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Preston CA, Sachithanandan N, Sim IW, van Heerden J, Farrell S. Insulinoma: Metastatic Recurrence 38 Years Following Initial Diagnosis in Pregnancy. JCEM CASE REPORTS 2024; 2:luad168. [PMID: 38196815 PMCID: PMC10773549 DOI: 10.1210/jcemcr/luad168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Indexed: 01/11/2024]
Abstract
A case of recurrent insulinoma spanning 4 decades is described. Following a delayed diagnosis, hyperinsulinemic hypoglycemia was confirmed in a 24-year-old woman during early pregnancy. Initial surgery, culminating in subtotal pancreatectomy, was noncurative. A 1-cm insulinoma was subsequently resected from the head of the pancreas postpartum, with postoperative resolution of hypoglycemia. However, 32 years later, the patient experienced a recurrence of hypoglycemic symptoms. Eventually, a subcentimeter extrapancreatic lesion was identified anterior to the pancreatic head on gallium-68 DOTA-Exendin-4 positron emission tomography/computed tomography. In 2022, a third operation was performed, with excision of a 4 × 3 mm tumor adjacent to the pancreatic head, and histology confirming insulinoma. She was again cured of symptoms.
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Affiliation(s)
- Christopher A Preston
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Fitzroy, Victoria 3065, Australia
- Department of Endocrinology & Diabetes, Western Health, Melbourne, Victoria 3021, Australia
| | - Nirupa Sachithanandan
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Fitzroy, Victoria 3065, Australia
- Department of Medicine, The University of Melbourne, Fitzroy, Victoria 3065, Australia
| | - Ie-Wen Sim
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Fitzroy, Victoria 3065, Australia
- Department of Endocrinology & Diabetes, Western Health, Melbourne, Victoria 3021, Australia
- Department of Medicine, The University of Melbourne, Fitzroy, Victoria 3065, Australia
- Department of Endocrinology & Diabetes, Monash Health and Eastern Health, Melbourne, Victoria 3168, Australia
- Department of Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Jon van Heerden
- Department of Surgery, Mayo Medical School, Rochester, MN 55905, USA
- Department of Surgery, Mayo Medical School, Mayo Clinic, Rochester, MN 55905, USA
- Department of Surgery, Medical University of South Carolina, Charleston 29425, USA
| | - Stephen Farrell
- Department of Surgery, St Vincent’s Hospital Melbourne, Fitzroy, Victoria 3065, Australia
- Department of Surgery, Austin Health, Heidelberg, Victoria 3084, Australia
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Friebe L, Freitag MT, Braun M, Nicolas G, Bauman A, Bushnell D, Christ E, Wild D. Peptide Receptor Radionuclide Therapy Is Effective for Clinical Control of Symptomatic Metastatic Insulinoma: A Long-Term Retrospective Analysis. J Nucl Med 2024; 65:228-235. [PMID: 38164592 DOI: 10.2967/jnumed.123.265894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/25/2023] [Indexed: 01/03/2024] Open
Abstract
Metastatic insulinoma is a rare malignant neuroendocrine tumor characterized by inappropriate insulin secretion, resulting in life-threatening hypoglycemia, which is often difficult to treat. There is currently very limited information about the efficacy of peptide receptor radionuclide therapy (PRRT) for clinical control of hypoglycemia. The aim of this long-term retrospective study was to evaluate the therapeutic efficacy of PRRT for improving hypoglycemia, to evaluate the change of medication after PRRT, and to calculate progression-free survival (PFS) and overall survival (OS). Methods: Inclusion criteria were histologically proven somatostatin receptor-positive metastatic malignant insulinoma and at least 2 cycles of [90Y]Y-DOTATOC or [177Lu]Lu-DOTATOC therapy from early 2000 to early 2022. A semiquantitative scoring system was used to quantify the severity and frequency of hypoglycemic episodes under background antihypoglycemic therapy (somatostatin analog, diazoxide, everolimus, corticosteroids): score 0, no hypoglycemic episodes; score 1, hypoglycemic events requiring additional conservative treatment with optimization of nutrition; score 2, severe hypoglycemia necessitating hospitalization and combined medication or history of hypoglycemic coma. Hypoglycemic score before and after PRRT was analyzed. Time of benefit was defined as a time range of fewer hypoglycemic episodes in the observation period than at baseline. Information on antihypoglycemic medication before and after therapy, PFS, and OS was recorded. Results: Twenty-six of 32 patients with a total of 106 [90Y]Y-DOTATOC/[177Lu]Lu-DOTATOC cycles were included. The average observation period was 21.5 mo (range, 2.3-107.4 mo). Before therapy, 81% (n = 21) of the patients had a hypoglycemia score of 2 and 19% (n = 5) had a score of 1. After PRRT, 81% of patients (n = 21) had a decreased score, and the remaining 5 patients showed a stable situation. There was temporary worsening of hypoglycemia just after injection of [90Y]Y-DOTATOC/[177Lu]Lu-DOTATOC in 19% of patients. The average time of benefit in the observation period was 17.2 mo (range, 0-70.2 mo). Antihypoglycemic medication reduction was achieved in 58% (n = 15) of patients. The median OS and PFS after the start of PRRT were 19.7 mo (95% CI, 6.5-32.9 mo) and 11.7 mo (95% CI, 4.9-18.5 mo), respectively. Conclusion: To our knowledge, our study included the largest cohort of patients with malignant insulinoma to be evaluated. Long-lasting symptom control and reduction of antihypoglycemic medications were shown in most patients after late-line PRRT.
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Affiliation(s)
- Liene Friebe
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Martin T Freitag
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- ENETS Center of Excellence for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel, Switzerland
- Clinic of Nuclear Medicine, University Hospital Freiburg, Freiburg, Germany
| | - Martin Braun
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Guillaume Nicolas
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- ENETS Center of Excellence for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel, Switzerland
| | - Andreas Bauman
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - David Bushnell
- Division of Nuclear Medicine, Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - Emanuel Christ
- ENETS Center of Excellence for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel, Switzerland
- Department of Endocrinology, Diabetology, and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Damian Wild
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland;
- ENETS Center of Excellence for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel, Switzerland
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Sözen M, Cantürk Z, Selek A, Çetinarslan B, Eryılmaz BH, Gezer E, Köksalan D. Clinicopathological Features of Insulinoma: A Single Tertiary Center Experience. Indian J Surg Oncol 2023; 14:564-570. [PMID: 37900637 PMCID: PMC10611634 DOI: 10.1007/s13193-023-01774-0] [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: 11/28/2022] [Accepted: 05/18/2023] [Indexed: 10/31/2023] Open
Abstract
Insulinoma is a rare pancreatic neuroendocrine tumor with an incidence of 1-4 cases per million. Here we present our 10 years of experience in 13 cases of insulinoma. We retrospectively reviewed all insulinoma patients diagnosed and treated between 2012 and 2022. Clinical and pathological features, diagnostic methods, and follow-up results of insulinoma patients were discussed. A total of 13 patients were included in this study (7 men, and 6 women). The mean age at the time of diagnosis was 58 (36.5-70.5) years. There is only one patient diagnosed with MEN-1 syndrome. The mean time from the onset of symptoms to the diagnosis was 15 (7-27.5) months. In the prolonged fasting test, symptomatic hypoglycemia occurred in all patients within 48 h. The median size of lesions was 15 (12-24) mm, and 46.2% of these lesions were isolated in the pancreatic tail. Ga-68 DOTATATE PET/CT detected lesions with 100% accuracy. Three patients met the criteria for malignant insulinoma. Octreotide LAR was given to 1 patient with metastatic disease and 1 patient who did not accept surgery. The metastatic patient received 8 cycles of Lu treatment and died after 51 months of follow-up. The diagnosis of insulinoma can be challenging. The 48-h fasting test period provided sufficient information for the diagnosis of insulinoma. Ga-68 DOTATATE PET/CT may be an alternative in cases where cross-sectional imaging cannot localize the pancreatic lesion.
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Affiliation(s)
- Mehmet Sözen
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Zeynep Cantürk
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Alev Selek
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Berrin Çetinarslan
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Baldan Huri Eryılmaz
- Department of Internal Medicine, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Emre Gezer
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Damla Köksalan
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
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Saniotis A. Is hyperinsulinemia a possible clinical explanation underlying the myth of Erysichthon? Acta Diabetol 2023; 60:1279-1282. [PMID: 37306712 DOI: 10.1007/s00592-023-02108-w] [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: 11/16/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND An insulinoma is an endocrine tumor of the pancreas, originating from the beta cells, and has a prevalence of 4 cases per 1 million patients. Insulinomas often follow a "90% rule": 90% are benign [1, 2], 90% originate in the pancreas, 90% are approximately 2 cm wide, and 90% are isolated. Individuals with an insulinoma may have episodic bouts of hyperinsulinemic hypoglycemia. Typically, an insulinoma is indicated by hypoglycemic symptoms which are a result of catecholamine reaction and neuroglycopenia. There is increased secretion of insulin in patients with an insulinoma despite having lower glucose levels. PURPOSE This paper examines the myth of Erysichthon and speculates whether the symptoms experienced by him are possibly related to those found in patients with an hyperinsulinoma. METHODS The myth of Erysichthon was taken from various sources (i.e. Hesiod, Callimachus, Ovid) and examined. Symptoms of Erysichthon were then examined. RESULTS The myth of Erysichthon depicts various sympathoadrenal and neuroglycopenic symptoms including anxiety and abnormal behaviour which can be found in insulinomas. Insulinomas may often present a diagnostic challenge due to their deceptive nature and overlapping symptoms with other disorders such as neurologic disease. Insulinomas inducing weight loss resemble Calamachus's account of Erysichthon whose body is finally emaciated, even though having polyphagia. CONCLUSION The myth of Erysichthon provides an interesting range of clinical symptoms which I have argued relate to symptoms found in patients with an insulinoma. Although, insulinomas were unknown in ancient medical lore, this paper has speculated that based on Erysichthon's symptoms, the possibility of an insulinoma cannot be ruled out.
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Affiliation(s)
- Arthur Saniotis
- Bachelor of Doctor Assistance Department, DDT College of Medicine, Gaborone, Botswana.
- School of Biomedicine, The University of Adelaide, Adelaide, Australia.
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Yin H, Liu G, Tan H, Shi D, Cheng D, Yu H, Shi H. Dynamic 68Ga-DOTA 0-Tyr 3-octreotate positron emission tomography-computed tomography for the evaluation of pancreatic neuroendocrine tumors: a pilot study. Quant Imaging Med Surg 2023; 13:5555-5567. [PMID: 37711843 PMCID: PMC10498240 DOI: 10.21037/qims-22-998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 06/05/2023] [Indexed: 09/16/2023]
Abstract
Background 68Ga-DOTA0-Tyr3-octreotate (68Ga-DOTATATE) is a radiolabeled somatostatin analog used for the diagnosis of pancreatic neuroendocrine tumors (pNETs), and standardized uptake value (SUV) measurements for therapeutic monitoring is recommended. However, changes in net influx rate (Ki) may better reflect treatment effects than may those of the SUV. The aim of this study was to investigate the value of dynamic 68Ga-DOTATATE positron emission tomography-computed tomography (PET-CT) in the evaluation of pNETs. Methods Dynamic PET-CT scans over 60 min were acquired for 7 patients with localized pancreatic mass before surgery. Maximal and mean SUV (SUVmax and SUVmean) were measured in tumors and normal pancreatic body as reference tissue (RT). Time-activity curves (TACs) were extracted from tumors and RT. A 2-tissue compartment model was used to calculate the rate constants K1, k2, and k3 (min-1); Ki (mL/g/min); and K1:k2 ratio. The following statistical tests were used to evaluate the results: the Shapiro-Wilk, Student t test, Mann-Whitney, Spearman, and Pearson rank correlation tests. Results Among 6 patients, 8 primary tumors were histopathologically proven to be pNETs. Moreover, 6 lesions with high uptake of 68Ga-DOTATATE showed an ascending TAC pattern, while 2 lesions with no or low uptake showed a descending TAC pattern. The mean SUVmax and SUVmean of pNETs were 46.4±40.2 (range, 3.9-109.9) and 21.9±16.0 (range, 0.5-42.8), respectively, which were significantly higher than the SUVmax of 4.2±0.6 (range, 3.1-4.9) and the SUVmean of 2.7±1.0 (range, 1.4-3.6) for the RT (P=0.021 and P=0.036), respectively. The Ki of pNETs was statistically higher than that of the RT [pNET: 0.366±0.372 (range, 0.019-0.992); RT: 0.060±0.017 (range, 0.04-0.08); P=0.036]. The mean K1:k2 ratio in pNETs was 12-fold higher than that of RT (6.06 vs. 0.50). In pNETs, there was a positive correlation between SUVmax and Ki (r=0.952; P<0.001) and between SUVmean and Ki (r=0.905; P=0.002). Another patient was diagnosed with intrapancreatic accessory spleen. Conclusions The uptake of 68Ga-DOTATATE by pNETs can be explained by its high Ki value and K1:k2 ratio. Dynamic 68Ga-DOTATATE PET-CT can serve as a potential tool for evaluating pNETs and support the further assessment of a larger cohort of patients.
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Affiliation(s)
- Hongyan Yin
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guobing Liu
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hui Tan
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dai Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dengfeng Cheng
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Haojun Yu
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hongcheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
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Hoskovec D, Krška Z, Škrha J, Klobušický P, Dytrych P. Diagnosis and Surgical Management of Insulinomas-A 23-Year Single-Center Experience. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1423. [PMID: 37629713 PMCID: PMC10456644 DOI: 10.3390/medicina59081423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/31/2023] [Accepted: 07/31/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Insulinoma is a rare tumor of the Langerhans islets of the pancreas. It produces insulin and causes severe hypoglycemia with neuroglycopenic symptoms. The incidence is low, at about 1-2 per 1 million inhabitants per year. The diagnosis is based on the presence of Whipple's triad and the result of a fasting test. Surgery is the treatment of choice. Objectives: A retrospective observational study of patients operated on for insulinoma in our hospital focused on the diagnosis, the type of surgery, and complications. Materials and Methods: We retrospectively reviewed patients operated on due to insulinoma. There were 116 surgeries between 2000 and 2022. There were 79 females and 37 males in this group. A fasting test and a CT examination were performed on all the patients. Results: The average duration of the fasting test was 18 h. Insulinoma was found in the body and tail of the pancreas in more than half of the patients. Enucleation was the most frequent type of surgery. Complications that were Clavien Dindo grade III or more occurred in 18% of the patients. The most frequent complications were abscesses and pancreatic fistula. Five patients had malignant insulinoma. Conclusions: Surgery is the treatment of choice in the case of insulinomas. The enucleation of the tumor is a sufficient treatment for benign insulinomas, which are not in contact with the main pancreatic duct. Due to the low incidence of the condition, the centralization of patients is recommended.
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Affiliation(s)
- David Hoskovec
- 1st Department of Surgery, General University Hospital, U nemocnice 2, 12000 Prague, Czech Republic (P.D.)
- 1st Medical Faculty, Charles University, Katerinska 32, 12000 Prague, Czech Republic (P.K.)
| | - Zdeněk Krška
- 1st Department of Surgery, General University Hospital, U nemocnice 2, 12000 Prague, Czech Republic (P.D.)
- 1st Medical Faculty, Charles University, Katerinska 32, 12000 Prague, Czech Republic (P.K.)
| | - Jan Škrha
- 1st Medical Faculty, Charles University, Katerinska 32, 12000 Prague, Czech Republic (P.K.)
- 3rd Department of Inner Medicine, General University Hospital, U nemocnice 2, 12000 Prague, Czech Republic
| | - Pavol Klobušický
- 1st Medical Faculty, Charles University, Katerinska 32, 12000 Prague, Czech Republic (P.K.)
| | - Petr Dytrych
- 1st Department of Surgery, General University Hospital, U nemocnice 2, 12000 Prague, Czech Republic (P.D.)
- 1st Medical Faculty, Charles University, Katerinska 32, 12000 Prague, Czech Republic (P.K.)
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Cigrovski Berkovic M, Ulamec M, Marinovic S, Balen I, Mrzljak A. Malignant insulinoma: Can we predict the long-term outcomes? World J Clin Cases 2022; 10:5124-5132. [PMID: 35812675 PMCID: PMC9210919 DOI: 10.12998/wjcc.v10.i16.5124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/17/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
Insulinomas are the most frequent type of functional pancreatic neuroendocrine tumors with a variety of neuroglycopenic and autonomic symptoms and well-defined diagnostic criteria; however, prediction of their clinical behavior and early differentiation between benign and malignant lesions remain a challenge. The comparative studies between benign and malignant cases are limited, suggesting that short clinical history, early hypoglycemia during fasting, high proinsulin, insulin, and C-peptide concentrations raise suspicion of malignancy. Indeed, malignant tumors are larger with higher mitotic count and Ki-67 proliferative activity, but there are no accurate histological criteria to distinguish benign from malignant forms. Several signaling pathways have been suggested to affect the pathophysiology and behavior of insulinomas; however, our knowledge is limited, urging a further understanding of molecular genetics. Therefore, there is a need for the identification of reliable markers of metastatic disease that could also serve as therapeutic targets in patients with malignant insulinoma. This opinion review reflects on current gaps in diagnostic and clinical aspects related to the malignant behavior of insulinoma.
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Affiliation(s)
- Maja Cigrovski Berkovic
- Department of Endocrinology, Diabetes, Metabolism and Clinical Pharmacology, Clinical Hospital Dubrava, Zagreb 10000, Croatia
- Department of Kinesiological Anthropology and Methodology, Faculty of Kinesiology, University of Zagreb, Zagreb 10000, Croatia
| | - Monika Ulamec
- Department of Pathology and Cytology “Ljudevit Jurak”, University Hospital Center “Sestre milosrdnice”, Zagreb 10000, Croatia
- Scientific Group for Research on Epigenetic Biomarkers and Department of Pathology, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Sonja Marinovic
- Laboratory for Personalized Medicine, Division of Molecular Medicine, Rudjer Boskovic Institute, Zagreb 10000, Croatia
| | - Ivan Balen
- Department of Gastroenterology and Endocrinology, General Hospital “Dr. Josip Bencevic”, Slavonski Brod 35000, Croatia
| | - Anna Mrzljak
- Department of Gastroenterology and Hepatology, UHC Zagreb, Zagreb 10000, Croatia
- School of Medicine, University of Zagreb, Zagreb 10000, Croatia
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Kurakawa KI, Okada A, Manaka K, Konishi T, Jo T, Ono S, Uda K, Michihata N, Matsui H, Fushimi K, Yamaguchi S, Yamauchi T, Nangaku M, Yasunaga H, Kadowaki T. Clinical Characteristics and Incidences of Benign and Malignant Insulinoma Using a National Inpatient Database in Japan. J Clin Endocrinol Metab 2021; 106:3477-3486. [PMID: 34343300 DOI: 10.1210/clinem/dgab559] [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: 03/20/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Insulinoma is the most common pancreatic functional neuroendocrine neoplasm, yet little information on recent clinical practice in patients with insulinoma, especially malignant insulinoma, is available. OBJECTIVE This work aims to clarify the characteristics and practice patterns in patients with insulinoma using a national inpatient database. METHODS Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified patients with insulinoma admitted between 2010 and 2018. We compared background characteristics and therapeutic interventions between patients with benign and malignant insulinoma. We also estimated the incidence of insulinoma using the number of patients with newly diagnosed insulinoma in 2012. RESULTS We identified 844 patients with benign insulinoma and 102 patients with malignant insulinoma. Patients with malignant insulinoma were younger (median, 55.5 vs 66.0 years, P < .001) and less likely to be female (55.9% vs 65.3%, P = .061) than patients with benign insulinoma. Analysis of therapeutic interventions revealed that patients with malignant insulinoma more frequently received medications (71.6% vs 49.6%, P < .001) but less frequently underwent pancreatic surgery (57.8% vs 72.0%, P = .003). Older patients were a smaller proportion of those undergoing surgery and a larger proportion of those managed with medications without surgery (P < .001). The incidence of insulinoma was estimated to be 3.27 (95% CI, 2.93-3.61) individuals per million Japanese adult population per year. CONCLUSION The present study using a nationwide database had a larger sample size than previous studies and revealed definitive differences in patient characteristics and therapeutic patterns between benign and malignant insulinoma.
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Affiliation(s)
- Kayo Ikeda Kurakawa
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Katsunori Manaka
- Division of Nephrology and Endocrinology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Taisuke Jo
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Sachiko Ono
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Kazuaki Uda
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo 113-8510, Japan
| | - Satoko Yamaguchi
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Toshimasa Yamauchi
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
| | - Takashi Kadowaki
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
- Toranomon Hospital, Tokyo 105-8470, Japan
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9
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Starr J, Puebla G, McMillan J, Lewis JT, Kasi PM. Microsatellite Instability-High, Malignant Insulinoma With Brain Metastasis. Cureus 2021; 13:e16969. [PMID: 34527457 PMCID: PMC8420138 DOI: 10.7759/cureus.16969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 12/24/2022] Open
Abstract
Insulinomas are the most common type of functional pancreatic neuroendocrine tumor. Although insulinomas usually are noninvasive or benign, 10% are deemed invasive or malignant. The pathologic mechanisms that lead to the malignant phenotype are not well elucidated. In this case report, we present a patient with stage 4 malignant insulinoma with metastasis to the liver, bone, and brain. Genetic analysis of the tumor showed that the tumor was mismatch-repair deficient and had a high rate of microsatellite instability. There was loss of MLH1- and PMS2-encoded protein expression, and MLH1 and MEN1 variants were identified. Notably, the liver metastasis showed considerable tumor heterogeneity (well differentiated) compared with the brain metastasis (poorly differentiated).
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Affiliation(s)
- Jason Starr
- Hematology/Oncology, Mayo Clinic, Jacksonville, USA
| | - Guillermo Puebla
- Hematology/Oncology, University of Puerto Rico, Medical Sciences Campus, San Juan, PRI
| | | | - Jason T Lewis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, USA
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Spada F, Rossi RE, Kara E, Laffi A, Massironi S, Rubino M, Grimaldi F, Bhoori S, Fazio N. Carcinoid Syndrome and Hyperinsulinemic Hypoglycemia Associated with Neuroendocrine Neoplasms: A Critical Review on Clinical and Pharmacological Management. Pharmaceuticals (Basel) 2021; 14:ph14060539. [PMID: 34199977 PMCID: PMC8228616 DOI: 10.3390/ph14060539] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 02/05/2023] Open
Abstract
The carcinoid syndrome (CS) and hyperinsulinemic hypoglycemia (HH) represent two of the most common clinical syndromes associated with neuroendocrine neoplasms (NENs). The former is mainly related to the serotonin secretion by a small bowel NEN, whereas the latter depends on an insulin hypersecretion by a pancreatic insulinoma. Both syndromes/conditions can affect prognosis and quality of life of patients with NENs. They are often diagnosed late when patients become strongly symptomatic. Therefore, their early detection and management are a critical step in the clinical management of NEN patients. A dedicated and experienced multidisciplinary team with appropriate therapeutic strategies is needed and should be encouraged to optimize clinical outcomes. This review aims to critically analyze clinical features, evidence and treatment options of CS and HH and therefore to improve their management.
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Affiliation(s)
- Francesca Spada
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology (IEO) IRCCS, via G. Ripamonti 435, 20141 Milano, Italy; (F.S.); (A.L.); (M.R.)
| | - Roberta E. Rossi
- Hepatology and Hepato-Pancreatic-Biliary Surgery and Liver Transplantation, Fondazione IRCCS, Istituto Nazionale Tumori (INT), via G. Venezian 1, 20133 Milano, Italy; (R.E.R.); (S.B.)
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, via Festa del Perdono 7, 20122 Milano, Italy
| | - Elda Kara
- Endocrinology and Metabolism Unit, University Hospital S. Maria della Misericordia, Piazzale Santa Maria della Misericordia, 15, 33100 Udine, Italy; (E.K.); (F.G.)
| | - Alice Laffi
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology (IEO) IRCCS, via G. Ripamonti 435, 20141 Milano, Italy; (F.S.); (A.L.); (M.R.)
| | - Sara Massironi
- Division of Gastroenterology, San Gerardo Hospital, Bicocca School of Medicine, University of Milano Bicocca, 20126 Milano, Italy;
| | - Manila Rubino
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology (IEO) IRCCS, via G. Ripamonti 435, 20141 Milano, Italy; (F.S.); (A.L.); (M.R.)
| | - Franco Grimaldi
- Endocrinology and Metabolism Unit, University Hospital S. Maria della Misericordia, Piazzale Santa Maria della Misericordia, 15, 33100 Udine, Italy; (E.K.); (F.G.)
| | - Sherrie Bhoori
- Hepatology and Hepato-Pancreatic-Biliary Surgery and Liver Transplantation, Fondazione IRCCS, Istituto Nazionale Tumori (INT), via G. Venezian 1, 20133 Milano, Italy; (R.E.R.); (S.B.)
| | - Nicola Fazio
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology (IEO) IRCCS, via G. Ripamonti 435, 20141 Milano, Italy; (F.S.); (A.L.); (M.R.)
- Correspondence: ; Tel.: +39-025-748-9258
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11
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Using the Secretion Ratios of Insulin and C-peptide During the 2-h Oral Glucose Tolerance Test to Diagnose Insulinoma. Dig Dis Sci 2021; 66:1533-1539. [PMID: 32529519 DOI: 10.1007/s10620-020-06379-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/30/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Insulinoma, owing to the low incidence and small volume of the tumor, is often undiagnosed. The 72-h fast test is centered on diagnosing insulinoma; however, it cannot be performed on outpatients. Our aim was to evaluate the results of a 3-h oral glucose tolerance test (3-h OGTT) for insulinoma diagnosis. METHODS Thirty-seven patients with insulinoma were enrolled for comparison with 42 control subjects. All patients underwent 3-h OGTT with measurements of insulin and C-peptide. The secretion ratios of insulin and C-peptide at 1, 2, and 3 h were calculated by comparison with their values at 0 h. We used logistic regression analysis to establish the predictive models and compared the diagnostic efficiency by receiver operating characteristic analysis. RESULTS The fasting insulin and C-peptide levels of insulinoma patients were both higher; however, the concentrations at 1 h and 2 h were both lower (P < 0.05). The levels at 3 h were not significantly different (P > 0.05). Our final logistic regression model was constructed as follows: logit (P) = 8.305 - 0.441 × insulin 2 h/0 h ratio - 1.679 × C-peptide 1 h/0 h ratio. A cutoff value of > 0.351 showed the highest diagnostic accuracy, with an area under the curve of 0.97, a sensitivity of 86.5%, and a specificity of 95.2%. CONCLUSIONS The 2-h/0-h insulin ratio, as well as the 1-h/0-h C-peptide ratio, has high diagnostic efficiency for insulinoma. The 2-h OGTT can be an alternative test for diagnosing insulinoma in outpatient settings.
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12
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Kriger A, Berelavichus S, Gorin D, Galkin G, Yukina M, Ilovayskaya I, Zektser V, Nuralieva N, Kaldarov AR. Successful surgical treatment of a patient with primary insulinoma of the liver. J Surg Case Rep 2020; 2020:rjaa519. [PMID: 33391648 PMCID: PMC7769218 DOI: 10.1093/jscr/rjaa519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/09/2020] [Accepted: 11/18/2020] [Indexed: 11/13/2022] Open
Abstract
Insulinoma is the most frequent functional neuroendocrine tumor of the pancreas, which causes organic hyperinsulinism with severe hypoglycemia. There are no cases of primary insulinoma of the liver described. A 63-year-old female was admitted to our center presenting symptoms of severe hypoglycemia due to confirmed endogenic hyperinsulinism. None of the performed diagnostic procedures could reveal a pancreatic tumor. However, a pathologic mass in the sixth segment of the liver was detected. We performed arterial calcium stimulation that showed increased levels of insulin and c-peptide in almost all stimulated arteries. The highest and most prolonged peaks were detected at the points of the common hepatic artery and the right hepatic artery. After the surgical removal of the liver tumor, the blood glucose level was stabilized within the normal range. Post-operative pathomorphological investigation confirmed the diagnosis of a neuroendocrine tumor. The long-term survival results show correct treatment tactics without any signs of disease recurrence.
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Affiliation(s)
- A Kriger
- Department No.1 of A.V. Vishnevsky Center of Surgery, 5 Universitetsky Prospekt 289, Moscow 119296, Russia
| | - S Berelavichus
- Department No.1 of A.V. Vishnevsky Center of Surgery, 16/1 Solov'iny Proezd 139, Moscow 117593, Russia
| | - D Gorin
- Department No.1 of A.V. Vishnevsky Center of Surgery, 40 Seslavinskaya Street 48, Moscow 121309, Russia
| | - G Galkin
- Department No.1 of A.V. Vishnevsky Center of Surgery, 37/21 Tuhachevskogo Street 131, Moscow 123159, Russia
| | - M Yukina
- Department of National Medical Research Centre of Endocrinology, 11, Dm Ulyanova, Moscow 117036, Russia
| | - I Ilovayskaya
- Moscow Regional Research & Clinical Institute (MONIKI), 61/2 Schepkina Street, Moscow 129110, Russia
| | - V Zektser
- I.M. Sechenov First Medical State University, 8/2 Trubetskaya street, Moscow 119991, Russia
| | - N Nuralieva
- Department of National Medical Research Centre of Endocrinology 11, Dm Ulyanova, Moscow 117036, Russia
| | - A R Kaldarov
- Department No.1 of A.V. Vishnevsky Center of Surgery, 9, Novoe Shosse 78, Drojjino, Moscow 142718, Russia
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13
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Siddiqui M, Vora A, Ali S, Abramowitz J, Mirfakhraee S. Pasireotide: A Novel Treatment for Tumor-Induced Hypoglycemia Due to Insulinoma and Non-Islet Cell Tumor Hypoglycemia. J Endocr Soc 2020; 5:bvaa171. [PMID: 33294765 PMCID: PMC7692539 DOI: 10.1210/jendso/bvaa171] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Indexed: 12/21/2022] Open
Abstract
Tumor-induced hypoglycemia is a serious disorder most commonly caused by insulinoma or non-islet cell tumor hypoglycemia (NICTH). The hypoglycemia can be severe and refractory to conventional therapy, leading to significant morbidity and mortality. The objective of this work is to describe a series of challenging cases in which refractory, tumor-induced hypoglycemia was shown to respond to the use of pasireotide, a second-generation somatostatin receptor ligand. We describe the clinical and biochemical features of 3 patients with tumor-induced hypoglycemia due to an occult insulinoma, malignant insulinoma, and non-islet cell tumor hypoglycemia. In these 3 individuals, the hypoglycemia remained refractory to guideline-recommended medical therapy, such as diazoxide, nonpasireotide somatostatin analogues, and glucocorticoids. Pasireotide was substituted to attenuate the refractory hypoglycemia for each patient. The addition of pasireotide led to prompt improvement in the frequency and severity of hypoglycemic episodes for each tumor-induced hypoglycemia patient. We demonstrate the successful treatment of 3 individuals with refractory, tumor-induced hypoglycemia with pasireotide. We offer the first reported use of pasireotide for the successful treatment of nonmalignant insulinoma and non-islet cell tumor hypoglycemia.
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Affiliation(s)
- Mahwash Siddiqui
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Amy Vora
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sadia Ali
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jessica Abramowitz
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sasan Mirfakhraee
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas
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14
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Ohya Y, Hayashida S, Inomata Y. Long-Term Survival After Distal Pancreatectomy With Simultaneous Living-Donor Liver Transplant for Treatment of Pancreatic Insulinoma With Hepatic Metastasis: a Case Report. EXP CLIN TRANSPLANT 2020; 19:88-91. [PMID: 32967594 DOI: 10.6002/ect.2020.0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pancreatic neuroendocrine tumors are a rare type of tumor with malignant potential, characterized by slowgrowth, frequent hepatic metastatic lesions that usually stay contained within the liver. In patients with unresectable liver metastatic pancreatic neuroendocrine tumors, liver transplant is the only treatment available. Insulinomas are the most common pancreatic neuroendocrine tumors, and 5% to 10% of insulinomas are malignant. We herein report a case of a living-donor liver transplant with distal pancreatectomy for a patient with hepatic metastatic pancreatic insulinoma with a 13-year postoperative survival.
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Affiliation(s)
- Yuki Ohya
- From the Department of Surgery, Kumamoto Rosai Hospital, Yatsushiro, Kumamoto, Japan
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15
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Hasanov R, Samadov E, Bayramov N, Ünlü A, Petrone P. Surgical management of insulinomas at the Azerbaijan Medical University: a retrospective study of 21 cases over a 10-year period. Turk J Med Sci 2020; 50:1262-1269. [PMID: 32394681 PMCID: PMC7491297 DOI: 10.3906/sag-2001-150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/05/2020] [Indexed: 11/27/2022] Open
Abstract
Background/aim This study represents the first report that evaluates the experience gathered from diagnosis, surgical treatment and outcome of insulinoma patients from Azerbaijan. Materials and methods We retrospectively review of insulinoma patients for a 10-year period. Collected data included patient demographics, laboratory and imaging tests, detailed surgical reports, histopathological examination of resected specimens, and clinical follow-up. Results Twenty-one insulinoma patients were identified. Male patients comprised 52.4%; mean age was 44 years. Mean time to diagnosis was 14 months; 61% patients had ≥3 medical referrals due to hypoglycemia-related symptoms. Diagnosis sensitivity of CT, MRI and US was 85%, 80%, and 55%, respectively. The mean glucose, insulin, C-peptide levels were 35.7 ± 9.5 mg/dL, 33.5 ± 21.9 µU/mL, and 3.74 ± 1.88 ng/mL, respectively. Pancreatic head and tail were the most frequent tumor locations; mean tumor size was 1.5 ± 0.7 cm. No statistical association was found between the tumor size and preoperative glucose, C-peptide and insulin levels. Distal pancreatectomy and enucleation were the most common surgical procedures. Local tumor recurrence rate was 14%. There was no mortality. Conclusions To prevent delayed diagnoses, physicians should be familiar with the typical symptoms of these rare tumors.
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Affiliation(s)
- Rovshan Hasanov
- Endocrinology Clinic, Leyla Medical Center; Baku, Azerbaijan
| | - Elgun Samadov
- General Surgery Clinic, Leyla Medical Center; Baku, Azerbaijan
| | - Nuru Bayramov
- General Surgery Department, Azerbaijan Medical University; Baku, Azerbaijan
| | - Aytekin Ünlü
- Department of General Surgery, University of Medical Sciences, Gulhane Medical University; Ankara, Turkey
| | - Patrizio Petrone
- Department of Surgery, NYU Langone Health – NYU Winthrop Hospital; NYU Long Island School of Medicine; Mineola, NY USA
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16
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Mpilla GB, Philip PA, El-Rayes B, Azmi AS. Pancreatic neuroendocrine tumors: Therapeutic challenges and research limitations. World J Gastroenterol 2020; 26:4036-4054. [PMID: 32821069 PMCID: PMC7403797 DOI: 10.3748/wjg.v26.i28.4036] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/08/2020] [Accepted: 07/16/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreatic neuroendocrine tumors (PNETs) are known to be the second most common epithelial malignancy of the pancreas. PNETs can be listed among the slowest growing as well as the fastest growing human cancers. The prevalence of PNETs is deceptively low; however, its incidence has significantly increased over the past decades. According to the American Cancer Society’s estimate, about 4032 (> 7% of all pancreatic malignancies) individuals will be diagnosed with PNETs in 2020. PNETs often cause severe morbidity due to excessive secretion of hormones (such as serotonin) and/or overall tumor mass. Patients can live for many years (except for those patients with poorly differentiated G3 neuroendocrine tumors); thus, the prevalence of the tumors that is the number of patients actually dealing with the disease at any given time is fairly high because the survival is much longer than pancreatic ductal adenocarcinoma. Due to significant heterogeneity, the management of PNETs is very complex and remains an unmet clinical challenge. In terms of research studies, modest improvements have been made over the past decades in the identification of potential oncogenic drivers in order to enhance the quality of life and increase survival for this growing population of patients. Unfortunately, the majority of systematic therapies approved for the management of advanced stage PNETs lack objective response or at most result in modest benefits in survival. In this review, we aim to discuss the broad challenges associated with the management and the study of PNETs.
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Affiliation(s)
- Gabriel Benyomo Mpilla
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI 48201, United States
| | - Philip Agop Philip
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI 48201, United States
| | - Bassel El-Rayes
- Department of Hematology Oncology, Emory Winship Institute, Atlanta, GA 30322, United States
| | - Asfar Sohail Azmi
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI 48201, United States
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17
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Malignant Insulinoma Is Largely Derived From Nonfunctioning Pancreatic Neuroendocrine Tumors: A Contemporary View. Pancreas 2020; 49:733-736. [PMID: 32590616 DOI: 10.1097/mpa.0000000000001562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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18
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Qu Y, Li H, Wang X, Chen Y, Guo Q, Pei Y, Du J, Dou J, Ba J, Lv Z, Mu Y. Clinical Characteristics and Management of Functional Pancreatic Neuroendocrine Neoplasms: A Single Institution 20-Year Experience with 286 Patients. Int J Endocrinol 2020; 2020:1030518. [PMID: 33204258 PMCID: PMC7665912 DOI: 10.1155/2020/1030518] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/23/2020] [Accepted: 10/15/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Functional pancreatic neuroendocrine neoplasms (PanNENs) are very rare disorders but have complex spectrum, including insulinoma, gastrinoma, glucagonoma, somatostatinoma, and VIPoma. Patients with PanNENs usually present with characteristic symptoms caused by corresponding hormone hypersecretion. It has always been challenging in dealing with such rare but complicated disorders. In this report, we analyzed the clinical characteristics of functional PanNENs in a large cohort of Chinese patients and summarized our clinical experience in diagnosis and treatment. METHODS The retrospective analysis was performed in patients with a definite diagnosis of functional PanNENs hospitalized in Chinese PLA General Hospital between 2000 and 2020. The clinical characteristics, surgical information, and pathological findings were extracted from their medical records and were analyzed. RESULTS Totally, 286 patients (gender: male 103 and female 183; age: 45.55 ± 15.23 years old) were diagnosed with definite functional PanNENs. The most frequent functional PanNENs were insulinoma (266/286) followed by glucagonoma (10/286), somatostatinoma (3/286), adrenocorticotropic hormone- (ACTH-) producing tumor (3/286), gastrinoma (2/286), and VIPoma (2/286). Nine patients were diagnosed with multiple endocrine neoplasia type 1 (MEN1) in which all the associated functional PanNENs were insulinomas. The duration from symptoms' onset to confirmed diagnosis was 3.67 ± 4.28 years. Two hundred and eighty patients with tumor localized in pancreatic or with limited metastasis underwent surgery. The symptoms associated with hormonal oversecretion were improved significantly after surgery. Five patients with unresectable metastases or tumor recurrence after surgery were administrated with systemic chemotherapy or other targeted therapies. With these various therapies, the symptoms were also partially relieved. According to findings in pathological and immunochemical examination, all the functional PanNENs were categorized into NEN-G1 (41.95%), NEN-G2 (54.90%), NEN-G3 (3.15%), and NEC-G3 (0%). CONCLUSION Patients with suspected functional PanNENs should have a systematic endocrine examination at diagnosis. Multidisciplinary collaborations are essential for precise diagnosis and tumor localization. A successful surgery or other targeted therapies can improve the prognosis of patients with such rare but complex disorders.
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Affiliation(s)
- Yuqing Qu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Department of Endocrinology, Yantai Yuhuangding Hospital, Yantai 264000, Shandong Province, China
| | - Haoming Li
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Department of Endocrinology, Shexian Hospital, Handan 056400, Hebei Province, China
| | - Xianling Wang
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Yulong Chen
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Qinghua Guo
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Yu Pei
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Jin Du
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Jingtao Dou
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Jianming Ba
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhaohui Lv
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Yiming Mu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
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Sun M, Luo Y, You Y, Han X, Zhao Y, Han X, Zhao Y. Ectopic insulinoma: case report. BMC Surg 2019; 19:197. [PMID: 31852474 PMCID: PMC6921582 DOI: 10.1186/s12893-019-0661-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/05/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Ectopic insulinoma is a rare entity that is difficult to diagnose before surgery. This article reports two cases of ectopic insulinoma. CASE PRESENTATION Two patients manifested recurrent hypoglycemia with a typical Whipple triad. In terms of the qualitative diagnosis, the oral glucose tolerance test (OGTT) suggested a diagnosis of hyperinsulinemic hypoglycemia. However, preoperative imaging did not show a significant mass in the pancreas. In one patient, preoperative abdominal enhanced volume perfusion computed tomography (CT), somatostatin receptor imaging and 99mTc-HYNIC-TOC SPECT/CT revealed a mass with a rich blood supply anterior to the duodenum. In the other patient, preoperative enhanced CT, magnetic resonance imaging (MRI) and 68Ga-Exendin-4 PET/CT showed a mass above the spleen. After surgical removal of the tumor, both patients received a confirmed diagnosis of neuroendocrine tumors by postoperative pathology. The symptoms of hypoglycemia were relieved after surgery, and the blood glucose level was significantly increased. CONCLUSION Ectopic insulinoma is difficult to locate before surgery. 68Ga-Exendin-4 PET/CT has a high diagnostic value. Surgical removal of the lesion is main treatment.
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Affiliation(s)
- Mengqing Sun
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Yaping Luo
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Yan You
- Department of Pathology, Peking Union Medical College Hospital, Beijing, China
| | - Xianlin Han
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Xianlin Han
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China.
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China.
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Torimoto K, Okada Y, Tanaka Y, Matsuoka A, Hirota Y, Ogawa W, Saisho Y, Kurihara I, Itoh H, Inada S, Koga M. Usefulness of hemoglobin A1c and glycated albumin measurements for insulinoma screening: an observational case-control study. BMC Cancer 2019; 19:174. [PMID: 30808334 PMCID: PMC6390316 DOI: 10.1186/s12885-019-5389-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/20/2019] [Indexed: 12/03/2022] Open
Abstract
Background Insulinoma represents hypoglycemia as a predominant symptom; the autonomic symptoms may be resolved by chronically recurrent hypoglycemia resulting in the persistence of non-specific symptoms alone. Therefore, it has been estimated that there are many patients in whom the disease takes longer to diagnose and has remained undiagnosed. Although some parameters exist for the definitive diagnosis of the disease, there are currently no indices for early screening. Indices of glycemic control, hemoglobin A1c (HbA1c), and glycated albumin (GA) may be useful for the screening of patients with insulinoma having chronic hypoglycemia because the values become low in such a condition. Because there are no articles that have reported the point, we examine the effective cutoff values of HbA1c and GA for the diagnosis of insulinoma in the present study. Methods In a multicenter cross-sectional study, 31 patients with insulinoma were included for comparison with 120 control subjects with normal glucose tolerance based on 75 g oral glucose tolerance tests whose characteristics were matched to the patients. The primary outcomes were optimal cutoff values of HbA1c and GA for the screening of insulinoma. Results HbA1c was significantly lower in the insulinoma group at 4.7 ± 0.4% compared to the healthy control group at 5.7 ± 0.3% (p < 0.001), and GA was significantly lower in the insulinoma group at 11.6 ± 1.8% compared to the healthy control group at 14.5 ± 1.0% (p < 0.001). According to a receiver operating characteristic (ROC) analysis, optimal cutoff values of HbA1c and GA for the diagnosis of insulinoma were 5.0 and 12.4%, respectively. Area under the curve values of HbA1c and GA were 0.970 and 0.929, respectively, showing no significant difference (p = 0.399). Conclusions In the present study, HbA1c and GA values in patients with insulinoma were significantly lower compared to the healthy controls, and effective cutoff values for screening were shown in the diagnosis of insulinoma for the first time. HbA1c and GA can be useful indices for insulinoma screening. Because malignant insulinoma have a similar diagnostic process to that of benign insulinoma, these could be useful for malignant insulinoma.
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Affiliation(s)
- Keiichi Torimoto
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan.
| | - Yosuke Okada
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan
| | - Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan
| | - Atsuko Matsuoka
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, 650-0017, Japan
| | - Yushi Hirota
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, 650-0017, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, 650-0017, Japan
| | - Yoshifumi Saisho
- Department of Internal Medicine, Keio University School of Medicine, Tokyo, 160-8582, Japan
| | - Isao Kurihara
- Department of Internal Medicine, Keio University School of Medicine, Tokyo, 160-8582, Japan
| | - Hiroshi Itoh
- Department of Internal Medicine, Keio University School of Medicine, Tokyo, 160-8582, Japan
| | - Shinya Inada
- Department of Internal Medicine, Kawanishi City Hospital, Hyogo, 666-0195, Japan
| | - Masafumi Koga
- Department of Internal Medicine, Hakuhokai Central Hospital, Hyogo, 669-0953, Japan
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