely negative. Two of 45 (4%) had false-positive localizations. CONCLUSION The CaStim has remained vastly superior to abdominal US, CT, or MRI over time as a preoperative localizing tool for insulinomas. The utility of the CaStim for this purpose and in this setting is thus validated.
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Affiliation(s)
- Jean-Marc Guettier
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, Maryland 20892, USA.
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Chang YH, Hsieh MC, Hsin SC, Shin SJ, Lin KD. Insulinoma-associated transient hypothalamus-pituitary-adrenal axis impairment and amelioration by steroid therapy and surgical intervention: a case report. Kaohsiung J Med Sci 2007; 23:526-30. [PMID: 18055299 DOI: 10.1016/s1607-551x(08)70011-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Insulinoma is the most common functional tumor among pancreatic islet cell tumors. This type of tumor is difficult to localize prior to surgery and can lead to serious hypoglycemia. This paper presents the case of a young female who suffered from insulinoma associated with transient hypothalamus-pituitary-adrenal axis impairment. To localize her insulinoma, we used two alternative testing methods, somatostatin receptor scintigraphy and selective arterial calcium stimulation with venous sampling, after a failure of conventional imaging methods. We treated her adrenal insufficiency and prevented serious hypoglycemia by giving her prednisolone. The impairment in her hypothalamus-pituitary-adrenal axis and her serious hypoglycemia recovered after excision of the tumor.
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Affiliation(s)
- Yu-Hung Chang
- Department of Endocrinology and Metabolism, Kaohsiung Medical University Hospital, 100 Shin-Chuan 1st Road, Kaohsiung, Taiwan
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Tseng LM, Chen JY, Won JGS, Tseng HS, Yang AH, Wang SE, Lee CH. The role of intra-arterial calcium stimulation test with hepatic venous sampling (IACS) in the management of occult insulinomas. Ann Surg Oncol 2007; 14:2121-7. [PMID: 17431724 DOI: 10.1245/s10434-007-9398-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2006] [Accepted: 02/17/2007] [Indexed: 12/17/2022]
Abstract
BACKGROUND Occult insulinomas remain a clinical challenge. Specifically designed protocols are necessary to aid detection and facilitate a focused pancreatic exploration. METHODS Seventeen non-multiple endocrine neoplasia (non-MEN) patients referred to this medical center in the past 10 years because of equivocal diagnosis, failure of previous operation or difficulty in localization for insulinomas were studied. A routine intra-arterial calcium stimulation test with venous sampling (IACS test) was done for lesion localization. An exploratory laparotomy with intraoperative ultrasound (IOUS) examinations was performed. RESULTS Preoperative imaging (sonography, high-resolution computed tomography scan, and magnetic resonance imaging) found six insulinomas, and IOUS found an additional six in the pancreatic regions; all were compatibly indicated by the IACS test. The remaining five patients with occult lesions by IOUS were treated by 40% (1) or 60-70% (4) distal pancreatectomies when insulin gradients were demonstrated on calcium stimulation to the splenic or to the superior mesenteric artery, respectively, and nesidioblastosis was found in each pathology examination. There were no complications related to the arterial stimulation and venous sampling (ASVS) test. No patient had recurrent hyperinsulinism, permanent morbidity, or mortality from surgery. CONCLUSIONS IACS test helps in the diagnosis of equivocal pancreatogenous hypoglycemia, indicating the pancreatic region of priority exploration and guiding a pancreatic resection.
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Affiliation(s)
- Ling-Ming Tseng
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
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Won JGS, Tseng HS, Yang AH, Tang KT, Jap TS, Lee CH, Lin HD, Burcus N, Pittenger G, Vinik A. Clinical features and morphological characterization of 10 patients with noninsulinoma pancreatogenous hypoglycaemia syndrome (NIPHS). Clin Endocrinol (Oxf) 2006; 65:566-78. [PMID: 17054456 DOI: 10.1111/j.1365-2265.2006.02629.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Noninsulinoma pancreatogenous hypoglycaemia syndrome (NIPHS), characterized by postprandial neuroglycopaenia, negative prolonged fasts and negative perioperative localization studies for insulinoma, but positive selective arterial calcium stimulation tests and nesidioblastosis in the gradient-guided resected pancreas, is a rare hypoglycaemic disorder of undetermined aetiology. We analysed the clinical, morphological and immunohistological features to further clarify the aetiology and pathogenesis of this rare disease. PATIENTS Ten consecutive patients with NIPHS (nine men and one woman, aged 29-78 years) were included in the study. Six of the 10 received a gradient-guided subtotal (70%) or distal (50%) pancreatectomy. In the remaining four patients, diazoxide treatment was initiated and the precise mechanism of its action was assessed by meal tests. RESULTS All of the patients showed a combination of postprandial neuroglycopaenia, negative prolonged fasts (except one patient) and negative localization studies for insulinoma, but positive calcium stimulation tests and nesidioblastosis in the gradient-guided resected pancreas. Immunohistological studies of the resected pancreatic tissues revealed neither an increased rate of proliferation of beta-cells nor an abnormal synthesis and/or processing of either proinsulin or amylin. Evidence of overexpression of the two pancreatic differentiation factors, PDX-1 and Nkx-6.1, as well as the calcium sensing receptor (CaSR) was absent. Nevertheless, abnormal expression of islet neogenesis-associated protein (INGAP), a human cytokine expressed only in the presence of islet neogenesis, in ducts and/or islets, was identified in three of the five patients studied. All of the six patients who received a surgical operation were relieved of further neuroglycopaenic attacks, but one patient who received a subtotal pancreatectomy developed diabetes. In the remaining four patients who received diazoxide treatment, hypoglycaemic episodes were satisfactorily controlled with an attenuated response of beta-cell peptides to meal stimulation. CONCLUSIONS Our results strengthen the existence of this unique clinical hypoglycaemic syndrome from beta-cell hyperfunction as well as the value of the selective arterial calcium stimulation test in its correct diagnosis and localization. The mechanisms underlying beta-cell hyperfunction and release of insulin to calcium, however, remain poorly characterized. Nevertheless, in a subset of patients with NIPHS, there exists some, as yet undefined, pancreatic humoral/paracrine factor(s) other than proinsulin, amylin, PDX-1, Nkx-6.1 and possibly glucagon-like peptide-1 (GLP-1) that are capable of inducing the INGAP gene and, if activated, will initiate ductal proliferation and islet neogenesis. As for the treatment, we recommend that diazoxide be tried first in each patient and, should it fail, a gradient-guided subtotal or distal pancreatectomy be attempted.
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Affiliation(s)
- Justin G S Won
- Department of Medicine, Veterans General Hospital - Taipei, Taiwan, Republic of China.
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Abstract
Although rare, insulinomas are the most common functioning islet cell tumour of the pancreas. Recognition of the key neuroglycopenic symptoms should trigger the initial investigation. Biochemical proof of endogenous hyperinsulinemic hypoglycemia establishes the diagnosis. Several options are available for imaging and localizing these tumours including ultrasonography, computed tomography, and intra-arterial calcium stimulation with venous sampling. The tumours are usually small, single, benign, well-circumscribed, and evenly distributed throughout the pancreas. This tumour may be a part of the multiple endocrine neoplasia type 1 (MEN-1) syndrome, in which case the tumours are almost always multiple. Surgical treatment is the only curative method, traditionally accomplished with enucleation or partial pancreatic resection. Patients are almost invariably cured lifelong with complete excision of a benign insulinoma. The most recent developments in this area are the recognition of noninsulinoma pancreatogenous hypoglycemia syndrome as a cause of organic hypoglycemia, and the development of laparoscopic techniques to excise these tumours.
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Affiliation(s)
- Clive S Grant
- Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street, SW Rochester, MN 55905, USA.
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Won JGS, Tseng HS, Yang AH, Tang KT, Jap TS, Kwok CF, Lee CH, Lin HD. Intra-arterial calcium stimulation test for detection of insulinomas: detection rate, responses of pancreatic peptides, and its relationship to differentiation of tumor cells. Metabolism 2003; 52:1320-9. [PMID: 14564685 DOI: 10.1016/s0026-0495(03)00200-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The selective intra-arterial calcium stimulation test has greatly facilitated the precise regionalization of insulinomas smaller than 2 cm, which noninvasive techniques (ultrasound [US], computed tomography [CT], magnetic resonance imaging [MRI]) often fail to localize. This study examined not only the role of the test in the localization of insulinomas, but also the responsiveness of 3 beta-cell peptides (insulin, C peptide, and proinsulin) and their relationship to the degree of differentiation of the tumor cells, using percentage decrease of both proinsulin/insulin (P/I) and proinsulin/C peptide (P/C) ratios after stimulation as indices. Ten consecutive surgically proven insulinoma patients each received an injection of calcium into the arteries supplying the pancreas after standard selective angiography and beta-cell peptide levels were measured in samples taken from the right hepatic vein before and 30, 60, 90, 120, and 180 seconds after each injection prior to operation. After surgery, the expressions of the calcium sensing receptor (CaSR) on the resected tumors were assessed by immunohistochemistry. Intra-arterial calcium stimulation with sampling either for insulin or for C peptide correctly predicted the site of insulinoma in 8 of 9 patients or in 7 of 8 patients if the 2 big malignant insulinomas were excluded; thus, the detection rate of this test was 89% and 88%, respectively. Calcium administration stimulated a marked and prompt release of insulin and C peptide simultaneously. Both peaked within 30 to 60 seconds, then declined gradually thereafter, remaining above the baseline at 180 seconds. The magnitude of increase correlated well with the corresponding percentage decrease of P/I and P/C ratios. The response of proinsulin was much less. Immunohistochemistry demonstrated variable membraneous staining for CaSR in normal pancreatic islets and in about 9% of the total normal beta cells, whereas staining in tumor cells was only minimally detectable. We conclude that selective intra-arterial calcium stimulation with hepatic venous sampling either for insulin or for C peptide is a highly sensitive method for the preoperative localization of small insulinomas. Calcium injection stimulates a brisk response of insulin, C peptide, and proinsulin simultaneously and the magnitude of increase of both insulin and C peptide appears to be correlated well with the degree of differentiation of the tumor cells. The exact mechanism by which calcium provokes the release of beta-cell peptides is less clear and whether the CaSR is involved in the mechanism of its action requires further study.
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Affiliation(s)
- Justin G s Won
- Department of Medicine, Veterans General Hospital-Taipei, Taiwan, Republic of China
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Sung YM, Do YS, Lee MK, Shin SW, Liu WC, Choo SW, Choo IW. Selective intra-arterial calcium stimulation with hepatic venous sampling for preoperative localization of insulinomas. Korean J Radiol 2003; 4:101-8. [PMID: 12845305 PMCID: PMC2698067 DOI: 10.3348/kjr.2003.4.2.101] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2003] [Accepted: 05/10/2003] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the value of selective intra-arterial calcium stimulation with hepatic venous sampling using serum insulin and C-peptide gradients for the preoperative localization of insulinomas. MATERIALS AND METHODS Seven consecutive patients (three men and four women aged 15-77 (mean, 42.7) years) with hypoglycemia underwent selective intra-arterial calcium stimulation in conjunction with hepatic venous sampling. Insulin gradients were calculated by an individual blinded to all other preoperative imaging studies and operative findings. In all patients except one, C-peptide gradients were also analyzed. The results were compared with the preoperative findings of ultrasonography, computed tomography, arteriography and endoscopic ultrasonography, as well as with the intraoperative findings of ultrasonography and palpation at surgery. RESULTS Eight insulinomas (mean diameter, 12.5 mm) were diagnosed after surgery. In six patients, the calcium stimulation test with insulin gradients allowed accurate localization of the pathologic source of insulin secretion. Both C-peptide and insulin gradients substantially increased diagnostic accuracy. In one patient, C-peptide gradients were more helpful than insulin gradients for tumor localization. CONCLUSION Selective intra-arterial calcium stimulation with hepatic venous sampling is a highly accurate and safe method for the preoperative localization of insulinomas. Additional C-peptide gradients seem to be helpful in assessing tumor location, but further study is needed.
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Affiliation(s)
- Yon Mi Sung
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Soo Do
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon-Kyu Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Wook Shin
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wei Chiang Liu
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Wook Choo
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In-Wook Choo
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
To make a diagnosis of insulinoma, one must consider it. Neuroglycopenic symptoms are the most prominent and convincing, and the combination of hypoglycemia and endogenous hyperinsulinemia are diagnostic of insulinoma. A glucose level of approximately 40 mg/dL with a concomitant insulin level of 6 microU/mL, a C-peptide level exceeding 200 pmol/L, and a negative screening for sulfonylurea must be documented to confirm the diagnosis. Although in the author's experience, preoperative ultrasound is the best and often the only test performed in the patient undergoing a first-time operation, arteriography is perhaps the single most effective localization test performed on a nationwide basis. Expertly performed intraoperative ultrasonography assists in tumor localization and in delineating important related anatomy and has become virtually routine in the author's surgical practice. Insulinomas are typically benign, single, and small, and are generally firmer than surrounding normal pancreas. Extensive surgical exposure may be required to identify and safely remove the tumor. Enucleation is preferred by the author, but distal pancreatectomy for tumors in the body or tail is an excellent method as well. Tumors in the head of the pancreas are usually enucleated, and pancreatoduodenectomy is rarely performed. The most troublesome complication is a pancreatic leakage causing pseudocyst, abscess, or fistula. Except in MEN 1 syndrome, in which a more extensive resection is usually indicated, excision of a single benign insulinoma leads to long-term cure of the disease. The successful excision of an insulinoma will profoundly affect a patient's life.
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Affiliation(s)
- C S Grant
- Department of Surgery, Mayo Medical School, Rochester, Minnesota, USA
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Abernethy LJ, Davidson DC, Lamont GL, Shepherd RM, Dunne MJ. Intra-arterial calcium stimulation test in the investigation of hyperinsulinaemic hypoglycaemia. Arch Dis Child 1998; 78:359-63. [PMID: 9623401 PMCID: PMC1717523 DOI: 10.1136/adc.78.4.359] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the use of a calcium infusion test in the diagnosis and localisation of insulin secreting tumours in children. PATIENTS Three patients with persistent hypoglycaemia of infancy (PHHI). PROCEDURE During planned selective coeliac and mesenteric arteriography, serial samples were taken from a catheter in the right hepatic vein for insulin measurement following the injection of calcium gluconate. RESULTS In all three children, selective intra-arterial calcium stimulation produced a significant rise in plasma insulin and was of value in localising the pancreatic abnormality in one child. In vitro studies on islets of Langerhans isolated from this patient following partial pancreatectomy showed unresponsive intracellular calcium signalling of the cells when stimulated with high extracellular concentrations of glucose and potassium or with sulphonylurea drugs (tolbutamide), but normal responsiveness to increasing extracellular calcium concentrations. CONCLUSIONS The findings suggest a functional abnormality of the calcium channel in PHHI and provide a rationale for the reported efficacy of channel blocking drugs in this condition. The role of selective intra-arterial calcium stimulation in the diagnosis of hyperinsulinaemic hypoglycaemia in childhood warrants further investigation.
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Imamura M, Shimada Y, Kato M, Doi R, Okada N, Hashimoto M. Usefulness of selective arterial calcium injection test and secretin test in patients with insulinoma. ACTA ACUST UNITED AC 1994. [DOI: 10.1007/bf01211915] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kung AW, Chan FL, Tam SC, Lam KS. Case report: localization of occult insulinoma by intra-arterial stimulation with calcium and venous sampling technique. Clin Radiol 1992; 46:55-6. [PMID: 1643786 DOI: 10.1016/s0009-9260(05)80036-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Hypoglycaemia as a result of insulin secreting tumours can be treated effectively by surgery. However pre-operative localization is desirable as the majority of these tumours are small and in 20% of the cases may be multiple. We describe a 1 cm insulinoma being localized pre-operatively by selective arterial stimulation with calcium and venous sampling for insulin. This technique is sensitive and relatively non-invasive. We believe that it is potentially very valuable in pre-operative localization of occult insulinomas.
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Affiliation(s)
- A W Kung
- Department of Medicine, University of Hong Kong
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Mozell E, Stenzel P, Woltering EA, Rösch J, O'Dorisio TM. Functional endocrine tumors of the pancreas: clinical presentation, diagnosis, and treatment. Curr Probl Surg 1990; 27:301-86. [PMID: 1973365 DOI: 10.1016/0011-3840(90)90025-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- E Mozell
- Department of Surgery, Oregon Health Sciences University, Portland
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Davis M, Nassberg B, Borges JL, Iranmanesh A, Lizzaralde G, Santen RJ, Drake C, Rogol AD, Kaiser DL, Thorner MO. Actions of calcium ions and a calcium-influx blocker on basal and TRH- and GnRH-stimulated hormone release in patients with pituitary adenomas. J Endocrinol Invest 1987; 10:427-33. [PMID: 3323290 DOI: 10.1007/bf03348164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We investigated the influence of calcium ions on the secretion of anterior pituitary hormones basally and in response to exogenous hypothalamic releasing factors in 6 men with pituitary tumors. To this end, concentrations of LH, FSH, TSH, growth hormone and prolactin were measured in blood collected at 10-min intervals basally and during a continuous infusion of combined TRH (2 micrograms/min) and GnRH (1 microgram/min). Study sessions were randomized to iv saline, calcium, or diltiazem infusions or oral diltiazem administration. Our results indicate that in contrast to responses in normal men, iv calcium injections do not suppress circulating prolactin concentrations in patients with prolactin-secreting pituitary tumors. Moreover, neither oral diltiazem administration for one week nor acute iv diltiazem infusion suppressed the hyperprolactinemia of tumor patients. However, there were significant effects of drug and calcium treatments on serum concentrations of FSH, GH and testosterone, but not LH or TSH. Moreover, during GnRH-TRH stimulation, there were significant differences in LH, TSH, and testosterone responses in tumor patients compared to normal men. In summary, iv calcium infusion was associated with invariant basal release of anterior pituitary tumoral hormones in patients with pituitary adenomas. However, there were significant differences in the GnRH/TRH-stimulated release of certain anterior pituitary hormones in tumor patients compared to normal men in response to iv calcium and the calcium-channel antagonist, diltiazem.
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Affiliation(s)
- M Davis
- Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville 22908
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Abstract
Many other hypoglycemic states can be confused with an insulinoma. This article presents the diagnosis, localization, and therapy of these islet cell tumors. Also presented is a discussion of the role of nesidioblastosis in persistent hyperinsulinemic hypoglycemia in the neonate.
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Abstract
The multiple endocrine neoplasia (MEN) syndromes are characterized by autosomal dominant inheritance with a high degree of penetrance but varying expression. This review gives a classification of these syndromes and a short summary of the historical background. The pathogenesis of the disease and its possible origin in the APUD cell system are discussed together with the mechanisms underlying normal and ectopic hormone production by MEN tumors on the basis of recent findings in molecular endocrinology. The natural history and the clinical manifestations of the different syndromes are described. The sensitivity and discriminative capacity of the tests used to detect the syndromes in an early stage are compared. The choice of therapy and criteria for the timing and extensiveness of treatment are also considered. Lastly, problems associated with the ethical and legal aspects of screening, central registration, and monitoring of relatives at risk are described.
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Praz GA, Halban PA, Wollheim CB, Blondel B, Strauss AJ, Renold AE. Regulation of immunoreactive-insulin release from a rat cell line (RINm5F). Biochem J 1983; 210:345-52. [PMID: 6134520 PMCID: PMC1154230 DOI: 10.1042/bj2100345] [Citation(s) in RCA: 202] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
1. An insulin-producing cell line, RINm5F, derived from a rat insulinoma was studied. 2. The cellular content of immunoreactive insulin was 0.19 pg/cell, which represents approx. 1% of the insulin content of native rat beta-cells, whereas that of immunoreactive glucagon and somatostatin was five to six orders of magnitude less than that of native alpha- or delta-cells respectively. 3. RINm5F cells released 7-12% of their cellular immunoreactive-insulin content at 2.8 mM-glucose during 60 min in Krebs-Ringer bicarbonate buffer. 4. Glucose utilization was increased by raising glucose from 2.8 to 16.7 mM. There was, however, no stimulation of immunoreactive-insulin release even when glucose was increased from 2.8 to 33.4 mM. A small stimulation of release was, however, found when glucose was raised from 0 to 2.8 mM. 5. Glyceraldehyde stimulated the release of immunoreactive insulin in a dose-dependent manner. 6. At 20 mM, leucine or arginine stimulated release at 2.8 mM-glucose. 7. Raising intracellular cyclic AMP by glucagon or 3-isobutyl-1-methylxanthine stimulated release at 2.8 mM-glucose with no additional stimulation at 16.7 mM-glucose. 8. Stimulation of immunoreactive-insulin release by K+ was dose-related between 2 and 30 mM. Another depolarizing agent, ouabain, also stimulated release. 9. Adrenaline (epinephrine) inhibited both basal (2.8 mM-glucose) release and that stimulated by 30 mM-K+. 10. Raising Ca2+ from 1 to 3 mM stimulated immunoreactive-insulin release, whereas a decrease from 1 to 0.3 or to 0.1 mM-Ca2+ lowered the release. 11. These findings could reflect a relatively specific impairment in glucose handling by RINm5F cells, contrasting with the preserved response to other modulators of insulin release.
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Harrop JS, Golding PR, Goodall P, Leveau VM, Steele GA, Ingle AR. C-peptide suppression test and sulphonylurea-induced factitious hypoglycaemia. BMJ 1982; 284:940-1. [PMID: 6802358 PMCID: PMC1496470 DOI: 10.1136/bmj.284.6320.940-a] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Erfurth EM, Hedner P. Importance of thyroxine in suppressing secretion of thyroid-stimulating hormone after thyroidectomy. BMJ 1982; 284:941-2. [PMID: 6802359 PMCID: PMC1496522 DOI: 10.1136/bmj.284.6320.941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Miller JL, Klaff LJ, Abrahamson MJ, Marine N. Failure of calcium infusion as a provocative test for insulinoma. N Engl J Med 1981; 304:1430. [PMID: 6262642 DOI: 10.1056/nejm198106043042319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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