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Hofland J, Refardt JC, Feelders RA, Christ E, de Herder WW. Approach to the Patient: Insulinoma. J Clin Endocrinol Metab 2024; 109:1109-1118. [PMID: 37925662 PMCID: PMC10940262 DOI: 10.1210/clinem/dgad641] [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: 08/22/2023] [Revised: 10/02/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
Insulinomas are hormone-producing pancreatic neuroendocrine neoplasms with an estimated incidence of 1 to 4 cases per million per year. Extrapancreatic insulinomas are extremely rare. Most insulinomas present with the Whipple triad: (1) symptoms, signs, or both consistent with hypoglycemia; (2) a low plasma glucose measured at the time of the symptoms and signs; and (3) relief of symptoms and signs when the glucose is raised to normal. Nonmetastatic insulinomas are nowadays referred to as "indolent" and metastatic insulinomas as "aggressive." The 5-year survival of patients with an indolent insulinoma has been reported to be 94% to 100%; for patients with an aggressive insulinoma, this amounts to 24% to 67%. Five percent to 10% of insulinomas are associated with the multiple endocrine neoplasia type 1 syndrome. Localization of the insulinoma and exclusion or confirmation of metastatic disease by computed tomography is followed by endoscopic ultrasound or magnetic resonance imaging for indolent, localized insulinomas. Glucagon-like peptide 1 receptor positron emission tomography/computed tomography or positron emission tomography/magnetic resonance imaging is a highly sensitive localization technique for seemingly occult, indolent, localized insulinomas. Supportive measures and somatostatin receptor ligands can be used for to control hypoglycemia. For single solitary insulinomas, curative surgical excision remains the treatment of choice. In aggressive malignant cases, debulking procedures, somatostatin receptor ligands, peptide receptor radionuclide therapy, everolimus, sunitinib, and cytotoxic chemotherapy can be valuable options.
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Affiliation(s)
- Johannes Hofland
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
| | - Julie C Refardt
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
- ENETS Center of Excellence, Division of Endocrinology, Diabetology and Metabolism, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Richard A Feelders
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
| | - Emanuel Christ
- ENETS Center of Excellence, Division of Endocrinology, Diabetology and Metabolism, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Wouter W de Herder
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
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Sulciner ML, Clancy TE. Surgical Management of Pancreatic Neuroendocrine Tumors. Cancers (Basel) 2023; 15:cancers15072006. [PMID: 37046665 PMCID: PMC10093271 DOI: 10.3390/cancers15072006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
Pancreatic neuroendocrine tumors (PNETs) are relatively uncommon malignancies, characterized as either functional or nonfunctional secondary to their secretion of biologically active hormones. A wide range of clinical behavior can be seen, with the primary prognostic indicator being tumor grade as defined by the Ki67 proliferation index and mitotic index. Surgery is the primary treatment modality for PNETs. While functional PNETs should undergo resection for symptom control as well as potential curative intent, nonfunctional PNETs are increasingly managed nonoperatively. There is increasing data to suggest small, nonfunctional PNETs (less than 2 cm) are appropriate follow with nonoperative active surveillance. Evidence supports surgical management of metastatic disease if possible, and occasionally even surgical management of the primary tumor in the setting of widespread metastases. In this review, we highlight the evolving surgical management of local and metastatic PNETs.
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de Carbonnières A, Challine A, Cottereau AS, Coriat R, Soyer P, Abou Ali E, Prat F, Terris B, Bertherat J, Dousset B, Gaujoux S. Surgical management of insulinoma over three decades. HPB (Oxford) 2021; 23:1799-1806. [PMID: 33975801 DOI: 10.1016/j.hpb.2021.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 04/09/2021] [Accepted: 04/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This paper reports our experience of the perioperative management of patients with sporadic, non-malignant, pancreatic insulinoma. METHODS A retrospective monocentric cohort study was performed from January 1989 to July 2019, including all the patients who had been operated on for pancreatic insulinoma. The preoperative work-up, surgical management, and postoperative outcome were analyzed. RESULTS Eighty patients underwent surgery for sporadic pancreatic insulinoma, 50 of which were female (62%), with a median age of 50 (36-70) years. Preoperatively, the tumors were localized in 76 patients (95%). Computed tomography (CT) and magnetic resonance imaging allowed exact preoperative tumor localization in 76% of the patients (64-85 and 58-88 patients, respectively), increasing to 96% when endoscopic ultrasonography was performed. Forty-one parenchyma-sparing pancreatectomies (PSP) (including enucleation, caudal pancreatectomy, and uncinate process resection) and 39 pancreatic resections were performed. The mortality rate was 6% (n = 5), with a morbidity rate of 72%, including 24 severe complications (30%) and 35 pancreatic fistulas (44%). No differences were found between formal pancreatectomy and PSP in terms of postoperative outcome procedures. The surgery was curative in all the patients. CONCLUSION CT used in combination with endoscopic ultrasonography allows accurate localization of insulinomas in almost all patients. When possible, a parenchyma-sparing pancreatectomy should be proposed as the first-line surgical strategy.
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Affiliation(s)
- Anne de Carbonnières
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Alexandre Challine
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Anne Ségolène Cottereau
- Université de Paris, 75006 Paris, France; Department of Nuclear Medicine, Cochin Hospital, APHP, 75014 Paris, France
| | - Romain Coriat
- Université de Paris, 75006 Paris, France; Department of Gastroenterology, Cochin Hospital, APHP, 75014 Paris, France
| | - Philippe Soyer
- Université de Paris, 75006 Paris, France; Department of Radiology, Cochin Hospital, APHP, 75014 Paris, France
| | - Einas Abou Ali
- Université de Paris, 75006 Paris, France; Department of Gastroenterology, Cochin Hospital, APHP, 75014 Paris, France
| | - Frédéric Prat
- Université de Paris, 75006 Paris, France; Department of Gastroenterology, Cochin Hospital, APHP, 75014 Paris, France
| | - Benoit Terris
- Université de Paris, 75006 Paris, France; Department of Pathology, Cochin Hospital, APHP, 75014 Paris, France
| | - Jérôme Bertherat
- Université de Paris, 75006 Paris, France; Department of Endocrinology, Cochin Hospital, APHP, 75014 Paris, France
| | - Bertrand Dousset
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, 75014 Paris, France; Université de Paris, 75006 Paris, France.
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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.
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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
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Usefulness of selective arterial calcium injection tests for functional pancreatic neuroendocrine tumors. Sci Rep 2021; 11:235. [PMID: 33420290 PMCID: PMC7794566 DOI: 10.1038/s41598-020-80538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 12/15/2020] [Indexed: 11/26/2022] Open
Abstract
The selective arterial calcium injection (SACI) test is useful for patients with functional pancreatic neuroendocrine tumors (F-PNETs). This study evaluated which patients with F-PNETs would benefit from the SACI test. We retrospectively analyzed the preoperative findings of patients on computed tomography (CT), magnetic resonance imaging (MRI), CT angiography (CTA), and the SACI test. Fourteen patients who underwent pancreatectomy between January 1997 and September 2016 for F-PNETs were evaluated. We classified these patients into groups A, B, and C; group A, one tumor detected by either CT or MRI; group B, multiple tumors detected; and group C, the tumor location was accordant on CT, MRI, and CTA, but the SACI test revealed another tumor. In group A, the tumor was also detected by CTA and the SACI test was positive on calcium injection. In group B, the focus tumor among the multiple tumors was detected by the SACI test. In group C, another tumor was identified by the SACI test, whose location was different from that detected using CT and MRI. The SACI test is more useful for multiple F-PNETs on CT or MRI. If CT or MRI detects a single tumor, the SACI test or CTA may be unnecessary.
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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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7
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Essentials of Insulinoma Localization with Selective Arterial Calcium Stimulation and Hepatic Venous Sampling. J Clin Med 2020; 9:jcm9103091. [PMID: 32992761 PMCID: PMC7601191 DOI: 10.3390/jcm9103091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/25/2022] Open
Abstract
Insulinomas are the most common functional pancreatic neuroendocrine tumor. Most insulinomas can be localized non-invasively with cross-sectional and nuclear imaging. Selective arterial calcium stimulation and hepatic venous sampling is an effective and safe minimally-invasive procedure for insulinoma localization that may be utilized when non-invasive techniques are inconclusive. The procedure’s technical success and proper interpretation of its results is dependent on the interventional radiologist’s knowledge of normal and variant pancreatic arterial perfusion. Accurate pre-operative localization aids in successful surgical resection. Technical and anatomic considerations of insulinoma localization with selective arterial calcium stimulation and hepatic venous sampling are reviewed.
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Ramonell KM, Saunders ND, Sarmiento J, Bercu Z, Martin L, Weber CJ, Sharma J, Patel SG. Avoiding Pitfalls in Insulinomas by Preoperative Localization with a Dual Imaging Approach. Am Surg 2020. [DOI: 10.1177/000313481908500735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Insulinomas are rare endocrine malignancies of the pancreas that require surgical resection but can be difficult to localize preoperatively. We sought to review and improve the accuracy of preoperative localization techniques at our institution. We retrospectively reviewed all insulinomas that underwent resection at our institution between 1998 and 2016. Localization techniques include selective arterial calcium stimulation (CaStim), CT, MRI, angiography, and somatostatin receptor scintigraphy. Thirty-eight patients had pathologically proven insulinomas on surgical resection. Localization accuracies of CaStim, CT, and MRI were 89 per cent (31/35), 67 per cent (22/33), and 46 per cent (11/24), respectively. When compared with CTalone and CaStim alone, the combination of these two modalities resulted in 100 per cent preoperative localization (30/30), whereas the use of CaStim alone resulted in 80 per cent (4/5) localization and the use of CT alone resulted in 66 per cent (2/3) localization. Four of our patients had both negative CT and MRI. Among these patients, CaStim was 100 per cent localizing and the only positive modality for these patients. These data confirm that CaStim is accurate in preoperatively identifying single and multiple insulinomas; and when combined with CT, this accuracy is increased to 100 per cent. Based on these data, we propose that a dual imaging approach is a superior means of preoperative localization.
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Affiliation(s)
| | | | | | - Zachary Bercu
- Division of Interventional Radiology, Department of Radiology, Emory University, Atlanta, Georgia
| | - Louis Martin
- Division of Interventional Radiology, Department of Radiology, Emory University, Atlanta, Georgia
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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.
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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
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Hayashi R, Minami I, Sasahara Y, Izumiyama H, Yoshimoto T, Kishino M, Kudo A, Tateishi U, Tanabe M, Yamada T. Diagnostic accuracy of selective arterial calcium injection test for localization of gastrinoma. Endocr J 2020; 67:305-315. [PMID: 31813923 DOI: 10.1507/endocrj.ej19-0413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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 appropriate localization of gastrinoma is still difficult. We aimed to evaluate the diagnostic accuracy of selective arterial calcium injection (SACI) for localization of gastrinomas including multiple lesions. This retrospective study included ten patients with surgically proven gastrinomas (gastrinoma group) and six patients without any findings suggesting Zollinger-Ellison syndrome (non-gastrinoma group). For SACI, calcium gluconate was injected into the arteries supplying pancreas, duodenum, and liver. Blood samples from the hepatic vein were obtained before and 30, 60, and 120 seconds after each injection. The results were considered positive when the increase in serum immunoreactive gastrin (IRG) levels within 60 seconds of calcium gluconate injection were more than 80 pg/mL and more than 20% from baseline. We evaluated the efficacy of SACI by comparing the SACI responses with definitive locations diagnosed by clinical and histopathological findings. In the gastrinoma group, false-positive responses were confirmed in seven of the ten patients. False-negative response was observed in one of the feeding arteries of one patient with gastrinomas in multiple locations. Conversely, the greatest increase in serum gastrin levels from baseline at 30 seconds indicated the true-positive responses in all patients with gastrinomas. In the non-gastrinoma group, calcium gluconate injection into gastroduodenal artery evoked positive responses in five of the six patients. In conclusion, our data suggest the strongest gastrin response evoked by SACI indicates the definitive location in patients with gastrinomas. In contrast, SACI could not accurately locate multiple gastrin-secreting lesions due to poor specificity.
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Affiliation(s)
- Ruriko Hayashi
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Isao Minami
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Endocrinology, Yokohama City Minato Red Cross Hospital, Kanagawa, Japan
| | - Yuriko Sasahara
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Endocrinology and Metabolism, Soka Municipal Hospital, Saitama, Japan
| | - Hajime Izumiyama
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takanobu Yoshimoto
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Diabetes and Endocrinology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Mitsuhiro Kishino
- Department of Diagnostic Radiology and Nuclear Medicine, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Kudo
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ukihide Tateishi
- Department of Diagnostic Radiology and Nuclear Medicine, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuya Yamada
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Shen Y, Song X, Ren Y. Insulin autoimmune syndrome induced by exogenous insulin injection: a four-case series. BMC Endocr Disord 2019; 19:148. [PMID: 31883520 PMCID: PMC6935495 DOI: 10.1186/s12902-019-0482-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Insulin autoimmune syndrome (IAS) is a rare cause of hypoglycemia and is characterized by the presence of insulin autoantibodies. Patients with IAS usually complain of hypoglycemia without any previous insulin received. Glucocorticoids and immunosuppressants are used to treat IAS. CASE PRESENTATION We report four patients with diabetes who were diagnosed with non-classical IAS and describe the treatment of these patients. Moreover, the differential diagnosis with hyperinsulinism is discussed. CONCLUSION High levels of insulin autoantibodies, as well as hyperinsulinemic hypoglycemia, are found in patients with diabetes mellitus and prior exogenous insulin exposure. This situation that we classified as non-classical IAS should be attached importance to.
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Affiliation(s)
- Yimin Shen
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, 310009 China
- Zhejiang University School of Medicine, Zhejiang, 310058 China
| | - Xiaoxiao Song
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, 310009 China
| | - Yuezhong Ren
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, 310009 China
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Andreassen M, Ilett E, Wiese D, Slater EP, Klose M, Hansen CP, Gercke N, Langer SW, Kjaer A, Maurer E, Federspiel B, Kann PH, Bartsch DK, Knigge U. Surgical Management, Preoperative Tumor Localization, and Histopathology of 80 Patients Operated on for Insulinoma. J Clin Endocrinol Metab 2019; 104:6129-6138. [PMID: 31369096 DOI: 10.1210/jc.2019-01204] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/26/2019] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Diagnosis and pathological classification of insulinomas are challenging. AIM To characterize localization of tumors, surgery outcomes, and histopathology in patients with insulinoma. METHODS Patients with surgically resected sporadic insulinoma were included. RESULTS Eighty patients were included. Seven had a malignant tumor. A total of 312 diagnostic examinations were performed: endoscopic ultrasonography (EUS; n = 59; sensitivity, 70%), MRI (n = 33; sensitivity, 58%), CT (n = 55; sensitivity, 47%), transabdominal ultrasonography (US; n = 45; sensitivity, 40%), somatostatin receptor imaging (n = 17; sensitivity, 29%), 18F-fluorodeoxyglucose positron emission tomography/CT (n = 1; negative), percutaneous transhepatic venous sampling (n = 10; sensitivity, 90%), arterial stimulation venous sampling (n = 20; sensitivity, 65%), and intraoperative US (n = 72; sensitivity, 89%). Fourteen tumors could not be visualized. Invasive methods were used in 7 of these 14 patients and localized the tumor in all cases. Median tumor size was 15 mm (range, 7 to 80 mm). Tumors with malignant vs benign behavior showed less staining for insulin (3 of 7 vs 66 of 73; P = 0.015) and for proinsulin (3 of 6 vs 58 of 59; P < 0.001). Staining for glucagon was seen in 2 of 6 malignant tumors and in no benign tumors (P < 0.001). Forty-three insulinomas stained negative for somatostatin receptor subtype 2a. CONCLUSION Localization of insulinomas requires many different diagnostic procedures. Most tumors can be localized by conventional imaging, including EUS. For nonvisible tumors, invasive methods may be a useful diagnostic tool. Malignant tumors showed reduced staining for insulin and proinsulin and increased staining for glucagon.
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Affiliation(s)
- Mikkel Andreassen
- Department of Endocrinology Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- European Neuroendocrine Tumor Society Center of Excellence, Rigshospitalet, Copenhagen, Denmark
| | - Emma Ilett
- Department of Endocrinology Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- European Neuroendocrine Tumor Society Center of Excellence, Rigshospitalet, Copenhagen, Denmark
| | - Dominik Wiese
- European Neuroendocrine Tumor Society, Philipps University, Marburg, Germany
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University, Marburg, Germany
| | - Emily P Slater
- European Neuroendocrine Tumor Society, Philipps University, Marburg, Germany
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University, Marburg, Germany
| | - Marianne Klose
- Department of Endocrinology Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- European Neuroendocrine Tumor Society Center of Excellence, Rigshospitalet, Copenhagen, Denmark
| | - Carsten Palnæs Hansen
- European Neuroendocrine Tumor Society Center of Excellence, Rigshospitalet, Copenhagen, Denmark
- Department of Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Norman Gercke
- European Neuroendocrine Tumor Society, Philipps University, Marburg, Germany
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University, Marburg, Germany
| | - Seppo W Langer
- European Neuroendocrine Tumor Society Center of Excellence, Rigshospitalet, Copenhagen, Denmark
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Kjaer
- European Neuroendocrine Tumor Society Center of Excellence, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Physiology, Nuclear Medicine, & PET and Cluster for Molecular Imaging, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth Maurer
- European Neuroendocrine Tumor Society, Philipps University, Marburg, Germany
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University, Marburg, Germany
| | - Birgitte Federspiel
- European Neuroendocrine Tumor Society Center of Excellence, Rigshospitalet, Copenhagen, Denmark
- Department of Pathology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Peter H Kann
- European Neuroendocrine Tumor Society, Philipps University, Marburg, Germany
- Department of Gastroenterology and Division of Endocrinology, Philipps University, Marburg, Germany
| | - Detlef K Bartsch
- European Neuroendocrine Tumor Society, Philipps University, Marburg, Germany
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University, Marburg, Germany
| | - Ulrich Knigge
- Department of Endocrinology Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- European Neuroendocrine Tumor Society Center of Excellence, Rigshospitalet, Copenhagen, Denmark
- Department of Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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13
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Wang H, Ba Y, Xing Q, Cai RC. Diagnostic value of ASVS for insulinoma localization: A systematic review and meta-analysis. PLoS One 2019; 14:e0224928. [PMID: 31743337 PMCID: PMC6863549 DOI: 10.1371/journal.pone.0224928] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 10/24/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Previous studies on the diagnostic value of arterial calcium stimulation with hepatic venous sampling (ASVS) for the localization of insulinoma have reported inconsistent results. Here, we performed a meta-analysis of the relevant published studies. METHODS PubMed, Embase, Web of Science, the Cochrane Library, and Wanfang Data were searched for studies on the diagnostic value of ASVS in insulinoma localization published up to May 2019. We calculated the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and receiver operating characteristic (ROC) curve of ASVS in the localization of insulinoma. RESULTS We included ten studies involving 337 patients in the study. The pooled sensitivity, specificity, PLR, and NLR were 0.93 (95% confidence interval [CI]: 0.83-0.97), 0.86 (95%CI: 0.75-0.93), 6.8(95%CI: 3.7-12.7), and 0.08 (95%CI: 0.03-0.19), respectively. The DOR was 84 (95%CI: 30-233), and the area under the ROC curve was 0.96 (95%CI: 0.94-0.97).The results of the heterogeneity of the studies (P = 0.00, I2 = 80.17) were calculated using forest plots of the DOR. CONCLUSION ASVS is of significant value in localization of insulinoma. If a qualitative diagnosis of insulinoma is definite and the imaging examination results are negative, ASVS should be performed to confirm the localization of insulinoma.
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Affiliation(s)
- Hao Wang
- Department of Endocrinology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
- * E-mail:
| | - Ying Ba
- Department of Endocrinology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Qian Xing
- Department of Endocrinology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Run-Ce Cai
- Department of Endocrinology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
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14
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Lee L, Ito T, Jensen RT. Imaging of pancreatic neuroendocrine tumors: recent advances, current status, and controversies. Expert Rev Anticancer Ther 2018; 18:837-860. [PMID: 29973077 PMCID: PMC6283410 DOI: 10.1080/14737140.2018.1496822] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Recently, there have been a number of advances in imaging pancreatic neuroendocrine tumors (panNETs), as well as other neuroendocrine tumors (NETs), which have had a profound effect on the management and treatment of these patients, but in some cases are also associated with controversies. Areas covered: These advances are the result of numerous studies attempting to better define the roles of both cross-sectional imaging, endoscopic ultrasound, with or without fine-needle aspiration, and molecular imaging in both sporadic and inherited panNET syndromes; the increased attempt to develop imaging parameters that correlate with tumor classification or have prognostic value; the rapidly increasing use of molecular imaging in these tumors and the attempt to develop imaging parameters that correlate with treatment/outcome results. Each of these areas and the associated controversies are reviewed. Expert commentary: There have been numerous advances in all aspects of the imaging of panNETs, as well as other NETs, in the last few years. The advances are leading to expanded roles of imaging in the management of these patients and the results being seen in panNETs/GI-NETs with these newer techniques are already being used in more common tumors.
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Affiliation(s)
- Lingaku Lee
- a Department of Medicine and Bioregulatory Science , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
- b Digestive Diseases Branch , NIDDK, NIH , Bethesda , MD , USA
| | - Tetsuhide Ito
- c Neuroendocrine Tumor Centra, Fukuoka Sanno Hospital International University of Health and Welfare 3-6-45 Momochihama , Sawara-Ku, Fukuoka , Japan
| | - Robert T Jensen
- b Digestive Diseases Branch , NIDDK, NIH , Bethesda , MD , USA
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15
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Mele C, Brunani A, Damascelli B, Tichà V, Castello L, Aimaretti G, Scacchi M, Marzullo P. Non-surgical ablative therapies for inoperable benign insulinoma. J Endocrinol Invest 2018; 41:153-162. [PMID: 28755102 DOI: 10.1007/s40618-017-0738-3] [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] [Received: 05/06/2017] [Accepted: 07/22/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Benign insulinoma is the most common functioning neuroendocrine tumor of the pancreas. The gold-standard therapeutic approach for insulinoma is surgery, which allows for tumor removal, histology and immunochemical analyses. If surgery is not feasible, minimally invasive ablative procedures performed by interventional radiology can lead to partial or complete remission of hormone hypersecretion and tumor control in insulinoma patients. METHODS We performed a review of existing literature on non-chemotherapeutic/radioactive ablative techniques employed for the treatment of benign, otherwise inoperable, pancreatic insulinoma. For this purpose, feasibility, effectiveness and safety of ablative treatments for pancreatic insulinoma were reviewed from literature data published from 1982 to date. RESULTS A total of 44 insulinoma cases treated with non-surgical ablative techniques were desumed, and divided as follows: 7 cases of tumor embolization, 26 ethanol ablations, 7 radiofrequency ablations, 2 high intensity focused ultrasound ablation, 1 irreversible electroporation and 1 percutaneous microwave ablation. Most cases involved single insulinoma, predominantly located in the pancreas head and body. In the majority of patients, ablation was chosen instead of surgery due to severe comorbidities. After an average follow-up of 16 months, the overall success rate of non-surgical ablative treatments of insulinoma was 84%, the recurrence/persistence rate was 16%, and transient adverse events were noted in 23% of cases. Adverse events were usually self-limiting and medically manageable. CONCLUSIONS Non-surgical ablation is a feasible, safe and repeatable procedure in patients with pancreatic insulinoma, who are not candidate to surgery or refuse it. Partial or complete control of symptoms and tumor growth is experienced by the majority of patients.
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Affiliation(s)
- C Mele
- Division of General Medicine, IRCCS Istituto Auxologico Italiano, Ospedale S. Giuseppe, Via Cadorna 90, 28824, Piancavallo, VB, Italy
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
| | - A Brunani
- Division of Rehabilitation Medicine, Istituto Auxologico Italiano, Ospedale S. Giuseppe, Via Cadorna 90, 28824, Piancavallo, VB, Italy
| | - B Damascelli
- Department of Interventional Radiology, EMO GVM Centro Cuore Columbus, Via Buonarroti 48, 20145, Milan, Italy
| | - V Tichà
- Radiology and Interventional Radiology Unit, ASST Santi Paolo e Carlo, San Carlo Borromeo Hospital, Via Pio II 3, 20153, Milan, Italy
| | - L Castello
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
| | - G Aimaretti
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
| | - M Scacchi
- Division of General Medicine, IRCCS Istituto Auxologico Italiano, Ospedale S. Giuseppe, Via Cadorna 90, 28824, Piancavallo, VB, Italy
| | - P Marzullo
- Division of General Medicine, IRCCS Istituto Auxologico Italiano, Ospedale S. Giuseppe, Via Cadorna 90, 28824, Piancavallo, VB, Italy.
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy.
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Ueda K, Ito T, Kawabe K, Lee L, Fujiyama T, Tachibana Y, Miki M, Yasunaga K, Takaoka T, Nishie A, Asayama Y, T Jensen R, Ogawa Y. Should the Selective Arterial Secretagogue Injection Test for Insulinoma Localization Be Evaluated at 60 or 120 Seconds? Intern Med 2017; 56:2985-2991. [PMID: 28943589 PMCID: PMC5725851 DOI: 10.2169/internalmedicine.9107-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 03/31/2017] [Indexed: 01/22/2023] Open
Abstract
Objective The selective arterial secretagogue injection (SASI) test is considered indispensable for the accurate localization of insulinoma. However, the optimum timing of the post-injection evaluation is controversial, as some studies recommend 60 seconds [SASI (60 seconds)] while others support 120 seconds [SASI (120 seconds)]. The aim of this study was to determine the optimum timing for the SASI test evaluation for insulinoma localization. Methods Thirteen patients with surgically proven insulinoma were studied retrospectively. For the SASI test, immunoreactive insulin (IRI) was determined at baseline and at 30, 60, 90, and 120 seconds after calcium gluconate injection. A two-fold or greater increase in IRI over the baseline value was considered positive. The localization abilities of SASI (60 seconds) and SASI (120 seconds) were then compared. Results In 13 patients, a secretagogue was injected into 40 arteries supplying the pancreas. In the SASI (60 seconds) and SASI (120 seconds), the respective findings were as follows: positive predictive value, 72.2% and 68.2%; false positive rate, 25.0% and 35.0%; and rate of positivity in the head and body/tail, 38.5% and 46.2%. When the artery with the largest change was taken as the dominant artery, the localization detection sensitivity was 76.9% for SASI (60 seconds) and 92.3% for SASI (120 seconds). The sensitivity of morphological imaging techniques for localization ranged from 61.5-91.7%. Conclusion Compared with SASI (60 seconds) or morphological imaging, the insulinoma localization ability of SASI (120 seconds) was superior. Given these findings, we believe that the IRI level should be measured at 120 seconds in the SASI test.
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Affiliation(s)
- Keijiro Ueda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Tetsuhide Ito
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Ken Kawabe
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Lingaku Lee
- Department of Gastroenterology, Kyushu Rosai Hospital, Japan
| | - Takashi Fujiyama
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yuichi Tachibana
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masami Miki
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Kohei Yasunaga
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Takehiro Takaoka
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Akihiro Nishie
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yoshiki Asayama
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Robert T Jensen
- Digestive Diseases Branch, National Institutes of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, USA
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Japan
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medicine Tokyo Medical and Dental University, Japan
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Shah P, Rahman SA, Demirbilek H, Güemes M, Hussain K. Hyperinsulinaemic hypoglycaemia in children and adults. Lancet Diabetes Endocrinol 2017; 5:729-742. [PMID: 27915035 DOI: 10.1016/s2213-8587(16)30323-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 09/16/2016] [Accepted: 09/28/2016] [Indexed: 02/08/2023]
Abstract
Pancreatic β cells are functionally programmed to release insulin in response to changes in plasma glucose concentration. Insulin secretion is precisely regulated so that, under normal physiological conditions, fasting plasma glucose concentrations are kept within a narrow range of 3·5-5·5 mmol/L. In hyperinsulinaemic hypoglycaemia, insulin secretion becomes dysregulated (ie, uncoupled from glucose metabolism) so that insulin secretion persists in the presence of low plasma glucose concentrations. Hyperinsulinaemic hypoglycaemia is the most common cause of severe and persistent hypoglycaemia in neonates and children. At a molecular level, mutations in nine different genes can lead to the dysregulation of insulin secretion and cause this disorder. In adults, hyperinsulinaemic hypoglycaemia accounts for 0·5-5·0% of cases of hypoglycaemia and can be due either to β-cell tumours (insulinomas) or β-cell hyperplasia. Rapid diagnosis and prompt management of hyperinsulinaemic hypoglycaemia is essential to avoid hypoglycaemic brain injury, especially in the vulnerable neonatal and childhood periods. Advances in the field of hyperinsulinaemic hypoglycaemia include use of rapid molecular genetic testing for the disease, application of novel imaging techniques (6-[fluoride-18]fluoro-levodopa [18F-DOPA] PET-CT and glucagon-like peptide 1 (GLP-1) receptor imaging), and development of novel medical treatments (eg, long-acting octreotide formulations, mTOR inhibitors, and GLP-1 receptor antagonists) and surgical therapies (eg, laparoscopic surgery).
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Affiliation(s)
- Pratik Shah
- Genetics and Genomic Medicine Programme, University College London (UCL) Institute of Child Health, London, UK; Endocrinology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sofia A Rahman
- Genetics and Genomic Medicine Programme, University College London (UCL) Institute of Child Health, London, UK
| | - Huseyin Demirbilek
- Department of Paediatric Endocrinology, Hacettepe University, Ankara, Turkey
| | - Maria Güemes
- Genetics and Genomic Medicine Programme, University College London (UCL) Institute of Child Health, London, UK; Endocrinology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Khalid Hussain
- Department of Pediatric Medicine, Sidra Medical & Research Center, Outpatient Clinic, Doha, Qatar.
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18
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Murtha TD, Lupsa BC, Majumdar S, Jain D, Salem RR. A Systematic Review of Proinsulin-Secreting Pancreatic Neuroendocrine Tumors. J Gastrointest Surg 2017; 21:1335-1341. [PMID: 28510792 DOI: 10.1007/s11605-017-3428-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/09/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (PNETs) are a heterogeneous group of islet cell-derived neoplasms with a propensity toward hormone production. Among PNETs, proinsulin-secreting tumors (proinsulinomas) are exceedingly rare. The objective of this study is to collect and summarize the existing literature to provide a comprehensive evaluation of this uncommon disease. METHODS A systematic review was performed to characterize the clinicopathologic features of proinsulinoma. Using the electronic biomedical databases PubMed, Ovid Medline, and Embase, 316 publications were screened for relevance of which 14 were selected. We also present two patients with proinsulinoma treated at Yale New Haven Hospital. RESULTS Of the 16 patients included in the study, the mean age was 56.8 and there was a 2:1 female predominance. The majority of patients presented with symptomatic hypoglycemia with normal or low insulin levels. Median tumor diameter was 1.2 cm and 80% were located in the body and tail of the pancreas. Following resection, most patients had normalization of hormonal levels without recurrence (75%; 12/16). CONCLUSION Proinsulinomas are rare pancreatic neuroendocrine tumors that have the potential to cause hypoglycemia. While insulinomas and proinsulin-secreting tumors have many physiologic parallels, these cases illustrate several key distinctions in their diagnosis and management.
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Affiliation(s)
- Timothy D Murtha
- Department of Surgery, Section of Surgical Oncology, Yale School of Medicine, Yale University, 333 Cedar Street, FMB 130, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Beatrice C Lupsa
- Department of Medicine: Endocrinology, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Sachin Majumdar
- Department of Medicine: Endocrinology, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Dhanpat Jain
- Department of Pathology: GI and Liver Pathology, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Ronald R Salem
- Department of Surgery, Section of Surgical Oncology, Yale School of Medicine, Yale University, 333 Cedar Street, FMB 130, P.O. Box 208062, New Haven, CT, 06520-8062, USA.
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19
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Ito T, Jensen RT. Molecular imaging in neuroendocrine tumors: recent advances, controversies, unresolved issues, and roles in management. Curr Opin Endocrinol Diabetes Obes 2017; 24:15-24. [PMID: 27875420 PMCID: PMC5195891 DOI: 10.1097/med.0000000000000300] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The purpose is to review recent advances in molecular imaging of neuroendocrine tumors (NETs), discuss unresolved issues, and review how these advances are affecting clinical management. RECENT FINDINGS Molecular imaging of NETs underwent a number of important changes in the last few years, leading to some controversies, unresolved issues, and significant changes in clinical management. The most recent changes are reviewed in this article. Particularly important is the rapid replacement in somatostatin receptor scintigraphy of In-diethylenetriamine penta-acetic acid-single-photon emission computed tomography/computed tomography (CT) by Ga-fluorodopa(F-D)PA), 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)-peptide-PET/CT imaging, which is now approved in many countries including the USA. Numerous studies in many different types of NETs demonstrate the greater sensitivity of Ga-DOTA-peptide PET/CT, its high specificity, and its impact on management. Other important developments in somatostatin receptor scintigraphy/molecular imaging include demonstrating the prognostic value of both Ga-DOTA-peptide PET/CT and F-fluoro-deoxyglucose PET/CT; how their use can be complementary; comparing the sensitivities and usefulness of Ga-DOTA-peptide PET/CT and F-FDOPA PET/CT; introducing new linkers and radiolabeled ligands such as Cu-DOTA-peptides with a long half-life, enhancing utility; and the introduction of somatostatin receptor antagonists which show enhanced uptake by NETs. In addition, novel ligands which interact with other receptors (GLP-1, bombesin, cholecystokinin, gastric inhibitory polpeptide, integrin, chemokines) are described, which show promise in the imaging of both NETs and other tumors. SUMMARY Molecular imaging is now required for all aspects of the management of patients with NETs. Its results are essential not only for the proper diagnostic management of the patient, but also for assessing whether the patient is a candidate for peptide receptor radionuclide therapy with Lu and also for providing prognostic value.
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Affiliation(s)
- Tetsuhide Ito
- aDepartment of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan bDigestive Diseases Branch, NIDDK, NIH, Bethesda, Maryland, USA
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Nockel P, Babic B, Millo C, Herscovitch P, Patel D, Nilubol N, Sadowski SM, Cochran C, Gorden P, Kebebew E. Localization of Insulinoma Using 68Ga-DOTATATE PET/CT Scan. J Clin Endocrinol Metab 2017; 102:195-199. [PMID: 27805844 PMCID: PMC6083884 DOI: 10.1210/jc.2016-3445] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/28/2016] [Indexed: 12/20/2022]
Abstract
CONTEXT Reliable localization of insulinoma is critical for successful treatment. OBJECTIVE This study compared the accuracy of 68Gallium DOTA-(Tyr3)-octreotate (Ga-DOTATATE) positron emission tomography (PET)/computed tomography (CT) to anatomic imaging modalities, selective arterial secretagogue injection (SASI), and intraoperative ultrasound (IO ultrasound) and palpation for localizing insulinoma in patients who were biochemically cured. DESIGN, SETTING, AND PATIENTS We conducted a retrospective analysis of 31 patients who had an insulinoma. The results of CT, magnetic resonance imaging (MRI), ultrasound, IO ultrasound, 68Ga-DOTATATE PET/CT, SASI, and operative findings were analyzed. INTERVENTION, MAIN OUTCOME MEASURES, AND RESULTS The insulinomas were correctly localized in 17 out of 31 (55%) patients by CT, in 17 out of 28 (61%) by MRI, in 6 out of 28 (21%) by ultrasound, and in 9 out of 10 (90%) by 68Ga-DOTATATE. In 29 of 31 patients (93.5%) who had IO ultrasound, an insulinoma was successfully localized. Thirty patients underwent SASI, and the insulinoma was regionalized in 28 out of 30 patients (93%). In 19 out of 23 patients (83%), manual palpation identified insulinoma. In patients who had all 4 noninvasive imaging studies, CT was concordant with 68Ga-DOTATATE in 6 out of 9 patients (67%), MRI in 8 out of 9 (78%), ultrasound in 0 out of 9; the lesion was only seen by 68Ga-DOTATATE in 1 out of 9 (11%). CONCLUSIONS 68Ga-DOTATATE PET/CT identifies most insulinomas and may be considered as an adjunct imaging study when all imaging studies are negative and when a minimally invasive surgical approach is planned.
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Affiliation(s)
- Pavel Nockel
- Endocrine Oncology Branch, National Cancer Institute
| | - Bruna Babic
- Endocrine Oncology Branch, National Cancer Institute
| | - Corina Millo
- Positron Emission Tomography Department, Clinical Center, and
| | | | - Dhaval Patel
- Endocrine Oncology Branch, National Cancer Institute
| | - Naris Nilubol
- Endocrine Oncology Branch, National Cancer Institute
| | - Samira M Sadowski
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland 1211
| | - Craig Cochran
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892; and
| | - Phillip Gorden
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892; and
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21
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Babic B, Keutgen X, Nockel P, Miettinen M, Millo C, Herscovitch P, Patel D, Nilubol N, Cochran C, Gorden P, Kebebew E. Insulinoma Due to Multiple Pancreatic Microadenoma Localized by Multimodal Imaging. J Clin Endocrinol Metab 2016; 101:3559-3563. [PMID: 27504852 PMCID: PMC5052346 DOI: 10.1210/jc.2016-2717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT Insulinomas are usually due to a solitary tumor, but they can be challenging to localize. CASE DESCRIPTION A 66-year-old woman presented with a 1-year history of episodic neuroglycopenic hypoglycemia and was suspected of having an insulinoma. On a supervised fast, she was found to be hypoglycemic at 39 mg/dL, with an insulin of 40 μU/mL 26 hours into the fast and a proinsulin of 35 pmol/L. Contrast-enhanced computed tomography and magnetic resonance imaging did not localize a pancreatic lesion. Intra-arterial calcium stimulation testing showed a step-up of venous insulin levels at injection of the superior mesenteric artery and proximal and mid-splenic artery, and a 68Ga-DOTATATE positron emission tomography/computed tomography showed focal uptake in the neck of the pancreas with a standardized uptake value of 12. Despite negative intraoperative pancreatic palpation and ultrasound, the patient underwent an extended distal pancreatectomy with normalization of biochemical levels and resolution of her symptoms. Pathology showed four subcentimeter neuroendocrine tumors that were positive for insulin, consistent with a diagnosis of multiple microadenomas. CONCLUSIONS Multiple microadenomas are a rare cause of hyperinsulinemic hypoglycemia and localization, and resection of these tumors may be facilitated by multimodal imaging.
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Affiliation(s)
- Bruna Babic
- Endocrine Oncology Branch (B.B., X.K., P.N., D.P., N.N., E.K.), and Laboratory of Pathology (M.M.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892; PET Department (C.M., P.H.), National Institutes of Health Clinical Center, Bethesda, Maryland 20814; and National Institute of Diabetes and Digestive and Kidney Diseases (C.C., P.G.), National Institutes of Health, Bethesda, Maryland 20892
| | - Xavier Keutgen
- Endocrine Oncology Branch (B.B., X.K., P.N., D.P., N.N., E.K.), and Laboratory of Pathology (M.M.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892; PET Department (C.M., P.H.), National Institutes of Health Clinical Center, Bethesda, Maryland 20814; and National Institute of Diabetes and Digestive and Kidney Diseases (C.C., P.G.), National Institutes of Health, Bethesda, Maryland 20892
| | - Pavel Nockel
- Endocrine Oncology Branch (B.B., X.K., P.N., D.P., N.N., E.K.), and Laboratory of Pathology (M.M.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892; PET Department (C.M., P.H.), National Institutes of Health Clinical Center, Bethesda, Maryland 20814; and National Institute of Diabetes and Digestive and Kidney Diseases (C.C., P.G.), National Institutes of Health, Bethesda, Maryland 20892
| | - Markke Miettinen
- Endocrine Oncology Branch (B.B., X.K., P.N., D.P., N.N., E.K.), and Laboratory of Pathology (M.M.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892; PET Department (C.M., P.H.), National Institutes of Health Clinical Center, Bethesda, Maryland 20814; and National Institute of Diabetes and Digestive and Kidney Diseases (C.C., P.G.), National Institutes of Health, Bethesda, Maryland 20892
| | - Corina Millo
- Endocrine Oncology Branch (B.B., X.K., P.N., D.P., N.N., E.K.), and Laboratory of Pathology (M.M.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892; PET Department (C.M., P.H.), National Institutes of Health Clinical Center, Bethesda, Maryland 20814; and National Institute of Diabetes and Digestive and Kidney Diseases (C.C., P.G.), National Institutes of Health, Bethesda, Maryland 20892
| | - Peter Herscovitch
- Endocrine Oncology Branch (B.B., X.K., P.N., D.P., N.N., E.K.), and Laboratory of Pathology (M.M.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892; PET Department (C.M., P.H.), National Institutes of Health Clinical Center, Bethesda, Maryland 20814; and National Institute of Diabetes and Digestive and Kidney Diseases (C.C., P.G.), National Institutes of Health, Bethesda, Maryland 20892
| | - Dhaval Patel
- Endocrine Oncology Branch (B.B., X.K., P.N., D.P., N.N., E.K.), and Laboratory of Pathology (M.M.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892; PET Department (C.M., P.H.), National Institutes of Health Clinical Center, Bethesda, Maryland 20814; and National Institute of Diabetes and Digestive and Kidney Diseases (C.C., P.G.), National Institutes of Health, Bethesda, Maryland 20892
| | - Naris Nilubol
- Endocrine Oncology Branch (B.B., X.K., P.N., D.P., N.N., E.K.), and Laboratory of Pathology (M.M.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892; PET Department (C.M., P.H.), National Institutes of Health Clinical Center, Bethesda, Maryland 20814; and National Institute of Diabetes and Digestive and Kidney Diseases (C.C., P.G.), National Institutes of Health, Bethesda, Maryland 20892
| | - Craig Cochran
- Endocrine Oncology Branch (B.B., X.K., P.N., D.P., N.N., E.K.), and Laboratory of Pathology (M.M.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892; PET Department (C.M., P.H.), National Institutes of Health Clinical Center, Bethesda, Maryland 20814; and National Institute of Diabetes and Digestive and Kidney Diseases (C.C., P.G.), National Institutes of Health, Bethesda, Maryland 20892
| | - Phillip Gorden
- Endocrine Oncology Branch (B.B., X.K., P.N., D.P., N.N., E.K.), and Laboratory of Pathology (M.M.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892; PET Department (C.M., P.H.), National Institutes of Health Clinical Center, Bethesda, Maryland 20814; and National Institute of Diabetes and Digestive and Kidney Diseases (C.C., P.G.), National Institutes of Health, Bethesda, Maryland 20892
| | - Electron Kebebew
- Endocrine Oncology Branch (B.B., X.K., P.N., D.P., N.N., E.K.), and Laboratory of Pathology (M.M.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892; PET Department (C.M., P.H.), National Institutes of Health Clinical Center, Bethesda, Maryland 20814; and National Institute of Diabetes and Digestive and Kidney Diseases (C.C., P.G.), National Institutes of Health, Bethesda, Maryland 20892
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99mTc Labeled Glucagon-Like Peptide-1-Analogue (99mTc-GLP1) Scintigraphy in the Management of Patients with Occult Insulinoma. PLoS One 2016; 11:e0160714. [PMID: 27526057 PMCID: PMC4985165 DOI: 10.1371/journal.pone.0160714] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 07/22/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The aim of this study was to assess the utility of [Lys40(Ahx-HYNIC-99mTc/EDDA)NH2]-exendin-4 scintigraphy in the management of patients with hypoglycemia, particularly in the detection of occult insulinoma. MATERIALS AND METHODS Forty patients with hypoglycemia and increased/confusing results of serum insulin and C-peptide concentration and negative/inconclusive results of other imaging examinations were enrolled in the study. In all patients GLP-1 receptor imaging was performed to localise potential pancreatic lesions. RESULTS Positive results of GLP-1 scintigraphy were observed in 28 patients. In 18 patients postsurgical histopathological examination confirmed diagnosis of insulinoma. Two patients had contraindications to the surgery, one patient did not want to be operated. One patient, who presented with postprandial hypoglycemia, with positive result of GLP-1 imaging was not qualified for surgery and is in the observational group. Eight patients were lost for follow up, among them 6 patients with positive GLP-1 scintigraphy result. One patient with negative scintigraphy was diagnosed with malignant insulinoma. In two patients with negative scintigraphy Munchausen syndrome was diagnosed (patients were taking insulin). Other seven patients with negative results of 99mTcGLP-1 scintigraphy and postprandial hypoglycemia with C-peptide and insulin levels within the limits of normal ranges are in the observational group. We would like to mention that 99mTc-GLP1-SPECT/CT was also performed in 3 pts with nesidioblastosis (revealing diffuse tracer uptake in two and a focal lesion in one case) and in two patients with malignant insulinoma (with the a focal uptake in the localization of a removed pancreatic headin one case and negative GLP-1 1 scintigraphy in the other patient). CONCLUSIONS 99mTc-GLP1-SPECT/CT could be helpful examination in the management of patients with hypoglycemia enabling proper localization of the pancreatic lesion and effective surgical treatment. This imaging technique may eliminate the need to perform invasive procedures in case of occult insulinoma.
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Kandaswamy L, Raghavan R, Pappachan JM. Spontaneous hypoglycemia: diagnostic evaluation and management. Endocrine 2016; 53:47-57. [PMID: 26951054 DOI: 10.1007/s12020-016-0902-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 02/15/2016] [Indexed: 02/07/2023]
Abstract
Spontaneous hypoglycemia is a puzzling clinical problem and an important reason for referral to endocrinologists. Several clinical conditions such as insulinomas, non-insulinoma pancreatogenous hypoglycemia syndrome, insulin autoimmune syndrome, postprandial hypoglycemia (reactive hypoglycemia), non-islet cell tumor hypoglycemia, primary adrenal insufficiency, hypopituitarism, and critical illness can be associated with spontaneous hypoglycemia. Rarely, in patients with mental health issues, factious hypoglycemia from extrinsic insulin use or ingestion of oral hypoglycemic agents can obfuscate the clinical picture for clinicians trying to identify an organic cause. In those presenting with Whipple's triad (symptoms ± signs of hypoglycemia, low plasma glucose, and resolution symptoms ± signs after hypoglycemia correction), a 72-h supervised fast test with measurement of plasma insulin, c-peptide, pro-insulin, and beta-hydroxybutyrate levels, coupled with plasma/urine sulphonylurea screen, forms the first step in diagnostic evaluation. A mixed meal test is preferable for those with predominantly postprandial symptoms. Additional non-invasive and/or invasive diagnostic evaluation is necessary if an organic hypoglycemic disorder is suspected. With the aid of a few brief clinical case scenarios, we discuss the diagnostic evaluation and management of spontaneous hypoglycemia through this comprehensive article.
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Affiliation(s)
- Leelavathy Kandaswamy
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
| | - Rajeev Raghavan
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
| | - Joseph M Pappachan
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK.
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Krieger AG, Smirnov AV, Berelavichus SV, Gorin DS, Kaldarov AR, Karel'skaya NA, Vetsheva NN, Kalinin DV, Lebedeva AN, Dugarova RS. Organic hyperinsulinism: radiological diagnostics and surgical treatment. Khirurgiia (Mosk) 2016:14-29. [PMID: 27296118 DOI: 10.17116/hirurgia2016614-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To optimize the diagnosis and surgical treatment of insulinoma and nesidioblastosis. MATERIAL AND METHODS 42 patients with organic hyperinsulinism (OH) were operated. There were 39 cases of insulinoma including 2 patients with insulinoma combined with nesidioblastosis and 3 cases of nesidioblastosis alone. Preoperative ray imaging consisted of percutaneous, endoscopic and intraoperative sonography, contrast-enhanced computed tomography, magnetic resonance imaging (MRI). Functional test included arterial-stimulated blood sampling (ASBS). Laparotomy and robot-assisted techniques were used in 22 and 20 patients. RESULTS Sensitivity was 62.0%, 76.9%, 83.3%, 87.5%, 94.8% and 100% in percutaneous sonography, CT, endoscopic sonography, MRI, intraoperative sonography and ASBS respectively. Postoperative complications were observed in 14 and 6 patients after conventional and robot-assisted surgery. 2 patients died. Overall mortality was 4.8%. None patient had recurrent hypoglycemic conditions in long-term postoperative period (mean follow-up 18.7 months). CONCLUSIONS Comprehensive survey allowed to define the cause of OH. Minimally invasive organ-sparing surgery has satisfactory immediate and remote results in these patients.
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Affiliation(s)
- A G Krieger
- A.V. Vishnevsky Institute of Surgery, Moscow, Russia
| | - A V Smirnov
- A.V. Vishnevsky Institute of Surgery, Moscow, Russia
| | | | - D S Gorin
- A.V. Vishnevsky Institute of Surgery, Moscow, Russia
| | - A R Kaldarov
- A.V. Vishnevsky Institute of Surgery, Moscow, Russia
| | | | - N N Vetsheva
- A.V. Vishnevsky Institute of Surgery, Moscow, Russia
| | - D V Kalinin
- A.V. Vishnevsky Institute of Surgery, Moscow, Russia
| | - A N Lebedeva
- A.V. Vishnevsky Institute of Surgery, Moscow, Russia
| | - R S Dugarova
- A.V. Vishnevsky Institute of Surgery, Moscow, Russia
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