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Hofland J, Refardt JC, Feelders RA, Christ E, de Herder WW. Approach to the Patient: Insulinoma. J Clin Endocrinol Metab 2024; 109:1109-1118. [PMID: 37925662 PMCID: PMC10940262 DOI: 10.1210/clinem/dgad641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/02/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
Insulinomas are hormone-producing pancreatic neuroendocrine neoplasms with an estimated incidence of 1 to 4 cases per million per year. Extrapancreatic insulinomas are extremely rare. Most insulinomas present with the Whipple triad: (1) symptoms, signs, or both consistent with hypoglycemia; (2) a low plasma glucose measured at the time of the symptoms and signs; and (3) relief of symptoms and signs when the glucose is raised to normal. Nonmetastatic insulinomas are nowadays referred to as "indolent" and metastatic insulinomas as "aggressive." The 5-year survival of patients with an indolent insulinoma has been reported to be 94% to 100%; for patients with an aggressive insulinoma, this amounts to 24% to 67%. Five percent to 10% of insulinomas are associated with the multiple endocrine neoplasia type 1 syndrome. Localization of the insulinoma and exclusion or confirmation of metastatic disease by computed tomography is followed by endoscopic ultrasound or magnetic resonance imaging for indolent, localized insulinomas. Glucagon-like peptide 1 receptor positron emission tomography/computed tomography or positron emission tomography/magnetic resonance imaging is a highly sensitive localization technique for seemingly occult, indolent, localized insulinomas. Supportive measures and somatostatin receptor ligands can be used for to control hypoglycemia. For single solitary insulinomas, curative surgical excision remains the treatment of choice. In aggressive malignant cases, debulking procedures, somatostatin receptor ligands, peptide receptor radionuclide therapy, everolimus, sunitinib, and cytotoxic chemotherapy can be valuable options.
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Affiliation(s)
- Johannes Hofland
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
| | - Julie C Refardt
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
- ENETS Center of Excellence, Division of Endocrinology, Diabetology and Metabolism, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Richard A Feelders
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
| | - Emanuel Christ
- ENETS Center of Excellence, Division of Endocrinology, Diabetology and Metabolism, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Wouter W de Herder
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
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Dudley A, Khalil MI, Mullins G, Delanty N, Naggar HE. Hypoglycaemic events resembling focal seizures -A case report and literature review. Seizure 2021; 94:10-17. [PMID: 34801833 DOI: 10.1016/j.seizure.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To review the literature, for cases of hypoglycaemia misdiagnosed as epilepsy, including our interesting case of a patient with Type 1 Diabetes Mellitus, diagnosed with focal epilepsy. METHODS A literature search was completed. 20 of 473 studies, with a total of 22 cases found using specified search terms were relevant to this review. The papers identified and reviewed were those that dealt with hypoglycaemia misdiagnosed as epilepsy. The majority are isolated case reports given the rarity of this entity. RESULTS An underlying insulinoma is the most common cause for hypoglycaemic episodes to be misdiagnosed as epilepsy. Early morning seizures were prominent in 9 of the 22 cases. CONCLUSION Although rare, hypoglycaemia is an important differential diagnosis for drug-resistant epilepsy and early morning events may be an indication. We report the first case of recurrent hypoglycaemia from exogenous insulin, misdiagnosed as focal epilepsy with an available video EEG. The unusual presentation appeared clinically indistinct from recurrent focal seizures.
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Affiliation(s)
- Alex Dudley
- National Epilepsy Center- Beaumont Hospital, Ireland.
| | | | | | - Norman Delanty
- National Epilepsy Center- Beaumont Hospital, Ireland; Royal College of Surgeons in Ireland; FutureNeuro Science Foundation Ireland Research Centre
| | - Hany El Naggar
- National Epilepsy Center- Beaumont Hospital, Ireland; Royal College of Surgeons in Ireland; FutureNeuro Science Foundation Ireland Research Centre
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Kikuchi T, Chujo D, Takahashi K, Takahashi N, Tanno Y, Tonoike M, Ihana N, Tsujimoto T, Tanabe A, Kajio H. Insulinoma Presenting with Reactive Hypoglycemia: Evaluating the Effect of Tumor Resection via Continuous Glucose Monitoring. Intern Med 2017; 56:3067-3071. [PMID: 28943561 PMCID: PMC5725862 DOI: 10.2169/internalmedicine.8766-16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
A 71-year-old woman previously diagnosed with reactive hypoglycemia was transferred to our emergency unit because of loss of consciousness. Her plasma glucose level was 27 mg/dL, and continuous glucose monitoring (CGM) revealed postprandial asymptomatic hypoglycemia. A hypervascular tumor was identified via computed tomography in the distal pancreas, and the diagnosis of insulinoma was confirmed using the selective arterial calcium stimulation test. Although no episodes of hypoglycemia were observed during CGM after resection, a pathological examination identified regional lymph node metastasis. It is important to consider insulinoma as a cause of postprandial hypoglycemia, and CGM is useful for evaluating treatment outcomes.
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Affiliation(s)
- Tomohiko Kikuchi
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital, National Center for Global Health and Medicine, Japan
| | - Daisuke Chujo
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital, National Center for Global Health and Medicine, Japan
| | - Kazuhisa Takahashi
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital, National Center for Global Health and Medicine, Japan
| | - Nobuyuki Takahashi
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital, National Center for Global Health and Medicine, Japan
| | - Yuuki Tanno
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital, National Center for Global Health and Medicine, Japan
| | - Mie Tonoike
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital, National Center for Global Health and Medicine, Japan
| | - Noriko Ihana
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital, National Center for Global Health and Medicine, Japan
| | - Tetsuro Tsujimoto
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital, National Center for Global Health and Medicine, Japan
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital, National Center for Global Health and Medicine, Japan
| | - Hiroshi Kajio
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital, National Center for Global Health and Medicine, Japan
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Gu W, Liu Y, Liu H, Yang G, Guo Q, Du J, Jin N, Zang L, Lv Z, Ba J, Mu Y, Dou J. Characteristics of glucose metabolism indexes and continuous glucose monitoring system (CGMS) in patients with insulinoma. Diabetol Metab Syndr 2017; 9:17. [PMID: 28293303 PMCID: PMC5348912 DOI: 10.1186/s13098-017-0215-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 03/02/2017] [Indexed: 01/10/2023] Open
Abstract
AIMS Analyze the clinical applicability of glucose metabolism indexes and continuous glucose monitoring data on the qualitative diagnosis of insulinoma. METHODS Involve 22 patients with insulinoma (insulinoma group), 11 patients with hypoglycemia (hypoglycemia group) and 31 people with normal glucose tolerance (control group). HbA1c, fasting blood glucose (FBG), insulin (FINS) and C-peptide (FCP) was tested. Using CGMS to monitor the blood glucose for three consecutive days and selecting the monitoring data of 24 h thereof, figuring out, with the aid of EasyGV Version 9.0, the mean glucose (MG), the standard deviation (SD) of blood glucose, CONGA (continuous overall net glycemic action), J-Index, LI (Lability Index), LBGI (Low Blood Glucose Index), HBGI (High Blood Glucose Index), GRADE (glycaemic risk assessment diabetes equation), MAGE (mean aplitude of glycaemic excursions), M value, MAG (mean absolute glucose). RESULTS (1) FBG and LBG of insulinoma group are lower than those of control group and those of hypoglycemia group while FINS and FCP of insulinoma group are markedly higher than those of the other two groups; (2) the MG and CONGA of insulinoma group are lower than those of control group and its indexes like ST, LI, LBGI, GRADE, MAGE, M value and MAG are higher than those of control group; there are differences between the indexes of insulinoma group and those of hypoglycemia group in CONGA (lower than that of hypoglycemia group), LBGI (higher than that of hypoglycemia group), and M value (higher than that of hypoglycemia group). By drawing the ROC curve and calculating Youden index, the cut-off values of LBGI, M value, CONGA are respectively as 4.06, 7.79, 4.38, and the best index of differential diagnosis is LBGI. CONCLUSION Continuous glucose monitoring data can be used to diagnose insulinoma and blood glucose fluctuation indicators such as LBGI, M value, CONGA might be useful to identify insulinoma.
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Affiliation(s)
- Weijun Gu
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Yixin Liu
- Department of Internal Medicine, The Affiliated Hospital of Institute of Aviation Medicine, Beijing, 100089 People’s Republic of China
| | - Hongyan Liu
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Guoqing Yang
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Qinghua Guo
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Jin Du
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Nan Jin
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Li Zang
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Zhaohui Lv
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Jianming Ba
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Yiming Mu
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
| | - Jingtao Dou
- Department of Endocrinology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853 People’s Republic of China
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Suzuki K, Kawasaki A, Miyamoto M, Miyamoto T, Kanbayashi T, Sato M, Shimizu T, Hirata K. Insulinoma Masquerading as Rapid Eye Movement Sleep Behavior Disorder: Case Series and Literature Review. Medicine (Baltimore) 2015; 94:e1065. [PMID: 26107678 PMCID: PMC4504631 DOI: 10.1097/md.0000000000001065] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Insulinoma is a rare endocrine tumor that can cause a wide variety of symptoms, including abnormal nocturnal behavior. We report on 3 patients with insulinoma who presented with abnormal nocturnal behavior and injury during sleep, which simulated rapid eye movement (REM) sleep behavior disorder (RBD). In case 1, the fasting glucose level was 15 mg/dL, and insulin levels were elevated (15 μU/mL). In case 3, when the patient was transferred to the hospital because of a disturbance of consciousness, hypoglycemia (29 mg/dL) was detected. In contrast, in case 2, fasting glucose sampling did not indicate hypoglycemia, but continuous glucose monitoring revealed nocturnal hypoglycemia. The time from initial symptoms to a diagnosis of insulinoma ranged from 7 months to 2 years. All 3 patients had previously received anticonvulsant drugs for suspected epilepsy, but the medications were ineffective. Polysomnography showed no evidence of REM sleep without atonia in any of the 3 patients. No patient remembered any events that occurred during sleep. When a patient manifests abnormal behavior during the night and early morning, glucose monitoring should be performed, especially during the night and early morning. Clinicians should be aware that although insulinomas are rare, they can mimic parasomnias, such as RBD.
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Affiliation(s)
- Keisuke Suzuki
- From the Department of Neurology (KS, AK, KH), Dokkyo Medical University, Tochigi, Japan; School of Nursing (MM), Dokkyo Medical University, Tochigi, Japan; Department of Neurology (TM), Dokkyo Medical University, Koshigaya Hospital, Saitama, Japan; Department of Neuropsychiatry (TK, MS, TS), Akita University School of Medicine, Akita, Japan; and International Institute for Integrative Sleep Medicine (WPI-IIIS) (TK, TS), University of Tsukuba, Tsukuba, Japan
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