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Ghosh N, Kumar A, Sharma V, Verma V. Non-islet cell tumor-related hypoglycemia in a case of metastatic gastrointestinal stromal tumor: A rare paraneoplastic syndrome: A case report. APOLLO MEDICINE 2022. [DOI: 10.4103/am.am_67_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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2
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Kumar N, Bhoriwal S, Das P, Deo SVS. A Rare Case of Paraneoplastic Hypoglycemia Induced by Abdominopelvic Gastrointestinal Stromal Tumor. J Gastrointest Cancer 2021; 51:1065-1069. [PMID: 32367463 DOI: 10.1007/s12029-020-00406-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Navin Kumar
- Department of Surgical Oncology, Dr. BRA-IRCH, All India Institute of Medical Sciences, New Delhi, India.
| | - Sandeep Bhoriwal
- Department of Surgical Oncology, Dr. BRA-IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - S V S Deo
- Department of Surgical Oncology, Dr. BRA-IRCH, All India Institute of Medical Sciences, New Delhi, India
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3
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van Doorn J. Insulin-like growth factor-II and bioactive proteins containing a part of the E-domain of pro-insulin-like growth factor-II. Biofactors 2020; 46:563-578. [PMID: 32026557 PMCID: PMC7497164 DOI: 10.1002/biof.1623] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/15/2020] [Indexed: 12/13/2022]
Abstract
Insulin-like growth factor (IGF)-II is considered to function as an important fetal growth factor, which is structurally and functionally related to IGF-I and proinsulin. At least in vitro, IGF-II actions are mediated through the IGF-I receptor and to a lesser extent the insulin receptor. After birth, the function of IGF-II is less clear although in adults the serum level of IGF-II exceeds that of IGF-I several fold. The IGF-II gene is maternally imprinted, with exception of the liver and several parts of the brain, where it is expressed from both alleles. The regulation, organization, and translation of the IGF-II gene is complex, with five different putative promotors leading to a range of noncoding and coding mRNAs. The 180-amino acid pre-pro-IGF-II translation product can be divided into five domains and include a N-terminal signal peptide of 24 amino acid residues, the 67 amino acid long mature protein, and an 89 residues extension at the COOH terminus, designated as the E-domain. After removal of the signal peptide, the processing of pro-IGF-II into mature IGF-II requires various steps including glycosylation of the E-domain followed by the action of endo-proteases. Several of these processing intermediates can be found in the human circulation. There is increasing evidence that, besides IGF-II, several incompletely processed precursor forms of the protein, and even a 34-amino acid peptide (preptin) derived from the E-domain of pro-IGF-II, exhibit distinct biological activities. This review will focus on the current insights regarding the specific roles of the latter proteins in cancer, glucose homeostasis, and bone physiology. To address this topic clearly in the right context, a concise overview of the biological and biochemical properties of IGF-II and several relevant aspects of the IGF system will be provided.
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Affiliation(s)
- Jaap van Doorn
- Department of Genetics, Section Metabolic DiagnosticsUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
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Lodzinska J, Ballber C, Smith SH, Bavcar S. Hypoglycaemia associated with gastrointestinal and extragastrointestinal stromal tumour in two dogs. VETERINARY RECORD CASE REPORTS 2019. [DOI: 10.1136/vetreccr-2018-000784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Joanna Lodzinska
- Hospital for Small AnimalsUniversity of Edinburgh Royal Dick School of Veterinary StudiesEaster BushUK
| | | | | | - Spela Bavcar
- Hospital for Small AnimalsUniversity of Edinburgh Royal Dick School of Veterinary StudiesEaster BushUK
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Sarmiento R, Bonginelli P, Cacciamani F, Salerno F, Gasparini G. Gastrointestinal Stromal Tumors (GISTs): From Science to Targeted Therapy. Int J Biol Markers 2018; 23:96-110. [DOI: 10.1177/172460080802300206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs represent a distinct category of tumors characterized by oncogenic mutations of the KIT receptor tyrosine kinase in a majority of patients. KIT is useful not only for the diagnosis but also for targeted therapy of this disease. Imatinib, a tyrosine kinase inhibitor, is widely used in advanced and metastatic GISTs. This agent revolutionized the treatment strategy of advanced disease and is being tested in the neoadjuvant and adjuvant settings with encouraging results. New therapeutic agents like sunitinib have now been approved, enriching the treatment scenario for imatinib-resistant GISTs. The present review reports on the peculiar characteristics of this disease through its biology and molecular patterns, focusing on the predictive value of KIT mutations and their correlation with clinical outcome as well as on the activity of and resistance to approved targeted drugs.
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Affiliation(s)
- R. Sarmiento
- Division of Medical Oncology, San Filippo Neri Hospital, Rome - Italy
| | - P. Bonginelli
- Division of Medical Oncology, San Filippo Neri Hospital, Rome - Italy
| | - F. Cacciamani
- Division of Medical Oncology, San Filippo Neri Hospital, Rome - Italy
| | - F. Salerno
- Division of Medical Oncology, San Filippo Neri Hospital, Rome - Italy
| | - G. Gasparini
- Division of Medical Oncology, San Filippo Neri Hospital, Rome - Italy
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Dimitriadis GK, Angelousi A, Weickert MO, Randeva HS, Kaltsas G, Grossman A. Paraneoplastic endocrine syndromes. Endocr Relat Cancer 2017; 24:R173-R190. [PMID: 28341725 DOI: 10.1530/erc-17-0036] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/24/2017] [Indexed: 12/13/2022]
Abstract
The majority of neoplasms are responsible for symptoms caused by mass effects to surrounding tissues and/or through the development of metastases. However, occasionally neoplasms, with or without endocrine differentiation, acquire the ability to secrete a variety of bioactive substances or induce immune cross-reactivity with the normal tissues that can lead to the development of characteristic clinical syndromes. These syndromes are named endocrine paraneoplastic syndromes when the specific secretory components (hormones, peptides or cytokines) are unrelated to the anticipated tissue or organ of origin. Endocrine paraneoplastic syndromes can complicate the patient's clinical course, response to treatment, impact prognosis and even be confused as metastatic spread. These syndromes can precede, occur concomitantly or present at a later stage of tumour development, and along with the secreted substances constitute the biological 'fingerprint' of the tumour. Their detection can facilitate early diagnosis of the underlying neoplasia, monitor response to treatment and/or detect early recurrences following successful initial management. Although when associated with tumours of low malignant potential they usually do not affect long-term outcome, in cases of highly malignant tumours, endocrine paraneoplastic syndromes are usually associated with poorer survival outcomes. Recent medical advances have not only improved our understanding of paraneoplastic syndrome pathogenesis in general but also enhanced their diagnosis and treatment. Yet, given the rarity of endocrine paraneoplastic syndromes, there is a paucity of prospective clinical trials to guide management. The development of well-designed prospective multicentre trials remains a priority in the field in order to fully characterise these syndromes and provide evidence-based diagnostic and therapeutic protocols.
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Affiliation(s)
- Georgios K Dimitriadis
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Anna Angelousi
- Division of PathophysiologyNational and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Martin O Weickert
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Harpal S Randeva
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Gregory Kaltsas
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
- Division of PathophysiologyNational and Kapodistrian University of Athens Medical School, Athens, Greece
- Oxford Centre for DiabetesEndocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Ashley Grossman
- Oxford Centre for DiabetesEndocrinology and Metabolism, University of Oxford, Oxford, UK
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Chiu CG, Zaghiyan KN, Silberman AW. Hyperammonemic Encephalopathy Associated With GI Stromal Tumor. J Clin Oncol 2016; 34:e51-3. [PMID: 24982462 DOI: 10.1200/jco.2013.48.9302] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Connie G Chiu
- Cedars-Sinai Medical Center, Los Angeles; John Wayne Cancer Institute, Santa Monica, CA
| | - Karen N Zaghiyan
- Cedars-Sinai Medical Center, Los Angeles; John Wayne Cancer Institute, Santa Monica, CA
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Hirai H, Ogata E, Ohki S, Fukuda I, Tanaka M, Watanabe T, Satoh H. Hypoglycemia Associated with a Gastrointestinal Stromal Tumor Producing High-molecular-weight Insulin Growth Factor II: A Case Report and Literature Review. Intern Med 2016; 55:1309-14. [PMID: 27181538 DOI: 10.2169/internalmedicine.55.5848] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 61-year-old woman with multiple metastatic and unresectable gastrointestinal stromal tumors (GISTs) was referred for investigation of refractory hypoglycemia that developed four months before this hospitalization. On admission, her fasting plasma glucose was 38 mg/dL despite 10% glucose infusion. Investigations revealed that her serum C-peptide, insulin and growth hormone levels were suppressed, and big insulin-like growth factor II was observed. She was diagnosed with non-islet cell tumor hypoglycemia, which resolved after glucocorticoid treatment. Clinicians should thus be vigilant to identify hypoglycemia in patients with large metastatic GISTs because glucocorticoid therapy is useful even if the GIST is inoperable.
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Affiliation(s)
- Hiroyuki Hirai
- Department of Nephrology, Hypertension, Diabetology, Endocrinology, and Metabolism, Fukushima Medical University, Japan
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Dimitriadis GK, Gopalakrishnan K, Rao R, Grammatopoulos DK, Randeva HS, Weickert MO, Murthy N. Severe paraneoplastic hypoglycemia secondary to a gastrointestinal stromal tumour masquerading as a stroke. Endocrinol Diabetes Metab Case Rep 2015; 2015:150062. [PMID: 26535131 PMCID: PMC4629400 DOI: 10.1530/edm-15-0062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 09/21/2015] [Indexed: 11/08/2022] Open
Abstract
UNLABELLED We report the case of a 70-year-old previously healthy female who presented acutely to the Accident and Emergency department with left-sided vasomotor symptoms including reduced muscle tone, weakness upon walking and slurred speech. Physical examination confirmed hemiparesis with VIIth nerve palsy and profound hepatomegaly. A random glucose was low at 1.7 mmol/l, which upon correction resolved her symptoms. In hindsight, the patient recalled having had similar episodes periodically over the past 3 months to which she did not give much attention. While hospitalized, she continued having episodes of symptomatic hypoglycaemia during most nights, requiring treatment with i.v. dextrose and/or glucagon. Blood tests including insulin and C-peptide were invariably suppressed, in correlation with low glucose. A Synacthen stimulation test was normal (Cort (0') 390 nmol/l, Cort (30') 773 nmol/l). A computed tomography scan showed multiple lobulated masses in the abdomen, liver and pelvis. An ultrasound guided biopsy of one of the pelvic masses was performed. Immunohistochemistry supported the diagnosis of a gastrointestinal stromal tumour (GIST) positive for CD34 and CD117. A diagnosis of a non islet cell tumour hypoglycaemia (NICTH) secondary to an IGF2 secreting GIST was confirmed with further biochemical investigations (IGF2=96.5 nmol/l; IGF2:IGF1 ratio 18.9, ULN <10). Treatment with growth hormone resolved the patient's hypoglycaemic symptoms and subsequent targeted therapy with Imatinib was successful in controlling disease progression over an 8-year observation period. LEARNING POINTS NICTH can be a rare complication of GISTs that may manifest with severe hypoglycaemia and neuroglucopenic symptoms.NICTH can masquerade as other pathologies thus causing diagnostic confusion.Histological confirmation of GIST induced NICTH and exclusion of other conditions causing hypoglycaemia is essential.Mutational analysis of GISTs should be carried out in all cases as it guides treatment decision.Tailored management of hypoglycaemia, in this case using growth hormone and targeted cyto-reductive therapy, minimizes the risk of possible life-threatening complications.
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Affiliation(s)
- G K Dimitriadis
- Warwick Institute for the Study of Endocrinology Diabetes and Metabolism (WISDEM Centre), The Arden NET Centre, University Hospitals of Coventry and Warwickshire, UHCW NHS Trust, ENETS CoE, Coventry, UK
- Division of Experimental Medicine, Faculty of Medicine, Imperial College London, Hammersmith Campus, London, UK
- Division of Translational and Systems Medicine, Warwick Medical School, University of Warwick, Coventry, UK
| | - K Gopalakrishnan
- Department of Histopathology, Coventry and Warwickshire, Pathology Service, UHCW NHS Trust, Coventry, UK
| | - R Rao
- Warwick Institute for the Study of Endocrinology Diabetes and Metabolism (WISDEM Centre), The Arden NET Centre, University Hospitals of Coventry and Warwickshire, UHCW NHS Trust, ENETS CoE, Coventry, UK
| | - D K Grammatopoulos
- Division of Translational and Systems Medicine, Warwick Medical School, University of Warwick, Coventry, UK
- Department of Clinical Biochemistry and Histopathology, Coventry and Warwickshire, Pathology Service, UHCW NHS Trust, Coventry, UK
| | - H S Randeva
- Warwick Institute for the Study of Endocrinology Diabetes and Metabolism (WISDEM Centre), The Arden NET Centre, University Hospitals of Coventry and Warwickshire, UHCW NHS Trust, ENETS CoE, Coventry, UK
- Division of Translational and Systems Medicine, Warwick Medical School, University of Warwick, Coventry, UK
| | - M O Weickert
- Warwick Institute for the Study of Endocrinology Diabetes and Metabolism (WISDEM Centre), The Arden NET Centre, University Hospitals of Coventry and Warwickshire, UHCW NHS Trust, ENETS CoE, Coventry, UK
| | - N Murthy
- Warwick Institute for the Study of Endocrinology Diabetes and Metabolism (WISDEM Centre), The Arden NET Centre, University Hospitals of Coventry and Warwickshire, UHCW NHS Trust, ENETS CoE, Coventry, UK
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Dynkevich Y, Rother KI, Whitford I, Qureshi S, Galiveeti S, Szulc AL, Danoff A, Breen TL, Kaviani N, Shanik MH, Leroith D, Vigneri R, Koch CA, Roth J. Tumors, IGF-2, and hypoglycemia: insights from the clinic, the laboratory, and the historical archive. Endocr Rev 2013; 34:798-826. [PMID: 23671155 DOI: 10.1210/er.2012-1033] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Tumors of mesenchymal and epithelial origin produce IGF-2, which activates pathways in the tumors. In a minority of patients, the tumors (hepatomas, fibromas, and fibrosarcomas are the most common among many) release into the circulation enough IGF-2-related peptides to mimic the fasting hypoglycemia characteristic of patients with insulin-producing islet-cell tumors. Rarely, markedly elevated IGF-2 levels produce somatic changes suggestive of acromegaly. Typically, the elevated IGF-2 levels are associated with suppressed plasma levels of insulin, IGF-1, and GH. Complicating the pathophysiology are the IGF binding proteins (IGFBPs) that can bind IGF-2 and IGF-1, modifying hormone metabolism and action. IGFBP concentrations are often altered in the presence of these tumors. At the cellular level, the 3 hormone-related ligands, IGF-2, IGF-1, and insulin, all bind to 4 (or more) types of IGF-1 receptor (IGF-1R) and insulin receptor (IR). Each receptor has its own characteristic affinity for each ligand, a tyrosine kinase, and overlapping profiles of action in the target cells. The IGF-2R, in addition to binding mannose-6-phosphate-containing proteins, provides an IGF-2 degradation pathway. Recent evidence suggests IGF-2R involvement also in signal transduction. Surgery, the treatment of choice, can produce a cure. For patients not cured by surgery, multiple therapies exist, for the tumor and for hypoglycemia. Potential future therapeutic approaches are sketched. From 1910 to 1930, hypoglycemia, insulin, insulinomas, and non-islet-cell tumors were recognized. The latter third of the century witnessed the emergence of the immunoassay for insulin; the IGFs, their binding proteins, and assays to measure them; and receptors for the insulin-related peptides as well as the intracellular pathways beyond the receptor. In closing, we replace non-islet-cell tumor hypoglycemia, an outdated and misleading label, with IGF-2-oma, self-explanatory and consistent with names of other hormone-secreting tumors.
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Affiliation(s)
- Yevgeniya Dynkevich
- MD, FACP, Investigator, Feinstein Institute for Medical Research, Laboratory of Diabetes and Diabetes-Related Research, 350 Community Drive, Manhasset, NY 11030.
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Samlani-Sebbane Z, Diffaa A, Krati K, Finech A, Rabbani K, Narjis Y, El Ansari N, El Mansouri F, Belaabidia B. Fatal hypoglycaemia from IGF II hyperproduction as a complication of a mesenteric gastrointestinal stromal tumour. Arab J Gastroenterol 2011; 12:171-2. [PMID: 22055601 DOI: 10.1016/j.ajg.2011.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Revised: 04/07/2011] [Accepted: 08/01/2011] [Indexed: 11/16/2022]
Affiliation(s)
- Zouhour Samlani-Sebbane
- Gastroenterology Department, King Mohamed VI Hospital, FMPM, UCAM, King Mohamed VI University Hospital, Medical School of Marrakech, Cadi Ayyad University, Marrakech, Morocco.
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12
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Gestion des effets secondaires des thérapies ciblées dans le cancer du rein : effets secondaires endocriniens et troubles métaboliques. Bull Cancer 2011; 98:S47-59. [DOI: 10.1684/bdc.2011.1441] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Rikhof B, de Jong S, Suurmeijer AJH, Meijer C, van der Graaf WTA. The insulin-like growth factor system and sarcomas. J Pathol 2009; 217:469-82. [PMID: 19148905 DOI: 10.1002/path.2499] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Sarcomas are a diverse group of malignant mesenchymal tumours arising from bone and soft tissues. The identification of critical cellular signalling pathways in sarcomas is an important issue for the development of new targeted therapies. This review highlights the experimental and clinical evidence supporting the role of the insulin-like growth factor (IGF) signalling system in the cellular transformation and progression of several types of sarcoma, including rhabdomyosarcoma, synovial sarcoma, leiomyosarcoma, Ewing's sarcoma and osteosarcoma. Preclinical data suggest that the IGF system could be a promising target for therapy in these sarcomas. Currently, therapies interrupting IGF signalling have been or are being developed. In recent phase 1 clinical studies with humanized monoclonal antibodies directed against IGF receptor type 1 (IGF-1R), objective tumour responses were observed in several patients with Ewing's sarcoma, encouraging further clinical testing in Ewing's sarcoma and other sarcoma (sub)types. Moreover, the occasional occurrence of paraneoplastic hypoglycaemia as a result of the secretion of incompletely processed forms of pro-IGF-II by sarcomas is discussed.
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Affiliation(s)
- Bart Rikhof
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, The Netherlands.
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Rikhof B, van Doorn J, Suurmeijer AJH, Rautenberg MW, Groenen PJTA, Verdijk MAJ, Jager PL, de Jong S, Gietema JA, van der Graaf WTA. Insulin-like growth factors and insulin-like growth factor-binding proteins in relation to disease status and incidence of hypoglycaemia in patients with a gastrointestinal stromal tumour. Ann Oncol 2009; 20:1582-1588. [PMID: 19276395 DOI: 10.1093/annonc/mdp038] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Patients with a gastrointestinal stromal tumour (GIST) suffering from non-islet cell tumour-induced hypoglycaemia (NICTH), being associated with increased plasma levels of pro-insulin-like growth factor (IGF)-IIE[68-88], have been reported occasionally. We studied the clinical relevance of pro-IGF-IIE[68-88] and other IGF-related proteins in GIST patients. PATIENTS AND METHODS Twenty-four patients were included. Plasma samples were collected before 1 week and median 5 months after start of treatment with imatinib, and levels of IGF-I, total IGF-II, pro-IGF-IIE[68-88], insulin-like growth factor-binding protein (IGFBP)-2, -3 and -6 were determined. GIST specimens from 17 patients and tumour cyst fluid from two patients were analysed for IGF-II and IGFBP-2. RESULTS Before treatment and/or during follow-up, 3 of 24 (13%) patients showed increased plasma levels of pro-IGF-IIE[68-88]. All three developed NICTH. Overall, patients with metastatic disease, elevated serum lactate dehydrogenase activity or total tumour size >12 cm had the highest pro-IGF-IIE[68-88] levels. Most patients had increased plasma IGFBP-2 levels and these levels were significantly higher in patients with progressive disease. (Pro-)IGF-II was expressed in 82% of GISTs and IGFBP-2 only in one case. CONCLUSION We identified pro-IGF-IIE[68-88] as a marker that may be used in the surveillance of GIST.
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Affiliation(s)
- B Rikhof
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen
| | - J van Doorn
- Department of Metabolic and Endocrine Diseases, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht
| | - A J H Suurmeijer
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen
| | - M W Rautenberg
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht
| | - P J T A Groenen
- Department of Pathology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - M A J Verdijk
- Department of Pathology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - P L Jager
- Department of Nuclear Medicine, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - S de Jong
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen
| | - J A Gietema
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen
| | - W T A van der Graaf
- Department of Medical Oncology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
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Hyperinsulinemic hypoglycemia with nesidioblastosis: histologic features and growth factor expression. Mod Pathol 2009; 22:239-45. [PMID: 18931647 DOI: 10.1038/modpathol.2008.169] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Hypoglycemia secondary to nesidioblastosis is rare in adults, and the pathogenesis of this condition is unknown. To determine factors leading to nesidioblastosis in adults, we analyzed 36 cases of nesidioblastosis including 27 cases of postgastric bypass nesidioblastosis and 9 cases of idiopathic nesidioblastosis in adults by immunohistochemistry using antibodies to insulin-like growth factor 1, insulin-like growth factor 2 (IGF2), insulin-like growth factor one receptor-alpha epidermal growth factor receptor, transforming growth factor-beta1 and 2, and transforming growth factor-beta receptor type 3. Fifty-two surgically excised pancreatic specimens from patients with benign exocrine tumors and no evidence of hypoglycemia were used as controls. There was increased IGF2, insulin-like growth factor receptor 1 receptor-alpha and transforming growth factor-beta receptor 3 expression in islets from nesidioblastosis patients compared to controls. Peliosis-type vascular ectasia was more common in nesidioblastosis patients compared to controls. These findings suggest that increased production of growth factors and growth factor receptors may contribute to the development of nesidioblastosis in adults.
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Tsikrikas S, Manolakopoulos S, Deutsch M, Alexakis G, Sialevris K, Giannopoulos D, Vassilopoulos D, Archimandritis AJ. Unusual combination of paraneoplastic manifestations in a patient with metastatic gastrointestinal stromal tumor (GIST). Scand J Gastroenterol 2008; 43:1012-5. [PMID: 19086169 DOI: 10.1080/00365520801886090] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Activating mutations in tyrosine kinase receptors KIT or platelet-derived growth factor receptor alpha (PDGFRA) are the main mechanisms causing the disease. Patients generally present with non-specific symptoms, while a number of tumors are discovered incidentally and may be metastatic at the time of diagnosis. Aggressive GISTs have a defined pattern of metastasis to the liver or throughout the abdomen, or both. Though GISTs rarely present systemic or isolated paraneoplastic reactions, a few cases have been reported in the literature. We present the case of a 54-year-old patient with metastatic GIST at diagnosis and the emergence of paraneoplastic manifestations during follow-up.
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Affiliation(s)
- Spyridon Tsikrikas
- 2nd Academic Department of Internal Medicine, University of Athens, Hippokration General Hospital, Athens, Greece
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John SKP, Basu S, Lawrance RJ, Davies N. An unusual presentation of a Gastrointestinal stromal tumour (GIST). World J Surg Oncol 2007; 5:78. [PMID: 17629936 PMCID: PMC1971264 DOI: 10.1186/1477-7819-5-78] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Accepted: 07/14/2007] [Indexed: 01/22/2023] Open
Abstract
Background Gastrointestinal stromal tumours (GIST) are rare tumours, now more frequently identified with the new imaging modalities like computerised tomography (CT) and magnetic resonance imaging (MRI). We report a rare presentation of a GIST with an unusual diagnostic workup in a multidisciplinary setting leading to a definitive diagnosis and treatment. Case presentation A 55-year-old lady was admitted under the general surgeons, with 3-day history of abdominal pain, three-week history of loss of appetite and weight. The patient was sequentially investigated with ultrasonography, computerised tomography and finally selective angiogram in a multidisciplinary setting. The selective angiogram showed a GIST with intratumour bleed, leading to successful surgical excision and being recurrence free at 22 month follow up. Conclusion Clinical presentation of these tumours can be varied and gastrointestinal bleeding is the commonest mode described in the literature. The clinician needs to be aware of much more rare presentations of the GIST including an intra tumour bleed. A structured multidisciplinary approach would lead to successful diagnosis and treatment.
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Affiliation(s)
- Solomon KP John
- Department of Surgery, Royal Bournemouth Hospital, Bournemouth, UK
| | - Sanjoy Basu
- Department of Surgery, Royal Bournemouth Hospital, Bournemouth, UK
| | | | - Nick Davies
- Department of Surgery, Royal Bournemouth Hospital, Bournemouth, UK
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18
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Guiteau J, Fanucchi M, Folpe A, Staley CA, Kooby DA. Hypoglycemia in the setting of advanced gastrointestinal stromal tumor. Am Surg 2007; 72:1225-30. [PMID: 17216825 DOI: 10.1177/000313480607201216] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report a rare case of symptomatic hypoglycemia in a patient with intra-abdominal recurrence of a previously resected gastrointestinal stromal tumor (GIST). The patient is a 65-year-old woman who underwent resection of a large abdominal mass arising from the stomach, histologically diagnosed as a high-grade leiomyosarcoma. She was lost to follow up. Five years later, the mass recurred; core biopsy demonstrated a CD 117-positive, spindle-cell tumor, consistent with a GIST. She was placed on Gleevec, as there was evidence of multifocal disease, but imaging revealed only mild improvement. Subsequently, her clinical status deteriorated, and she was hospitalized for dehydration, vomiting, and mental status changes. Her blood glucose on admission was 22 mg/dL, and a dextrose infusion (50%) was necessary to maintain adequate blood glucose levels. Measurements of insulin, proinsulin, c-peptide, beta-hydroxybutyrate, and thyroid-stimulating hormone were normal, as were cosyntropin stimulation and glucagon response tests. Suspicions arose for tumor-secreted insulin-like factor. She underwent resection of the dominant 44-cm recurrence, with immediate rebound hyperglycemia, followed by complete normalization of her blood glucose levels. She was discharged on postoperative Day 5 without symptoms or insulin, and is alive with disease at 20 months. Paraneoplastic syndromes occur in only 15 per cent of patients with known malignancies (e.g., lung cancer and metastatic carcinoid), and are rarely reported in the setting of GIST. Hypoglycemia is most often observed in presence of insulinoma and only isolated case reports in GIST patients exist. Overexpression of insulin-like growth factor II is thought to be the mechanism of action. Supportive management and palliative resection or debulking is recommended when possible.
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Affiliation(s)
- Jacfranz Guiteau
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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19
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Escobar GA, Robinson WA, Nydam TL, Heiple DC, Weiss GJ, Buckley L, Gonzalez R, McCarter MD. Severe paraneoplastic hypoglycemia in a patient with a gastrointestinal stromal tumor with an exon 9 mutation: a case report. BMC Cancer 2007; 7:13. [PMID: 17229322 PMCID: PMC1781460 DOI: 10.1186/1471-2407-7-13] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Accepted: 01/17/2007] [Indexed: 11/10/2022] Open
Abstract
Background Non-islet cell tumor induced hypoglycemia (NICTH) is a very rare phenomenon, but even more so in gastrointestinal stromal tumors. It tends to present in large or metastatic tumors, and can appear at any time in the progression of the disease. We present herein a case of NICTH in a GIST tumor and report an exon 9 mutation associated to it. Case presentation A thirty nine year-old man with a recurrent, metastatic gastrointestinal stromal tumor presented to the hospital with nausea, dizziness, loss of consciousness, and profound hypoglycemia (20 mg/dL). There was no evidence of factitious hypoglycemia. He was stabilized with a continuous glucose infusion and following selective vascular embolization, the patient underwent debulking of a multicentric 40 cm × 25 cm × 10 cm gastrointestinal stromal tumor. After resection, the patient became euglycemic and returned to his normal activities. Tumor analysis confirmed excessive production of insulin-like growth factor II m-RNA and the precursor protein, "big" insulin-like growth factor II. Mutational analysis also identified a rare, 6 bp tandem repeat insert (gcctat) at position 1530 in exon 9 of KIT. Conclusion Optimal management of gastrointestinal stromal tumor-induced hypoglycemia requires a multidisciplinary approach, and surgical debulking is the treatment of choice to obtain immediate symptom relief. Imatinib or combinations of glucocorticoids and growth hormone are alternative palliative strategies for symptomatic hypoglycemia. In addition, mutations in exon 9 of the tyrosine kinase receptor KIT occur in 11–20% of GIST and are often associated with poor patient outcomes. The association of this KIT mutation with non-islet cell tumor induced hypoglycemia has yet to be established.
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Affiliation(s)
- Guillermo A Escobar
- Department of Surgery, Division of GI, Tumor and Endocrine Surgery, University of Colorado Health Sciences Center. 4200 E. 9Ave, Denver, CO, 80262, USA
| | - William A Robinson
- Department of Medicine, Divisions of Medical Oncology and Endocrinology, University of Colorado Health Sciences Center. 4200 E. 9Ave, Denver, CO, 80262, USA
| | - Trevor L Nydam
- Department of Surgery, Division of GI, Tumor and Endocrine Surgery, University of Colorado Health Sciences Center. 4200 E. 9Ave, Denver, CO, 80262, USA
| | - Drew C Heiple
- Department of Medicine, Divisions of Medical Oncology and Endocrinology, University of Colorado Health Sciences Center. 4200 E. 9Ave, Denver, CO, 80262, USA
| | - Glen J Weiss
- Department of Medicine, Divisions of Medical Oncology and Endocrinology, University of Colorado Health Sciences Center. 4200 E. 9Ave, Denver, CO, 80262, USA
| | - Linda Buckley
- Department of Medicine, Divisions of Medical Oncology and Endocrinology, University of Colorado Health Sciences Center. 4200 E. 9Ave, Denver, CO, 80262, USA
| | - Rene Gonzalez
- Department of Medicine, Divisions of Medical Oncology and Endocrinology, University of Colorado Health Sciences Center. 4200 E. 9Ave, Denver, CO, 80262, USA
| | - Martin D McCarter
- Department of Surgery, Division of GI, Tumor and Endocrine Surgery, University of Colorado Health Sciences Center. 4200 E. 9Ave, Denver, CO, 80262, USA
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20
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Davda R, Seddon BM. Mechanisms and management of non-islet cell tumour hypoglycaemia in gastrointestinal stromal tumour: case report and a review of published studies. Clin Oncol (R Coll Radiol) 2007; 19:265-8. [PMID: 17433971 DOI: 10.1016/j.clon.2006.12.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2006] [Accepted: 12/11/2006] [Indexed: 10/23/2022]
Abstract
Tumour-related hypoglycaemia is a rare paraneoplastic phenomenon most frequently occurring with insulinomas, but also associated with non-islet cell tumours. It has been observed in a range of tumour types, but recently a small number of cases have been described in association with gastrointestinal stromal tumours. We describe a further case of a patient with gastrointestinal stromal tumour that was complicated by non-islet cell tumour hypoglycaemia, and discuss the mechanisms and management of non-islet cell tumour hypoglycaemia in the context of gastrointestinal stromal tumour.
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Affiliation(s)
- R Davda
- London Bone and Soft Tissue Tumour Service, Department of Oncology, University College Hospital, London, UK
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21
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Hamberg P, de Jong FA, Boonstra JG, van Doorn J, Verweij J, Sleijfer S. Non-islet-cell tumor induced hypoglycemia in patients with advanced gastrointestinal stromal tumor possibly worsened by imatinib. J Clin Oncol 2006; 24:e30-1. [PMID: 16782905 DOI: 10.1200/jco.2006.06.5318] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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22
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Singh R, Grey A, Miller M, Gresnigt MG, Hoogerbrugge CM, van Doorn J. Non-hyperinsulinemic hypoglycemia in a patient with a gastrointestinal stromal tumor. Eur J Intern Med 2006; 17:127-9. [PMID: 16490691 DOI: 10.1016/j.ejim.2005.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2005] [Revised: 09/01/2005] [Accepted: 09/26/2005] [Indexed: 10/25/2022]
Abstract
One of the authors (JvD) recently reported a case of non-islet cell tumor hypoglycemia caused by the production of "big" IGF-II by a gastrointestinal stromal tumor (GIST). Here, we report a patient with a GIST in whom non-hyperinsulinemic hypoglycemia was not attributable to aberrant tumoral IGF-II processing, but instead was caused by a combination of cachexia, renal and hepatic dysfunction, and tumoral glucose consumption.
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Affiliation(s)
- R Singh
- Department of Endocrinology, Auckland City Hospital, Auckland, New Zealand
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23
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Rikhof B, Van Den Berg G, Van Der Graaf WTA. Non-islet cell tumour hypoglycaemia in a patient with a gastrointestinal stromal tumour. Acta Oncol 2006; 44:764-6. [PMID: 16227170 DOI: 10.1080/02841860500267816] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Bart Rikhof
- Department of Internal Medicine, Division of Medical Oncology, University Medical Center Groningen, University of Groningen, The Netherlands.
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