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Karamitopoulou-Diamantis E. [Exocrine meets neuroendocrine: mimickers of pancreatic neuroendocrine neoplasms]. PATHOLOGIE (HEIDELBERG, GERMANY) 2024; 45:42-49. [PMID: 38091082 DOI: 10.1007/s00292-023-01286-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 01/31/2024]
Abstract
Neuroendocrine neoplasms (NENs) originate from various epithelial or neuroectodermal tissues, can occur in any organ, including the pancreas, and are characterized by the expression of the neuroendocrine markers synaptophysin and chromogranin A. Pancreatic neuroendocrine tumors (PanNETs) are well-differentiated epithelial neoplasms with morphological and immunohistochemical features of neuroendocrine differentiation of low, intermediate, or high grade. Pancreatic neuroendocrine carcinomas (PanNECs) are clinically aggressive, high-grade (poorly differentiated) carcinomas with morphologic features suggesting neuroendocrine differentiation, a high proliferative rate (> 20 mitoses per 2 mm2 and Ki67 index > 20%), and immunohistochemical labeling for neuroendocrine markers. They include the small cell neuroendocrine carcinoma and the large cell neuroendocrine carcinoma categories.Neuroendocrine-like morphology coupled with immunohistochemical markers of neuroendocrine differentiation are highly specific. However, neuroendocrine markers may also be expressed in non-neuroendocrine neoplasms, which can therefore be confused with NENs. Mimickers of pancreatic NENs comprise a number of important pitfall tumors, including epithelial and non-epithelial neoplasms, such as acinar cell carcinomas, solid pseudopapillary neoplasms (SPNs), or even non-neoplastic lesions. All of these lesions have the expression of neuroendocrine markers in common, such as synaptophysin and chromogranin A, and although they are comparatively rare, they can cause considerable diagnostic problems. This review article deals with some of the most important mimickers of pancreatic neuroendocrine neoplasms and even non-neoplastic lesions, such as islet aggregation. The similarities and differences between these entities and pancreatic neuroendocrine neoplasms are highlighted, and key findings that facilitate the correct diagnosis are discussed.
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Affiliation(s)
- Eva Karamitopoulou-Diamantis
- Institut für Gewebemedizin und Pathologie, Universität Bern, Bern, Schweiz.
- PATHOLOGIE INSTITUT ENGE, Hardturmstr. 133, 8005, Zürich, Schweiz.
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Zhu G, Xie L, Hu X. Diagnosis of pancreatic focal nesidioblastosis assisted by dual‑nuclide tracer positron emission tomography/computed tomography: A case report. Exp Ther Med 2024; 27:42. [PMID: 38125355 PMCID: PMC10731402 DOI: 10.3892/etm.2023.12330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023] Open
Abstract
Nesidioblastosis is a rare cause of hyperinsulinemic hypoglycemia in adults and its clinical features are similar to those of insulinoma with recurrent hypoglycemic attacks. The present study reports the case of a 48-year-old man who visited the Affiliated Hospital of Zunyi Medical University (Zunyi, China) with a 5-year history of recurrent hypoglycemic symptoms such as dizziness and palpitations. Abdominal magnetic resonance imaging (MRI) showed a mass of ~1.2x1.0 cm in the head of the pancreas, which was suspected to be an insulinoma. For confirmation, the patient underwent both fluorine-18-fluorodeoxyglucose (18F-FDG) and gallium-68-labeled 1,4,7,10-tetraazacyclododecane-1,4,7,10-teraacetic acid-d-Phel-Tyr3-Thr8-OC (68Ga-DOTATATE) positron emission tomography/computed tomography (PET/CT), which showed a moderately increased uptake of 18F-FDG but no uptake of 68Ga-DOTATATE in the corresponding lesion. The patient subsequently underwent surgery to remove the lesion, which was pathologically confirmed as a pancreatic nesidioblastosis. This case showed that nesidioblastosis should be considered a differential diagnosis for insulinoma and that dual nuclear tracer PET/CT imaging is helpful for differentiating between the two. If conventional imaging techniques such as ultrasound, CT and MRI cannot identify the cause of hypoglycemia in future cases, dual-nuclide tracer PET/CT imaging should be considered.
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Affiliation(s)
- Guangwen Zhu
- Department of Endocrinology, Zunyi Hospital of Traditional Chinese Medicine, Zunyi, Guizhou 563000, P.R. China
| | - Liting Xie
- Department of Gynaecology, Zunyi Hospital of Traditional Chinese Medicine, Zunyi, Guizhou 563000, P.R. China
| | - Xianwen Hu
- Department of Nuclear Medicine, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou 563003, P.R. China
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3
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Arjoonsingh A, Guess S, Campbell B, Salmelin B. Nesidioblastosis and Subsequent Diabetes Mellitus in a Dog with Hyperinsulinemic Hypoglycemia Treated with Partial Pancreatectomy. J Am Anim Hosp Assoc 2024; 60:45-48. [PMID: 38175975 DOI: 10.5326/jaaha-ms-7374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 01/06/2024]
Abstract
A 6.5 yr old castrated male mixed-breed dog was presented for clinical signs associated with hypoglycemia. Hyperinsulinemic hypoglycemia was diagnosed as the cause of the persistent hypoglycemia. No obvious pancreatic mass was seen on abdominal computed tomography and exploratory laparotomy. A partial pancreatectomy was performed with the suspicion of an insulinoma-causing hyperinsulinemic hypoglycemia. Nesidioblastosis was diagnosed based clinical, biochemical, and histopathologic findings. There was beta cell hyperplasia and no evidence of neoplasia. The dog was euglycemic postoperatively after a partial pancreatectomy. Long-term follow-up after 2 yr revealed that the dog was diagnosed with diabetes mellitus.
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Affiliation(s)
- Avin Arjoonsingh
- From the College of Veterinary Medicine, University of Florida, Gainesville, Florida (A.A.); and
| | | | | | - Bettina Salmelin
- Department of Veterinary Clinical Sciences (B.S.), College of Veterinary Medicine, Washington State University, Pullman, Washington
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Thapa S, Kaur K, Yadav GK, Kumari D, Phulware RH. Non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS)/Nesidioblastosis as the underlying cause of recurrent hypoglycemia in a diabetic adult. Autops Case Rep 2023; 13:e2023451. [PMID: 38034512 PMCID: PMC10687782 DOI: 10.4322/acr.2023.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/05/2023] [Indexed: 12/02/2023]
Abstract
Non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS), without previous bariatric surgery, is a rare form of hypoglycemia in adult patients and is associated with nesidioblastosis. Adult-onset nesidioblastosis in diabetic patients is rare and histologically identical to "non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS)". Nesidioblastosis is rare in adults and clinically and biochemically mimics Insulinoma. In the literature, there have only been four cases of adult nesidioblastosis that followed diabetes mellitus. We report a case of nesidioblastosis in a 36-year-old diabetic female presenting with dizziness, sweating, and palpitations for three years. Selective non-invasive techniques failed to detect a tumor. Based on the pursuit of an insulinoma, a distal pancreatectomy specimen was received at our laboratory, and a diagnosis of nesidioblastosis was made. She is currently on follow-up with a favorable outcome. The definitive diagnosis of nesidioblastosis is made on a histological basis. The preferred form of treatment is pancreatic surgical resection. Nesidioblastosis should be taken into consideration in cases where diabetes transforms into hyperinsulinemic hypoglycemia.
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Affiliation(s)
- Samikshya Thapa
- All India Institute of Medical Sciences AIIMS, Department of Pathology & Laboratory Medicine, Rishikesh, Uttarakhand, India
| | - Kirandeep Kaur
- All India Institute of Medical Sciences, Department of Endocrinology, Rishikesh, Uttarakhand, India
| | - Gajendra Kumar Yadav
- All India Institute of Medical Sciences AIIMS, Department of Pathology & Laboratory Medicine, Rishikesh, Uttarakhand, India
| | - Divya Kumari
- All India Institute of Medical Sciences AIIMS, Department of Pathology & Laboratory Medicine, Rishikesh, Uttarakhand, India
| | - Ravi Hari Phulware
- All India Institute of Medical Sciences AIIMS, Department of Pathology & Laboratory Medicine, Rishikesh, Uttarakhand, India
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Elghobashy M, Gama R, Sulaiman RA. Investigation and Causes of Spontaneous (Non-Diabetic) Hypoglycaemia in Adults: Pitfalls to Avoid. Diagnostics (Basel) 2023; 13:3275. [PMID: 37892096 PMCID: PMC10606153 DOI: 10.3390/diagnostics13203275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
Although adult spontaneous (non-diabetic) hypoglycaemia is rare, its recognition is important for the preventative or curative treatment of the underlying cause. Establishing Whipple's triad-low blood glucose, neuroglycopaenia and resolution of neuroglycopaenia on increasing blood glucose levels to normal or above-is essential to verify hypoglycaemia. Awareness that hypoglycaemia may occur in severely ill patients is important for its prevention. Further investigation in such cases is unnecessary unless another cause of hypoglycaemia is suspected. Patients are often asymptomatic and normoglycaemic at review. Their history of medication, self-medication, access to hypoglycaemic drugs, alcohol use and comorbidity may provide aetiological clues. The investigation involves obtaining blood samples during symptoms for laboratory glucose measurement or provoking fasting or postprandial hypoglycaemia as directed by symptoms. If confirmed, insulin, c-peptide, proinsulin and beta-hydroxybutyrate are analysed in hypoglycaemic samples. These will classify hypoglycaemia due to non-ketotic hyperinsulinaemia, non-ketotic hypoinsulinaemia and ketotic hypoinsulinaemia, and direct investigations to identify the underlying cause. There are, however, many pitfalls that may mislabel healthy individuals as "hypoglycaemic" or misdiagnose treatable or preventable causes of spontaneous hypoglycaemia. Clinical acumen and appropriate investigations will mostly identify hypoglycaemia and its cause.
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Affiliation(s)
- Maiar Elghobashy
- Clinical Chemistry, Black Country Pathology Services, Royal Wolverhampton Trust, Wolverhampton WV10 0QP, UK; (M.E.); (R.G.)
| | - Rousseau Gama
- Clinical Chemistry, Black Country Pathology Services, Royal Wolverhampton Trust, Wolverhampton WV10 0QP, UK; (M.E.); (R.G.)
- School of Medicine and Clinical Practice, Wolverhampton University, Wolverhampton WV1 1LY, UK
| | - Raashda Ainuddin Sulaiman
- Department of Medical Genomics, Center for Genomic Medicine, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
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Nakagawa R, Minamiguchi S, Kataoka TR, Fujikura J, Masui T, Fujimoto M, Yamada Y, Takeuchi Y, Teramoto Y, Ito H, Saka M, Kitamura K, Otsuki S, Nishijima R, Haga H. Circularity of islets is a distinct marker for the pathological diagnosis of adult non-neoplastic hyperinsulinemic hypoglycemia using surgical specimens. Diagn Pathol 2023; 18:115. [PMID: 37864201 PMCID: PMC10588153 DOI: 10.1186/s13000-023-01403-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/17/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Adult non-neoplastic hyperinsulinemic hypoglycemia (ANHH), also known as adult-onset nesidioblastosis, is a rare cause of endogenous hyperinsulinemic hypoglycemia in adults. This disease is characterized by diffuse hyperplasia of pancreatic endocrine cells and is diagnosed by a pathological examination. While diagnostic criteria for this disease have already been proposed, we established more quantitative criteria for evaluating islet morphology. METHODS We measured the number, maximum diameter, total area, and circularity (representing how closely islets resemble perfect spheres) of islets contained in representative sections of ANHH (n = 4) and control cases (n = 5) using the NIS-Elements software program. We also measured the average cell size, percentage of cells with enlarged nuclei, and percentage of cells with recognizable nucleoli for each of three representative islets. We also assessed the interobserver diagnostic concordance of ANHH between five experienced and seven less-experienced pathologists. RESULTS There was no significant difference in the number, maximum diameter, or total area of islets between the two groups, even after correcting for these parameters per unit area. However, the number of islets with low circularity (< 0.71) per total area of the pancreatic parenchyma was significantly larger in ANHH specimens than in controls. We also found that the percentage of cells with recognizable nucleoli was significantly higher in the ANHH group than in the controls. There were no significant differences in the average cell size or the number of cells with enlarged nuclei between the groups. The correct diagnosis rate with the blind test was 47.5% ± 6.12% for experienced pathologists and 50.0% ± 8.63% for less-experienced pathologists, with no significant differences noted. CONCLUSIONS Low circularity, which indicates an irregular islet shape, referred to as "irregular shape and occasional enlargement of islets" and "lobulated islet structure" in a previous report, is a useful marker for diagnosing ANHH. An increased percentage of recognizable nucleoli, corresponding to "macronucleoli in β-cells," has potential diagnostic value.
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Affiliation(s)
- Ryota Nakagawa
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Pathology, Iwate Medical University, Yahaba-cho, Shiwa-gun, Iwate, 028-3694, Japan
| | - Sachiko Minamiguchi
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Tatsuki R Kataoka
- Department of Pathology, Iwate Medical University, Yahaba-cho, Shiwa-gun, Iwate, 028-3694, Japan
| | - Junji Fujikura
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Toshihiko Masui
- Department of Department of Hepatobiliary Pancreatic Surgery and Transplantation, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Masakazu Fujimoto
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yosuke Yamada
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yasuhide Takeuchi
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yuki Teramoto
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hiroaki Ito
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Manduwa Saka
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kyohei Kitamura
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shinya Otsuki
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Ryohei Nishijima
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hironori Haga
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
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7
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Dieterle MP, Husari A, Prozmann SN, Wiethoff H, Stenzinger A, Röhrich M, Pfeiffer U, Kießling WR, Engel H, Sourij H, Steinberg T, Tomakidi P, Kopf S, Szendroedi J. An Uncommon Cause of Recurrent Presyncope, Dizziness, and Tachycardia: A Case Report of Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS). Biomedicines 2023; 11:1741. [PMID: 37371836 DOI: 10.3390/biomedicines11061741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Neurovegetative and autonomic symptoms are common presentations of various diseases, ranging from psychosomatic to severe organic disorders. A 23-year-old man presented with a history of recurrent presyncope, dizziness, and tachycardia. Repeated diagnostic work-up in various clinical settings could not identify any definite cause for approximately eight years. However, the incidental detection of postprandial and exercise-induced hypoglycemia was suggestive of an insulin-related disorder. A 72 h plasma glucose fasting test revealed endogenous hyperinsulinism. Upon imaging studies, no tumor mass potentially indicating insulinoma could be detected. 68Ga-DOTA-Exendin-4 PET/CT showed diffuse tracer enrichment throughout the whole pancreas. A subtotal pancreatectomy was performed, and the diagnosis of diffuse, adult-onset nesidioblastosis was established histopathologically. This corresponds to the clinical findings of a functional β-cell disorder, also known as non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). After nine months, the symptoms recurred, making complete pancreatectomy necessary. Postoperative laboratory evaluation exhibited no residual endogenous C-peptide production. This case illustrates the diagnostic challenges in patients presenting with unspecific, neurovegetative and autonomic symptoms with a severe and rare underlying cause.
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Affiliation(s)
- Martin Philipp Dieterle
- Center for Dental Medicine, Division of Oral Biotechnology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Ayman Husari
- Center for Dental Medicine, Department of Orthodontics, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Sophie Nicole Prozmann
- Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Hendrik Wiethoff
- Institute of Pathology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Uwe Pfeiffer
- Pfalzklinikum for Psychiatry and Neurology AdÖR, Weinstr. 100, 76889 Klingenmünster, Germany
| | | | - Helena Engel
- Cancer Immune Regulation Group, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8010 Graz, Austria
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, 8036 Graz, Austria
| | - Thorsten Steinberg
- Center for Dental Medicine, Division of Oral Biotechnology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Pascal Tomakidi
- Center for Dental Medicine, Division of Oral Biotechnology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Stefan Kopf
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
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Dieterle MP, Husari A, Prozmann SN, Wiethoff H, Stenzinger A, Röhrich M, Pfeiffer U, Kießling WR, Engel H, Sourij H, Steinberg T, Tomakidi P, Kopf S, Szendroedi J. Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS): Review of the Literature of a Rare Cause of Hyperinsulinemic Hypoglycemia. Biomedicines 2023; 11:1732. [PMID: 37371827 DOI: 10.3390/biomedicines11061732] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Differential diagnosis of hypoglycemia in the non-diabetic adult patient is complex and comprises various diseases, including endogenous hyperinsulinism caused by functional β-cell disorders. The latter is also designated as nesidioblastosis or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Clinically, this rare disease presents with unspecific adrenergic and neuroglycopenic symptoms and is, therefore, often overlooked. A combination of careful clinical assessment, oral glucose tolerance testing, 72 h fasting, sectional and functional imaging, and invasive insulin measurements can lead to the correct diagnosis. Due to a lack of a pathophysiological understanding of the condition, conservative treatment options are limited and mostly ineffective. Therefore, nearly all patients currently undergo surgical resection of parts or the entire pancreas. Consequently, apart from faster diagnosis, more elaborate and less invasive treatment options are needed to relieve the patients from the dangerous and devastating symptoms. Based on a case of a 23-year-old man presenting with this disease in our department, we performed an extensive review of the medical literature dealing with this condition and herein presented a comprehensive discussion of this interesting disease, including all aspects from epidemiology to therapy.
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Affiliation(s)
- Martin Philipp Dieterle
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Ayman Husari
- Department of Orthodontics, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Sophie Nicole Prozmann
- Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Hendrik Wiethoff
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Uwe Pfeiffer
- Pfalzklinikum for Psychiatry and Neurology AdÖR, Weinstr. 100, 76889 Klingenmünster, Germany
| | | | - Helena Engel
- Cancer Immune Regulation Group, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8010 Graz, Austria
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, 8010 Graz, Austria
| | - Thorsten Steinberg
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Pascal Tomakidi
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Stefan Kopf
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
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Kim K, Greenspan JL, Mehrara S, Wynne D, Ennis E. Nesidioblastosis: an uncommon complication seen post Roux-en-Y gastric bypass. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0361. [PMID: 36571473 PMCID: PMC9875027 DOI: 10.1530/edm-22-0361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/05/2022] [Indexed: 12/27/2022] Open
Abstract
Summary Adult-onset nesidioblastosis is a rare complication of Roux-en-Y gastric bypass surgery and may occur months to years after the initial surgical procedure. It is manifested by a hyperinsulinemic, hypoglycemic state. The annual incidence of adult-onset hyperinsulinemic hypoglycemia is believed to be less than 0.1 in 1 000 000 with a mean age of onset of 47 years (1). Here, we describe a patient who presented with worsening hypoglycemic symptoms for 1 year prior to presentation that eventually progressed to hypoglycemic seizures. The onset of this hypoglycemia was 5 years after Roux-en-Y gastric bypass surgery. A full neurological evaluation, which included an EEG, head CT, and MRI, was performed to rule out epilepsy and other seizure-related disorders. After hypoglycemia was confirmed, extensive laboratory studies were obtained to elucidate the cause of the hypoglycemia and differentiate nesidioblastosis from insulinoma. Once the diagnosis of nesidioblastosis was established, a sub-total pancreatectomy was performed, and the patient was discharged and placed on acarbose, a competitive reversible inhibitor of pancreatic α-amylase and intestinal brush border α-glucosidases which slows carbohydrate absorption. The lack of information and understanding of nesidioblastosis due to its rarity makes any knowledge of this rare but important surgical complication essential. As incidence of obesity increases, the number of gastric bypasses being performed increases with it, and understanding this disease process will be essential for the primary care provider. This is the primary reason for the writing of this publication. Learning points Nesidioblastosis is a persistent hyperinsulinemic, hypoglycemic state, mostly seen after Roux-en-Y gastric bypass surgery, with symptoms occurring postprandially. The incidence is 0.1-0.3% of all post Roux-en-Y gastric bypass patients. The key diagnostic clue to identifying nesidioblastosis is a positive selective arterial calcium stimulation test, showing a diffuse pattern of increased basal hepatic venous insulin concentration, whereas insulinomas would show focal increases. Pathological specimen of pancreas will show diffuse hypertrophy of beta cells. Management includes acarbose and total or subtotal pancreatectomy, which can be curative. With the prevalence of obesity increasing and more patients turning to Roux-en-Y gastric bypass, more patients may be at risk of this potential surgical complication.
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Affiliation(s)
- Kiveum Kim
- VCOM-Auburn, 910 S Donahue Dr, Auburn, AL
| | | | | | - David Wynne
- FACP, Grandview Medical Center, 3570 Grandview Pkwy #100a, Birmingham, AL
| | - Elizabeth Ennis
- FACP, Princeton Baptist Medical Center, 701 Princeton Ave SW, Birmingham, AL
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10
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Functional Localization of Adult-Onset Idiopathic Nesidioblastosis. Case Rep Endocrinol 2022; 2022:2802975. [PMID: 36248221 PMCID: PMC9568342 DOI: 10.1155/2022/2802975] [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: 06/29/2022] [Accepted: 09/24/2022] [Indexed: 11/17/2022] Open
Abstract
Nesidioblastosis is a rare pancreatic disorder involving enlarged beta cells throughout the pancreas, causing elevated insulin production. We present the case of a 53-year-old woman with the initial symptom of fasting hypoglycemia. No pancreatic lesions were indicated on computed tomography and magnetic resonance imaging scans, and an octreotide scan was negative for insulinoma. Selective arterial calcium stimulation (SACST) showed increased insulin production from the stimulation of 3 out of 5 arteries. The SACST results suggested a diagnosis of nesidioblastosis, which was confirmed by histopathology after a subtotal distal pancreatectomy. The patient has normal glucose tolerance after surgery with no further problems of hypoglycemia, indicating that this is a rare case of nesidioblastosis extending only partially through the pancreas.
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Sharma A, Varshney P, Kasliwal R, Nagar A, Venkatatelikicherla K, Sarin S, Choubey RP, Kapoor VK. Insulinoma—Accurate Preoperative Localization Is the Key to Management: An Initial Experience. Indian J Surg Oncol 2022; 13:403-411. [DOI: 10.1007/s13193-022-01534-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 04/19/2022] [Indexed: 11/30/2022] Open
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12
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Hayashida R, Tsuchiya K, Sekine T, Momose T, Sato F, Sakurada M, Nishida K, Hayashi T, Morita Y, Okada H, Fukushima N, Yamada T, Tsujino M. A Clinical Case of Insulinoma Presenting with Postprandial Hypoglycemia in a Patient with a History of Gastric Bypass Surgery. Intern Med 2022; 61:1189-1195. [PMID: 34645754 PMCID: PMC9107972 DOI: 10.2169/internalmedicine.7428-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 08/23/2021] [Indexed: 11/06/2022] Open
Abstract
A 61-year-old man with a history of total gastrectomy for cancer with Roux-en-Y reconstruction showed severe postprandial hypoglycemia accompanied by endogenous hyperinsulinemia. Abdominal ultrasonography and contrast-enhanced computed tomography showed no abnormal findings in the pancreas. A selective arterial secretagogue injection test showed the marked induction of serum immunoreactive insulin when calcium was injected into the splenic artery. A pathological analysis following distal pancreatectomy with splenectomy revealed a pancreatic neuroendocrine microadenoma containing insulin-producing cells in the resected pancreas. This case highlights the importance of carefully evaluating refractory and severe hypoglycemia in patients with a history of gastric surgery to exclude insulinoma.
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Affiliation(s)
- Ryosuke Hayashida
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Tama Medical Center, Japan
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Japan
| | - Kyoichiro Tsuchiya
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Japan
| | - Tetsuo Sekine
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Japan
| | - Takashi Momose
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Tama Medical Center, Japan
| | - Fuminori Sato
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Tama Medical Center, Japan
| | - Maya Sakurada
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Tama Medical Center, Japan
| | - Kenji Nishida
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Tama Medical Center, Japan
| | - Tatsuya Hayashi
- Department of Gastrointestinal and General Surgery, Tokyo Metropolitan Tama Medical Center, Japan
| | - Yasuhiro Morita
- Department of Gastrointestinal and General Surgery, Tokyo Metropolitan Tama Medical Center, Japan
| | - Haruka Okada
- Department of Pathology, Tokyo Metropolitan Tama Medical Center, Japan
| | | | - Tetsuya Yamada
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Motoyoshi Tsujino
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Tama Medical Center, Japan
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Castillo-López MG, Fernandez MF, Sforza N, Barbás NC, Pattin F, Mendez G, Ogresta F, Gondolesi I, Barros Schelotto P, Musso C, Gondolesi GE. Hyperinsulinemic hypoglycemia in adolescents: case report and systematic review. Clin Diabetes Endocrinol 2022; 8:3. [PMID: 35296370 PMCID: PMC8925193 DOI: 10.1186/s40842-022-00138-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 02/14/2022] [Indexed: 11/26/2022] Open
Abstract
Background Hyperinsulinemic hypoglycemia is the most common cause of severe and persistent hypoglycemia in neonates and children. It is a heterogeneous condition with dysregulated insulin secretion, which persists in the presence of low blood glucose levels. Case presentation We report a case of a 15 year-old male with hyperinsulinemic hypoglycemia, who underwent a subtotal pancreatectomy after inadequate response to medical therapy. Pathological examination was positive for nesidioblastosis (diffuse β-cell hyperplasia by H-E and immunohistochemical techniques). The patient’s blood glucose levels normalized after surgery and he remains asymptomatic after 1 year of follow-up. The systematic review allowed us to identify 41 adolescents from a total of 205 cases reported in 22 manuscripts, from a total of 454 found in the original search done in PubMed and Lilacs. Conclusions Although very well reported in children, hyperinsulinemic hypoglycemia can occur in adolescents or young adults, as it happens in our reported case. These patients can be seen, treated and reported by pediatricians or adult teams either way due to the wide age range used to define adolescence. Most of them do not respond to medical treatment, and subtotal distal pancreatectomy has become the elected procedure with excellent long-term response in the vast majority.
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Affiliation(s)
- M G Castillo-López
- Diabetes Metabolic department, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - M F Fernandez
- General Surgery, Liver, Intestinal and Pancreas Transplant Services, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - N Sforza
- Diabetes Metabolic department, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - N C Barbás
- Anatomo pathology department, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - F Pattin
- General Surgery, Liver, Intestinal and Pancreas Transplant Services, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - G Mendez
- Oncology department Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - F Ogresta
- Imaxe Radiology Institute, Buenos Aires, Argentina
| | - I Gondolesi
- Medical Student, Facultad de Medicina, Universidad Favaloro, Buenos Aires, Argentina
| | - P Barros Schelotto
- General Surgery, Liver, Intestinal and Pancreas Transplant Services, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - C Musso
- Diabetes Metabolic department, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - G E Gondolesi
- General Surgery, Liver, Intestinal and Pancreas Transplant Services, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina. .,General Surgery Department, and Liver, Pancreas and Intestinal Transplant Units., University Hospital, Favaloro Foundation, Avenida Belgrano 1782, 7mo piso (1093), Buenos Aires, Argentina.
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14
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Doi S, Yamada T, Kito Y, Obara S, Fujii Y, Nishimura T, Kato T, Nakayama H, Tsutsumi M, Okamura R. Adult-Onset Focal Nesidioblastosis With Nodular Formation Mimicking Insulinoma. J Endocr Soc 2022; 6:bvab185. [PMID: 35024540 PMCID: PMC8743044 DOI: 10.1210/jendso/bvab185] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Indexed: 11/21/2022] Open
Abstract
Nesidioblastosis is defined as the neoformation of the islets of Langerhans from the pancreatic ductal epithelium and is recognized as the most common cause of hyperinsulinemic hypoglycemia in infants. We herein report an extremely rare case of adult-onset focal nesidioblastosis with the unusual feature of hyperplastic nodular formation. A 55-year-old woman was admitted to our hospital for a tumor detected in the body of the pancreas by magnetic resonance imaging screening. Laboratory examinations showed a high insulin level in the blood. Contrast-enhanced computed tomography and the selective arterial calcium injection test suggested the presence of multiple insulinomas in the body and tail of the pancreas, and, thus, the patient underwent distal pancreatectomy. A histopathological examination of the tumor in the body of the pancreas showed the nodular hyperplasia of islet-like cell clusters. In addition, many small intralobular ductules and islet cells appeared to be budding from the proliferating ductal epithelium, forming “ductuloinsular complexes”. No other abnormal lesion was detected in the remainder of the pancreas. The histopathological diagnosis was focal nesidioblastosis. The patient has remained free of the recurrence of hypoglycemic episodes for more than 31 months. The present case of rare adult-onset focal nesidioblastosis with hyperplastic nodular formation was preoperatively identified as an apparent pancreatic tumor mimicking insulinoma. Nesidioblastosis and insulinoma need to be considered in cases of hyperinsulinemic hypoglycemia, even in adult patients.
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Affiliation(s)
- Shunsuke Doi
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Takatsugu Yamada
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Yoshinori Kito
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Shinsaku Obara
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Yusuke Fujii
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Takao Nishimura
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Tatsushi Kato
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Hiroyuki Nakayama
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Masahiro Tsutsumi
- Department of Pathology, Saiseikai Chuwa Hospital, Nara 633-0054, Japan
| | - Ryuji Okamura
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
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15
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Chen J, Wang P, Lv K, Zhou W. Case report: composite pancreatic intraductal papillary mucinous neoplasm and neuroendocrine tumor: a new mixed neuroendocrine-non-neuroendocrine neoplasm? Diagn Pathol 2021; 16:108. [PMID: 34801052 PMCID: PMC8606070 DOI: 10.1186/s13000-021-01165-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN) of the pancreas are extremely rare. Their pathogenesis and molecular landscape are largely unknown. Here, we report a case of mixed pancreatic intraductal papillary mucinous neoplasm (IPMN) and well-differentiated neuroendocrine tumor (NET) and identify its genetic alterations by next-generation sequencing (NGS). CASE PRESENTATION A fifty-year-old male was admitted into the hospital for evaluation of a pancreatic lesion detected during a routine examination. Abdominal ultrasound indicated a hypoechoic mass of 2.6 cm at the head of the pancreas. Malignancy was suspected and partial pancreatectomy was performed. Thorough histopathological examination revealed a mixed IPMN-NET. In some areas, the two components were relatively separated, whereas in other areas IPMN and NET grew in a composite pattern: The papillae were lined with epithelial cells of IPMN, and there were clusters of NET nests in the stroma of papillary axis. NGS revealed shared somatic mutations (KRAS, PCK1, MLL3) in both components. The patient has been uneventful 21 months after the surgery. CONCLUSIONS Our case provides evidence of a common origin for mixed IPMN-NET with composite growth features. Our result and literature review indicate that KRAS mutation might be a driver event underlying the occurrence of MiNEN. We also recommend the inclusion of mixed non-invasive exocrine neoplasms and neuroendocrine neoplasms into MiNEN.
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Affiliation(s)
- Jingci Chen
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Pengyan Wang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ke Lv
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Weixun Zhou
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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16
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Spada F, Rossi RE, Kara E, Laffi A, Massironi S, Rubino M, Grimaldi F, Bhoori S, Fazio N. Carcinoid Syndrome and Hyperinsulinemic Hypoglycemia Associated with Neuroendocrine Neoplasms: A Critical Review on Clinical and Pharmacological Management. Pharmaceuticals (Basel) 2021; 14:ph14060539. [PMID: 34199977 PMCID: PMC8228616 DOI: 10.3390/ph14060539] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 02/05/2023] Open
Abstract
The carcinoid syndrome (CS) and hyperinsulinemic hypoglycemia (HH) represent two of the most common clinical syndromes associated with neuroendocrine neoplasms (NENs). The former is mainly related to the serotonin secretion by a small bowel NEN, whereas the latter depends on an insulin hypersecretion by a pancreatic insulinoma. Both syndromes/conditions can affect prognosis and quality of life of patients with NENs. They are often diagnosed late when patients become strongly symptomatic. Therefore, their early detection and management are a critical step in the clinical management of NEN patients. A dedicated and experienced multidisciplinary team with appropriate therapeutic strategies is needed and should be encouraged to optimize clinical outcomes. This review aims to critically analyze clinical features, evidence and treatment options of CS and HH and therefore to improve their management.
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Affiliation(s)
- Francesca Spada
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology (IEO) IRCCS, via G. Ripamonti 435, 20141 Milano, Italy; (F.S.); (A.L.); (M.R.)
| | - Roberta E. Rossi
- Hepatology and Hepato-Pancreatic-Biliary Surgery and Liver Transplantation, Fondazione IRCCS, Istituto Nazionale Tumori (INT), via G. Venezian 1, 20133 Milano, Italy; (R.E.R.); (S.B.)
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, via Festa del Perdono 7, 20122 Milano, Italy
| | - Elda Kara
- Endocrinology and Metabolism Unit, University Hospital S. Maria della Misericordia, Piazzale Santa Maria della Misericordia, 15, 33100 Udine, Italy; (E.K.); (F.G.)
| | - Alice Laffi
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology (IEO) IRCCS, via G. Ripamonti 435, 20141 Milano, Italy; (F.S.); (A.L.); (M.R.)
| | - Sara Massironi
- Division of Gastroenterology, San Gerardo Hospital, Bicocca School of Medicine, University of Milano Bicocca, 20126 Milano, Italy;
| | - Manila Rubino
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology (IEO) IRCCS, via G. Ripamonti 435, 20141 Milano, Italy; (F.S.); (A.L.); (M.R.)
| | - Franco Grimaldi
- Endocrinology and Metabolism Unit, University Hospital S. Maria della Misericordia, Piazzale Santa Maria della Misericordia, 15, 33100 Udine, Italy; (E.K.); (F.G.)
| | - Sherrie Bhoori
- Hepatology and Hepato-Pancreatic-Biliary Surgery and Liver Transplantation, Fondazione IRCCS, Istituto Nazionale Tumori (INT), via G. Venezian 1, 20133 Milano, Italy; (R.E.R.); (S.B.)
| | - Nicola Fazio
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology (IEO) IRCCS, via G. Ripamonti 435, 20141 Milano, Italy; (F.S.); (A.L.); (M.R.)
- Correspondence: ; Tel.: +39-025-748-9258
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17
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Luchini C, Pelosi G, Scarpa A, Mattiolo P, Marchiori D, Maragliano R, Sessa F, Uccella S. Neuroendocrine neoplasms of the biliary tree, liver and pancreas: a pathological approach. Pathologica 2021; 113:28-38. [PMID: 33686308 PMCID: PMC8138696 DOI: 10.32074/1591-951x-231] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 11/30/2020] [Indexed: 12/14/2022] Open
Abstract
Neuroendocrine neoplasms of the pancreatobiliary tract and liver are a heterogeneous group that encompass a spectrum of entities with distinct morphological, biological and clinical features. Although in the various anatomical sub-sites of this region they show specific characteristics, these tumors, as a whole, share several etiological and clinical aspects. This review systematically addresses NENs arising in the extrahepatic bile ducts, gallbladder, liver and pancreas, with the principal aim of pinpointing essential diagnostic and classification issues. In addition, the section on hepatic NENs has been expanded to include metastatic disease of unknown primary site.
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Affiliation(s)
- Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Italy
| | - Giuseppe Pelosi
- Department of Oncology and Hemato-Oncology, University of Milan, Italy.,Inter-Hospital Pathology Division, IRCCS MultiMedica, Milan, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Italy.,ARC-NET Research Centre, University of Verona, Italy
| | - Paola Mattiolo
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Italy
| | - Deborah Marchiori
- Department of Medicine and Surgery, Unit of Pathology, University of Insubria, Varese, Italy
| | - Roberta Maragliano
- Department of Medicine and Surgery, Unit of Pathology, University of Insubria, Varese, Italy
| | - Fausto Sessa
- Department of Medicine and Surgery, Unit of Pathology, University of Insubria, Varese, Italy
| | - Silvia Uccella
- Department of Medicine and Surgery, Unit of Pathology, University of Insubria, Varese, Italy
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18
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Pitfalls in the Detection of Insulinomas With Glucagon-Like Peptide-1 Receptor Imaging. Clin Nucl Med 2020; 45:e386-e392. [PMID: 32558709 DOI: 10.1097/rlu.0000000000003124] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Physiological pancreaticoduodenal uptake of radiolabeled exendin-4 in Brunner glands of the proximal duodenum is the most common pitfall for false interpretation of glucagon-like peptide-1 receptor (GLP-1R) imaging. The aim of this study was to analyze the pancreaticoduodenal uptake in GLP-1R PET/CT and SPECT/CT images and to identify additional potential reading pitfalls in patients with suspected insulinoma. METHODS A post hoc analysis of a prospective study, including 52 consecutive patients, was performed. All patients underwent 1 Ga-exendin-4 PET/CT and 2 In-exendin-4 SPECT/CT scans (4 and 72 hours postinjection) in a randomized crossover order. Three board-certified nuclear medicine physicians read all scans independently. They were unaware of other results. Reference standard was surgery with histopathological confirmation of an insulinoma/nesidioblastosis and normalization of blood glucose levels after surgery. RESULTS There were no false-positive readings. However, there were a number of false-negative PET/CT and SPECT/CT readings, respectively: (1) due to false interpretation of uptake in the pancreaticoduodenal region (falsely interpreted as physiological uptake in Brunner glands instead of an insulinoma in 0.6% vs 9.0%), (2) due to ectopic insulinoma (0% vs 2.6%), (3) due to small insulinoma (1.9% vs 5.1%), (4) due to insulinoma overlap with kidneys (1.9% vs 4.5%), and (5) due to nesidioblastosis (0.6% and 1.9%). Pitfalls were identified in all GLP-1R PET/CT and SPECT/CT scans. CONCLUSIONS Peripancreatic uptake, small size of an insulinoma, insulinoma overlap with kidneys, and presence of nesidioblastosis are potential pitfalls in GLP-1R imaging, which can lead to false reading results.
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19
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Lopes AA, Miranda AC, Maior MS, de Mello RV, Bandeira FA. Nesidioblastosis Associated with Pancreatic Heterotopia as a Differential Diagnosis of Hypoglycemia: A Literature Review and Case Report. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e922778. [PMID: 32624567 PMCID: PMC7360359 DOI: 10.12659/ajcr.922778] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patient: Male, 32-year-old Final Diagnosis: Nesidioblastosis Symptoms: Hypoglycemia Medication:— Clinical Procedure: Distal pancreatectomy • magnetic resonance image • selective arterial calcium stimulation test with hepatic venous sampling Specialty: Endocrinology and Metabolic
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Affiliation(s)
- Aline A Lopes
- Division of Endocrinology and Diabetes, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife, PE, Brazil
| | - Ana C Miranda
- Division of Endocrinology and Diabetes, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife, PE, Brazil
| | - Marcelo S Maior
- Department of Pathology, Federal University of Pernambuco, Recife, PE, Brazil
| | - Roberto V de Mello
- Department of Pathology, Federal University of Pernambuco, Recife, PE, Brazil
| | - Francisco A Bandeira
- Division of Endocrinology and Diabetes, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife, PE, Brazil
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20
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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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21
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Dardano A, Daniele G, Lupi R, Napoli N, Campani D, Boggi U, Del Prato S, Miccoli R. Nesidioblastosis and Insulinoma: A Rare Coexistence and a Therapeutic Challenge. Front Endocrinol (Lausanne) 2020; 11:10. [PMID: 32047477 PMCID: PMC6996476 DOI: 10.3389/fendo.2020.00010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/07/2020] [Indexed: 01/04/2023] Open
Abstract
Background: Nesidioblastosis and insulinoma are disorders of the endocrine pancreas causing endogenous hyperinsulinemic hypoglycemia. Their coexistence is very unusual and treatment represents a still unresolved dilemma. Case Description: The patient was a 43-year-old Caucasian woman, with a 2-year history of repeated severe hypoglycemic events. The diagnostic work-up was strongly suggestive of insulinoma and the patient was submitted to surgical treatment carried out laparoscopically under robotic assistance. However, surgical exploration and intraoperative ultrasonography failed to detect a pancreatic tumor. Resection was therefore carried out based on the results of selective intra-arterial calcium stimulation test, following a step-up approach, eventually leading to a pancreatoduodenectomy at the splenic artery. The histopathology examination and the immunohistochemical staining were consistent with adult-onset nesidioblastosis. After surgery, the patient continued to experience hypoglycemia with futile response to medical treatments (octreotide, calcium antagonists, diazoxide, and prednisone). Following multidisciplinary evaluation and critical review of a repeat abdominal computed tomography scan, a small nodular lesion was identified in the tail of the pancreas. The nodule was enucleated laparoscopically and the pathological examination revealed an insulinoma. In spite of the insulinoma resection, glycemic values were only partially restored, with residual nocturnal hypoglycemia. Administration of uncooked cornstarch (1.25 g/kg body weight) at bedtime was associated with significant improvement of interstitial glucose levels (p < 0.0001) and reduction of nocturnal hypoglycemia episodes (p = 0.0002). Conclusions: This report describes a rare coexistence of adult-onset nesidioblastosis and insulinoma, suggesting the existence of a wide and continuous spectrum of proliferative β-cell changes. Moreover, we propose that uncooked cornstarch may offer an additional approach to alleviate the hypoglycemic episodes when surgery is impracticable/unaccepted.
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Affiliation(s)
- Angela Dardano
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- *Correspondence: Angela Dardano
| | - Giuseppe Daniele
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto Lupi
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | | | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Stefano Del Prato
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto Miccoli
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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22
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Wong M, Conway L, Cooper C, Sinha A, Nandi N. NESIDIOBLASTOSIS IN AN ADULT WITH SHORT GUT SYNDROME AND TYPE 2 DIABETES. AACE Clin Case Rep 2019; 5:e375-e379. [PMID: 31967075 DOI: 10.4158/accr-2019-0243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 08/02/2019] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Adult nesidioblastosis is characterized by endogenous hyperinsulinemia typically causing post-prandial hypoglycemia, and most commonly occurs post-Roux-en-Y gastric bypass. METHODS We report a unique case of nesidioblastosis occurring in a 67-year-old female. RESULTS A 5-year history of symptomatic hypoglycemia occurred in a patient with short bowel syndrome and type 2 diabetes mellitus (T2DM) managed previously with a glucagon-like peptide 1 (GLP-1) agonist, which achieved significant weight loss. Continuous glucose monitoring captured 42 hypoglycemia episodes in a 2-week period, and following an oral glucose tolerance test there was the suggestion of a hyperinsulinemia state. She was managed with an open distal pancreatectomy, and subsequently required medical therapy to maintain euglycemia. CONCLUSION We present the first case of nesidioblastosis occurring in a patient with short bowel syndrome, pre-existing T2DM managed with a GLP-1 agonist which achieved significant weight loss, all of which we speculate could have predisposed to hypoglycemia and development of nesidioblastosis.
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Schovanek J, Cibickova L, Ctvrtlik F, Tudos Z, Karasek D, Iacobone M, Frysak Z. Hypoglycemia as a Symptom of Neoplastic Disease, with a focus on Insulin-like Growth Factors Producing Tumors. J Cancer 2019; 10:6475-6480. [PMID: 31777577 PMCID: PMC6856902 DOI: 10.7150/jca.30472] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 06/23/2019] [Indexed: 01/02/2023] Open
Abstract
This article reviews the current knowledge of uncommon causes of hypoglycemia, with a focus on neoplastic disease. However, these situations are rare. They commonly accompany severely ill patients and therefore a proper diagnosis is the basis for relevant treatment. Here we discuss the pathophysiological foundation of hypoglycemia - situations caused by increased insulin production or sensitivity - but we also focus on different cytokines which could cause hypoglycemia, especially IGF-II production in what are called nonislet cell tumors. From the clinical perspective we can divide the patients who are affected into "seemingly ill” or “healthy patients” and lead the diagnostic process accordingly.
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Affiliation(s)
- Jan Schovanek
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Lubica Cibickova
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Filip Ctvrtlik
- Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Zbynek Tudos
- Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - David Karasek
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Italy, Via Giustiniani 2, 35128 Padova, Italy
| | - Zdenek Frysak
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
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Abstract
Persistent hyperinsulinemic hypoglycemia in adults is most commonly caused by insulinomas, which pose a diagnostic challenge to physicians, surgeons, and radiologists and require multimodality imaging for precise localization and staging. PET tracers such as F-FDOPA and glucagon-like peptide 1 receptor analogs have been used for imaging insulinomas. Glucagon-like peptide 1 receptor analogs have recently shown promising results in preoperative localization of these tumors, as all insulinomas express glucagon-like peptide 1 receptors. Ga-DOTA-Exendin PET and MRI done in the present case helped in precise localization and management of the culprit lesion, whereas contrast-enhanced CT and F-FDOPA PET failed to do so.
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Orujov M, Lai KK, Forse CL. Concurrent Adult-Onset Diffuse β-Cell Nesidioblastosis and Pancreatic Neuroendocrine Tumor: A Case Report and Review of the Literature. Int J Surg Pathol 2019; 27:912-918. [PMID: 31244364 DOI: 10.1177/1066896919858129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Nesidioblastosis is an uncommon cause of organic persistent hyperinsulinemic hypoglycemia in adults. We report a case of adult-onset diffuse β-cell nesidioblastosis in a 49-year-old woman who was status-post Roux-en-Y gastric bypass and distal pancreatectomy for a well-differentiated pancreatic neuroendocrine tumor. While the neuroendocrine tumor was suspected to be an insulinoma, persistent hypoglycemia postoperatively suggested either incomplete resection or a second pancreatic neoplasm. Completion pancreatectomy revealed islet β-cell hyperplasia and nuclear pleomorphism consistent with β-cell nesidioblastosis. The patient's blood glucose levels normalized after completion pancreatectomy. While β-cell nesidioblastosis and insulinomas can coexist in the same patient, pathologists should be aware of β-cell nesidioblastosis as a potential cause for hyperinsulinemic hypoglycemia and should exclude it in patients who have not shown definitive clinical response after surgical excision of a pancreatic neuroendocrine tumor.
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Affiliation(s)
- Mushfig Orujov
- Cleveland Clinic, Cleveland, OH, USA.,Azerbaijan Medical University, Baku, Azerbaijan
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26
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Adult Nesidioblastosis in Chronic Kidney Disease. Case Rep Endocrinol 2019; 2019:7640384. [PMID: 30895162 PMCID: PMC6393863 DOI: 10.1155/2019/7640384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/18/2019] [Accepted: 02/05/2019] [Indexed: 11/24/2022] Open
Abstract
Context Nesidioblastosis is a rare cause of hyperinsulinemic hypoglycemia in adults. The diagnosis is further complicated in patients with kidney failure, since impaired renal function can cause hypoglycemia by itself and diagnostic criteria for this clinical scenario have not been developed yet. Case Description We present the case report of a 36-year-old patient with end stage chronic kidney disease who presented to the emergency department because of hypoglycemia. However, the patient's hypoglycemia did not respond well to medical treatment; the diagnosis of hyperinsulinemic hypoglycemia was made due to the presence of inappropriately high levels of insulin, proinsulin, and C-peptide during an episode of hypoglycemia. Imaging studies were performed without any conclusive findings; so selective intra-arterial pancreatic stimulation with hepatic venous sampling (SACTS) was done. Based on the results of this study the patient was referred for subtotal pancreatectomy. Classic criteria for the diagnosis of insulinoma with SACTS required a 2-fold increase in insulin levels but newer criteria suggest thresholds that are useful in the differential diagnosis of insulinoma and nesidioblastosis. In our patient, the former criteria were positive; however, the new criteria were not compatible with insulinoma but with nesidioblastosis, which was the final histopathological diagnosis. Conclusion This seems to be the first case report of a patient with end stage chronic kidney disease and nesidioblastosis, as well as the first case of hyperinsulinemic hypoglycemia in the context of kidney failure diagnosed by SACTS. We consider this method to be very useful in patients with renal impairment because peripancreatic insulin levels do not depend on the renal function.
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27
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Stamatiades GA, Echouffo-Tcheugui JB, Garber JR. Sulfasalazine-Induced Hypoglycemia in a Patient with Type 2 Diabetes and End-Stage Renal Disease. AACE Clin Case Rep 2018. [DOI: 10.4158/accr-2018-0067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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68Ga DOTA-Exendin PET/CT for Detection of Insulinoma in a Patient With Persistent Hyperinsulinemic Hypoglycemia. Clin Nucl Med 2018; 43:e285-e286. [PMID: 29877881 DOI: 10.1097/rlu.0000000000002155] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Insulinomas are the most common functioning pancreatic neuroendocrine tumors and the leading cause of persistent hypoglycemia with hyperinsulinemia in adults. Glucagon-like-peptide-1 (GLP) receptor analogs are the latest agents being used in the detection of insulinomas, with initial reports suggesting high sensitivity due to universal GLP1 receptor expression on these tumors. PET/CT imaging in this patient using Ga DOTA-Exendin, a GLP receptor analog, proved useful for accurate localization of the culprit lesion, aiding in the definitive management of the patient.
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29
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Polansky BJ, Martinez SA, Chalkley MD. Resolution of hyperinsulinemic hypoglycemia following partial pancreatectomy in a dog with nesidioblastosis. J Am Vet Med Assoc 2018; 253:893-896. [PMID: 30211650 DOI: 10.2460/javma.253.7.893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CASE DESCRIPTION A 6-year-old castrated male Australian Shepherd was evaluated because of a recent onset of persistent hypoglycemia. CLINICAL FINDINGS Physical examination results were generally unremarkable. No abnormalities were detected on thoracic radiographs, and abdominal ultrasonography revealed no obvious pancreatic lesion. Hematologic analysis revealed hypoglycemia with a high serum insulin-to-glucose concentration ratio. TREATMENT AND OUTCOME Insulinoma was suspected; medical treatment with prednisone was initiated, and exploratory laparotomy was performed. No pancreatic lesions or masses were observed. Partial left pancreatectomy and hepatic and local lymph node biopsies were performed. Histologic examination revealed islet cell hypertrophy and hyperplasia, with no evidence of neoplasia. Results of a PCR assay of the pancreatic tissue for Bartonella infection were negative. Clinical, biochemical, and histopathologic findings were compatible with nesidioblastosis. The clinical signs, including hypoglycemia, resolved after surgery. On follow-up examination 8 months later, the dog was apparently healthy and results of a CBC and serum biochemical analysis, including blood glucose concentration, were within respective reference ranges. CLINICAL RELEVANCE To our knowledge, this is the first report of nesidioblastosis in a dog for which clinical signs and clinicopathologic abnormalities resolved after partial pancreatectomy. Although extremely rare, nesidioblastosis should be considered a differential diagnosis in dogs with signs suggestive of insulinoma.
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Abstract
The pancreas is a complex organ that may give rise to large number of neoplasms and non-neoplastic lesions. This article focuses on benign neoplasms, such as serous neoplasms, and tumorlike (pseudotumoral) lesions that may be mistaken for neoplasm not only by clinicians and radiologists, but also by pathologists. The family of pancreatic pseudotumors, by a loosely defined conception of that term, includes a variety of lesions including heterotopia, hamartoma, and lipomatous pseudohypertrophy. Autoimmune pancreatitis and paraduodenal ("groove") pancreatitis may also lead to pseudotumor formation. Knowledge of these entities will help in making an accurate diagnosis.
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Affiliation(s)
- Olca Basturk
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Gokce Askan
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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31
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Hambrook LE, Ciavarella AA, Nimmo JS, Wayne J. Hyperinsulinaemic, hypoglycaemic syndrome due to acquired nesidioblastosis in a cat. JFMS Open Rep 2017; 2:2055116916657846. [PMID: 28491431 PMCID: PMC5362857 DOI: 10.1177/2055116916657846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2016] [Indexed: 11/16/2022] Open
Abstract
Case summary A 6-year-old, neutered female British Shorthair cat presented with acute-onset weakness and mental dullness. Initially the cat was mildly hyperglycaemic (9.9 mmol/l; reference interval [RI] 3.3-6.7 mmol/l). Over the following 12 h the cat developed central blindness, tremors, intermittent seizures and opisthotonus. Repeat blood sampling revealed a marked hypoglycaemia (0.8 mmol/l). Insulin level (performed on a serum sample collected while the cat was hypoglycaemic) was inappropriately elevated (1575 mIU/l; RI 10-80 mIU/l). An abdominal ultrasound was unremarkable. An exploratory laparotomy revealed a firm and erythematous left limb of the pancreas. Following surgical resection of the left limb of the pancreas, the cat returned to a euglycaemic state after a brief rebound hyperglycaemia. Histopathology revealed pancreatic fibrosis with marked multifocal micronodular hyperplasia of exocrine and endocrine cells. Synaptophysin immunohistochemistry confirmed nodular β-cell hyperplasia. Relevance and novel information Nesidioblastosis describes a syndrome of acquired hyperinsulinaemia and associated hypoglycaemia secondary to focal or diffuse (non-neoplastic) β-cell hyperplasia within the pancreas. Acquired nesidioblastosis has been reported in humans, where β-cell dysregulation is thought to occur in response to pancreatic injury. This is the first reported case of clinically significant hypoglycaemia due to acquired nesidioblastosis in an adult domestic cat. While this condition is rare, nesidioblastosis is being increasingly recognised in humans and it is an important differential diagnosis to consider when investigating hypoglycaemia as it cannot be distinguished from insulinoma without histopathological evaluation. While recurrence has been occasionally reported in humans, the prognosis is considered good.
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Affiliation(s)
- Lydia E Hambrook
- Small Animal Medicine Department, Advanced Vetcare, Melbourne, VIC, Australia
| | - Amanda A Ciavarella
- Small Animal Medicine Department, Advanced Vetcare, Melbourne, VIC, Australia
| | - Judith S Nimmo
- Australian Specialised Animal Pathology Laboratory, Melbourne, VIC, Australia
| | - Julie Wayne
- Australian Specialised Animal Pathology Laboratory, Melbourne, VIC, Australia
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Davi MV, Pia A, Guarnotta V, Pizza G, Colao A, Faggiano A. The treatment of hyperinsulinemic hypoglycaemia in adults: an update. J Endocrinol Invest 2017; 40:9-20. [PMID: 27624297 DOI: 10.1007/s40618-016-0536-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/17/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Treatment of hyperinsulinemic hypoglycaemia (HH) is challenging due to the rarity of this condition and the difficulty of differential diagnosis. The aim of this article is to give an overview of the recent literature on the management of adult HH. METHODS A search for reviews, original articles, original case reports between 1995 and 2016 in PubMed using the following keywords: hyperinsulinemic hypoglycaemia, insulinoma, nesidioblastosis, gastric bypass, autoimmune hypoglycaemia, hyperinsulinism, treatment was performed. RESULTS One hundred and forty articles were selected and analysed focusing on the most recent treatments of HH. CONCLUSIONS New approaches to treatment of HH are available including mini-invasive surgical techniques and alternative local-regional ablative therapy for benign insulinoma and everolimus for malignant insulinoma. A correct differential diagnosis is of paramount importance to avoid unnecessary surgical operations and to implement the appropriate treatment mainly in the uncommon forms of HH, such as nesidioblastosis and autoimmune hypoglycaemia.
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Affiliation(s)
- M V Davi
- Section of Endocrinology, Medicina Generale e Malattie Aterotrombotiche e Degenerative, Department of Medicine, University of Verona, Piazzale LA Scuro, Policlinico G.B. Rossi, 37134, Verona, Italy.
| | - A Pia
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - V Guarnotta
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - G Pizza
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Colao
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Faggiano
- Thyroid and Parathyroid Surgery Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione G. Pascale" IRCCS, Naples, Italy
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33
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Ma Z, Björklund A, Islam MS. A TRPM4 Inhibitor 9-Phenanthrol Inhibits Glucose- and Glucagon-Like Peptide 1-Induced Insulin Secretion from Rat Islets of Langerhans. J Diabetes Res 2017; 2017:5131785. [PMID: 29098165 PMCID: PMC5643033 DOI: 10.1155/2017/5131785] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/18/2017] [Accepted: 09/10/2017] [Indexed: 11/29/2022] Open
Abstract
Pancreatic β-cells express several ion channels of the transient receptor potential family, which play important roles in mediating the stimulus-secretion coupling. One of these channels, the TRPM4 is a Ca2+-activated monovalent cation channel. This channel is inhibited by 9-phenanthrol, which also inhibits the TMEM16a Cl- channel, and activates the Ca2+-activated K+ channel, Kca3.1. The net effects of ion-channel modulation by 9-phenantherol on the insulin secretion remain unclear. We tested the effects of 9-phenanthrol on glucose- and GLP-1-induced insulin secretion from isolated rat islets in static incubations. When applied to the islets in the presence of 3.3 mM glucose, 9-phenanthrol caused a small increase in insulin secretion (~7% of the insulin secretion stimulated by 10 mM glucose). 10 μM 9-phenanthrol did not inhibit glucose- or GLP-1-induced insulin secretion. 20 μM and 30 μM 9-phenanthrol inhibited glucose-induced insulin secretion by ~80% and ~85%, respectively. Inhibition of the GLP-1-induced insulin secretion by 20 μM and 30 μM 9-phenanthrol was 65% and 94%, respectively. Our study shows that the major effect of 9-phenanthrol on the islets is a strong inhibition of insulin secretion, and we speculate that compounds related to 9-phenanthrol may be potentially useful in treating the pancreatogenous hyperinsulinemic hypoglycemia syndromes.
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Affiliation(s)
- Zuheng Ma
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Anneli Björklund
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Md. Shahidul Islam
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Research Center, 3rd Floor, 118 83 Stockholm, Sweden
- Department of Emergency Care and Internal Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
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34
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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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35
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Agrawal T, Blau AJ, Chwals WJ, Tischler AS. A Unique Case of Mediastinal Teratoma with Mature Pancreatic Tissue, Nesidioblastosis, and Aberrant Islet Differentiation: a Case Report and Literature Review. Endocr Pathol 2016; 27:21-4. [PMID: 26318442 DOI: 10.1007/s12022-015-9393-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Mediastinal teratomas with elements of mature pancreatic tissue are rare. Only a very few cases of pancreatic tissue with nesidioblastosis in teratoma have been reported. Here, we report a case of a 12-year-old male who presented with pleural effusion and was revealed to have a large anterior mediastinal mass. Biopsy of the mass revealed benign mature teratoma. After biopsy, the teratoma ruptured into the right thoracic cavity. It was then excised and sent to pathology for further evaluation. Preoperatively, there was no evidence of hyperinsulinemia or hypoglycemia. Postoperatively, there was no change in blood glucose levels. Histologically, the mass showed large areas of mature pancreatic tissue flanking a small intestine-like structure. Numerous endocrine cell islets, poorly defined groups of neuroendocrine cells and ductular-insular complexes characteristic of nesidioblastosis were dispersed in the exocrine pancreatic parenchyma. In addition, other parts of the tumor containing keratinizing squamous epithelium with cutaneous adnexal glands, small intestine, and bronchus including cartilage and respiratory epithelium were observed. Some islets contained two or more cell types while others were monophenotypic. Immunohistochemical staining showed pronounced expression of pancreatic polypeptide, moderate expression of somatostatin and insulin and nearly complete absence of glucagon-containing cells. The selective deletion of glucagon might hold clues to an important regulatory mechanism in pancreatic development.
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Affiliation(s)
- Tanupriya Agrawal
- Departments of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA.
| | - Adam J Blau
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Walter J Chwals
- Department of Pediatric Surgery, Tufts Medical Center, Boston, MA, USA
| | - Arthur S Tischler
- Departments of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
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Prasad V, Sainz-Esteban A, Arsenic R, Plöckinger U, Denecke T, Pape UF, Pascher A, Kühnen P, Pavel M, Blankenstein O. Role of (68)Ga somatostatin receptor PET/CT in the detection of endogenous hyperinsulinaemic focus: an explorative study. Eur J Nucl Med Mol Imaging 2016; 43:1593-600. [PMID: 26923247 DOI: 10.1007/s00259-016-3331-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 02/07/2016] [Indexed: 01/29/2023]
Abstract
PURPOSE To explore the role of (68)Ga-DOTATATE/DOTATOC PET/CT (SR PET/CT) in patients with suspicion of or histopathologically proven pancreatogenic hyperinsulinaemic hypoglycaemia. METHODS We included 13 patients with histopathologically proven or a high clinical suspicion of pancreatogenic hyperinsulinaemia. All the patients underwent a SR PET/CT scan. The results were correlated with histopathological findings. Normalization of blood glucose levels after resection of the pancreatic lesion, as well as a cytological and/or pathological diagnosis of insulinoma, was considered the diagnostic gold standard for insulinoma. The diagnosis of nesidioblastosis was based on exclusion of an insulinoma and conclusive pathological examination of a segment of the pancreas. Malignant insulinoma was defined as the presence of locoregional or distant metastases. RESULTS Based on histopathology, 13 patients were found to have pancreatic hyperinsulinaemia: two patients had malignant insulinoma, eight had nonmetastasized insulinoma, and three had nesidioblastosis. SR PET was positive in 11 of the 13 patients (84.6 %) with a final diagnosis of endogenous pancreatic hypoglycaemia. Histopathological staining confirmed 16 foci of hyperinsulinism (insulin positivity). SR PET detected 14 of the 16 lesions, resulting in a sensitivity of 87 %. One intrapancreatic spleen was falsely diagnosed as insulinoma focus on SR PET, resulting in positive predictive value of 93.3 %. Immunohistochemical staining of somatostatin receptor (SSR) subtype 2a was available in ten specimens: two nesidioblastosis, and seven benign and one malignant insulinoma. Eight out of the ten specimens (80 %) stained strongly to moderately positive. Seven of the eight SSR2a-positive lesions were picked up on SR PET. Based on the results of SR PET/CT, nine patients achieved complete remission of the hypoglycaemic events during follow-up. CONCLUSION This explorative study suggests that SR PET in combination with CT may play a significant role in the detection and management of patients with pancreatogenic hyperinsulinaemic hypoglycaemia. A large proportion of insulinomas express SSR2a, and a larger study is needed to fully assess the diagnostic accuracy of SR PET in patients with insulinoma and nesidioblastosis compared with current localizing studies used in clinical practice.
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Affiliation(s)
- Vikas Prasad
- Department of Nuclear Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Aurora Sainz-Esteban
- Department of Nuclear Medicine, Hospital Clínico Universitario Valladolid, Valladolid, Spain
| | - Ruza Arsenic
- Institute of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ursula Plöckinger
- Interdisziplinären Stoffwechsel-Centrum, Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Timm Denecke
- Department of Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrich-Frank Pape
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Kühnen
- Institute for Experimental Paediatric Endocrinology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Marianne Pavel
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Oliver Blankenstein
- Institute for Experimental Paediatric Endocrinology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
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Synchronous Nesidioblastosis, Endocrine Microadenoma, and Intraductal Papillary Mucinous Neoplasia in a Man Presenting With Hyperinsulinemic Hypoglycemia. Pancreas 2016; 45:154-9. [PMID: 26658039 DOI: 10.1097/mpa.0000000000000430] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Herein, we report the first case of concomitant nesidioblastosis, pancreatic neuroendocrine tumor, and intraductal papillary mucinous neoplasia. The combination is significant as each of these pathological entities is independently very rare. The patient was a 33-year-old man who presented with symptomatic hyperinsulinemic hypoglycemia and no risk factors for pancreatic disease. Abdominal imaging showed an isolated 12 mm pancreatic lesion, whilst selective arterial calcium stimulation testing demonstrated multiple territories of insulin excess. He proceeded to subtotal pancreatectomy. Histopathology revealed an endocrine microadenoma, α and β cell nesidioblastosis, and multifocal intraductal papillary mucinous neoplasia. The endocrine microadenoma and nesidioblastosis stained for insulin, suggesting both likely contributed to hypoglycemia. Glucagon immunohistochemistry was also positive, though there were no clinical features of glucagon excess. Hypoglycemia resolved postoperatively. This case and other evidence from the literature suggest that hyperplasia and neoplasia may occur sequentially in the pancreas, and that endocrine and exocrine tumorigenesis may be linked in some individuals. Further study is required to identify a unifying mechanism, and to elucidate potential ramifications in the management of patients with pancreatic neoplasms.
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Qin H, Li Z, Qu L, Liu Y, Gao Y, Li F, Wang G. A rare case of focal nesidioblastosis causing adult-onset hypoglycemia. Exp Ther Med 2015; 10:723-726. [PMID: 26622382 DOI: 10.3892/etm.2015.2541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 05/01/2015] [Indexed: 11/05/2022] Open
Abstract
Nesidioblastosis is a major cause of persistent hyperinsulinemic hypoglycemia of infancy and is caused by hypertrophy of the pancreatic endocrine islands. The disease can be categorized histologically into diffuse and focal forms. The condition rarely occurs in adults and only one adult case of suspected, but not histologically confirmed, focal nesidioblastosis has been reported. The present study describes the case of a 62-year-old man suffering from symptomatic hypoglycemia for 3 years and exhibiting a nodule in the pancreatic tail. Pathological evaluation following surgical enucleation of the pancreatic body and tail revealed focal nesidioblastosis. The hypoglycemic symptoms of the patient disappeared postoperatively. To the best of our knowledge, this is the first histologically-confirmed case of focal adult nesidioblastosis, suggesting that the possibility of nesidioblastosis should be taken into account in adult patients with persistent hypoglycemia.
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Affiliation(s)
- Hanjiao Qin
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Zhuo Li
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Limei Qu
- Department of Pathology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yujia Liu
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Ying Gao
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Fei Li
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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Christ E, Wild D, Antwi K, Waser B, Fani M, Schwanda S, Heye T, Schmid C, Baer HU, Perren A, Reubi JC. Preoperative localization of adult nesidioblastosis using ⁶⁸Ga-DOTA-exendin-4-PET/CT. Endocrine 2015; 50:821-3. [PMID: 26001537 DOI: 10.1007/s12020-015-0633-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 05/13/2015] [Indexed: 01/04/2023]
Affiliation(s)
- Emanuel Christ
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital of Bern, Inselspital, Bern, Switzerland
| | - Damian Wild
- Clinic of Radiology and Nuclear Medicine, University of Basel Hospital, Basel, Switzerland
| | - Kwadwo Antwi
- Clinic of Radiology and Nuclear Medicine, University of Basel Hospital, Basel, Switzerland
| | - Beatrice Waser
- Division of Experimental Pathology, Department of Pathology, Institute of Pathology, University of Bern, 3010, Bern, Switzerland
| | - Melpomeni Fani
- Clinic of Radiology and Nuclear Medicine, University of Basel Hospital, Basel, Switzerland
| | - Stefanie Schwanda
- Department of Internal Medicine, Limmattalspital Schlieren, Schlieren, Switzerland
| | - Tobias Heye
- Clinic of Radiology and Nuclear Medicine, University of Basel Hospital, Basel, Switzerland
| | - Christoph Schmid
- Division of Endocrinology, Diabetology and Clinical Nutrition, University Hospital of Zürich, Zurich, Switzerland
| | - Hans Ulrich Baer
- Department of Visceral Surgery, Hirslanden Clinic, Zurich, Switzerland
| | - Aurel Perren
- Division of Experimental Pathology, Department of Pathology, Institute of Pathology, University of Bern, 3010, Bern, Switzerland
| | - Jean Claude Reubi
- Division of Experimental Pathology, Department of Pathology, Institute of Pathology, University of Bern, 3010, Bern, Switzerland.
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Abstract
BACKGROUND Nesidioblastosis is a rare cause of endocrine disease which represents between 0.5% - 5% of cases. This has been associated with other conditions, such as in patients previously treated with insulin or sulfonylurea, in anti-tumour activity in pancreatic tissue of patients with insulinoma, and in patients with other tumours of the Langerhans islet cells. In adults it is presented as a diffuse dysfunction of β cells of unknown cause. CLINICAL CASE The case concerns 46 year-old female, with a history of Sheehan syndrome of fifteen years of onset, and with repeated events characterized with hypoglycaemia in the last three years. Body scan was performed with octreotide, revealing an insulinoma in the pancreatic region. A distal pancreatectomy was performed on the patient. The study reported a pancreatic fragment 8.5 × 3 × 1.5 cm with abnormal proliferation of pancreatic islets in groups of varying size, some of them in relation to the ductal epithelium. Histopathology study was showed positive for chromogranin, confirmed by positive synaptophysin, insulin and glucagon, revealing islet hyperplasia with diffuse nesidioblastosis with negative malignancy. The patient is currently under metabolic control and with no remission of hypoglycaemic events. CONCLUSIONS Nesidioblastosis is a disease of difficult diagnosis should be considered in all cases of failure to locate an insulinoma, as this may be presented in up to 4% of persistent hyperinsulinaemic hypoglycaemia.
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Total pancreatectomy for the management of refractory post-gastric bypass hypoglycemia. Dig Dis Sci 2015; 60:1505-9. [PMID: 25344909 DOI: 10.1007/s10620-014-3408-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 10/15/2014] [Indexed: 12/19/2022]
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Woo CY, Jeong JY, Jang JE, Leem J, Jung CH, Koh EH, Lee WJ, Kim MS, Park JY, Lee JB, Lee KU. Clinical features and causes of endogenous hyperinsulinemic hypoglycemia in Korea. Diabetes Metab J 2015; 39:126-31. [PMID: 25922806 PMCID: PMC4411543 DOI: 10.4093/dmj.2015.39.2.126] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 07/24/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Endogenous hyperinsulinemic hypoglycemia (EHH) is characterized by an inappropriately high plasma insulin level, despite a low plasma glucose level. Most of the EHH cases are caused by insulinoma, whereas nesidioblastosis and insulin autoimmune syndrome (IAS) are relatively rare. METHODS To evaluate the relative frequencies of various causes of EHH in Korea, we retrospectively analyzed 84 patients who were diagnosed with EHH from 1998 to 2012 in a university hospital. RESULTS Among the 84 EHH patients, 74 patients (88%), five (6%), and five (6%) were diagnosed with insulinoma, nesidioblastosis or IAS, respectively. The most common clinical manifestation of EHH was neuroglycopenic symptoms. Symptom duration before diagnosis was 14.5 months (range, 1 to 120 months) for insulinoma, 1.0 months (range, 6 days to 7 months) for nesidioblastosis, and 2.0 months (range, 1 to 12 months) for IAS. One patient, who was diagnosed with nesidioblastosis in 2006, underwent distal pancreatectomy but was later determined to be positive for insulin autoantibodies. Except for one patient who was diagnosed in 2007, the remaining three patients with nesidioblastosis demonstrated severe hyperinsulinemia (157 to 2,719 µIU/mL), which suggests that these patients might have had IAS, rather than nesidioblastosis. CONCLUSION The results of this study suggest that the prevalence of IAS may be higher in Korea than previously thought. Therefore, measurement of insulin autoantibody levels is warranted for EHH patients, especially in patients with very high plasma insulin levels.
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Affiliation(s)
- Chang-Yun Woo
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yun Jeong
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Eun Jang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jaechan Leem
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Hee Jung
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Hee Koh
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo Je Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Seon Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Joong-Yeol Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Bok Lee
- Department of Statistics, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Up Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
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Imamura M, Nakamoto Y, Uose S, Komoto I, Awane M, Taki Y. Diagnosis of functioning pancreaticoduodenal neuroendocrine tumors. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:602-9. [PMID: 25624017 DOI: 10.1002/jhbp.209] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 12/11/2014] [Indexed: 12/15/2022]
Abstract
Functioning pancreaticoduodenal neuroendocrine tumors (PD-NETs) are popular in a textbook, but they are still unfamiliar to a general clinician, and delay of diagnosis or misdiagnosis has been reported even today. It is a consensus that sporadic functioning PD-NET is cured only by surgical resection. So, early detection and early resection is the gold standard for the treatment of functioning PD-NET. Functioning PD-NETs in patients with multiple endocrine neoplasia type 1 (MEN 1) are often multiple. You should check about MEN 1 whenever you encountered multiple PD-NET. They are diagnosed in younger age than sporadic cases. In most cases they are accompanied with numerous microscopic or macroscopic nonfunctioning P-NETs, which are potentially metastatic and the most common cause of death in MEN 1 patients.
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Affiliation(s)
- Masayuki Imamura
- Neuroendocrine Tumor Center, Kansai Electric Power Hospital, 2-1-7 Fukushima, Fukushima, Osaka, 553-0003, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Suguru Uose
- Department of Gastroenterology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Izumi Komoto
- Neuroendocrine Tumor Center, Kansai Electric Power Hospital, 2-1-7 Fukushima, Fukushima, Osaka, 553-0003, Japan.,Department of Surgery, Kansai Electric Power Hospital, Fukushima, Osaka, Japan
| | - Masaaki Awane
- Department of Surgery, Kansai Electric Power Hospital, Fukushima, Osaka, Japan
| | - Yoshiro Taki
- Department of Surgery, Kansai Electric Power Hospital, Fukushima, Osaka, Japan
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Kriger AG, Smirnov AV, Kalinin DV, Glotov AV, Berelavichus SV, Konyaeva GI, Lebedeva AN, Karel'skaya NA, Tsygankov VN. [Nesidioblastosis (diagnosis, surgical treatment)]. Khirurgiia (Mosk) 2015:16-29. [PMID: 26978464 DOI: 10.17116/hirurgia20151016-29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Nesidioblastosis (NB) is rare disease with organic hyperinsulinism syndrome and caused by diffuse hyperplasia and/or hypertrophy of pancreatic islands of Langerhans. MATERIAL AND METHODS The results of surgical treatment of 3 patients with NB are presented. In all patients the diagnosis was suspected at the preoperative stage and confirmed by histological examination later. Herewith in 2 patients NB was combined with insulinoma. All patients underwent corpora-caudal pancreatectomy. RESULTS In postoperative period one patient hadn't episodes of hypoglycemia for the entire follow-up period (5 months), in another patient hypoglycemic states occurred at 1.5 months after surgery. The third patient required pancreatic head extirpation at 11 days after surgery due to persistent severe course of organic hyperinsulinism. In immediate postoperative period in the same patient hyperinsular hypoglycemia was observed that pointed on extrapancreatic source of insulin secretion. However contrast-enhanced CT did not reveal any formations. CONCLUSION Thus, corpora-caudal pancreatectomy is preferable as surgical treatment. Results of surgical management can provide a complete regression of the symptoms, but do not guarantee absence of recurrence and even any changes in frequency and severity of hypoglycemic states.
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Affiliation(s)
- A G Kriger
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - A V Smirnov
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - D V Kalinin
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - A V Glotov
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - S V Berelavichus
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | | | - A N Lebedeva
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - N A Karel'skaya
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - V N Tsygankov
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
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Abstract
Pancreatic neuroendocrine neoplasms (Pan-NENs) are rare but clinically important lesions. Pan-NENs are known for and often categorized by their capacity to produce clinical syndromes mediated by the production of hormones. Despite sometimes presenting dramatically from excessive hormone production, not all Pan-NENs produce functional hormone, and they can pose diagnostic challenges to practicing pathologists. Distinguishing Pan-NENs from mimics can be crucial, because Pan-NENs carry different prognoses and have unique treatments available due to their specific biological properties. This article reviews the current categorization and features of Pan-NENs.
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Affiliation(s)
- J N Rosenbaum
- Department of Surgical Pathology, University of Wisconsin Hospital and Clinics, Room A4/204-3224, 600 Highland Ave., Madison, WI 53792-3224, USA
| | - Ricardo Vincent Lloyd
- Department of Surgical Pathology, University of Wisconsin Hospital and Clinics, Room A4/204-3224, 600 Highland Ave., Madison, WI 53792-3224, USA.
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Lin CL, Williams L, Seki Y, Kaur H, Hartil K, Fiallo A, Glenn AS, Katz EB, Charron MJ, Vuguin PM. Effects of genetics and in utero diet on murine pancreatic development. J Endocrinol 2014; 222:217-27. [PMID: 24895417 PMCID: PMC4287255 DOI: 10.1530/joe-14-0114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intrauterine (IU) malnutrition could alter pancreatic development. In this study, we describe the effects of high-fat diet (HFD) during pregnancy on fetal growth and pancreatic morphology in an 'at risk' animal model of metabolic disease, the glucose transporter 4 (GLUT4) heterozygous mouse (G4+/-). WT female mice mated with G4+/- males were fed HFD or control diet (CD) for 2 weeks before mating and throughout pregnancy. At embryonic day 18.5, fetuses were killed and pancreata isolated for analysis of morphology and expression of genes involved in insulin (INS) cell development, proliferation, apoptosis, glucose transport and function. Compared with WT CD, WT HFD fetal pancreata had a 2.4-fold increase in the number of glucagon (GLU) cells (P=0.023). HFD also increased GLU cell size by 18% in WT pancreata compared with WT CD. Compared with WT CD, G4+/- CD had an increased number of INS cells and decreased INS and GLU cell size. Compared with G4+/- CD, G4+/- HFD fetuses had increased pancreatic gene expression of Igf2, a mitogen and inhibitor of apoptosis. The expression of genes involved in proliferation, apoptosis, glucose transport, and INS secretion was not altered in WT HFD compared with G4+/- HFD pancreata. In contrast to WT HFD pancreata, HFD exposure did not alter pancreatic islet morphology in fetuses with GLUT4 haploinsufficiency; this may be mediated in part by increased Igf2 expression. Thus, interactions between IU diet and fetal genetics may play a critical role in the developmental origins of health and disease.
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Affiliation(s)
- Chia-Lei Lin
- Departments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USA
| | - Lyda Williams
- Departments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USA
| | - Yoshinori Seki
- Departments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USA
| | - Harpreet Kaur
- Departments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USADepartments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USADepartments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USA
| | - Kirsten Hartil
- Departments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USA
| | - Ariana Fiallo
- Departments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USA
| | - A Scott Glenn
- Departments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USA
| | - Ellen B Katz
- Departments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USA
| | - Maureen J Charron
- Departments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USADepartments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USADepartments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USA
| | - Patricia M Vuguin
- Departments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USADepartments of PediatricsNeonatologyBiochemistryObstetrics and Gynecology and Women's HealthMedicineAlbert Einstein College of Medicine, 1300 Morris Park Avenue, F312, Bronx, New York 10461, USADepartment of PediatricsHofstra School of Medicine, Cohen Children's Medical Center, 1991 Marcus Avenue, Lake Success, New York 11402, USA
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Martens P, Tits J. Approach to the patient with spontaneous hypoglycemia. Eur J Intern Med 2014; 25:415-21. [PMID: 24641805 DOI: 10.1016/j.ejim.2014.02.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 02/27/2014] [Accepted: 02/28/2014] [Indexed: 12/18/2022]
Abstract
UNLABELLED Hypoglycemia is common in daily clinical practice and often occurs during the treatment of diabetes mellitus. However, a small minority of hypoglycemia encountered in clinical practice is spontaneous and thus not induced by glycemic lowering agents. These spontaneous hypoglycemic events confront the clinician with a diagnostic enigma. Although the trained clinician can recognize the autonomic and neuroglycopenic symptoms of hypoglycemia even in a patient not on insulin, it remains challenging to decipher the etiology of a spontaneous hypoglycemic event. A logical and stepwise approach to the spontaneous hypoglycemic event allows for a conclusive diagnosis. This diagnostic process consists of adequately diagnosing hypoglycemia by fulfilling Whipple's triad, stratifying patients according to their clinical status and analyzing a full hypoglycemic blood panel. A complete hypoglycemic blood panel should include the analysis of glucose, insulin, C-peptide, pro-insulin, insulin antibodies and the presence of oral hypoglycemic agents. For patients with episodes of hypoglycemia induced by excessive endogenous insulin, additional imaging is often required to detect the presence of an underlying insulinoma. By diagnosing the underlying cause of the spontaneous hypoglycemia, the physician also diagnosis the mechanism by which the hypoglycemic event occurs. Allowing for a problem orientated therapeutic approach. METHODOLOGY The present review is based upon a comprehensive PubMed search between 1985 and 2013. This uses search terms of spontaneous hypoglycemia, insulinoma, nesidioblastosis, insulin auto-immunity, noninsulinoma pancreatogenous hypoglycemia syndrome, hormone deficiency, pro-IGF II, and pro-insulin growth factor II, and cross reference searching of pivotal articles in the subject.
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Affiliation(s)
- Pieter Martens
- Department of Internal Medicine, University Hospital Gasthuisberg Leuven, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Jos Tits
- Department of Endocrinology, Hospital Ziekenhuis Oost-Limburg ZOL, Genk, Belgium
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de Santibañes M, Cristiano A, Mazza O, Grossenbacher L, de Santibañes E, Sánchez Clariá R, Sivori E, García Mónaco R, Pekolj J. Endogenous hyperinsulinemic hypoglycemia syndrome: surgical treatment. Cir Esp 2014; 92:547-52. [PMID: 24491350 DOI: 10.1016/j.ciresp.2013.04.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 04/15/2013] [Accepted: 04/28/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND The endogenous hyperinsulinemic hypoglicemia syndrome (EHHS) can be caused by an insulinoma, or less frequently, by nesidioblastosis in the pediatric population, also known as non insulinoma pancreatic hypoglycemic syndrome (NIPHS) in adults. The aim of this paper is to show the strategy for the surgical treatment of ehhs. MATERIAL AND METHODS A total of 19 patients with a final diagnosis of insulinoma or NIPHS who were treated surgically from january 2007 until june 2012 were included. We describe the clinical presentation and preoperative work-up. Emphasis is placed on the surgical technique, complications and long-term follow-up. RESULTS All patients had a positive fasting plasma glucose test. Preoperative localization of the lesions was possible in 89.4% of cases. The most frequent surgery was distal pancreatectomy with spleen preservation (9 cases). Three patients with insulinoma presented with synchronous metastases, which were treated with simultaneous surgery. There was no perioperative mortality and morbidity was 52.6%. Histological analysis revealed that 13 patients (68.4%) had benign insulinoma, 3 malignant insulinoma with liver metastases and 3 with a final diagnosis of SHPNI. Median follow-up was 20 months. All patients diagnosed with benign insulinoma or NIPHS had symptom resolution. CONCLUSION The surgical treatment of EHHS achieves excellent long-term results in the control of hypoglucemic symptoms.
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Affiliation(s)
- Martín de Santibañes
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina.
| | - Agustín Cristiano
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina
| | - Oscar Mazza
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina
| | - Luis Grossenbacher
- Sector de Endocrinología, Departamento de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina
| | - Rodrigo Sánchez Clariá
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina
| | - Enrique Sivori
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina
| | - Ricardo García Mónaco
- Sector de Angiografía y Radiología Intervencionista, Departamento de Diagnóstico por Imágenes, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Pekolj
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina
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Mala T. Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgical treatment. Surg Obes Relat Dis 2014; 10:1220-5. [PMID: 25002326 DOI: 10.1016/j.soard.2014.01.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 01/09/2014] [Accepted: 01/14/2014] [Indexed: 12/15/2022]
Abstract
An association between post-Roux-en-Y gastric bypass (RYGB) hypoglycemia and nesidioblastosis was reported in 2005 and may cause serious neuroglycopenic symptoms. Most patients with postprandial hypoglycemia after RYGB respond to nutritional and medical treatment. A subset of patients, however, may not respond adequately and surgery may be considered. This review describes the current experience with surgical intervention for severe post-RYGB hypoglycemia. PubMed and MEDLINE searches were made for reports describing clinical outcome after such surgery. Fourteen papers including 75 patients were identified. Different surgical interventions were applied including gastric tube placement, reversal of the bypass with and without concomitant sleeve resection, gastric pouch restriction, and pancreatic resection and reresection. Pancreatic resection was performed in 51 (68%) patients, 17 (23%) had RYGB reversal and eleven (15%) had gastric pouch restriction alone. Eight (11%) patients received 2 or more consecutive procedures for hypoglycemia and combined interventions were made in several patients. Resolution of the symptoms occurred in 34/51 (67%) patients after pancreatic resection, 13/17 (76%) after reversal, and 9/11 (82%) after pouch restriction. Mean follow up, however, was short for most series and the methods applied for evaluation of hypoglycemia varied. Weight regain, diabetes and recurrent symptoms were late complications. The optimal therapy for hypoglycemia after RYGB is not defined. Long-term evaluations and knowledge about the physiology of post-RYGB hypoglycemia, may enable therapy with improved control of the glucose excursions.
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Affiliation(s)
- Tom Mala
- Department of Morbid Obesity and Bariatric Surgery/Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.
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García-Santos EP, Manzanares-Campillo MDC, Padilla-Valverde D, Villarejo-Campos P, Gil-Rendo A, Muñoz-Atienza V, Sánchez-García S, Puig-Rullán AM, Rodríguez-Peralto JL, Martín-Fernández J. Nesidioblastosis. A case of hyperplasia of the islets of Langerhans in the adult. Pancreatology 2013; 13:544-8. [PMID: 24075522 DOI: 10.1016/j.pan.2013.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 06/02/2013] [Accepted: 06/27/2013] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Nesidioblastosis is a rare disease caused by hyperplasia of pancreatic islets, developing a state of hypoglycemia due to an increase in the insulin production. It is the leading cause of hyperinsulinic hypoglycemia in childhood, whereas in adults it only represents the 0.5-5% of cases. The pathogenesis is still unknown. We have studied several genetic mutations associated with dependent potassium channel of ATP present in the beta cells of the pancreas, as well as in patients underwent bariatric surgery because of the metabolic changes involved. REPORT Woman (38 years old) attends consultation of General Surgery derived from Endocrinology before symptoms of persistent hypoglycemia. Factitious hypoglycemia and syndromes of neuroendocrine origin were ruled out. Imaging tests failed to identify space-occupying lesions. The medical treatment failed, persisting hypoglycemia symptoms. Before the given analytical and radiological findings obtained, and the persistence of symptoms affecting the quality of life of the patient, we opted for surgical treatment performing a pancreatectomy of the 80% of the gland. The final pathologic diagnosis was nesidioblastosis. DISCUSSION Nesidioblastosis is a rare pathology, but it must be present in the differential diagnosis of hypoglycemia symptoms with endogenous hyperinsulinism in adults, once the intake of sulfonylureas and possible pancreatic neoformations have been ruled out.
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Affiliation(s)
- Esther Pilar García-Santos
- Servicio de Cirugía General y de Aparato Digestivo, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain.
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