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Boateng WK, Ezeh KJ, Botros Y, Spira E, Shen T. A Rare Case of Malignant Insulinoma Associated With Gastrointestinal Bleed. Cureus 2024; 16:e64894. [PMID: 39156287 PMCID: PMC11330681 DOI: 10.7759/cureus.64894] [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] [Accepted: 07/18/2024] [Indexed: 08/20/2024] Open
Abstract
A gastrointestinal bleed (GIB) in the setting of metastatic insulinoma is a rare phenomenon. It appears that cases of metastatic insulinoma causing GIB are rare, often influenced by the tumor's location. Our case involves an 82-year-old male with dementia and a history of recurrent hypoglycemia, presenting with an episode of altered mental status. The patient exhibited hypoglycemia alongside a melena episode and anemia. Diagnostic criteria, including Whipple's triad, confirmed endogenous insulin production. Computed tomography (CT) showed a left paraaortic/retroperitoneal mass. Esophagogastroduodenoscopy (EGD) visualized an extrinsic mass at the gastric body, which caused an ulcerated surface that was treated with clipping and hemostasis. The patient's recurrent hypoglycemic episodes were treated with glucose, while his GIB was managed with hemostasis and clipping. However, the patient was not a surgical candidate, and further medical treatment was ceased by the family.
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Affiliation(s)
| | | | - Youssef Botros
- Gastroenterology and Hepatology, Jersey City Medical Center, Jersey City, USA
| | - Etan Spira
- Gastroenterology and Hepatology, Jersey City Medical Center, Jersey City, USA
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Guerrero-Pérez F, Vilarrasa N, Huánuco LV, Busquets J, Secanella L, Vercher-Conejero JL, Vidal N, Näf Cortés S, Villabona C. Ectopic insulinoma: a systematic review. Rev Endocr Metab Disord 2023; 24:1135-1146. [PMID: 37434098 DOI: 10.1007/s11154-023-09824-2] [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] [Accepted: 07/07/2023] [Indexed: 07/13/2023]
Abstract
Knowledge of ectopic insulinomas comes from single cases. We performed a systematic review through PubMed, Web of Science, Embase, eLibrary and ScienceDirect of all cases reported in the last four decades. We also describe one unreported patient. From 28 patients with ectopic insulinoma, 78.6% were female and mean age was 55.7 ± 19.2 years. Hypoglycaemia was the first symptom in 85.7% while 14.3% complained of abdominal pain or genital symptoms. Median tumour diameter was 27.5 [15-52.5] mm and it was localised by CT (73.1%), MRI (88.9%), [68Ga]Ga-DOTA-exedin-4 PET/CT (100%), 68Ga-labelled-DOTA-conjugated somatostatin analogue PET/TC (100%), somatostatin receptor scintigraphy (40%) and endoscopic ultrasound (50%). Ectopic insulinomas were located at duodenum (n = 3), jejunum (n = 2), and one respectively at stomach, liver, appendix, rectum, mesentery, ligament of Treitz, gastrosplenic ligament, hepatoduodenal ligament and splenic hilum. Seven insulinomas were affecting the female reproductive organs: ovary (n = 5), cervix (n = 2) and remaining tumours were at retroperitoneum (n = 3), kidney (n = 2), spleen (n = 1) and pelvis (n = 1). 89.3% underwent surgery (66.7% surgery vs. 33.3% laparoscopy) and 16% underwent an ineffective pancreatectomy. 85.7% had localized disease at diagnosis and 14.3% developed distant metastasis. Median follow-up time was 14.5 [4.5-35.5] months and mortality was reported in 28.6% with median time until death of 60 [5-144] months. In conclusion, ectopic insulinomas are presented as hypoglycaemia with female preponderance. Functional imaging [68Ga]Ga-DOTA-exedin-4 PET/CT and 68Ga-labelled-DOTA-conjugated somatostatin analogue PET/TC have very high sensitivity. Clinicians should be alert to the possibility of extra-pancreatic insulinomas when classic diagnostic tests and intraoperative pancreas exploration failed to locate the tumour.
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Affiliation(s)
- Fernando Guerrero-Pérez
- Department of Endocrinology, Bellvitge University Hospital, Barcelona, Spain.
- Biomedical Research Institute of Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain.
| | - Nuria Vilarrasa
- Department of Endocrinology, Bellvitge University Hospital, Barcelona, Spain
- Biomedical Research Institute of Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain
| | - Lidia V Huánuco
- Department of Endocrinology, Bellvitge University Hospital, Barcelona, Spain
- Biomedical Research Institute of Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Juli Busquets
- Biomedical Research Institute of Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Department of Hepatobiliary and Pancreatic Surgery, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Lluis Secanella
- Biomedical Research Institute of Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Department of Hepatobiliary and Pancreatic Surgery, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - José L Vercher-Conejero
- Biomedical Research Institute of Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Department of Nuclear Medicine-PET Unit, University Hospital Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Noemi Vidal
- Biomedical Research Institute of Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Department of Pathology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Silvia Näf Cortés
- Department of Endocrinology, Joan XXIII University Hospital, Tarragona, Spain
| | - Carles Villabona
- Department of Endocrinology, Bellvitge University Hospital, Barcelona, Spain
- Biomedical Research Institute of Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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Gan L, Zhu X, Gao Y, Zhong M, Liao S, Huang G, Yan Y. A review on nondiabetic hypoglycemia from various causes: Case series report. Medicine (Baltimore) 2023; 102:e36273. [PMID: 38013348 PMCID: PMC10681503 DOI: 10.1097/md.0000000000036273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/02/2023] [Indexed: 11/29/2023] Open
Abstract
RATIONALE Hypoglycemia is common in patients with glucose regulation disorders and related diabetic treatments but is rare in nondiabetic patients. Severe hypoglycemia can cause harm to patients' cognition, consciousness, central nervous system, cardiovascular and cerebrovascular system, and even death. However, the most fundamental way to control hypoglycemia is to identify the cause and deal with the primary disease. This article introduces 3 cases of nondiabetic hypoglycemia with different causes, aiming to improve our understanding of nondiabetic hypoglycemia and improve the ability of early diagnosis and differential diagnosis. PATIENT CONCERNS Case 1 is a 19-year-old female with a history of recurrent coma, and magnetic resonance imaging and endoscopic ultrasound of the pancreas suggest insulinoma. Case 2 is a 74-year-old male with a history of viral hepatitis, and computerized tomography shows multiple nodules in the liver, which is diagnosed as liver cancer. Case 3 is a 39-year-old female with a history of taking methimazole, who tested positive for insulin antibodies, and was diagnosed with insulin autoimmune syndrome. DIAGNOSIS All 3 patients were diagnosed with nondiabetic hypoglycemia, but the causes varied, and included insulinoma, non-islet cell tumor-induced hypoglycemia, and insulin autoimmune syndrome. INTERVENTIONS Case 1 underwent pancreatic tail resection; case 2 refused anti-tumor treatment and received glucose injections for palliative treatment only; and case 3 stopped taking methimazole. OUTCOMES After surgery, the blood sugar in case 1 returned to normal, and the blood sugar in case 2 was maintained at about 6.0 mmol/L. The symptoms of hypoglycemia gradually improved in case 3 after stopping the medication. LESSONS Non-diabetic hypoglycemia requires further examination to clarify the cause, and the correct differential diagnosis can provide timely and effective treatment, improving the patient's prognosis.
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Affiliation(s)
- Lulu Gan
- Department of Endocrinology, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Xuan Zhu
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Yue Gao
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Mingyao Zhong
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Shibo Liao
- Department of Endocrinology, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
| | - Gao Huang
- Department of Endocrinology, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
| | - Yimin Yan
- Department of Endocrinology, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
- Medical College of Wuhan University of Science and Technology, Wuhan, China
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Helderman NC, Suerink M, Kilinç G, van den Berg JG, Nielsen M, Tesselaar MET. Relation between WHO Classification and Location- and Functionality-Based Classifications of Neuroendocrine Neoplasms of the Digestive Tract. Neuroendocrinology 2023; 114:120-133. [PMID: 37690447 PMCID: PMC10836754 DOI: 10.1159/000534035] [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: 03/27/2023] [Accepted: 08/21/2023] [Indexed: 09/12/2023]
Abstract
Practice of neuroendocrine neoplasms (NENs) of the digestive tract, which comprise of a highly diverse group of tumors with a rising incidence, faces multiple biological, diagnostic, and therapeutic issues. Part of these issues is due to misuse and misinterpretation of the classification and terminology of NENs of the digestive tract, which make it increasingly challenging to evaluate and compare the literature. For instance, grade 3 neuroendocrine tumors (NETs) are frequently referred to as neuroendocrine carcinomas (NECs) and vice versa, while NECs are, by definition, high grade and therefore constitute a separate entity from NETs. Moreover, the term NET is regularly misused to describe NENs in general, and NETs are frequently referred to as benign, while they should always be considered malignancies as they do have metastatic potential. To prevent misconceptions in future NEN-related research, we reviewed the most recent terminology used to classify NENs of the digestive tract and created an overview that combines the classification of these NENs according to the World Health Organization (WHO) with location- and functionality-based classifications. This overview may help clinicians and researchers in understanding the current literature and could serve as a guide in the clinic as well as for writing future studies on NENs of the digestive tract. In this way, we aim for the universal use of terminology, thereby providing an efficient foundation for future NEN-related research.
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Affiliation(s)
- Noah C Helderman
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Manon Suerink
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Gül Kilinç
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
| | - José G van den Berg
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maartje Nielsen
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Margot E T Tesselaar
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Walker MP, Shenoy V, Metz DC, Stanley CA, Fraker D, Chandrasekhara V, Amaro A. Case presentation of 8-year follow up of recurrent malignant duodenal Insulinoma and lymph node metastases and literature review of malignant Insulinoma management. BMC Endocr Disord 2022; 22:310. [PMID: 36494838 PMCID: PMC9733155 DOI: 10.1186/s12902-022-01219-9] [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: 12/13/2021] [Accepted: 11/04/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Insulinoma is an uncommon insulin-secreting neuroendocrine tumor that presents with severe recurrent hypoglycemia. Although cases of extrapancreatic insulinomas have been reported, the majority of insulinomas occur in the pancreas. The number of reported cases of ectopic insulinomas with follow-up assessments is limited and they do not report disease recurrence. The current report presents the first documented case of recurrent extrapancreatic insulinoma with 8 years of follow-up, provides relevant literature review, and proposes surveillance and treatment strategies. CASE PRESENTATION We describe an insulinoma localized in the duodenal wall of a 36-year-old female who presented in 2013 with weight gain and Whipple's triad and was successfully managed with duodenotomy and enucleation. She presented again in 2017 with recurrent Whipple's triad and was found to have metastatic disease localized exclusively to peripancreatic lymph nodes. Primary pancreatic insulinoma was not evident and her hypoglycemia resolved following lymph node dissection. Eight years after initial presentation continuous glucose monitoring (CGM) showed a trend for euglycemia, and PET-CT Gallium 68 DOTATATE scan evaluation indicated absence of recurrent disease. CONCLUSION Insulinomas are rare clinical entities and extrapancreatic insulinomas are particularly uncommon. Follow-up evaluation and treatment strategies for ectopic insulinoma recurrence presents a significant clinical challenge as the condition has hitherto remained undescribed in the literature. Available evidence in the literature indicates that lymph node metastases of intrapancreatic insulinomas likely do not change prognosis. Given the absence of long-term data informing the management and monitoring of patients with extrapancreatic insulinoma, we suggest patient education for hypoglycemic symptoms, monitoring for hypoglycemia with CGM, annual imaging, and a discussion with patients regarding treatment with octreotide or alternative somatostatin receptor analog therapies.
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Affiliation(s)
- Michelle P Walker
- Department of Endocrinology, University of Pennsylvania, 3400 Civic Center Boulevard, West Pavilion, 4th Floor, Philadelphia, PA, 19104, USA.
| | - Vikram Shenoy
- Department of Endocrinology, Christiana Care, 4735 Ogletown Stanton Road, Suite MAP2, Newark, DE, 19713, USA
| | - David C Metz
- Department of Gastroenterology, University of Pennsylvania, 3400 Civic Center Boulevard, South Pavilion, 4th Floor, Philadelphia, PA, 19104, USA
| | - Charles A Stanley
- Department of Endocrinology and Metabolism, Children's Hospital of Philadelphia, 3516 Civic Center Boulevard #802, Philadelphia, PA, 19104, USA
| | - Douglas Fraker
- Department of Endocrine and Oncologic Surgery, University of Pennsylvania, 3400 Civic Center Boulevard, West Pavilion, 3rd Floor, Philadelphia, PA, 19104, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street. SW, Rochester, MN, 55905, USA
| | - Anastassia Amaro
- Department of Endocrinology, University of Pennsylvania, 3400 Civic Center Boulevard, West Pavilion, 4th Floor, Philadelphia, PA, 19104, USA
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Zhang X, Jia H, Li F, Fang C, Zhen J, He Q, Liu M. Ectopic insulinoma diagnosed by 68Ga-Exendin-4 PET/CT: A case report and review of literature. Medicine (Baltimore) 2021; 100:e25076. [PMID: 33787590 PMCID: PMC8021326 DOI: 10.1097/md.0000000000025076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/15/2021] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Ectopic insulinomas are extremely rare and challenging to diagnose for clinicians. Precise preoperative localization is essential to successful treatment. PATIENT CONCERNS A 23-year-old man presented with a 1-year history of recurrent hypoglycemia. DIAGNOSIS Examinations in the local hospital did not reveal any pancreatic lesion. After admission, a fasting test and a 5-hour oral glucose tolerance test (OGTT) suggested a diagnosis of endogenous hyperinsulinemic hypoglycemia. Enhanced volume perfusion computed tomography (VPCT) revealed 2 nodules in the tail of the pancreas, a nodule in the gastric antrum, and a nodule in the hilum of the spleen. To differentiate which nodule was responsible for hypoglycemia, we performed 68Ga-Exendin-4 PET/CT and 68Ga-DOTATATE PET/CT which helped to make a conclusive diagnosis that the lesion in the gastric antrum was an ectopic insulinoma. INTERVENTIONS The patient was cured with minimally invasive laparoscopic resection of the tumor. OUTCOMES The symptoms were relieved and the blood glucose level remained normal after surgery. CONCLUSIONS This case shows that 68Gallium-exendin-4 PET/CT is useful for precise localization and thereby successful treatment of insulinoma, especially for occult insulinomas and those derived from an ectopic pancreas.
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Affiliation(s)
- Xiaona Zhang
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital
- Nankai University State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, China
| | - Hongwei Jia
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital
| | - Fengao Li
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital
| | - Chunyun Fang
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital
| | - Jinyang Zhen
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital
| | - Qing He
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital
| | - Ming Liu
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital
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