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Yamashita A, Park SH, Zeng L, Stiles WR, Ahn S, Bao K, Kim J, Kang H, Choi HS. H-Dot Mediated Nanotherapeutics Mitigate Systemic Toxicity of Platinum-Based Anticancer Drugs. Int J Mol Sci 2023; 24:15466. [PMID: 37895146 PMCID: PMC10607179 DOI: 10.3390/ijms242015466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
Platinum-based anticancer agents have revolutionized oncological treatments globally. However, their therapeutic efficacy is often accompanied by systemic toxicity. Carboplatin, recognized for its relatively lower toxicity profile than cisplatin, still presents off-target toxicities, including dose-dependent cardiotoxicity, neurotoxicity, and myelosuppression. In this study, we demonstrate a delivery strategy of carboplatin to mitigate its off-target toxicity by leveraging the potential of zwitterionic nanocarrier, H-dot. The designed carboplatin/H-dot complex (Car/H-dot) exhibits rapid drug release kinetics and notable accumulation in proximity to tumor sites, indicative of amplified tumor targeting precision. Intriguingly, the Car/H-dot shows remarkable efficacy in eliminating tumors across insulinoma animal models. Encouragingly, concerns linked to carboplatin-induced cardiotoxicity are effectively alleviated by adopting the Car/H-dot nanotherapeutic approach. This pioneering investigation not only underscores the viability of H-dot as an organic nanocarrier for platinum drugs but also emphasizes its pivotal role in ameliorating associated toxicities. Thus, this study heralds a promising advancement in refining the therapeutic landscape of platinum-based chemotherapy.
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Affiliation(s)
- Atsushi Yamashita
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (A.Y.); (S.H.P.); (L.Z.); (W.R.S.); (S.A.); (K.B.); (J.K.); (H.K.)
| | - Seung Hun Park
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (A.Y.); (S.H.P.); (L.Z.); (W.R.S.); (S.A.); (K.B.); (J.K.); (H.K.)
| | - Lingxue Zeng
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (A.Y.); (S.H.P.); (L.Z.); (W.R.S.); (S.A.); (K.B.); (J.K.); (H.K.)
- Department of Biomedical & Nutritional Sciences, University of Massachusetts Lowell, Lowell, MA 01854, USA
| | - Wesley R. Stiles
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (A.Y.); (S.H.P.); (L.Z.); (W.R.S.); (S.A.); (K.B.); (J.K.); (H.K.)
| | - Sung Ahn
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (A.Y.); (S.H.P.); (L.Z.); (W.R.S.); (S.A.); (K.B.); (J.K.); (H.K.)
| | - Kai Bao
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (A.Y.); (S.H.P.); (L.Z.); (W.R.S.); (S.A.); (K.B.); (J.K.); (H.K.)
| | - Jonghan Kim
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (A.Y.); (S.H.P.); (L.Z.); (W.R.S.); (S.A.); (K.B.); (J.K.); (H.K.)
- Department of Biomedical & Nutritional Sciences, University of Massachusetts Lowell, Lowell, MA 01854, USA
| | - Homan Kang
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (A.Y.); (S.H.P.); (L.Z.); (W.R.S.); (S.A.); (K.B.); (J.K.); (H.K.)
| | - Hak Soo Choi
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (A.Y.); (S.H.P.); (L.Z.); (W.R.S.); (S.A.); (K.B.); (J.K.); (H.K.)
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Park GK, Lee JH, Soriano E, Choi M, Bao K, Katagiri W, Kim DY, Paik JH, Yun SH, Frangioni JV, Clancy TE, Kashiwagi S, Henary M, Choi HS. Rapid and Selective Targeting of Heterogeneous Pancreatic Neuroendocrine Tumors. iScience 2020; 23:101006. [PMID: 32268281 PMCID: PMC7139119 DOI: 10.1016/j.isci.2020.101006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 02/10/2020] [Accepted: 03/18/2020] [Indexed: 01/12/2023] Open
Abstract
Design of tissue-specific contrast agents to delineate tumors from background tissues is a major unmet clinical need for ultimate surgical interventions. Bioconjugation of fluorophore(s) to a ligand has been mainly used to target overexpressed receptors on tumors. However, the size of the final targeted ligand can be large, >20 kDa, and cannot readily cross the microvasculature to meet the specific tissue, resulting in low targetability with a high background. Here, we report a small and hydrophilic phenoxazine with high targetability and retention to pancreatic neuroendocrine tumor. This bioengineered fluorophore permits sensitive detection of ultrasmall (<0.5 mm) ectopic tumors within a few seconds after a single bolus injection, highlighting every tumor in the pancreas from the surrounding healthy tissues with reasonable half-life. The knowledge-based approach and validation used to develop structure-inherent tumor-targeted fluorophores have a tremendous potential to improve treatment outcome by providing definite tumor margins for image-guided surgery.
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Affiliation(s)
- G Kate Park
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Jeong Heon Lee
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Eduardo Soriano
- Department of Chemistry, Center for Diagnostics and Therapeutics, Georgia State University, 100 Piedmont Ave SE, Atlanta, Georgia 30303, USA
| | - Myunghwan Choi
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, MA 02139, USA
| | - Kai Bao
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Wataru Katagiri
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Do-Yeon Kim
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Ji-Hye Paik
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Seok-Hyun Yun
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, MA 02139, USA
| | | | - Thomas E Clancy
- Division of Surgical Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Satoshi Kashiwagi
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Maged Henary
- Department of Chemistry, Center for Diagnostics and Therapeutics, Georgia State University, 100 Piedmont Ave SE, Atlanta, Georgia 30303, USA.
| | - Hak Soo Choi
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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Gouta EL, Jerraya H, Dougaz W, Chaouech MA, Bouasker I, Nouira R, Dziri C. Endogenous hyperinsulinism: diagnostic and therapeutic difficulties. Pan Afr Med J 2019; 33:57. [PMID: 31448019 PMCID: PMC6689824 DOI: 10.11604/pamj.2019.33.57.18885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 05/17/2019] [Indexed: 11/26/2022] Open
Abstract
Endogenous hyperinsulinism is an abnormal clinical condition that involves excessive insulin secretion, related in 55% of cases to insulinoma. Other causes are possible such as islet cell hyperplasia, nesidioblastosis or antibodies to insulin or to the insulin receptor. Differentiation between these diseases may be difficult despite the use of several morphological examinations. We report six patients operated on for endogenous hyperinsulinism from 1st January 2000 to 31st December 2015. Endogenous hyperinsulinism was caused by insulinoma in three cases, endocrine cells hyperplasia in two cases and no pathological lesions were found in the last case. All patients typically presented with adrenergic and neuroglycopenic symptoms with a low blood glucose level concomitant with high insulin and C-peptide levels. Computed tomography showed insulinoma in one case out of two. MRI was carried out four times and succeeded to locate the lesion in the two cases of insulinoma. Endoscopic ultrasound showed one insulinoma and provided false positive findings three times out of four. Intra operative ultrasound succeeded to localize the insulinoma in two cases but was false positive in two cases. Procedures were one duodenopancreatectomy, two left splenopancreatectomy and two enucleations. For the sixth case, no lesion was radiologically objectified. Hence, a left blind pancreatectomy was practised but the pathological examination showed normal pancreatic tissue. Our work showed that even if morphological examinations are suggestive of insulinoma, other causes of endogenous hyperinsulinism must be considered and therefore invasive explorations should be carried out.
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Affiliation(s)
- Esma Leila Gouta
- Surgical Department B, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Hichem Jerraya
- Surgical Department B, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Wejih Dougaz
- Surgical Department B, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Ali Chaouech
- Surgical Department B, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ibtissem Bouasker
- Surgical Department B, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ramzi Nouira
- Surgical Department B, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Chadly Dziri
- Surgical Department B, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Abstract
Insulinoma is the most common functioning islet cell tumor of the pancreas, with an annual incidence of 4 cases/1 million individuals. It is treated by surgical methods. Open surgery was once considered the standard approach for the treatment of insulinoma. However, the procedure is traumatic and requires a large incision, which does not satisfy the growing expectations of minimally invasive management of small-sized tumors. Insulinomas are usually benign solitary tumors and mostly occur sporadically, which makes them suitable candidates for laparoscopic management. The potential advantages of laparoscopic management of insulinoma over open surgery include shorter duration of hospitalization, quicker recovery, and better cosmetic effect. However, because of the small tumor size as well as the depth and uncertainty of the location of the tumor, laparoscopic localization of the lesion without tactile sensation is difficult. Laparoscopic ultrasonography can detect about 90% of insulinomas, and its sensitivity is comparable to that of manual palpation along with intraoperative ultrasonography during open surgery; thus, it ensures the feasibility of laparoscopic management of insulinoma and reinforces its advantage as a minimally invasive procedure. Laparoscopic ultrasonography is vital for the localization of insulinomas and characterization of the surrounding pancreatic structure and should, therefore, be considered an integral part of the laparoscopic management of insulinoma.
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Affiliation(s)
- Mengwei Wu
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Huaitao Wang
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Xiaobo Zhang
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Feng Gao
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Peng Liu
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Boqiang Yu
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Huanbing Qiu
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Guanlong Huang
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Xiaodong Tan
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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James PD, Tsolakis AV, Zhang M, Belletrutti PJ, Mohamed R, Roberts DJ, Heitman SJ. Incremental benefit of preoperative EUS for the detection of pancreatic neuroendocrine tumors: a meta-analysis. Gastrointest Endosc 2015; 81:848-56.e1. [PMID: 25805462 DOI: 10.1016/j.gie.2014.12.031] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 12/01/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Current guidelines recommend CT scan or magnetic resonance imaging as the initial imaging modalities for the work-up of suspected pancreatic neuroendocrine tumors (PNETs). OBJECTIVE To determine the incremental benefit of preoperative EUS (IBEUS) for the detection of suspected PNETs after other investigative modalities have been attempted. DESIGN This systematic review searched MEDLINE, EMBASE, bibliographies of included articles, and conference proceedings for studies reporting original data regarding the preoperative detection of PNETs. Pooled IBEUS was calculated by using random effects models. Heterogeneity was explored by using stratified meta-analysis and meta-regression. Evidence of small-study effects was assessed by using funnel plots and the Begg test. PATIENTS Patients with suspected PNETs. INTERVENTIONS EUS evaluation. MAIN OUTCOME MEASUREMENTS The pooled IBEUS for the detection of PNETs after CT scan, with or without additional investigative modalities. RESULTS Among 4505 citations identified, we included 17 cohort studies (612 patients). EUS identified PNETs in 97% of cases. Improved PNET identification with EUS was observed in all of the studies. After adjusting for small-study effects, meta-analysis showed that EUS alone could identify PNETs in approximately 1 in 4 patients (adjusted IBEUS 26%; 95% confidence interval, 17%-37%). The pooled IBEUS varied based on the study design, study size, type of CT scan used, and the number of modalities used prior to EUS. LIMITATIONS The majority of included studies were retrospective. Small-study effects were observed. CONCLUSION Preoperative EUS is associated with an increase in PNET detection after other modalities are attempted.
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Affiliation(s)
- Paul D James
- Department of Medicine and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Apostolos V Tsolakis
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Department of Medical Sciences, Section of Endocrine Oncology, Uppsala University, Uppsala, Sweden
| | - Mei Zhang
- Department of Medical Sciences, Section of Endocrine Oncology, Uppsala University, Uppsala, Sweden
| | - Paul J Belletrutti
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Rachid Mohamed
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Derek J Roberts
- Department of Surgery and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Steven J Heitman
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Chihaoui M, Hmaissi R, Abid M, Chaieb L, Ben Abdallah N, Zaouech A, Houman H, Rokbani L, Slimane H. Management of insulinoma: Tunisians' experience. Pancreas 2012; 41:807-9. [PMID: 22695091 DOI: 10.1097/mpa.0b013e31823b684b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Ramos-Prol A, del Olmo-García M, Pérez-Lázaro A, Caballero-Soto M, Argente-Pla M, León-de Zayas B, Merino-Torres JF. Metabolic acidosis as a complication of intravenous dextrose administration in a patient with insulinoma. Endocrine 2010; 38:402-5. [PMID: 20972720 DOI: 10.1007/s12020-010-9400-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Accepted: 08/25/2010] [Indexed: 11/28/2022]
Abstract
There are few cases published in literature in which the use of intravenous dextrose as treatment for an insulinoma resulted in a metabolic acidosis. This is due perhaps to the usual method of administration, which is usually at low concentrations, for limited periods or low volumes. We present the case of a woman with suspected insulinoma by laboratory findings in which an endogenous hyperinsulinism was observed. During hospitalization, the patient required a progressive increase of the glucose infusion to prevent severe hypoglycemia. Two days before surgery, the patient presented symptoms of malaise and muscle weakness and a metabolic acidosis with hypokalemia became apparent in the blood analysis. This metabolic imbalance was attributed to a long period of treatment with high volume of intravenous dextrose infusion. If large doses of dextrose are required in a patient with an insulinoma, then the possibility of a metabolic imbalance must be considered during the follow-up. When the suspicion of an insulinoma is high, and all the attempts of pre-operative localization fail, patients should be derived early to specialized centers with modern imaging techniques, so that surgery is not delayed, and this rare and threatening complication could be avoided.
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Affiliation(s)
- Agustín Ramos-Prol
- Endocrinology and Nutrition Department, Hospital Universitario La Fe, Valencia Avenida Campanar, 21, 46009 Valencia, Spain.
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Abstract
BACKGROUND Minimally invasive pancreatic surgery, although known to be feasible and safe, is still not considered a standard procedure. We report our experience with laparoscopic pancreatic surgery in a retrospective case series. MATERIALS AND METHODS Fifteen consecutive patients (3 male, 12 female) underwent primarily laparoscopic pancreatic surgery from February 2000 to June 2005. Histologically confirmed diagnoses were: neuroendocrine pancreatic tumors (n = 11), adult nesidioblastosis (n = 1), serous cystadenoma (n = 1), and pseudocysts due to chronic pancreatitis (n = 2). RESULTS Enucleation (n = 3) or left pancreatic resection with spleen preservation (n = 6) was performed laparoscopically in 9 patients. The mean (+/-standard deviation) operative time was 173 +/- 48 minutes (range, 120-250 minutes) and the mean postoperative hospital stay was 5.5 +/- 1.2 days (range, 5-8 days) for the laparoscopic cases. Conversion to open surgery was necessary in 6 patients because of: closeness of the lesion to the portal/mesenteric vein (n = 3), inadequate intraoperative tumor localization (n = 2), or stapler device dysfunction (n = 1). In these patients, open enucleation (n = 1), middle segment pancreatectomy (n = 2), left pancreatic resection (n = 2), and pylorus-preserving Whipple resection (n = 1) were performed. The mean operative time was 268 +/- 74 minutes (range, 150-360 minutes) with a mean postoperative hospital stay of 8 +/- 2 days (range, 6-10 days). Both operative time and hospital stay were significantly longer in patients with secondary open surgery compared to patients with successful laparoscopic operations. CONCLUSION Laparoscopic enucleation or distal pancreatectomy with spleen preservation for benign lesions located in the body or tail of the pancreas can be performed safely, with all the potential benefits of minimally invasive surgery. Preoperative tumor localization is of utmost importance to limit pancreatic mobilization and to avoid blind pancreatic resection and conversion to open surgery.
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Affiliation(s)
- Urs Giger
- Department of Surgery, Hôpital Cantonal Fribourg, Fribourg, Switzerland
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Luo Y, Liu R, Hu MG, Mu YM, An LC, Huang ZQ. Laparoscopic surgery for pancreatic insulinomas: a single-institution experience of 29 cases. J Gastrointest Surg 2009; 13:945-50. [PMID: 19224293 DOI: 10.1007/s11605-009-0830-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2008] [Accepted: 01/28/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic approach has been increasingly used in the treatment of pancreatic benign diseases. This report evaluates our experience with laparoscopic surgery for pancreatic insulinomas. METHODS Between July 2000 and December 2007, laparoscopic pancreatectomy was attempted in 29 consecutive patients with insulinomas. The localization of tumors, operating characteristics, and clinical outcomes were analyzed. RESULTS Tumors were precisely localized in 28 of 29 (96.6%) patients by a combination of preoperative imaging techniques and intraoperative ultrasonography. Laparoscopic pancreatectomy was successfully performed in 26 patients, including enucleation (n = 14), hand-assisted enucleation (n = 2), and distal pancreatectomy with (n = 9) or without (n = 1) spleen preservation. Two conversions to open procedure were required because of unfavorable locations of the tumors. The pancreatic fistula occurred in four patients who underwent tumor enucleation. The median hospital stay was 5.5 days (range, 3-18 days) after laparoscopic procedure. Twenty-eight patients with pancreatic resection were free of symptoms and remained normoglycemic after a median follow-up period of 19 months (range, 10-36 months). CONCLUSION Laparoscopic pancreatic resection is a feasible and safe procedure for patients with insulinomas. Further studies are required to evaluate the potential application of the hand-assisted approach for tumors located at anatomically unfavorable positions.
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Affiliation(s)
- Ying Luo
- Department of Hepatobiliary Surgery, The General Hospital of Chinese People Liberation Army, 28 Fu Xing Road, Beijing, China
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Abstract
Insulinomas continue to pose a diagnostic challenge to physicians, surgeons and radiologists alike. Most are intrapancreatic, benign and solitary. Biochemical diagnosis is obtained and imaging techniques to localize lesions continue to evolve. Surgical resection is the treatment of choice. Despite all efforts, an occult insulinoma (occult insulinoma refers to a biochemically proven tumor with indeterminate anatomical site before operation) may still be encountered. New localization preoperative techniques decreases occult cases and the knowledge of the site of the mass before surgery allows to determine whether enucleation of the tumor or pancreatic resection is likely to be required and whether the tumor is amenable to removal via a laparoscopic approach. In absence of preoperative localization and intraoperative detection of an insulinoma, blind pancreatic resection is not recommended.
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Queiroz Almeida M, Machado MCC, Correa-Giannella ML, Giannella-Neto D, Albergaria Pereira MA. Endogenous hyperinsulinemic hypoglycemia: diagnostic strategies, predictive features of malignancy and long-term survival. J Endocrinol Invest 2006; 29:679-87. [PMID: 17033255 DOI: 10.1007/bf03344176] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Diagnostic strategies, malignancy predictors and long-term survival were retrospectively evaluated in patients with hyperinsulinemic hypoglycemia (64 insulinomas). Lower median glycemia was 30 (range 20-53) mg/dl [1.6 (1.1-2.9) mmol/l] with concurrent insulin of 48 (13.2-217) microU/ml and 15 (2-46) microU/ml measured by radioimmunoassay (RIA) and immunofluorimetric assay (IFMA), respectively. All patients with insulinomas had a positive prolonged fast within 48 h. Sensitivity of localization methods was: ultrasonography (US) 23%, computed tomography (CT) 28%, magnetic resonance imaging (MRI) 65%, endoscopic US 75%, arteriography 38%, portal venous sampling 67%, selective arterial calcium stimulation 67%, intraoperative US 94% and palpation 92%. Nine patients (14%) had malignant insulinomas. Age at diagnosis (mean+/-SD, 53.8+/-19 vs 39.4+/-16.3 yr; p=0.03), insulin (1372+/-730 vs 785+/-659% (percentage of the method's diagnostic cut-off; 6 and 3 microU/ml for RIA and IFMA, respectively; p=0.007) and C-peptide levels (9.8+/-2.9 vs 3.9+/-2.8 ng/ml (3.2+/-0.9 vs 1.3+/-0.9 nmol/l; p=0.006), and tumor size (6.2+/-4.1 vs 1.5+/-0.6 cm; p=0.0002) were increased in malignant insulinomas. C-peptide level above 6.1 ng/ml (2.0 nmol/l) had a 100% sensitivity and 96% specificity, and tumor size above 2.6 cm yielded a sensitivity of 88% and specificity of 100% in predicting malignancy. Survival of patients with malignant insulinomas was significantly impaired (16 vs 100% at 5 yr; p=0.0000001). The diagnosis of insulinoma can be made within 48 h of fasting. The association between intraoperative US and palpation evidenced the tumor in 95% of the patients. C-peptide and tumor size were reliable malignancy predictors.
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Affiliation(s)
- M Queiroz Almeida
- Unidade de Endocrinologia Geral, Disciplina de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil.
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Sa Cunha A, Beau C, Rault A, Catargi B, Collet D, Masson B. Laparoscopic versus open approach for solitary insulinoma. Surg Endosc 2006; 21:103-8. [PMID: 17008952 DOI: 10.1007/s00464-006-0021-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Accepted: 04/10/2006] [Indexed: 12/14/2022]
Abstract
BACKGROUND In recent years, advances in laparoscopic techniques have allowed surgeons to treat pancreatic lesions laparoscopically. Insulinoma, the most prevalent pancreatic endocrine tumor, is mostly benign and curable with surgical resection. This study aimed to assess the results from laparoscopic resection (LG) of insulinomas and to compare them with the results from open surgery (OG). METHODS From September 1999 to December 2005, 56 laparoscopic pancreatic resections were performed for selected patients, including 12 laparoscopic resections of insulinomas. The results were compared with those of patients who underwent open resection of insulinomas selected from the authors' pancreatic database. RESULTS Three conversions to the open approach were required because of inability to identify the tumor. There were no deaths in either group, and the morbidity rates were 25% (3/12) for LG and 55% (5/9) for OG (nonsignificant difference). The pancreatic fistula rate after laparoscopic enucleation was statistically lower than after open enucleation (14% vs 100%; p = 0.015). The mean postoperative hospital stay was 13 +/- 5.9 days for LG and 17.6 +/- 7.5 days for OG (nonsignificant difference). After exclusion of the patients who underwent conversion to laparotomy, the mean postoperative hospital stay was 11.5 +/- 5.8 days for LG and 17.6 +/- 7.5 days for OG (p = 0.04). CONCLUSION This study demonstrates the feasibility and safety of laparoscopic resection of insulinomas. The laparoscopic approach was associated with a decrease in hospital stay and pancreatic fistula after enucleation. Preoperative localization tests and laparoscopic ultrasonography seem necessary to prevent conversion.
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Affiliation(s)
- Antonio Sa Cunha
- Department of Digestive Surgery, Chu Bordeaux, Avenue Magellan, Pessac, France, 33604.
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McAuley G, Delaney H, Colville J, Lyburn I, Worsley D, Govender P, Torreggiani WC. Multimodality preoperative imaging of pancreatic insulinomas. Clin Radiol 2005; 60:1039-50. [PMID: 16179163 DOI: 10.1016/j.crad.2005.06.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Revised: 05/29/2005] [Accepted: 06/01/2005] [Indexed: 12/17/2022]
Abstract
Pancreatic insulinomas are rare tumours of the islet cells of the pancreas, which account for the majority of functional neuroendocrine tumours of the pancreas. There is often a typical history of recurrent hypoglycaemic collapse and dizzy spells. Insulinomas are usually solitary, and the vast majority are intra-pancreatic in location. They are characteristically small with approximately 66% being less than 2cm at presentation. Insulinomas continue to pose a diagnostic challenge to physicians, surgeons and radiologists alike. The role of imaging is to detect and provide precise anatomical localization and staging of tumours prior to surgery. Due to their small size at clinical presentation, they are notoriously difficult to localize radiologically, and specifically designed protocols are necessary to aid detection. In this review, we describe the current "state of the art" imaging protocols that may be used in the preoperative localization of insulinomas.
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Affiliation(s)
- G McAuley
- Department of Radiology, The Adelaide and Meath Hospital incorporating The National Children's Hospital, Tallaght, Dublin 24, Ireland
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Wiesli P, Brändle M, Schmid C, Krähenbühl L, Furrer J, Keller U, Spinas GA, Pfammatter T. Selective arterial calcium stimulation and hepatic venous sampling in the evaluation of hyperinsulinemic hypoglycemia: potential and limitations. J Vasc Interv Radiol 2005; 15:1251-6. [PMID: 15525744 DOI: 10.1097/01.rvi.0000140638.55375.1e] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To describe the potential and limitations of selective arterial calcium stimulation and hepatic venous sampling (ASVS) in the evaluation of patients with hyperinsulinemic hypoglycemia. MATERIALS AND METHODS Twenty-seven consecutive adult patients with documented hyperinsulinemic hypoglycemia undergoing an ASVS test and histologically confirmed diagnosis were included. RESULTS By histology, 24 patients were found to have an insulinoma, two had islet cell hyperplasia, and one had insulin-secreting neuroendocrine carcinoma of the liver. ASVS correctly predicted the source of excessive insulin secretion in 26 of 27 (sensitivity, 96%) patients. In two patients with an insulinoma, ASVS had to be repeated for correct diagnosis; in one patient with a glucose-sensitive insulinoma, ASVS was falsely negative. In one patient, a falsely negative ASVS test was caused by diazoxide treatment; in another patient a falsely negative ASVS test occurred because of extraordinarily high baseline insulin levels when the calcium stimulation was performed. CT and/or MR imaging correctly predicted the source of excessive insulin secretion in 59% of patients, the sensitivity of the intraoperative exploration was 88%. CONCLUSIONS In the authors' experience, the ASVS test is superior to CT/MR imaging and even the intraoperative exploration in identifying the source of excessive insulin secretion in patients with hyperinsulinemic hypoglycemia. To prevent false negative ASVS tests, medications with an influence on insulin secretion have to be discontinued prior to ASVS and two baseline blood samples should be obtained before the calcium stimulation is performed.
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Affiliation(s)
- Peter Wiesli
- Department of Internal Medicine, Division of Endocrinology and Diabetes, University Hospital of Zurich, Zurich, Switzerland.
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15
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Abstract
The feasibility of laparoscopic pancreatic resection has been demonstrated. However, the real clinical benefit for the patients remains questioned. The best indication for a laparoscopic approach appears to be the resection of benign or neuro-endocrine tumors without a need for pancreato-enteric reconstruction (i.e enucleation or distal pancreatectomy). The use of the laparoscopic approach for malignant tumors still remains controversial. The benefits of minimally invasive surgery are clearly correlated with the successful management of the pancreatic stump. Pancreatic related complication rate (fistula and collection) is 15% when using pancreatic transection with a laparoscopic endostappler.
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Affiliation(s)
- J-Y Mabrut
- Service de chirurgie générale, digestive et de la transplantation hépatique, hôpital de la Croix-Rousse, 103, Grande rue de la Croix-Rousse, 69317 Lyon 04, France.
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Goletti O, Celona G, Monzani F, Caraccio N, Zocco G, Lippolis PV, Battini A, Seccia M, Cavina E. Laparoscopic treatment of pancreatic insulinoma. Surg Endosc 2003; 17:1499. [PMID: 12802660 DOI: 10.1007/s00464-002-4273-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2002] [Accepted: 10/24/2002] [Indexed: 01/29/2023]
Abstract
Laparoscopy and laparoscopic ultrasonography (LUS) have been proposed for the diagnosis and treatment of pancreatic insulinoma. We present for cases of pancreatic insulinoma approached by laparoscopy guided by LUS. In three cases, insulinomas were in the pancreatic body and in one case in the pancreatic head. All lesions were detected preoperatively by abdominal US and confirmed by computed tomography. Laparoscopy was performed under general anesthesia. LUS was performed using a 10-mm flexible probe. In two cases the adenoma was enucleated using scissors and electrocoagulation, major vessels were controlled using clips, and enucleation was completed using a 30-mm endo-GIA. In one case a laparoscopic distal pancreatectomy with spleen preservation was performed. In one case the adenoma was deep in the pancreatic head; minilaparotomy was performed and the adenoma enucleated. Patients were discharged in good health 5-7 days after surgery. The postoperative course was complicated in one case of enucleation by peripancreatic fluid collection that was treated percutaneously. Our experience confirms that accurate localization followed by excision of tumors via the laparoscopic approach constitute a significant advance in the management of insulinoma.
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Affiliation(s)
- O Goletti
- Department of Surgery, University of Pisa, Via Roma 67, 56100 Pisa, Italy.
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