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Sakaki K, Murakami T, Fujimoto H, Shimizu Y, Miyake KK, Otani D, Kiyobayashi S, Okada T, Fujimoto M, Hakata T, Yamauchi I, Shimada K, Shimizu H, Nagai K, Nakamoto Y, Inagaki N. 18F-labeled PEGylated exendin-4 imaging noninvasively differentiates insulinoma from an accessory spleen: the first case report of [18F]FB(ePEG12)12-exendin-4 positron emission tomography/computed tomography for insulinoma. Front Endocrinol (Lausanne) 2023; 14:1245573. [PMID: 37720533 PMCID: PMC10501723 DOI: 10.3389/fendo.2023.1245573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
Background Insulinomas are the most common functioning pancreatic neuroendocrine neoplasms, and these tumors induce hypoglycemia due to hyperinsulinemia. Hypoglycemia caused by insulinomas can cause seizures, coma or death due to the delayed diagnosis. The only curative treatment is surgical resection. To perform curative surgical resection of insulinomas, preoperative localization is crucial. However, localization of insulinomas is often challenging using conventional imaging methods such as computed tomography (CT) and magnetic resonance imaging. Although endoscopic ultrasound (EUS) fine-needle aspiration and selective arterial calcium stimulation test, which can reflect the endocrine character of the tumor, are performed in such cases, these modalities are invasive and require operator-dependent techniques. Additionally, somatostatin receptor (SSTR)-targeted imaging has a relatively low sensitivity for detecting insulinomas due to its low SSTR type 2 expression. Thus, there is an urgent need for developing a noninvasive diagnostic technique which is specific for detecting insulinomas. Consequently, glucagon-like peptide-1 receptor-targeted imaging has recently emerged and gained a wide interest. Recently, we have developed a novel 18F-labeled exendin-4-based probe conjugated with polyethylene glycol, [18F]FB(ePEG12)12-exendin-4 (18F-exendin-4), for positron emission tomography (PET) imaging. Here we report a case of insulinoma in which 18F-exendin-4 PET/CT noninvasively provided critical information for localization. Case description This is a case of a 58-year-old male with symptomatic hypoglycemia for 10 years; however, a preoperative diagnosis of insulinoma was not established due to the difficulty in differentiating it from an accessory spleen using conventional imaging. Moreover, the patient requested to avoid invasive diagnostic procedures including EUS. 18F-exendin-4 PET/CT revealed significant uptakes in the pancreatic tail whereas no apparent uptakes were observed in the spleen; thus, curative laparoscopic enucleation of the pancreatic tail was performed. The diagnosis of insulinoma was confirmed via histopathological examination. This is the first case report of insulinoma diagnosed using 18F-exendin-4 PET/CT. Conclusion In this case, PET information led to curative resection through enucleation of the pancreas. 18F-exendin-4 PET/CT may serve as a useful noninvasive clinical tool for insulinoma localization.
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Affiliation(s)
- Kentaro Sakaki
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takaaki Murakami
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroyuki Fujimoto
- Radioisotope Research Center, Agency for Health, Safety and Environment, Kyoto University, Kyoto, Japan
| | - Yoichi Shimizu
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kanae Kawai Miyake
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Daisuke Otani
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sakura Kiyobayashi
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takuya Okada
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masakazu Fujimoto
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takuro Hakata
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ichiro Yamauchi
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kotaro Shimada
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hironori Shimizu
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazuyuki Nagai
- Division of Hepatobiliary Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nobuya Inagaki
- Medical Research Institute Kitano HospitalPIIF Tazuke-kofukai, Osaka, Japan
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Keidai Y, Murakami T, Yamamura N, Tsunoda S, Ikeda A, Hida K, Nagao M, Yamada Y, Fukui A, Ogura M, Fukuda I, Nakamoto Y, Obama K, Inagaki N. Big insulin-like growth factor 2-producing multiple solitary fibrous tumors treated with debulking surgery: A case report. Front Endocrinol (Lausanne) 2023; 14:1071899. [PMID: 36742395 PMCID: PMC9895772 DOI: 10.3389/fendo.2023.1071899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/10/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Non-islet cell tumor hypoglycemia (NICTH) is a rare paraneoplastic syndrome caused by a tumor-producing high molecular weight form of insulin-like growth factor 2 (IGF2) known as big IGF2. The only curative treatment for this condition is surgical resection of the responsible tumors. However, this may not be feasible in cases with multiple metastases at diagnosis of NICTH, and no standard treatment strategy for multiple tumors has been established. The effects of pharmacological therapies including somatostatin analogs are often inefficient and remain difficult to predict. CASE DESCRIPTION A 68-year-old man was admitted to our hospital due to impaired consciousness and severe hypoglycemia. His medical history included diagnosis of a left temporal solitary fibrous tumor (SFT) at the age of 48 years, after which local recurrent and metastatic tumors were repeatedly resected. Four years before admission, multiple intraabdominal and subcutaneous tumors were detected and, being asymptomatic, were managed conservatively. Laboratory exam on admission demonstrated hypoglycemia accompanied with low serum insulin and IGF1 levels. Computed tomography (CT) scan revealed multiple intraabdominal and subcutaneous tumors increasing in size. Serum big IGF2 was detected on immunoblot analysis, and he was diagnosed as NICTH. In addition, tumor uptake was observed on 68Ga-labelled 1,4,7,10-tetraazacyclododecane-N,N',N'',N'''-tetraacetic acid-d-Phe1-Tyr3-octreotide positron emission tomography/CT (DOTATOC-PET/CT). Since larger tumor is more suspicious about responsible producibility of big IGF2, we planned to resect large ones preferentially and reduce the amounts of residual tumors. Debulking surgery was performed by removing eleven intraabdominal tumors; the hypoglycemia was then completely corrected. Histological analyses revealed the resected tumors to be metastases of SFT having somatostatin receptor 2 expression. In immunoblot analysis, the resected tumors were found to be positive for big IGF2; serum big IGF2 was undetectable after surgery. CONCLUSION We present a case of NICTH with multiple metastatic SFTs. We strategically performed debulking surgery, which led to remission of hypoglycemia. This result demonstrates a pioneering practical solution for NICTH cases with multiple tumors. In addition, in cases of SFTs presenting with NICTH, positivity of DOTATOC-PET/CT as well as single-dose administration of octreotide may be predictive of the efficacy of somatostatin-based therapy.
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Affiliation(s)
- Yamato Keidai
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takaaki Murakami
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- *Correspondence: Takaaki Murakami, ; Nobuya Inagaki,
| | - Nana Yamamura
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shigeru Tsunoda
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Ikeda
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koya Hida
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mototsugu Nagao
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yosuke Yamada
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | - Ayaka Fukui
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | - Masahito Ogura
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Izumi Fukuda
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazutaka Obama
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- *Correspondence: Takaaki Murakami, ; Nobuya Inagaki,
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Villanueva‐Rodríguez LG, Reza‐Albarrán AA, Cárdenas E, Ángeles A, Lester J. Impaired glucose tolerance with neurological manifestations in insulinoma. Clin Case Rep 2021; 9:e04532. [PMID: 34532041 PMCID: PMC8435222 DOI: 10.1002/ccr3.4532] [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: 03/06/2020] [Revised: 03/30/2021] [Accepted: 06/10/2021] [Indexed: 11/13/2022] Open
Abstract
Insulinoma may have an atypical presentation and it should be suspected in patients with neurological manifestations in spite of an atypical insulin and proinsulin levels associated with hypoglycemia. Fast test is an important tool to reach the diagnosis.
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Affiliation(s)
| | | | - Enrique Cárdenas
- Neurology/NeurophysiologyInstituto Mexicano de Neurociencias/Hospital Angeles LomasHuixquilucanMexico
| | - Arturo Ángeles
- Pahology DepartmentInstituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”TlalpanMexico
| | - Jacobo Lester
- NeurologyInstituto Mexicano de NeurocienciasHuixquilucanMexico
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Adarsh M, Salman M, Kumar MS, Shetty M. Unusual presentation of an insulinoma in an elderly male patient. J Postgrad Med 2021; 67:164-167. [PMID: 34414928 PMCID: PMC8445128 DOI: 10.4103/jpgm.jpgm_1165_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Insulinoma is a rare neuroendocrine tumor originating from hypersecreting beta-cells of islets of Langerhans in the pancreas. We report a case of 72-year-old male, with chronic alcohol abuse, presenting with atypical features like refractory recurrent secondary generalized seizures and behavioral disturbances with increased irritability, initially mistreated as alcohol withdrawal. Detailed history, particularly the relationship of the symptoms with food intake, made us think of other causes of seizures. Fasting biochemical investigations and localizing studies helped clinch the diagnosis. The tumor was localized with the help of endoscopic ultrasonography and whole-body Ga68-DOTANOC PET-CT. The patient was treated conservatively with diazoxide and is doing well on follow-up. The present case report emphasizes the importance of detailed clinical history, more so in atypically presenting cases of refractory seizures. Insulinoma can be medically managed despite surgery being the gold standard curative treatment.
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Affiliation(s)
- M Adarsh
- Department of General Medicine, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - M Salman
- Department of General Medicine, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - M Shiva Kumar
- Department of General Medicine, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - M Shetty
- Department of General Medicine, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Hatoko T, Murakami T, Sone M, Yabe D, Masui T, Nakamoto Y, Furuta A, Uza N, Kodama Y, Harada N, Ogura M, Yasoda A, Inagaki N. Low-dose Selective Arterial Calcium Stimulation Test for Localizing Insulinoma: A Single-center Experience of Five Consecutive Cases. Intern Med 2020; 59:2397-2403. [PMID: 32611954 PMCID: PMC7644493 DOI: 10.2169/internalmedicine.4396-20] [Citation(s) in RCA: 2] [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] [Indexed: 11/09/2022] Open
Abstract
The selective arterial calcium stimulation test (SACST) is one of the most useful localization tests for insulinoma but can cause false-positive and/or unexpected multi arterial positive results that hamper clinical decisions. There are also several adverse effects, such as nausea and hypoglycemia, at the conventional dose (0.025 mEq/kg) of calcium injection. We herein report five consecutive insulinoma cases in which low-dose (0.005-0.007 mEq/kg) calcium injection for SACST led to successful insulinoma localization. No adverse effects of SACST were observed. In conclusion, a low-dose SACST can be a favorable option as an insulinoma localization test in terms of accuracy and safety.
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Affiliation(s)
- Tomonobu Hatoko
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Takaaki Murakami
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Masakatsu Sone
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Daisuke Yabe
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
- Department of Diabetes and Endocrinology, Graduate School of Medicine, Gifu University, Japan
| | - Toshihiko Masui
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Japan
| | - Akihiro Furuta
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Japan
| | - Norimitsu Uza
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Japan
| | - Yuzo Kodama
- Department of Gastroenterology, Kobe University Graduate School of Medicine, Japan
| | - Norio Harada
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Masahito Ogura
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Akihiro Yasoda
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
- Clinical Research Center, National Hospital Organization Kyoto Medical Center, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
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Suminaga K, Murakami T, Yabe D, Sone M, Sugawa T, Masui T, Uza N, Yoshizawa A, Ogura M, Yasoda A, Inagaki N. Factory-calibrated continuous glucose monitoring and capillary blood glucose monitoring in a case with insulinoma: usefulness and possible pitfall under chronic hyperinsulinemic hypoglycemia. Endocr J 2020; 67:361-366. [PMID: 31761874 DOI: 10.1507/endocrj.ej19-0339] [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] [Indexed: 11/23/2022] Open
Abstract
The accuracy of factory-calibrated continuous glucose monitoring (fCGM) within hypoglycemic ranges, especially under the status of chronic hyperinsulinemic hypoglycemia like insulinomas, remains an issue. Even so, fCGM is known to be useful for detecting hypoglycemia unawareness in insulinoma cases. A 25-year-old woman presenting with sudden unconsciousness was diagnosed with insulinoma; fCGM facilitated diagnosis by continuous monitoring for hypoglycemia. Before surgery, she was treated with continuous and frequent bolus infusions of 50% glucose via central venous catheter. To evaluate the accuracy of fCGM values in this case, a comparison between fCGM and capillary blood glucose (CBG) values was also performed. According to the simultaneously measured values, those of fCGM were largely in accordance with those of CBG. Moreover, compared with the previously reported case not having glucose infusions via central venous catheter, both the mean absolute relative differences (MARDs) and the absolute differences (Δ glucose) between fCGM and CBG values were larger in the present case, although no significant differences of MARDs and Δ glucose between the two cases were observed in several different conditions including fasting, post-meal, hypoglycemia, and others. Therefore, we should note possible increased differences between fCGM and CBG values in cases using frequent intravenous glucose infusions as well as case-dependent differing levels of consistency between them.
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Affiliation(s)
- Keiichiro Suminaga
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takaaki Murakami
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Daisuke Yabe
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Diabetes and Endocrinology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masakatsu Sone
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Taku Sugawa
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Toshihiko Masui
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Norimitsu Uza
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiko Yoshizawa
- Department of Diagnostic Pathology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masahito Ogura
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiro Yasoda
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Lyerla RC, Bajaj A, Shrestha RT. USE OF A CONTINUOUS GLUCOSE MONITOR FOR PREOPERATIVE MONITORING AND TREATMENT OF HYPOGLYCEMIA IN A CASE OF PANCREATIC NEUROENDOCRINE TUMOR. AACE Clin Case Rep 2020; 5:e255-e258. [PMID: 31967047 DOI: 10.4158/accr-2018-0590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/13/2019] [Indexed: 12/22/2022] Open
Abstract
Objective Pancreatic neuroendocrine tumors secreting proinsulin and insulin could lead to life-threatening hypoglycemia. We aim to show this can be avoided by utilizing continuous glucose monitoring. Methods We describe a case of a 55-year-old female with hypoglycemia unawareness and seizures diagnosed with proinsulinoma. She utilized an intermittently scanned continuous glucose monitor (isCGM) to monitor hypoglycemia preoperatively. Results The patient underwent biochemical and radiographic evaluation to confirm the diagnosis of proinsulinoma. Utilizing isCGM to monitor blood glucose, she was able to prevent hypoglycemia-related seizures prior to definitive surgery. Conclusion In the time leading up to a definitive surgery, patients with proinsulinomas are at risk of hypoglycemic events leading to falls, seizures, and even death. isCGMs can be utilized for preoperative monitoring and treatment of hypoglycemia in these patients.
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Sugawa T, Murakami T, Yabe D, Kashima R, Tatsumi M, Ooshima S, Joo E, Wada K, Yoshizawa A, Masui T, Nakamoto Y, Yamauchi Y, Kodama Y, Iemura Y, Ogura M, Yasoda A, Inagaki N. Hypoglycemia Unawareness in Insulinoma Revealed with Flash Glucose Monitoring Systems. Intern Med 2018; 57:3407-3412. [PMID: 30101920 PMCID: PMC6306522 DOI: 10.2169/internalmedicine.1173-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The delayed diagnosis of insulinoma remains a clinical issue. One of the main causes of such a delay is hypoglycemia unawareness. A 53-year-old woman fell unconscious during postprandial exercises. Flash glucose monitoring (FGM) systems revealed glucose profiles with fasting hypoglycemia, which facilitated the clinical diagnosis of insulinoma even though she was unaware of her hypoglycemia. The preoperative comparison of the blood glucose values provided by FGM with those obtained from capillary blood were consistent. Thus, FGM may have potential utility in revealing the presence of insulinoma-induced hypoglycemia.
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Affiliation(s)
- Taku Sugawa
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Takaaki Murakami
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Daisuke Yabe
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Riko Kashima
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Makiko Tatsumi
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Shinobu Ooshima
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Erina Joo
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Keiko Wada
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Atsushi Yoshizawa
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Japan
| | - Toshihiko Masui
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Japan
| | - Yuki Yamauchi
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Japan
| | - Yuzo Kodama
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Japan
| | - Yoshiki Iemura
- Department of Diagnostic Pathology, Kyoto University Graduate School of Medicine, Japan
| | - Masahito Ogura
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Akihiro Yasoda
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan
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