1
|
Jürgensen C, Eckart M, Haberbosch L, Tacke F, Sandforth A, Birkenfeld AL, Overkamp D, Daniels M, Mogl M, Goretzki P, Strasburger C, Mai K, Spranger J, Jumpertz von Schwartzenberg R. Endoscopic ultrasound-guided ethanol ablation versus surgical resection of insulinomas. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024. [PMID: 37931914 DOI: 10.1055/a-2204-5814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
PURPOSE Insulinoma is a rare tumor of the pancreas that can lead to hypoglycemia. To date, the standard therapy is surgical resection. After the first case report of successful endoscopic ultrasound-guided (EUS) ethanol injection 16 years ago, the need for establishing an alternative treatment method remains unchanged given the high morbidity rates of surgery and its unsuitability in some patients. MATERIALS AND METHODS Here, we provide retrospective data from 33 insulinoma patients that were treated at our center between 2010 and 2021. Of these, 9 patients were treated with EUS-guided ethanol injection and 24 underwent pancreatic surgery. RESULTS The ethanol group was older (ethanol: mean ± SE 67.8±11.2 years vs. surgery: 52.3±15.7, p=0.014) with a higher Charlson Comorbidity Index (3.0 (1.0;4.0) vs. 1.0 (0.0;2.0), p=0.008). The lowest glucose values were similar between groups before (ethanol: 2.09±0.17 mmol/l vs. surgery: 1.81±0.08, p=0.158) and after (4.95±0.74 vs. 5.41±0.28, p=0.581) the respective treatments. Complications occurred more frequently in the surgery group (11 % vs. 54 %, p=0.026). One patient after prior partial pancreatectomy died postoperatively. The hospitalization time was significantly shorter in the ethanol group (4.78±0.78 days vs. 19.88±4.07, p<0.001). CONCLUSION EUS-guided ethanol injection can be similarly effective for the treatment of hyperinsulinemic hypoglycemia compared with pancreatic surgery but seems to be associated with less severe complications. This implies the need for prospective randomized trials in insulinoma patients with a low risk for malignancy.
Collapse
Affiliation(s)
- Christian Jürgensen
- Department of Hepatology and Gastroenterology, Charité University Medicine, Berlin, Germany
| | - Marius Eckart
- Department of Hepatology and Gastroenterology, Charité University Medicine, Berlin, Germany
| | - Linus Haberbosch
- Department of Endocrinology and Metabolic Diseases (including Lipid Metabolism), Charité University Medicine, Berlin, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité University Medicine, Berlin, Germany
| | - Arvid Sandforth
- Department of Internal Medicine IV, Division of Diabetology, Endocrinology and Nephrology, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM), Helmholtz Center Munich, Neuherberg, Germany
| | - Andreas L Birkenfeld
- Department of Internal Medicine IV, Division of Diabetology, Endocrinology and Nephrology, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM), Helmholtz Center Munich, Neuherberg, Germany
| | - Dietrich Overkamp
- Department of Internal Medicine IV, Division of Diabetology, Endocrinology and Nephrology, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Martin Daniels
- Department of Endocrinology and Metabolic Diseases (including Lipid Metabolism), Charité University Medicine, Berlin, Germany
| | - Martina Mogl
- Department of Surgery, Charité University Medicine, Berlin, Germany
| | - Peter Goretzki
- Department of Surgery, Charité University Medicine, Berlin, Germany
| | - Christian Strasburger
- Department of Endocrinology and Metabolic Diseases (including Lipid Metabolism), Charité University Medicine, Berlin, Germany
| | - Knut Mai
- Department of Endocrinology and Metabolic Diseases (including Lipid Metabolism), Charité University Medicine, Berlin, Germany
| | - Joachim Spranger
- Department of Endocrinology and Metabolic Diseases (including Lipid Metabolism), Charité University Medicine, Berlin, Germany
- Berlin Institute of Health at Charite, Berlin, Germany
| | - Reiner Jumpertz von Schwartzenberg
- Department of Internal Medicine IV, Division of Diabetology, Endocrinology and Nephrology, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM), Helmholtz Center Munich, Neuherberg, Germany
- German Center for Diabetes Research, München-Neuherberg, Germany
| |
Collapse
|
2
|
Andreasi V, Partelli S, Muffatti F, Battistella A, Fermi F, Balzano G, Crippa S, Tamburrino D, Pecorelli N, De Cobelli F, Arcidiacono PG, Falconi M. Diagnostic work-up and surgical management of insulinoma: A retrospective analysis from a tertiary referral center. J Neuroendocrinol 2023; 35:e13353. [PMID: 37915303 DOI: 10.1111/jne.13353] [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: 01/21/2023] [Revised: 06/05/2023] [Accepted: 09/11/2023] [Indexed: 11/03/2023]
Abstract
Insulinoma is a multifaceted disease that poses several challenges in terms of clinical presentation, diagnostic work-up, and surgical management. The aim of this study was to describe diagnostic work-up, surgical management, and postoperative outcomes of patients with insulinoma. All consecutive patients who underwent surgery for insulinoma at San Raffaele Hospital (Milan, Italy) between January 2008 and January 2022 were included. Overall, 98 patients were considered. The median delay between presenting symptoms and insulinoma diagnosis was 10 months (IQR, 4-21). Insulinoma diagnosis was made at our Institution in 45 patients, 20 of whom referred within 6 months from symptoms onset. In this subgroup, the median interval between symptoms presentation and insulinoma diagnosis was 4 months (IQR, 2-6), as compared to 14 months (IQR, 10-26) in patients (n = 25) who referred to our institution after 6 months from symptoms onset (p < .001). The insulinoma was localized preoperatively in all the cases. All patients underwent ≥1 high-quality imaging: computed tomography (CT: n = 87, sensitivity 84%), magnetic resonance imaging (MRI: n = 55, sensitivity 85%) and endoscopic ultrasound (EUS: n = 79, sensitivity 100%). MRI identified the tumor in eight patients with negative CT. EUS localized the insulinoma in three patients with negative CT and negative MRI. Parenchyma-sparing resections were performed in 41 patients. Contact with major vessels, lesion close to Wirsung duct and suspect of malignancy were the main reasons to perform a formal resection. An early referral to high-volume centers is important for reducing diagnostic delay in patients with insulinoma. The diagnostic work-up of insulinoma frequently requires several imaging modalities to be performed, with EUS being the most sensitive one. Parenchyma-sparing surgery for insulinoma should be performed whenever technically and oncologically feasible.
Collapse
Affiliation(s)
- Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
| | - Anna Battistella
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesca Fermi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Domenico Tamburrino
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
| | - Nicolò Pecorelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco De Cobelli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Radiology & Center for Experimental Imaging, IRCCS San Raffaele Hospital, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Pancreato-Biliary Endoscopy and Endosonography Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
3
|
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.
Collapse
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.)
| |
Collapse
|
4
|
Wang F, Yang Z, Chen X, Peng Y, Jiang H, Qin S. A novel diagnostic model for insulinoma. Discov Oncol 2022; 13:68. [PMID: 35916979 PMCID: PMC9346017 DOI: 10.1007/s12672-022-00534-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 07/27/2022] [Indexed: 11/28/2022] Open
Abstract
The aim is to describe a simple and feasible model for the diagnosis of insulinoma. This retrospective study enrolled 37 patients with insulinoma and 44 patients with hypoglycemia not due to insulinoma at the First Affiliated Hospital of Guangxi Medical University. General demographic and clinical characteristics; hemoglobin A1c (HbA1c), insulin and C-peptide concentrations; and the results of 2-h oral glucose tolerance tests (OGTT) were recorded, and a logistic regression model predictive of insulinoma was determined. Body mass index (BMI), HbA1c concentration, 0-h C-peptide concentration, and 0-h and 1-h plasma glucose concentrations (P < 0.05 each) were independently associated with insulinoma. A regression prediction model was established through multivariate logistics regression analysis: Logit p = 7.399+(0.310 × BMI) - (1.851 × HbA1c) - (1.467 × 0-h plasma glucose) + (1.963 × 0-h C-peptide) - (0.612 × 1-h plasma glucose). Using this index to draw a receiver operating characteristic (ROC) curve, the area under the curve (AUC) was found to be 0.957. The optimal cut-off value was - 0.17, which had a sensitivity of 89.2% and a specificity of 86.4%. Logit P ≥ - 0.17 can be used as a diagnostic marker for predicting insulinoma in patients with hypoglycemia.
Collapse
Affiliation(s)
- Feng Wang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Zhe Yang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - XiuBing Chen
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Yiling Peng
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - HaiXing Jiang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China.
| | - ShanYu Qin
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China.
| |
Collapse
|
5
|
Wild D, Antwi K, Fani M, Christ ER. Glucagon-like Peptide-1 Receptor as Emerging Target: Will It Make It to the Clinic? J Nucl Med 2021; 62:44S-50S. [PMID: 34230073 DOI: 10.2967/jnumed.120.246009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/11/2020] [Indexed: 11/16/2022] Open
Abstract
The glucagon-like peptide-1 receptor (GLP-1R) is an emerging target due to its high expression in benign insulinomas as well as in islet cell hypertrophia/hyperplasia (nesidioblastosis) and pancreatic β-cells. In 2008, occult insulinomas were localized for the first time in men using the metabolically stable radiolabeled glucagon-like peptide-1 (GLP-1) agonist [Lys40(Ahx-DTPA-111In)NH2]-exendin-4 (111In-DTPA-exendin-4). Afterward, several radiopharmaceuticals for GLP-1R PET/CT imaging were synthesized and evaluated, for example, [Nle14,Lys40(Ahx-DOTA-68Ga)NH2]-exendin-4 (68Ga-DOTA-exendin-4), [Cys40(MAL-NOTA-68Ga)NH2]-exendin-4 (68Ga-NOTA-exendin-4), and [Lys40(NODAGA-68Ga)NH2]-exendin-4 (68Ga-NODAGA-exendin-4). Several prospective comparison studies provided evidence that GLP-1R PET/CT is significantly more sensitive than contrast-enhanced MRI (ceMRI), contrast-enhanced CT (ceCT), GLP-1R SPECT/CT, somatostatin receptor PET/CT, and SPECT/CT in the detection of benign insulinomas, and insulinomas in the context of multiple endocrine neoplasia type 1. As a result, the European Neuroendocrine Tumor Society guidelines recommend GLP-1R imaging or selective intraarterial calcium stimulation and venous sampling (ASVS) in patients for whom there is a clinical suspicion of having an insulinoma but who have a negative ceMRI/ceCT or negative endoscopic ultrasound. Furthermore, there is growing evidence that GLP-1R PET/CT can visualize and localize adult nesidioblastosis. This is clinically relevant as the distinction between focal and diffuse nesidioblastosis is critical in directing a therapeutic strategy in these patients. Prospective studies have proven the clinical relevance of GLP-1R imaging as it is often the only imaging modality able to localize the insulinoma or nesidioblastosis. It is therefore likely that this noninvasive imaging modality will replace the invasive localization of insulinomas using ASVS. More experimental indications for GLP-1R imaging include the diagnosis of an insulinoma/nesidioblastosis in patients with postprandial hypoglycemia after bariatric bypass surgery and monitoring β-cells in patients with brittle type 1 diabetes after islet-cell transplantation. We believe that these indications and possibly future indications will bring GLP-1R imaging to the clinic.
Collapse
Affiliation(s)
- Damian Wild
- Division of Nuclear Medicine, University Hospital Basel, Basel, Switzerland; .,Center for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel, Switzerland
| | - Kwadwo Antwi
- Division of Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Melpomeni Fani
- Division of Radiopharmaceutical Chemistry, University Hospital Basel, Basel, Switzerland; and
| | - Emanuel R Christ
- Center for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel, Switzerland.,Division of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
6
|
Song P, Yan JY, Wang Y, Li X. Value of multi-detector computed tomography during intra-arterial infusion of contrast medium for locating insulinomas. J Int Med Res 2020; 48:300060519889432. [PMID: 32212878 PMCID: PMC7370806 DOI: 10.1177/0300060519889432] [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] [Indexed: 11/25/2022] Open
Abstract
Objective This study aimed to evaluate the accuracy of multi-detector computed tomography (CT) during intra-arterial infusion of contrast medium (MDCT-IA) for locating insulinomas. Methods This retrospective study included patients with insulinomas who underwent surgery at the Chinese PLA General Hospital in 2013 to 2014. The patients’ case notes and investigation results were reviewed. Preoperative tumor localization was carried out by MDCT-IA and noninvasive methods including MDCT, magnetic resonance imaging (MRI), and contrast-enhanced ultrasound (CEUS). Insulinoma localization using these methods was compared with the histologically confirmed location following surgical excision. Results Twelve insulinomas were identified in 12 patients, all of which were treated surgically. All patients received MDCT-IA (100%), 11 patients also underwent MRI (91.7%), seven underwent CT (58.3%), and all 12 underwent CEUS (100%). Tumor localization was determined successfully in 12/12 patients by MDCT-IA (100%), in 9/11 by MRI (81.8%), 4/7 by CT (57.1%), and 7/12 by CEUS (58.3%). Overall, MDCT-IA correctly localized 100% of the lesions. Conclusions MDCT-IA can be used to determine the preoperative localization of insulinomas.
Collapse
Affiliation(s)
- Peng Song
- Department of Interventional Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Jie-Yu Yan
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, China
| | - Yan Wang
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, China
| | - Xiao Li
- Department of Interventional Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical college, Beijing, China
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Christ E, Antwi K, Fani M, Wild D. Innovative imaging of insulinoma: the end of sampling? A review. Endocr Relat Cancer 2020; 27:R79-R92. [PMID: 31951592 PMCID: PMC7040495 DOI: 10.1530/erc-19-0476] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 01/17/2020] [Indexed: 12/16/2022]
Abstract
Receptors for the incretin glucagon-like peptide-1 (GLP-1R) have been found overexpressed in selected types of human tumors and may, therefore, play an increasingly important role in endocrine gastrointestinal tumor management. In particular, virtually all benign insulinomas express GLP-1R in high density. Targeting GLP-1R with indium-111, technetium-99m or gallium-68-labeled exendin-4 offers a new approach that permits the successful localization of small benign insulinomas. It is likely that this new non-invasive technique has the potential to replace the invasive localization of insulinomas by selective arterial stimulation and venous sampling. In contrast to benign insulinomas, malignant insulin-secreting neuroendocrine tumors express GLP-1R in only one-third of the cases, while they more often express the somatostatin subtype 2 receptors. Importantly, one of the two receptors appears to be always overexpressed. In special cases of endogenous hyperinsulinemic hypoglycemia (EHH), that is, in the context of MEN-1 or adult nesidioblastosis GLP-1R imaging is useful whereas in postprandial hypoglycemia in the context of bariatric surgery, GLP-1R imaging is probably not helpful. This review focuses on the potential use of GLP-1R imaging in the differential diagnosis of EHH.
Collapse
Affiliation(s)
- Emanuel Christ
- Division of Endocrinology, Diabetology and Metabolism, University Hospital of Basel, University of Basel, Basel, Switzerland
- Center for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel Switzerland
| | - Kwadwo Antwi
- Clinic of Radiology and Nuclear Medicine, University Hospital, Basel, Switzerland
| | - Melpomeni Fani
- Clinic of Radiology and Nuclear Medicine, University Hospital, Basel, Switzerland
| | - Damian Wild
- Center for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel Switzerland
- Clinic of Radiology and Nuclear Medicine, University Hospital, Basel, Switzerland
| |
Collapse
|
9
|
Waters AM, Maizlin II, Russell RT, Dellinger M, Gow KW, Goldin A, Goldfarb M, Nuchtern JG, Langer M, Vasudevan SA, Doski JJ, Raval M, Beierle EA. Pancreatic islet cell tumors in adolescents and young adults. J Pediatr Surg 2019; 54:2103-2106. [PMID: 30954230 DOI: 10.1016/j.jpedsurg.2019.01.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/26/2018] [Accepted: 01/09/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreatic islet cell tumors are rare in adolescents, and most studies published to date focus on older patients. We utilized a national database to describe the histology and clinical pattern of pancreatic islet cell tumors in adolescent and young adult (AYA) patients, and to compare AYAs to older adults. We hypothesized that AYAs with pancreatic islet cell tumors would have better overall survival. METHODS The National Cancer Data Base (NCDB, 1998-2012) was queried for AYA patients (15-39 years) with a pancreatic islet cell tumor diagnosis. Demographics, tumor characteristics, treatment modalities, and outcomes were abstracted and compared to adults (≥40 years). RESULTS 383 patients (56.4% female, 65% non-Hispanic Whites) were identified, with a median age of 27 (IQR 16-34) years. Islet cell carcinoma was the most common histology. Of patients with known stage of disease, 49% presented with early stage (I or II). Seventy percent of patients underwent surgical resection, including local excision 44%, Whipple procedure 37.5%, or total pancreatectomy 19%. Chemotherapy was utilized in 27% and radiotherapy in 7%. All-cause mortality was 36%. AYA patients underwent more extensive resections (p = 0.001) and had lower mortality rates (p < 0.001), with no differences in tumor stage or use of adjuvant therapies, when compared to adults. CONCLUSIONS AYA patients with pancreatic islet cell tumors had comparable utilization of adjuvant therapies but underwent more extensive resections and demonstrated a higher overall survival rate than adult counterparts. Further investigation into approaches to earlier diagnosis and tailoring of multimodality therapy of these neoplasms in the AYA population is needed. LEVELS OF EVIDENCE Prognostic Study, Level II - retrospective study.
Collapse
Affiliation(s)
- Alicia M Waters
- Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Ilan I Maizlin
- Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Robert T Russell
- Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Matthew Dellinger
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - Kenneth W Gow
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - Adam Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - Melanie Goldfarb
- Department of Surgery, John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, CA
| | - Jed G Nuchtern
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Monica Langer
- Department of Surgery, Maine Children's Cancer Program, Tufts University, Portland, ME
| | - Sanjeev A Vasudevan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - John J Doski
- Department of Surgery, Methodist Children's Hospital of South Texas, University of Texas Health Science Center-San Antonio, San Antonio, TX
| | - Mehul Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Elizabeth A Beierle
- Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL.
| |
Collapse
|
10
|
Open and minimally invasive pancreatic neoplasms enucleation: a systematic review. Surg Endosc 2019; 33:3192-3199. [PMID: 31363894 DOI: 10.1007/s00464-019-06967-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 07/01/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatic enucleation (pEN) as parenchyma-sparing procedure for small pancreatic neoplasms is quickly becoming the most common surgical option in such setting. Nowadays, pEN is frequently carried out through a minimally invasive approach either laparoscopic or robotic. Its impact on overall perioperative complications and pancreatic fistula (POPF) is still under evaluation. The scope of our systematic review is to assess pEN's perioperative outcomes and to evaluate the effect of the minimally invasive techniques over POPF and other surgical complications. METHODS We performed a systematic literature search (time-frame January 1999-September 2018), considering exclusively those studies which included at least 5 cases of either open or minimally invasive pEN. Data regarding postoperative outcome and POPF were extracted and analyzed. We defined postoperative morbidities by the Clavien-Dindo classification while POPF according to the International Study Group of Pancreatic Fistula (ISGPF) definition. RESULTS Sixty-three studies met the criteria selected, accounting for a study population of 2485 patients. 27.7% had a minimally invasive pEN. The overall postoperative morbidity rate was 46.1% with 11.9% rated as severe (Clavien-Dindo ≥ 3). Mortality rate was 0.69%. The minimally invasive approach to pEN led to a statistically significant reduction of both the overall POPF rate (28.7% vs. 45.9%, p < 0.001), and clinically significant B-C POPF (p < 0.027). The postoperative overall morbidity rate was clearly in favor of the minimally invasive approach (27.6% vs. 55.2%, p < 0.001). CONCLUSIONS Our review confirms that pEN is a safe and feasible technique for the treatment of small benign or low-grade pancreatic neoplasms and it can be implemented with an acceptable morbidity rate along with low mortality. The minimally invasive approach is gaining widespread acceptance due to its supposed non-inferiority compared with the traditional open approach. In our review, it showed to be even better in terms of POPF incidence rate and short-term postoperative outcome. Still, such data need to be corroborated by randomized clinical trials.
Collapse
|
11
|
Liang M, Jiang J, Dai H, Hong X, Han X, Cong L, Tong A, Li F, Luo Y, Liu W, Zhou L, Di W, Wu W, Zhao Y. Robotic enucleation for pediatric insulinoma with MEN1 syndrome: a case report and literature review. BMC Surg 2018; 18:44. [PMID: 29921249 PMCID: PMC6009035 DOI: 10.1186/s12893-018-0376-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/11/2018] [Indexed: 01/20/2023] Open
Abstract
Background A patient with a rare pediatric insulinoma and MEN1 syndrome was treated by robotic enucleation surgery. Case presentation We present a case of a 9-year-old girl presenting with repeated loss of consciousness, concomitant with a pale face, palpitations, and convulsions, which had persisted for 2 years and had been aggravated during the previous 2 months. She was previously misdiagnosed with epilepsy in another hospital. We further examined her while she was hospitalized. By combining her medical history and imaging examination and lab test results, a diagnosis of insulinoma was confirmed. Sanger-directed sequencing on a peripheral blood sample revealed an MEN1 gene mutation, indicating pediatric insulinoma with MEN1 syndrome. The patient underwent minimally invasive insulinoma enucleation surgery under the Da Vinci robot-assisted system with intraoperative ultrasound (IOUS) connected. The surgery was successfully completed within 65 min, and the girl recovered well postoperatively and no longer experienced symptoms of hypoglycemia. Conclusion This is the first report of a case of pediatric insulinoma treated using robotic enucleation. This experience demonstrates the feasibility and safety of combining robotic surgery with the enucleation procedure as an excellent strategy for pediatric insulinoma.
Collapse
Affiliation(s)
- Mei Liang
- Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Jialin Jiang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Hongmei Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xiafei Hong
- Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xianlin Han
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Lin Cong
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Anli Tong
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Fang Li
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Yaping Luo
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Weinan Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Liangrui Zhou
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Wenyu Di
- Department of Pathology, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Wenming Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.
| |
Collapse
|
12
|
Kann PH. Is endoscopic ultrasonography more sensitive than magnetic resonance imaging in detecting and localizing pancreatic neuroendocrine tumors? Rev Endocr Metab Disord 2018; 19:133-137. [PMID: 30267296 DOI: 10.1007/s11154-018-9464-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
To compare endoscopic ultrasonography (EUS) and magnetic resonance imaging (MRI) in terms of their sensitivities to localize pancreatic neuroendocrine tumors (pNET) preoperatively. Systematic analysis of the literature; sensitivity of EUS and MRI in insulinomas and pancreaticoduodenal NETs in multiple endocrine neoplasia type 1 (MEN1) in series of at least 20 subjects referring to tumors confirmed by surgery and histopathology. Other imaging methods reported were also assessed. Eighteen publications on insulinomas (782 cases) could be analyzed, no study in MEN1 fulfilled the inclusion criteria and compared EUS to MRI. Data quality was moderate: all publications referred to case series. Mean correct detection / localization rates (sensitivity) were calculated: EUS 80%, MRI 66%, computed tomography 63%, angiography 52%, somatostatin receptor scintigraphy 42%, ultrasonography 23%; arterial calcium stimulation with hepatic venous sampling regionalized correctly in 80%. EUS seems to be more sensitive than MRI in localizing pancreatic neuroendocrine tumors. If a specialized endosonographist is available, EUS is the preferable imaging procedure. Otherwise, MRI is a suitable alternative.
Collapse
Affiliation(s)
- Peter Herbert Kann
- Centre for Endocrinology, Diabetology & Osteology, Endocrine Laboratory, Philipp's University and University Hospital Marburg, Marburg, Germany.
- German Centre for Endocrine Care, Frankfurt / Main, Germany.
| |
Collapse
|
13
|
Qin S, Liu Y, Ning H, Tao L, Luo W, Lu D, Luo Z, Qin Y, Zhou J, Chen J, Jiang H. EUS-guided lauromacrogol ablation of insulinomas: a novel treatment. Scand J Gastroenterol 2018; 53:616-620. [PMID: 29141488 DOI: 10.1080/00365521.2017.1402206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS EUS-guided ablation with ethanol has been used to treat insulinoma since 2006 as a minimally invasive alternative for those who are unwilling or unsuitable for surgeries. However, pancreatic fistula, pancreatitis and other adverse effects were found after the procedure in these patients. Herein, we aimed to find a novel feasible injection. METHODS Seven patients with different chief complaints were diagnosed with insulinoma by symptoms, lab results and pathology results from EUS fine needle aspiration. All the patients refused to have surgeries and were treated by EUS-guided ablation with lauromacrogol. The injection volume was calculated by tumor size. All the patients were followed up by at least 1 month to see if there is any adverse effect. Blood glucose (BG), insulin and C-peptide levels were monitored before and after the procedure. RESULTS Insulinoma size ranged from 0.76 cm ×0.84 cm to 3.39 cm ×1.84 cm. With a mean injection volume of 1.9 ml (range from 0.9 to 3.9 ml), all the patients showed relief in symptoms after the procedure. During the follow up, their BG, insulin and C-peptide levels went back to normal. None of the patients had any adverse effect. CONCLUSIONS EUS-guided ablation with lauromacrogol showed good treatment results and received no adverse effect after the procedure. Hence, we consider it as an effective and safe method to treat insulinoma.
Collapse
Affiliation(s)
- Shanyu Qin
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Yongru Liu
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Hongjian Ning
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Lin Tao
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Wei Luo
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Donghong Lu
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Zuojie Luo
- b Endocrinology Department , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Yingfen Qin
- b Endocrinology Department , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Jia Zhou
- b Endocrinology Department , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Junqiang Chen
- c Department of Gastrointestinal Surgery , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| | - Haixing Jiang
- a Department of Gastroenterology , First Affiliated Hospital of Guangxi Medical University , Nanning , P.R. China
| |
Collapse
|
14
|
Shao S, Zeng Z, Hu S. An observational analysis of insulinoma from a single institution. QJM 2018; 111:237-241. [PMID: 29319794 DOI: 10.1093/qjmed/hcy006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Insulinoma is the commonest functioning pancreatic neuroendocrine tumor causing hyperinsulinemic hypoglycemia. AIM This study is aimed to evaluate the clinical features, preoperative laboratory and imaging diagnosis and pathologic findings of insulinoma. METHODS Data of the patients from 2001 to 2016 diagnosed as insulinoma in Tongji Hospital, China were retrospectively extracted and analyzed. RESULTS A total of 40 patients were diagnosed as insulinoma with a male/female ratio of 0.68:1. The median onset age was 46.5 years. Nearly all the included patients presented neurological symptoms and 60% presented autonomic symptoms. More than 95% of the patients met the functional European Neuroendocrine Tumor Society criteria including glucose, insulin and C-peptide levels. The preoperative detection rates of ultrasonography, enhanced computed tomography, magnetic resonance imaging, and endoscopic ultrasonography were 60.50%, 84.95%, 80% and 83.3% respectively. The joint imaging examinations can markedly increase the detection rate. The mean tumor size was 1.89 ± 0.72 cm. Ki-67 index by histopathological diagnosis were all less than 20%. The positive rates of insulin, synaptophysin and chromogranin A were close to 100%. CONCLUSION Laboratory tests of glucose, insulin and C-peptide are reliable for preoperative diagnosis. Combination of the imaging examinations can improve the diagnosis.
Collapse
Affiliation(s)
- S Shao
- From the Division of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan 430030, PR China
| | - Z Zeng
- From the Division of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan 430030, PR China
| | - S Hu
- From the Division of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan 430030, PR China
| |
Collapse
|
15
|
Qian SY, Hare MJL, Pham A, Topliss DJ. Insulinoma presenting with post-prandial hypoglycaemia following fundoplication. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM-17-0131. [PMID: 29367876 PMCID: PMC5777165 DOI: 10.1530/edm-17-0131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 12/18/2017] [Indexed: 11/08/2022] Open
Abstract
Insulinomas are rare neuroendocrine tumours that classically present with fasting hypoglycaemia. This case report discusses an uncommon and challenging case of insulinoma soon after upper gastrointestinal surgery. A 63-year-old man presented with 6 months of post-prandial hypoglycaemia beginning after a laparoscopic revision of Toupet fundoplication. Hyperinsulinaemic hypoglycaemia was confirmed during a spontaneous episode and in a mixed-meal test. Localisation studies including magnetic resonance imaging (MRI), endoscopic ultrasound (EUS) and gallium dotatate positron emission tomography (68Ga Dotatate PET) were consistent with a small insulinoma in the mid-body of the pancreas. The lesion was excised and histopathology was confirmed a localised well-differentiated neuroendocrine pancreatic neoplasm. There have been no significant episodes of hypoglycaemia since. This case highlights several key points. Insulinoma should be sought in proven post-prandial hyperinsulinaemic hypoglycaemia - even in the absence of fasting hypoglycaemia. The use of nuclear imaging targeting somatostatin and GLP1 receptors has improved accuracy of localisation. Despite these advances, accurate surgical resection can remain challenging. Learning points Hypoglycaemia is defined by Whipple's triad and can be provoked by fasting or mixed-meal tests.Although uncommon, insulinomas can present with post-prandial hypoglycaemia.In hypoglycaemia following gastrointestinal surgery (i.e. bariatric surgery or less commonly Nissen fundoplication) dumping syndrome or non-insulinoma pancreatogenous hypoglycaemia syndrome (NIPHS) should be considered.Improved imaging techniques including MRI, endoscopic ultrasound and functional nuclear medicine scans aid localisation of insulinomas.Despite advances in imaging and surgical techniques, accurate resection of insulinomas remains challenging.
Collapse
Affiliation(s)
- Sarah Y Qian
- Department of Endocrinology and DiabetesThe Alfred Hospital, Melbourne, Australia
| | - Matthew J L Hare
- Department of Endocrinology and DiabetesThe Alfred Hospital, Melbourne, Australia
| | - Alan Pham
- Department of Anatomical PathologyThe Alfred Hospital, Melbourne, Australia
| | - Duncan J Topliss
- Department of Endocrinology and DiabetesThe Alfred Hospital, Melbourne, Australia.,Department of MedicineMonash University, Melbourne, Australia
| |
Collapse
|