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Avari P, Eng PC, Hu M, Chen R, Popovic N, Polychronakos C, Spalding D, Rutter GA, Oliver N, Wernig F. A Novel Somatic Mutation Implicates ATP6V0D1 in Proinsulin Processing. J Endocr Soc 2023; 7:bvac196. [PMID: 36694809 PMCID: PMC9856271 DOI: 10.1210/jendso/bvac196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Indexed: 12/31/2022] Open
Abstract
Context Prohormone convertase 1/3 (PC1/3), encoded by protein convertase subtilisin kexin type 1 (PCSK1), converts inactive prohormones into biologically active peptides. Somatic mutations of insulinomas are associated with genetic defects interfering with control of insulin secretion from pancreatic beta cells. However, somatic mutations in proinsulinomas have not been described. Objective We report a case of a proinsulinoma, with suppressed insulin and C-peptide levels. Methods A 70-year-old woman presented with a 20-year history of "blackouts." During a 72-hour fast, blood glucose level dropped to 1.9 mmol/L with suppressed plasma insulin and C-peptide levels, but proinsulin levels were raised at 37 pmol/L (<10 pmol/L). Results Imaging revealed 3 distinct DOTATATE-avid pancreatic lesions. Laparoscopic spleen-preserving distal pancreatomy was performed. In view of discordant insulin, C-peptide, and proinsulin levels, whole exome sequencing analysis was performed on the tumor. In the somatic exome of the tumor, we found mutations in PCSK expression regulators, as well as a novel truncating somatic mutation in ATP6V0D1, a subunit of the ion pump that acidifies the β-cell compartments where the PCSKs act. Conclusion Appropriately suppressed insulin levels in the context of hypoglycemia do not always indicate the absence of a neuroendocrine islet cell tumor and proinsulin levels may be indicated to solidify the diagnosis. In the context of elevated proinsulin levels, low insulin and C-peptide levels might be explained by somatic mutations that likely implicate proinsulin processing within the tumor. Furthermore, we propose several mechanistic candidates, including ATP6V0D1. Experimental validation using cellular approaches may in future confirm pathomechanisms involved in this rare condition.
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Affiliation(s)
- Parizad Avari
- Correspondence: Parizad Avari, PhD, Department of Endocrinology, Hammersmith Hospital, Du Cane Road, London W12 ONN, UK.
| | | | - Ming Hu
- Section of Cell Biology and Functional Genomics, Department of Metabolism, Diabetes and Reproduction, Imperial College London, London W120NN, UK
| | - Runzhi Chen
- Section of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust London, London W120HS, UK
| | - Natalija Popovic
- The Endocrine Genetics Laboratory, Research Institute of the McGill University Health Centre and the Montreal Children's Hospital, Montréal, QC H4A3J1, Canada
| | - Constantin Polychronakos
- The Endocrine Genetics Laboratory, Research Institute of the McGill University Health Centre and the Montreal Children's Hospital, Montréal, QC H4A3J1, Canada
- Department of Endocrinology, Zhejiang University Children's Hospital, Hangzhou 310006, People's Republic of China
| | - Duncan Spalding
- Department of Hepatobiliary Surgery, Hammersmith Hospital, Imperial College London Healthcare NHS Trust London, London H2X049, UK
| | - Guy A Rutter
- Section of Cell Biology and Functional Genomics, Department of Metabolism, Diabetes and Reproduction, Imperial College London, London W120NN, UK
- Faculty of Medicine, CHUM Research Center and University of Montreal, Montreal, QC 639798, Canada
- Lee Kong Chian School of Medicine, Nan Yang Technological University, Singapore 308232, Singapore
| | - Nick Oliver
- Section of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust London, London W120HS, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London W120NN, UK
- Section of Cell Biology and Functional Genomics, Department of Metabolism, Diabetes and Reproduction, Imperial College London, London W120NN, UK
| | - Florian Wernig
- Section of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust London, London W120HS, UK
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Kriger AG, Berelavichus SV, Kaldarov AR, Panteleev VI, Gorin DS, Dugarova RS, Yukina MY. Proinsulin-Secreting Neuroendocrine Tumors of the Pancreas: A Single-Centre Experience. Gastrointest Tumors 2019; 6:64-70. [PMID: 31768350 DOI: 10.1159/000501455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 06/09/2019] [Indexed: 11/19/2022] Open
Abstract
Background Proinsulinoma is a neuroendocrine tumor (NET) of the pancreas that produces prohormone proinsulin. These tumors are very rare. In the literature, they are most often presented in the form of case reports. Materials and Methods We studied 177 patients with NET of the pancreas who underwent surgical treatment in the A.V. Vishnevsky National Medical Research Centre of Surgery from January 2007 to December 2018. Results Of 81 patients with organic hyperinsulinism caused by functioning NETs of the pancreas during the study period, 3 (3.7%) had a proinsulinoma; 2 were female; and 1 was male. None of them admitted to weight gain during this period, and their BMI was normal. All patients presented with Whipple's triad during the 72-h fast. Tumor-enucleating surgery was performed: one robot assisted, two laparotomies. A normal glucose level after treatment was achieved in all cases. Conclusion In cases where clinical hypoglycemia is present, but the serum insulin level is within the normal range or even decreased, proinsulinoma should be suspected. For now, surgical resection remains the only effective method of treatment. Further investigation of pro-insulinomas is needed.
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Affiliation(s)
| | | | | | | | - David Semjonovich Gorin
- Abdominal Surgery, Department of A.V. Vishnevsky Centre of Surgery, Moscow, Russian Federation
| | | | - Marina Yur'evna Yukina
- Therapeutic Endocrinology Department, National Medical Research Centre of Endocrinology, Moscow, Russian Federation
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Mele C, Brunani A, Damascelli B, Tichà V, Castello L, Aimaretti G, Scacchi M, Marzullo P. Non-surgical ablative therapies for inoperable benign insulinoma. J Endocrinol Invest 2018; 41:153-162. [PMID: 28755102 DOI: 10.1007/s40618-017-0738-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 07/22/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Benign insulinoma is the most common functioning neuroendocrine tumor of the pancreas. The gold-standard therapeutic approach for insulinoma is surgery, which allows for tumor removal, histology and immunochemical analyses. If surgery is not feasible, minimally invasive ablative procedures performed by interventional radiology can lead to partial or complete remission of hormone hypersecretion and tumor control in insulinoma patients. METHODS We performed a review of existing literature on non-chemotherapeutic/radioactive ablative techniques employed for the treatment of benign, otherwise inoperable, pancreatic insulinoma. For this purpose, feasibility, effectiveness and safety of ablative treatments for pancreatic insulinoma were reviewed from literature data published from 1982 to date. RESULTS A total of 44 insulinoma cases treated with non-surgical ablative techniques were desumed, and divided as follows: 7 cases of tumor embolization, 26 ethanol ablations, 7 radiofrequency ablations, 2 high intensity focused ultrasound ablation, 1 irreversible electroporation and 1 percutaneous microwave ablation. Most cases involved single insulinoma, predominantly located in the pancreas head and body. In the majority of patients, ablation was chosen instead of surgery due to severe comorbidities. After an average follow-up of 16 months, the overall success rate of non-surgical ablative treatments of insulinoma was 84%, the recurrence/persistence rate was 16%, and transient adverse events were noted in 23% of cases. Adverse events were usually self-limiting and medically manageable. CONCLUSIONS Non-surgical ablation is a feasible, safe and repeatable procedure in patients with pancreatic insulinoma, who are not candidate to surgery or refuse it. Partial or complete control of symptoms and tumor growth is experienced by the majority of patients.
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Affiliation(s)
- C Mele
- Division of General Medicine, IRCCS Istituto Auxologico Italiano, Ospedale S. Giuseppe, Via Cadorna 90, 28824, Piancavallo, VB, Italy
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
| | - A Brunani
- Division of Rehabilitation Medicine, Istituto Auxologico Italiano, Ospedale S. Giuseppe, Via Cadorna 90, 28824, Piancavallo, VB, Italy
| | - B Damascelli
- Department of Interventional Radiology, EMO GVM Centro Cuore Columbus, Via Buonarroti 48, 20145, Milan, Italy
| | - V Tichà
- Radiology and Interventional Radiology Unit, ASST Santi Paolo e Carlo, San Carlo Borromeo Hospital, Via Pio II 3, 20153, Milan, Italy
| | - L Castello
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
| | - G Aimaretti
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
| | - M Scacchi
- Division of General Medicine, IRCCS Istituto Auxologico Italiano, Ospedale S. Giuseppe, Via Cadorna 90, 28824, Piancavallo, VB, Italy
| | - P Marzullo
- Division of General Medicine, IRCCS Istituto Auxologico Italiano, Ospedale S. Giuseppe, Via Cadorna 90, 28824, Piancavallo, VB, Italy.
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy.
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Pérez-Pevida B, Idoate MÁ, Fernández-Landázuri S, Varo N, Escalada J. Hypoglycemic Syndrome without Hyperinsulinemia. A Diagnostic Challenge. Endocr Pathol 2016; 27:50-4. [PMID: 26801953 DOI: 10.1007/s12022-016-9415-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The most common cause of organic fasting hypoglycemia in adults is the presence of an insulin-producing pancreatic adenoma, but when high insulin levels are not found, the differential diagnosis is challenging. Misdiagnosis can lead to an unnecessary pancreatectomy. Insulin concentrations may be low in some cases despite a clinical history suggestive of insulinoma. In these cases, a proinsulinoma should be suspected, although the rarity of this condition requires an extensive workup before reaching a final diagnosis. We describe an unusual case of a 38-year-old man with a severe hypoglycemic syndrome due to a proinsulin-secreting pancreatic adenoma. Insulin was measured by the specific assay and suppressed under the lower detection limit during fasting hypoglycemia. Serum proinsulin and C-peptide levels were abnormally elevated, and further tests revealed an islet cell tumor. The tumor was surgically removed, relieving the fasting hypoglycemia. Histopathological study showed a conventional well-differentiated neuroendocrine tumor with high immunoreactivity against proinsulin and with lesser intensity against insulin. Interestingly, GS-9A8 antibody clone used for immunostaining proinsulin did not cross-react with human insulin or C-peptide, providing an unbiased picture of proinsulin secretion. The resolution of symptoms, the fall of proinsulin concentrations after tumor removal and the histopathology study confirmed the diagnosis of proinsulinoma.
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Affiliation(s)
- Belén Pérez-Pevida
- Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, Avenida Pio XII 36, 31008, Pamplona, Spain.
| | | | | | - Nerea Varo
- Department of Biochemistry, Clínica Universidad de Navarra, Pamplona, Spain
| | - Javier Escalada
- Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, Avenida Pio XII 36, 31008, Pamplona, Spain
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A systematic review of non-surgical treatments for pancreatic neuroendocrine tumours. Cancer Treat Rev 2014; 40:376-89. [DOI: 10.1016/j.ctrv.2013.08.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 08/28/2013] [Accepted: 08/30/2013] [Indexed: 12/31/2022]
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Koivisto C, Flake GP, Kolenda-Roberts H, Masinde T, Kissling GE, Sills RC, Hoenerhoff MJ. Immunohistochemical investigation of F344/N rat islet cell tumors from national toxicology program studies. Toxicol Pathol 2012; 40:751-63. [PMID: 22477723 DOI: 10.1177/0192623312441407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
In this study, we have investigated the immunoexpression of peptide hormones and mediators associated with human islet cell tumors in a group of proliferative islet cell lesions in F344 rats including islet cell hyperplasias, adenomas, and carcinomas, as defined by conventional histopathologic criteria. All proliferative islets expressed synaptophysin, although decreased expression intensity was observed in hyperplasias and adenomas. Most of the proliferative lesions expressed insulin, which generally decreased as lesions progressed toward malignancy. The distribution of glucagon, somatostatin, and gastrin-expressing cells was altered in proliferative islet lesions but did not comprise a large proportion of cells. Islet cell tumors were associated with increased nuclear expression of cyclin-dependent kinase 4 as well as increased proliferating cell nuclear antigen and decreased β-catenin expression. c-Myelocytomatosis oncogene expression was variable. This is the first study to describe the immunophenotype of islet cell tumors in the F344 rat and to show that islet cell tumors in the F344 rat exhibit similarities in protein expression to the human counterpart.
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Affiliation(s)
- Christopher Koivisto
- Cellular and Molecular Pathology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
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Dasanu CA, Majumder S, Gopal S, Stoica-Mustafa E, Trikudanathan G. Emerging therapeutic options for advanced enteropancreatic neuroendocrine tumors. Expert Opin Pharmacother 2012; 13:461-71. [PMID: 22292707 DOI: 10.1517/14656566.2012.656089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Several chemotherapy agents and combinations have proven effective in the therapy of advanced enteropancreatic neuroendocrine tumors (EP-NETs). However, their toxicity can be significant. Recent understanding of the molecular mechanisms of these tumors, especially the central role of tumor angiogenesis, has led to the identification of new therapeutic targets and agents directed at the molecular level. AREAS COVERED This paper gives a comprehensive evaluation of the existing therapeutic armamentarium for EP-NETs. Narrated in a historical perspective, this review analyzes the available information on traditional chemotherapy agents, interferon-α and somatostatin analogs, as well as newer therapies and experimental agents. EXPERT OPINION Despite recent advances, a curative approach for metastatic EP-NETs is yet to be discovered. To date, sunitinib and everolimus have been shown to impact progression-free survival only in pancreatic NETs, and the duration of this benefit has not yet been established. Further research is necessary to determine whether a combination of these drugs, either together or with other therapies, may yield superior outcomes. Moreover, sequential use of these agents should be explored in an attempt to improve survival. Efficacy of a variety of experimental agents is also being tested in clinical trials.
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Affiliation(s)
- Constantin A Dasanu
- Department of Hematology-Oncology, St. Francis Hospital and Medical Center, Hartford, CT 06105, USA.
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Abstract
Hypoglycemia can be common in patients using insulin injections or certain antidiabetes medications. In rare cases, hypoglycemia can be caused by a pancreatic insulinoma. We report a case of a 33-year-old woman found to have severe recurrent hypoglycemia. Diagnostic studies such as continuous glucose monitoring and a hospitalized fast provided biochemical evidence for a proinsulinoma. After abdominal multidetector contrast-enhanced computerized tomography failed to detect pancreatic abnormalities, endoscopic ultrasonography identified and localized a 9-mm pancreatic tail lesion. At the time of endoscopy, the lesion was tattooed with ultrasonographic guidance for subsequent laparoscopic visualization and curative resection.
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Ong GSY, Henley DE, Hurley D, Turner JH, Claringbold PG, Fegan PG. Therapies for the medical management of persistent hypoglycaemia in two cases of inoperable malignant insulinoma. Eur J Endocrinol 2010; 162:1001-8. [PMID: 20164213 DOI: 10.1530/eje-09-1010] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Hypoglycaemia poses a significant management challenge in patients with unresectable functional malignant insulinoma. Novel agents such as mammalian target of rapamycin (mTOR) inhibitors and radiolabelled peptides may be effective where there is failure of conventional therapy. DESIGN We present the cases of two men diagnosed with inoperable malignant insulinoma and hepatic metastases who developed severe symptomatic hypoglycaemia, and review potential therapies for glycaemic support. METHOD Despite treatment with diazoxide, frequent oral carbohydrate, prednisolone and somatostatin analogue therapy, both men required hospital admission for treatment with continuous i.v. dextrose. Both were treated with Lutetium-177 octreotate. One man was also treated with everolimus, a mTOR inhibitor. RESULT Use of Lutetium-177 octreotate, and in one case everolimus, successfully achieved normoglycaemia, facilitating safe discharge from hospital. Both men also had regression in the size and number of hepatic metastases. CONCLUSION Lutetium-177 octreotate and everolimus are options for managing hypoglycaemia due to unresectable malignant insulinoma when refractory to conventional supportive therapies.
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Affiliation(s)
- Gregory S Y Ong
- Department of Endocrinology and Diabetes, Fremantle Hospital and Health Service, Fremantle, Western Australia, Australia
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Impact of splenectomy on thrombocytopenia, chemotherapy, and survival in patients with unresectable pancreatic cancer. J Gastrointest Surg 2010; 14:1012-8. [PMID: 20309646 PMCID: PMC2872015 DOI: 10.1007/s11605-010-1187-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Accepted: 02/23/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with unresectable pancreatic cancer (PDAC) or endocrine tumors (PET) often develop splenic vein thrombosis, hypersplenism, and thrombocytopenia which limits the administration of chemotherapy. METHODS From 2001 to 2009, 15 patients with recurrent or unresectable PDAC or PET underwent splenectomy for hypersplenism and thrombocytopenia. The clinical variables of this group of patients were analyzed. The overall survival of patients with PDAC was compared to historical controls. RESULTS Of the 15 total patients, 13 (87%) had PDAC and 2 (13%) had PET. All tumors were either locally advanced (n = 6, 40%) or metastatic (n = 9, 60%). The platelet counts significantly increased after splenectomy (p < 0.01). All patients were able to resume chemotherapy within a median of 11.5 days (range 6-27). The patients with PDAC had a median survival of 20 months (range 4-67) from the time of diagnosis and 10.6 months (range 0.6-39.8) from the time of splenectomy. CONCLUSIONS Splenectomy for patients with unresectable PDAC or PET who developed hypersplenism and thrombocytopenia that limited the administration of chemotherapy, significantly increased platelet counts, and led to resumption of treatment in all patients. Patients with PDAC had better disease-specific survival as compared to historical controls.
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EUS for pancreatic endocrine tumors: do we need to know our pancreatic endocrine tumor's DNA? Gastrointest Endosc 2009; 69:1081-4. [PMID: 19410041 DOI: 10.1016/j.gie.2008.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Accepted: 08/03/2008] [Indexed: 12/10/2022]
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