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Dai M, Mullins CS, Lu L, Alsfasser G, Linnebacher M. Recent advances in diagnosis and treatment of gastroenteropancreatic neuroendocrine neoplasms. World J Gastrointest Surg 2022; 14:383-396. [PMID: 35734622 PMCID: PMC9160679 DOI: 10.4240/wjgs.v14.i5.383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/17/2022] [Accepted: 04/28/2022] [Indexed: 02/06/2023] Open
Abstract
Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) are a rare group of tumors originating from neuroendocrine cells of the digestive system. Their incidence has increased over the last decades. The specific pathogenetic mechanisms underlying GEP-NEN development have not been completely revealed. Unfunctional GEP-NENs are usually asymptomatic; some grow slowly and thus impede early diagnosis, which ultimately results in a high rate of misdiagnosis. Therefore, many GEP-NEN patients present with later staged tumors. Motivated hereby, research attention for diagnosis and treatment for GEP-NENs increased in recent years. The result of which is great progress in clinical diagnosis and treatment. According to the most recent clinical guidelines, improved grading standards can accurately define poorly differentiated grade 3 neuroendocrine tumors and neuroendocrine carcinomas (NECs), which are subclassified into large and small cell NECs. Combining different functional imaging methods facilitates precise diagnosis. The expression of somatostatin receptors helps to predict prognosis. Genetic analyses of mutations affecting death domain associated protein (DAXX), multiple endocrine neoplasia type 1 (MEN 1), alpha thalassemia/intellectual disability syndrome X-linked (ATRX), retinoblastoma transcriptional corepressor 1 (RB 1), and mothers against decapentaplegic homolog 4 (SMAD 4) help distinguishing grade 3 NENs from poorly differentiated NECs. The aim of this review is to summarize the latest research progress on diagnosis and treatment of GEP-NENs.
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Affiliation(s)
- Meng Dai
- Clinic of General Surgery, Molecular Oncology and Immunotherapy, Rostock University Medical Center, 18057 Rostock, Germany
| | - Christina S Mullins
- Clinic of General Surgery, Molecular Oncology and Immunotherapy, Rostock University Medical Center, 18057 Rostock, Germany
| | - Lili Lu
- Clinic of General Surgery, Molecular Oncology and Immunotherapy, Rostock University Medical Center, 18057 Rostock, Germany
| | - Guido Alsfasser
- Clinic of General Surgery, Rostock University Medical Center, 18057 Rostock, Germany
| | - Michael Linnebacher
- Clinic of General Surgery, Molecular Oncology and Immunotherapy, Rostock University Medical Center, 18057 Rostock, Germany
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Magalhães D, Sampaio IL, Ferreira G, Bogalho P, Martins-Branco D, Santos R, Duarte H. Peptide receptor radionuclide therapy with 177Lu-DOTA-TATE as a promising treatment of malignant insulinoma: a series of case reports and literature review. J Endocrinol Invest 2019; 42:249-260. [PMID: 29949120 DOI: 10.1007/s40618-018-0911-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/04/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Insulinomas are a rare type of pancreatic neuroendocrine tumours characterized by insulin hypersecretion. They are considered malignant when metastases are present. Traditional therapies often promote only temporarily symptomatic relief and may be associated with severe adverse effects. There is scarce experience in treating malignant insulinomas with peptide receptors radionuclide therapy (PRRNT). PATIENTS AND METHODS We describe PRRNT results in four patients with inoperable malignant insulinomas with poorly controllable hypoglycaemia. All patients received therapy with 177Lu-DOTA-TATE after conventional therapies failed in controlling disease progression and symptoms. The activity administered per cycle was 4.8-7.4 GBq. The interval between cycles was 10-16 weeks. Haematology, liver and kidney function tests were performed before treatment initiation and 5 and 10 weeks after each cycle. RESULTS Patient 1 presented significant clinical benefit for 13 months after PRRNT, with imaging improvement. Patient 2 obtained reduction of the number and severity of hypoglycaemic episodes during 15 months after therapy. Patient 3 is asymptomatic since PRRNT first cycle performed 23 months ago and revealed significant imaging improvement. Patient 4 had resolution of hypoglycaemia only 3 days after PRRNT first cycle and today, 16 months after therapy, the disease seems to be in remission and the patient maintains euglycaemic state. PRRNT was well tolerated, with only hematologic grade 2 toxicity in patient 1 and mild kidney toxicity in patient 3. CONCLUSIONS After the start of 177Lu-DOTA-TATE all patients achieved hypoglycaemia symptomatic control and had evident improvement of their quality of life. Three patients showed imagiological improvement suggesting reduced tumour load.
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Affiliation(s)
- D Magalhães
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
- Faculty of Medicine, University of Porto, Porto, Portugal.
- Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal.
| | - I L Sampaio
- Nuclear Medicine Department, Instituto Português de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
- Medical Physics, Radiobiology and Radiological Protection Group, Centro de Investigação do IPO-Porto, Porto, Portugal
| | - G Ferreira
- Nuclear Medicine Department, Instituto Português de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
| | - P Bogalho
- Endocrinology Department, Hospital Curry Cabral, Rua da Beneficência, n.º 8, 1069-166, Lisboa, Portugal
| | - D Martins-Branco
- Oncology Department, Instituto Português de Oncologia de Lisboa, R. Prof. Lima Basto, 1099-023, Lisboa, Portugal
| | - R Santos
- Endocrinology Department, Instituto Português de Oncologia de Lisboa, R. Prof. Lima Basto, 1099-023, Lisboa, Portugal
| | - H Duarte
- Nuclear Medicine Department, Instituto Português de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
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Caliri M, Verdiani V, Mannucci E, Briganti V, Landoni L, Esposito A, Burato G, Rotella CM, Mannelli M, Peri A. A case of malignant insulinoma responsive to somatostatin analogs treatment. BMC Endocr Disord 2018; 18:98. [PMID: 30591061 PMCID: PMC6307122 DOI: 10.1186/s12902-018-0325-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 12/13/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Insulinoma is a rare tumour representing 1-2% of all pancreatic neoplasms and it is malignant in only 10% of cases. Locoregional invasion or metastases define malignancy, whereas the dimension (> 2 cm), CK19 status, the tumor staging and grading (Ki67 > 2%), and the age of onset (> 50 years) can be considered elements of suspect. CASE PRESENTATION We describe the case of a 68-year-old man presenting symptoms compatible with hypoglycemia. The symptoms regressed with food intake. These episodes initially occurred during physical activity, later also during fasting. The fasting test was performed and the laboratory results showed endogenous hyperinsulinemia compatible with insulinoma. The patient appeared responsive to somatostatin analogs and so he was treated with short acting octreotide, obtaining a good control of glycemia. Imaging investigations showed the presence of a lesion of the uncinate pancreatic process of about 4 cm with a high sst2 receptor density. The patient underwent exploratory laparotomy and duodenocephalopancreasectomy after one month. The definitive histological examination revealed an insulinoma (T3N1MO, AGCC VII G1) with a low replicative index (Ki67: 2%). CONCLUSIONS This report describes a case of malignant insulinoma responsive to octreotide analogs administered pre-operatively in order to try to prevent hypoglycemia. The response to octreotide analogs is not predictable and should be initially assessed under strict clinical surveillance.
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Affiliation(s)
- Mariasmeralda Caliri
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Careggi University Hospital, Florence, Italy
| | - Valentina Verdiani
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Careggi University Hospital, Florence, Italy
| | - Edoardo Mannucci
- Diabetology Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Careggi University Hospital, Florence, Italy
| | - Vittorio Briganti
- Division of Nuclear Medicine, Careggi University Hospital, Florence, Italy
| | - Luca Landoni
- General and Pancreatic Surgery Department, The Pancreas Institute-University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- General and Pancreatic Surgery Department, The Pancreas Institute-University of Verona Hospital Trust, Verona, Italy
| | - Giulia Burato
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Carlo Maria Rotella
- Diabetology Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Careggi University Hospital, Florence, Italy
| | - Massimo Mannelli
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Careggi University Hospital, Florence, Italy
| | - Alessandro Peri
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Careggi University Hospital, Florence, Italy
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Kanno A, Ide K, Kurita K, Terano T, Yamamoto K. Octreotide LAR was useful for avoiding hypoglycemia in an elderly patient with insulinoma. Nihon Ronen Igakkai Zasshi 2018; 54:172-178. [PMID: 28592737 DOI: 10.3143/geriatrics.54.172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An 80-year-old woman was admitted to our hospital with a hypoglycemia attack. She was diagnosed with insulinoma based on her high insulin level at the time of the hypoglycemia attack and the presence of a hypervascular tumor in her pancreas. The patient refused surgical treatment and octreotide was used to prevent hypoglycemia.It is known that octreotide suppresses the secretion of insulin from the pancreas; however, insulin secretion is not always suppressed in patients with insulinoma. Moreover, there is no particular protocol for the use of octreotide in the treatment of insulinoma.We examined the effect of octreotide in preventing hypoglycemia using CGM. The injection of octreotide (50 μg) at 21: 00 prevented hypoglycemia during the night.However the patient could not perform self-injection due to the sequelae of a cerebral infarction. We therefore chose to have her eat an extra meal at 11 pm.After a while the patient became exhausted by eating meals at night. We examined the effects of octreotide LAR using CGM, and it was found to prevent hypoglycemia for 4 weeks. The patient's QOL was improved by being released from a restriction that affected her daily life.
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Affiliation(s)
- Ayaka Kanno
- Department of Internal Medicine, Chiba Aoba Municipal Hospital
| | - Kana Ide
- Department of Internal Medicine, Chiba Aoba Municipal Hospital
| | - Kenichi Kurita
- Department of Internal Medicine, Chiba Aoba Municipal Hospital
| | - Takashi Terano
- Department of Internal Medicine, Chiba Aoba Municipal Hospital
| | - Kyohei Yamamoto
- Department of Internal Medicine, Chiba Aoba Municipal Hospital
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Ito T, Lee L, Jensen RT. Treatment of symptomatic neuroendocrine tumor syndromes: recent advances and controversies. Expert Opin Pharmacother 2016; 17:2191-2205. [PMID: 27635672 DOI: 10.1080/14656566.2016.1236916] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Neuroendocrine tumors(NETs), once thought rare, are increasing in frequency in most countries and receiving increasing-attention. NETs present two-treatment problems. A proportion is aggressive and a proportion has a functional, hormone-excess-state(F-NET), each of which must be treated. Recently, there have been many advances, well-covered in reviews/consensus papers on imaging-NETs; new, novel anti-tumor treatments and understanding their pathogenesis. However, little attention has been paid to advances in the treatment of the hormone-excess-state. These advances are usually reported in case-series, and case-reports with few large studies. In this paper these advances are reviewed. Areas covered: Advances in the last 5-years are concentrated on, but a review of literature from the last 10-years was performed. PubMed and other databases (Cochrane, etc.) were searched for F-NET-syndromes including carcinoid-syndrome, as well as meeting-abstracts on NETs. All advances that controlled hormone-excess-states or facilitated-control were covered. These include new medical-therapies [serotonin-synthesis inhibitors(telotristat), Pasireotide, new agents for treating ACTHomas], increased dosing with conventional therapies (octreotide-LAR, Lanreotide-Autogel), mTor inhibitors(everolimus), Tyrosine-kinase inhibitors(sunitinib),cytoreductive surgery, liver-directed therapies (embolization, chemoembolization, radioembolization, RFA), peptide radio-receptor-therapy(PRRT) and 131I-MIBG, ablation of primary F-NETs. Expert opinion: Although many of the newer therapies controlling the hormone-excess-states in F-NETs are reported in relatively few patients, all the approaches show promise. Their description also generates some controversies/unresolved areas,such as the order of these new treatments, their longterm-efficacy, and effectiveness of combinations which may require large,controlled studies.
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Affiliation(s)
- Tetsuhide Ito
- a Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences , Kyushu University , Fukuoka , Japan
| | - Lingaku Lee
- a Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences , Kyushu University , Fukuoka , Japan
| | - Robert T Jensen
- b Digestive Diseases Branch , NIDDK, NIH , Bethesda , MD , USA
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Nakamura A, Mitsuhashi T, Takano Y, Miyoshi H, Kameda H, Nomoto H, Nagai S, Hatanaka Y, Shimizu C, Terauchi Y, Atsumi T. Usefulness of the octreotide test in Japanese patients for predicting the presence/absence of somatostatin receptor 2 expression in insulinomas. Endocr J 2016; 63:135-42. [PMID: 26567922 DOI: 10.1507/endocrj.ej15-0371] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We investigated the relationship between the results of the octreotide test and somatostatin receptor (SSTR) 2 expression in insulinoma patients, to evaluate the usefulness of this test for predicting SSTR2 expression in insulinomas in Japanese patients. Five females and one male were included in the study. All patients underwent the octreotide test before the surgery carried out to resect the tumor, and histopathological examination of the resected tumor was performed by a single experienced pathologist. SSTR2 expression was evaluated by the SSTR2 immunohistochemistry scoring system. Insulinoma was clinically diagnosed and surgically resected in all six patients. In the octreotide test, suppression of insulin secretion was sufficient after loading in patients 1-4 and 6. In patient 5, however, the suppression of insulin secretion was insufficient, which resulted in severe hypoglycemia with endogenous relative hyperinsulinemia after the octreotide loading. The histopathological findings revealed SSTR2 expression in the insulinomas of patients 1-4 and 6, but not in the insulinoma of patient 5. In conclusion, improvement of hyperinsulinemic hypoglycemia by octreotide in Japanese insulinoma patients was associated with SSTR2 expression in the tumor. Our results suggest that the octreotide test could be useful for predicting SSTR2 expression in the tumor.
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Affiliation(s)
- Akinobu Nakamura
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Cives M, Strosberg J. The Expanding Role of Somatostatin Analogs in Gastroenteropancreatic and Lung Neuroendocrine Tumors. Drugs 2015; 75:847-58. [DOI: 10.1007/s40265-015-0397-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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8
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Baudin E, Caron P, Lombard-Bohas C, Tabarin A, Mitry E, Reznick Y, Taieb D, Pattou F, Goudet P, Vezzosi D, Scoazec JY, Cadiot G, Borson-Chazot F, Do Cao C. [Malignant insulinoma: recommendations for workup and treatment]. Presse Med 2014; 43:645-59. [PMID: 24857257 DOI: 10.1016/j.lpm.2013.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 07/15/2013] [Accepted: 08/19/2013] [Indexed: 02/09/2023] Open
Abstract
Insulinoma are malignant in 4 to 14 % of cases. Their rarity and the sparse data available in the literature have limited publication of specific guidelines for their management. The following review aim to provide up-to-date recommendations on initial evaluation including pathologic grading, measures to control hypoglycemia, antitumor strategies and long term follow-up. Will be discussed in detail respective indications of surgery, diazoxide, somatostatin analogs, everolimus, sunitinib, liver directed treatments including arterial embolization, chemotherapy and radiometabolic therapy. A Medline search using terms "insulinoma", "neuroendocrine pancreatic tumors", "islet cell carcinoma", "malignant insulinoma" was performed limiting the selection to English language articles and adult age cases, along with cross referencing.
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Affiliation(s)
- Eric Baudin
- Institut Gustave-Roussy, service de médecine nucléaire et d'oncologie endocrinienne, 94805 Villejuif cedex, France.
| | - Philippe Caron
- CHU Rangueil-Larrey, pôle cardiovasculaire et métabolique, service d'endocrinologie et maladies métaboliques, 31059 Toulouse cedex 9, France
| | | | - Antoine Tabarin
- Hôpital Haut-Lévêque, service d'endocrinologie, 33600 Pessac, France
| | - Emmanuel Mitry
- Institut Curie, hôpital René-Huguenin, service d'onco-gastroentérologie, 92210 Saint-Cloud, France
| | - Yves Reznick
- CHU Côte-de-Nacre, unité fonctionnelle d'endocrinologie et maladies métaboliques, 14033 Caen cedex, France
| | - David Taieb
- CHU de la Timone, service central de biophysique et de médecine nucléaire, 13005 Marseille, France
| | - François Pattou
- Hôpital Claude-Huriez, service de chirurgie endocrinienne, 59000 Lille, France
| | - Pierre Goudet
- CHU de Dijon, service de chirurgie générale et endocrinienne, 21000 Dijon, France
| | - Delphine Vezzosi
- CHU Rangueil-Larrey, pôle cardiovasculaire et métabolique, service d'endocrinologie et maladies métaboliques, 31059 Toulouse cedex 9, France
| | - Jean-Yves Scoazec
- Institut Gustave-Roussy, service de biologie et de pathologie médicales, 94805 Villejuif cedex, France
| | - Guillaume Cadiot
- Hôpital Robert-Debré, service d'hépato-gastro-entérologie et de cancérologie digestive, 51100 Reims, France
| | - Françoise Borson-Chazot
- Hospices Civils de Lyon, Fédération d'endocrinologie du pole Est, Fédération d'endocrinologie et centre de médecine nucléaire, 69500 Lyon, France
| | - Christine Do Cao
- Hôpital Claude-Huriez, service d'endocrinologie et de maladies métaboliques, 59000 Lille, France
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Baudin E, Caron P, Lombard-Bohas C, Tabarin A, Mitry E, Reznick Y, Taieb D, Pattou F, Goudet P, Vezzosi D, Scoazec JY, Cadiot G, Borson-Chazot F, Do Cao C. Malignant insulinoma: recommendations for characterisation and treatment. ANNALES D'ENDOCRINOLOGIE 2013; 74:523-33. [PMID: 23993836 DOI: 10.1016/j.ando.2013.07.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 07/05/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Eric Baudin
- Service de médecine nucléaire et d'oncologie endocrinienne, institut Gustave-Roussy, 94800 Villejuif, France
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Tabarin A, Goichot B. Treatment: symptomatic treatment of hypoglycaemia. ANNALES D'ENDOCRINOLOGIE 2013; 74:196-9. [PMID: 23791453 DOI: 10.1016/j.ando.2013.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Antoine Tabarin
- Service d'endocrinologie-diabétologie et maladies métaboliques, hôpital Haut-Lévêque, groupe hospitalier Sud, CHU de Bordeaux, 33604 Pessac cedex, France.
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Quinn TJ, Yuan Z, Adem A, Geha R, Vrikshajanani C, Koba W, Fine E, Hughes DT, Schmid HA, Libutti SK. Pasireotide (SOM230) is effective for the treatment of pancreatic neuroendocrine tumors (PNETs) in a multiple endocrine neoplasia type 1 (MEN1) conditional knockout mouse model. Surgery 2012; 152:1068-77. [PMID: 23102680 DOI: 10.1016/j.surg.2012.08.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 08/16/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pasireotide (SOM230), a long-acting somatostatin analogue (LAR), has improved agonist activity at somatostatin receptors. We tested the effect of SOM230 on insulin secretion, serum glucose concentrations, tumor growth, and survival using an MEN1 transgenic mouse model. METHODS Eight 12-month-old conditional Men1 knockout mice with insulinoma were assessed. The treatment (n = 4) and control groups (n = 4) received monthly subcutaneous injections of SOM230 or PBS. Serum insulin and glucose levels were determined by enzyme-linked immunosorbent assay and enzymatic colorimetric assay, respectively. Tumor activity, growth, and apoptosis were determined by microPET/CT scan and histologic analysis. RESULTS On day 7, there was a decrease in serum insulin levels from 1.06 ± 0.28 μg/L to 0.37 ± 0.17 μg/L (P = .0128) and a significant increase in serum glucose from 4.2 ± 0.45 mmol/L to 7.12 ± 1.06 mmol/L (P = .0075) in the treatment group but no change in the control group. Tumor size was less in the treatment group (2,098 ± 388 μm(2)) compared with the control group (7,067 ± 955 μm(2); P = .0024). Furthermore, apoptosis was increased in the treatment group (6.9 ± 1.23%) compared with the control group (0.29 ± 0.103%; P = .002). CONCLUSION SOM230 demonstrates antisecretory, antiproliferative, and proapoptotic activity in our MEN1 model of insulinoma. Further studies of the effects of SOM230 in PNET patients with MEN1 mutations are warranted.
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Affiliation(s)
- Thomas J Quinn
- Department of Surgery, Albert Einstein College of Medicine, New York, NY 10467, USA
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Chen S. Advanced diagnostic approaches and current medical management of insulinomas and adrenocortical disease in ferrets (Mustela putorius furo). Vet Clin North Am Exot Anim Pract 2010; 13:439-452. [PMID: 20682429 DOI: 10.1016/j.cvex.2010.05.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Endocrine neoplasia is the most common tumor type in domestic ferrets, especially in middle-aged to older ferrets. Islet cell tumors and adrenocortical tumors constitute the major types of endocrine neoplasms. Insulinoma is a tumor that produces and releases excessive amounts of insulin. Evaluation of fasted blood glucose levels provides a quick diagnostic assessment for the detection of insulinomas. Use of glucocorticoids, diazoxide, and diet modification are some of the medical treatment options for insulinomas. Adrenocortical neoplasia in ferrets usually overproduces one or more sex hormones. Sex hormones which can result in progressive alopecia, vulvar swelling in females, and prostagomegaly in males. Abdominal ultrasonography and sex hormone assays can be used to diagnose adrenocortical neoplasms. Drugs such as leuprolide acetate, deslorelin acetate, and the hormone melatonin can be used to treat adrenocortical neoplasms in ferrets when surgery is not an option.
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Affiliation(s)
- Sue Chen
- Gulf Coast Avian & Exotics, Gulf Coast Veterinary Specialists, 1111 West Loop South, Suite 110, Houston, TX 77027, USA.
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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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14
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Grycewicz J, Ścibór Z, Ćwikła JB, Lewiński A, Cypryk K. Recurrent hypoglycaemia in a type 2 diabetes patient - diagnostic difficulties. Arch Med Sci 2010; 6:126-9. [PMID: 22371733 PMCID: PMC3278956 DOI: 10.5114/aoms.2010.13520] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2008] [Revised: 03/20/2009] [Accepted: 04/19/2009] [Indexed: 11/17/2022] Open
Abstract
Hypoglycaemia is the most frequent acute complication of diabetes, regardless of the type of diabetes and the treatment method. Hormonally active tumours of the pancreas, insulinomas, which belong to digestive tract neuroendocrine tumours, constitute one of the less frequent causes of hypoglycaemia. This paper presents a case of a 60-year-old type 2 diabetes patient with recurrent hypoglycaemic events, in whom an insulin-secreting hepatic neuroendocrine tumour was diagnosed. We suggest performing a diagnostic workup taking into consideration insulinoma in patients with diabetes who experience frequent otherwise inexplicable hypoglycaemic events, particularly when they recur despite decreased dose or discontinuation of hypoglycaemic agents.
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Affiliation(s)
- Joanna Grycewicz
- Department of Diabetology and Metabolic Diseases, Medical University of Lodz, Poland
- Department of Endocrinology and Metabolic Diseases, Polish Mother's Memorial Hospital – Research Institute (RI PMMH), Lodz, Poland
| | - Zdzistawa Ścibór
- Department of Diabetology and Metabolic Diseases, Medical University of Lodz, Poland
- Department of Endocrinology and Metabolic Diseases, Polish Mother's Memorial Hospital – Research Institute (RI PMMH), Lodz, Poland
| | - Jarosław B. Ćwikła
- Department of Radiology and Diagnostic Imaging, Postgraduate Medical Centre and Central Clinical Hospital of the Ministry of Internal Affairs and Administration, Warsaw, Poland
| | - Andrzej Lewiński
- Department of Endocrinology and Metabolic Diseases, Polish Mother's Memorial Hospital – Research Institute (RI PMMH), Lodz, Poland
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, Poland
| | - Katarzyna Cypryk
- Department of Diabetology and Metabolic Diseases, Medical University of Lodz, Poland
- Department of Endocrinology and Metabolic Diseases, Polish Mother's Memorial Hospital – Research Institute (RI PMMH), Lodz, Poland
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15
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Moreira RO, Moreira RBM, Machado NAM, Gonçalves TB, Coutinho WF. Post-prandial hypoglycemia after bariatric surgery: pharmacological treatment with verapamil and acarbose. Obes Surg 2008; 18:1618-21. [PMID: 18566871 DOI: 10.1007/s11695-008-9569-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Accepted: 05/13/2008] [Indexed: 12/21/2022]
Abstract
Postprandial hypoglycemia is a common complication of bariatric surgery. It is usually caused by late dumping syndrome, but a few other causes have already been described, including insulinoma and noninsulinoma pancreatogenous hypoglycemic syndrome (NIPHS). Considering that NIPHS is a recently described syndrome and is also very rare, therapeutic approaches are still not consensual. We report the case of a 26-year-old woman who was submitted to bariatric surgery and presented episodic postprandial hypoglycemic episodes after 16 months. Fasting C-peptide, insulin, and glucose were normal. Because of the possibility of NIPHS, clinical treatment was initiated with verapamil and acarbose, leading to a significant reduction of hypoglycemic episodes and also their severity. Surgery is the most common approach to NIPHS. However, in cases of mild or moderate symptoms, it is important to consider the possibility of pharmacological treatment. This approach may result, at least for some time, in an amelioration of symptoms without the need of an aggressive procedure.
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Affiliation(s)
- Rodrigo O Moreira
- Obesity and Eating Disorders Group (GOTA), Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione/Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB), Rio de Janeiro, Brazil.
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16
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Vezzosi D, Bennet A, Courbon F, Caron P. Short- and long-term somatostatin analogue treatment in patients with hypoglycaemia related to endogenous hyperinsulinism. Clin Endocrinol (Oxf) 2008; 68:904-11. [PMID: 18031316 DOI: 10.1111/j.1365-2265.2007.03136.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The long-term efficacy of somatostatin analogues on insulinomas has not been studied. DESIGN A prospective study to evaluate the response of octreotide in 21 patients with hypoglycaemia related to endogenous hyperinsulinism who were not treated by surgery. RESULTS Reasons for not undergoing surgery were: refusal (n = 3), old age with multiple diseases (n = 5), unlocalized insulinomas (n = 2), malignant unresectable insulinomas (n = 5), multiple insulinomas (n = 3) and diffuse beta-cell disease (n = 3). Hypoglycaemia was responsive to octreotide in 14 of the 21 patients. A short 100-microg octreotide test correctly predicted the efficacy of treatment in six patients with benign insulinomas. Octreoscan scintigraphy was positive in 6 of the 16 patients of whom three were responsive and three unresponsive to octreotide. Octreoscan scintigraphy was negative in 10 of the 16 patients, eight of whom were responsive to octreotide. Subcutaneous octreotide treatment was prolonged for > 6 months (7-144 months, 67 +/- 47 months) in 11 responsive patients. No tachyphylaxis was observed. However, the octreotide dose had to be increased in two patients after 3 and 18 months, respectively. Only one patient suffered from symptomatic biliary lithiasis after 3 years of treatment. CONCLUSION Long-term octreotide treatment can be used to control hypoglycaemia in patients with endogenous hyperinsulinism who are not eligible for surgery; octreotide efficacy on hypoglycaemia could be predicted by a short 100 microg-octreotide test in patients with benign insulinomas, but was not correctly predicted by Octreoscan scintigraphy.
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Affiliation(s)
- D Vezzosi
- Department of Endocrinology, Centre Hospitalier Universitaire, Toulouse, France
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17
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Schober AK, Hahn EG, Harsch IA. [A 67-year-old patient with recurrent hypoglycemia]. Internist (Berl) 2008; 49:485-9. [PMID: 18324381 DOI: 10.1007/s00108-008-2046-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 67 year old female patient was admitted to our clinic with recurrent hypoglycemia in December 2006. Laboratory findings revealed an elevated insulin, and C-peptide. Imaging techniques revealed a tumor of the pancreas involving the spleen with metastases of the liver, expressing somatostatin receptors. Ultrasound-guided biopsy was performed and confirmed the suspected insulinoma. Since the hypoglycemias could not sufficiently be controlled by subcutaneous administration of octreotide and by oral glucose intake, surgical debulking was performed in a palliative intention. After resection the patient was free of hypoglycemia. In case of diagnosed insulinoma, underlying MEN (multiple endocrine neoplasia) should be considered. Excision of the tumor is recommended in patients with benign solitary insulinomas. If complete excision is impossible, there are several therapeutic options that aim at preventing hypoglycemia. Thus, in contrast to other extended tumors, surgery is reasonable in malignant insulinoma even in case of metastatic disease.
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Affiliation(s)
- A K Schober
- Schwerpunkt Endokrinologie und Stoffwechsel, Medizinische Klinik I, Friedrich-Alexander Universität, Ulmenweg 18, 91054, Erlangen, Germany
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18
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Abstract
Insulinomas continue to pose a diagnostic challenge to physicians, surgeons and radiologists alike. Most are intrapancreatic, benign and solitary. Biochemical diagnosis is obtained and imaging techniques to localize lesions continue to evolve. Surgical resection is the treatment of choice. Despite all efforts, an occult insulinoma (occult insulinoma refers to a biochemically proven tumor with indeterminate anatomical site before operation) may still be encountered. New localization preoperative techniques decreases occult cases and the knowledge of the site of the mass before surgery allows to determine whether enucleation of the tumor or pancreatic resection is likely to be required and whether the tumor is amenable to removal via a laparoscopic approach. In absence of preoperative localization and intraoperative detection of an insulinoma, blind pancreatic resection is not recommended.
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Abstract
Pancreatic endocrinopathies, especially insulinomas, are a common finding in ferrets. Surgical resection remains the treatment of choice for insulinomas because it can provide longer disease-free intervals and survival times. Because of the high rate of metastasis, owners should be advised that treatment is rarely curative and is aimed at controlling the clinical signs of hypoglycemia by stopping or slowing the progression of the insulinoma. Although less common, diabetes mellitus can occur in ferrets, but is often a postsurgical sequela to insulinoma resection. Current advancements in diabetes management can be applied to ferrets with diabetes mellitus.
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Affiliation(s)
- Sue Chen
- Gulf Coast Veterinary Specialists, 1111 West Loop South, Suite 110, Houston, TX 77027, USA.
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