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Yoshioka K, Nakano Y, Horichi M, Aono D, Takeshita Y, Takamura T. Metastatic Pheochromocytoma/Paraganglioma Overproducing Multiple Catecholamines. JCEM CASE REPORTS 2025; 3:luae241. [PMID: 39726667 PMCID: PMC11669864 DOI: 10.1210/jcemcr/luae241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Indexed: 12/28/2024]
Abstract
Pheochromocytoma and paraganglioma (PPGL) are rare chromaffin-cell tumors producing adrenaline and/or noradrenaline, or solely dopamine. A 52-year-old man presenting with hypertension (141/79 mm Hg) and weight loss (10 kg in 6 months) was admitted to our hospital. Computed tomography revealed a massive right adrenal mass (150 mm) with partial necrosis, accompanied by multiple liver nodules. These nodules showed a high signal intensity on T2-weighted magnetic resonance imaging. Subsequently, a diagnosis of PPGL was made based on elevated urinary excretion of adrenaline (355 µg/day [1937 nmol/day]; normal range: 3.4-26.9 µg/day; 18-146 nmol/day), noradrenaline (1690 µg/day [9989 nmol/day]; normal range: 48.6-168.4 µg/day; 287-995 nmol/day), and dopamine (53 000 µg/day [258 322 nmol/day]; normal range: 365-961.5 µg/day; 1779-4686 nmol/day). The 123I-metaiodobenzylguanidine scintigraphy and fluorodeoxyglucose positron emission tomography scan showed heterogenous uptake among the adrenal and the liver foci, respectively. Clustering analysis of previous PPGL cases highlighted the unique catecholamine profile of this case. These findings suggest a possibility that internodular heterogeneity between primary and metastatic foci on nuclear imaging may indicate varying differentiation grades and resultant catecholamine secretion. Further studies will be needed to verify these results and confirm this hypothesis.
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Affiliation(s)
- Keiko Yoshioka
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Kanazawa University, Kanazawa, 920-8641, Ishikawa, Japan
| | - Yujiro Nakano
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Kanazawa University, Kanazawa, 920-8641, Ishikawa, Japan
| | - Moeka Horichi
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Kanazawa University, Kanazawa, 920-8641, Ishikawa, Japan
| | - Daisuke Aono
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Kanazawa University, Kanazawa, 920-8641, Ishikawa, Japan
| | - Yumie Takeshita
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Kanazawa University, Kanazawa, 920-8641, Ishikawa, Japan
| | - Toshinari Takamura
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Kanazawa University, Kanazawa, 920-8641, Ishikawa, Japan
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2
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Sato H, Fujii S, Okada T, Kawabata H, Kamikokura Y, Fujiya M. Small Insulinoma Followed-up as an Indolent Pancreatic Tumor. Intern Med 2024; 63:2929-2937. [PMID: 38432990 PMCID: PMC11604390 DOI: 10.2169/internalmedicine.3194-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/21/2024] [Indexed: 03/05/2024] Open
Abstract
A woman in her 60s presented with a small pancreatic head tumor. Imaging studies revealed a 13-mm well-defined pancreatic head tumor. A neuroendocrine neoplasm was suspected, and the patient opted for observation at that time. After 8 months, the patient began experiencing sweating while fasting, and blood tests during regular follow-up visits showed hypoglycemia. Hypoglycemia was induced during fasting test. The tumor exhibited clear features of an insulinoma during follow-up observation. While small neuroendocrine neoplasms are often managed through observation, caution should be exercised regarding their transformation into functional neuroendocrine tumors.
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Affiliation(s)
- Hiroki Sato
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Japan
| | - Shozaburo Fujii
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Japan
| | - Tetsuhiro Okada
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Japan
| | - Hidemasa Kawabata
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Japan
| | - Yuki Kamikokura
- Department of Diagnostic Pathology, Asahikawa Medical University Hospital, Japan
| | - Mikihiro Fujiya
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Japan
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3
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Tarris G, Rouland A, Guillen K, Loffroy R, Lariotte AC, Rat P, Bouillet B, Andrianiaina H, Petit JM, Martin L. Case Report: Giant insulinoma, a very rare tumor causing hypoglycemia. Front Endocrinol (Lausanne) 2023; 14:1125772. [PMID: 37234805 PMCID: PMC10206132 DOI: 10.3389/fendo.2023.1125772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/17/2023] [Indexed: 05/28/2023] Open
Abstract
Insulinomas, with an incidence of 4 cases per million individuals per year, remain amongst the most frequent functional neuroendocrine tumors. The usual diameter of insulinomas usually remains under 3 cm of major axis. However, 44 exceptional cases of "giant insulinomas", have been reported worldwide, generally exceeding 9 cm in major axis. In this article, we report the case of a 38-year-old woman whom suffered from chronic hypoglycemia despite treatment with diazoxide. Abdominal CT-scan revealed a 88 x 73 mm mass located at the tail of the pancreas. Following surgical excision, histopathological analysis confirmed G1 neuroendocrine tumor, with focal cytoplasmic expression of insulin in tumor cells. After a 16-month follow-up period, the patient didn't address any specific complaint, and no disease recurrence and/or metastasis were observed. A 68Ga-DOTATATE-PET scan was performed 6 months after surgery, which came back normal. Genetic evaluation has not been performed in our patient. The physiopathology of giant insulinomas remain unexplained, however with possible relationship with type 1 multiple endocrine neoplasia, sporadic somatic YY1 mutations and possible transformation of bulky non-functional pancreatic neuroendocrine tumors to a functional phenotype, with slow insulin secretion. While giant insulinomas remain rare in the literature, multicentric genetic analysis of tumor samples might reveal unique features of this rare subtype of neuroendocrine pancreatic tumors. Insulinomas of large size tend to have greater malignancy and higher rates of invasiveness. Careful follow-up, especially for liver and lymph node metastases, must be performed using functional imaging techniques to avoid disease relapse.
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Affiliation(s)
- Georges Tarris
- Department of Pathology, University Hospital of Dijon, Dijon, France
| | - Alexia Rouland
- Department of Endocrinology and Diabetology, University Hospital of Dijon, Dijon, France
| | - Kévin Guillen
- Department of Radiology, University Hospital of Dijon, Dijon, France
| | - Romaric Loffroy
- Department of Radiology, University Hospital of Dijon, Dijon, France
| | | | - Patrick Rat
- Department of Digestive and Bariatric Surgery, University Hospital of Dijon, Dijon, France
| | - Benjamin Bouillet
- Department of Endocrinology and Diabetology, University Hospital of Dijon, Dijon, France
| | | | - Jean-Michel Petit
- Department of Endocrinology and Diabetology, University Hospital of Dijon, Dijon, France
| | - Laurent Martin
- Department of Pathology, University Hospital of Dijon, Dijon, France
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4
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Chatterjee R, Ali B, Nguyen SH, Chen R, Sada YH. Malignant Insulinoma Arising From Nonfunctioning Pancreatic Neuroendocrine Tumor. ACG Case Rep J 2023; 10:e00954. [PMID: 38445216 PMCID: PMC10914231 DOI: 10.14309/crj.0000000000000954] [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: 07/31/2022] [Accepted: 12/09/2022] [Indexed: 03/07/2024] Open
Abstract
Pancreatic neuroendocrine tumors are rare neoplasms characterized into nonfunctioning (NF-PNET) and functioning (F-PNET) subtypes. F-PNETs typically involve overt symptoms related to excessive hormone secretion but may rarely present first as NF-PNETs with delayed transformation. We present a patient with known NF-PNET with liver metastases who developed hypoglycemia 2 years after initial diagnosis due to malignant insulinoma. Hypoglycemia was refractory to continuous dextrose but improved temporarily after diazoxide and hepatic artery embolization. Malignant insulinomas are usually metastatic at presentation and portend poor prognosis. Hypoglycemia may be medically managed with steroids, somatostatin analogues, and diazoxide, along with therapies to reduce tumor burden.
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Affiliation(s)
- Ritodhi Chatterjee
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX
| | - Basim Ali
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX
| | - Son H. Nguyen
- Section of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, Baylor College of Medicine, Houston, TX
| | - Rui Chen
- Section of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, Baylor College of Medicine, Houston, TX
| | - Yvonne H. Sada
- Section of Hematology and Oncology, Department of Internal Medicine, Baylor College of Medicine, Houston, TX
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5
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Mowrey K, Northrup H, Rougeau P, Hashmi SS, Krueger DA, Ebrahimi-Fakhari D, Towbin AJ, Trout AT, Capal JK, Franz DN, Rodriguez-Buritica D. Frequency, Progression, and Current Management: Report of 16 New Cases of Nonfunctional Pancreatic Neuroendocrine Tumors in Tuberous Sclerosis Complex and Comparison With Previous Reports. Front Neurol 2021; 12:627672. [PMID: 33897589 PMCID: PMC8062856 DOI: 10.3389/fneur.2021.627672] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/15/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Tuberous sclerosis complex (TSC) is a genetic condition that causes benign tumors to grow in multiple organ systems. Nonfunctional pancreatic neuroendocrine tumors (PNETs) are a rare clinical feature of TSC with no specific guidelines outlined for clinical management at this time. Our purpose is to calculate the frequency of nonfunctional PNETs as well as characterize the presentation, current clinical management, and assess the impact of systemic mammalian target of rapamycin (mTOR) on nonfunctional PNETs in TSC. Methods: This retrospective chart review was performed by a query of the TS Alliance's Natural History Database and the Cincinnati Children's Hospital TSC Database for patients with nonfunctional PNET. Clinical data from these two groups was summarized for patients identified to have a nonfunctional PNET and compared to previously reported cases with TSC and nonfunctional PNETs. Results: Our calculated frequency of nonfunctional PNETs is 0.65%. We identified 16 individuals, nine males and seven females, with a median age of 18.0 years (interquartile range: −15.5 to 25.5). Just over half (56.3%, n = 9) of the patients provided results from genetic testing. Six had pathogenic variants in TSC2 whereas three had pathogenic variants in TSC1. The average age at PNET diagnosis was 15.0 years (range: 3–46 years). Almost all individuals were diagnosed with a PNET during routine TSC surveillance, 56.3% (n = 9) by MRI, 12.5% (n = 2) by CT, 25% (n = 4) by ultrasound, and 6.2% (n = 1) through a surgical procedure. Follow up after diagnosis involved 68.8% (n = 11) having serial imaging and nine of the sixteen individuals proceeding with surgical removal of the PNET. Eight individuals had a history of using systemic mTOR inhibitors. Tumor growth rate was slightly less in individuals taking an mTOR inhibitor (−0.8 mm/yr, IQR: −2.3 to 2.2) than those without (1.6 mm/yr; IQR: −0.99 to 5.01, p > 0.05). Conclusions: Nonfunctional PNETs occurred at younger ages in our TSC cohort and more commonly compared to ages and prevalence reported for the general population. PNETs in patients on systemic mTOR inhibitors had lower rates of growth. The outcome of this study provides preliminary evidence supporting the use of mTOR inhibitor therapy in conjunction with serial imaging as medical management for nonfunctional PNETs as an alternative option to invasive surgical removal.
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Affiliation(s)
- Kate Mowrey
- Division of Medical Genetics, Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Hope Northrup
- Division of Medical Genetics, Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Peyton Rougeau
- Division of Medical Genetics, Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - S Shahrukh Hashmi
- Department of Pediatrics, Pediatric Research Center, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Darcy A Krueger
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Division of Neurology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Daniel Ebrahimi-Fakhari
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of General Pediatrics, University Children's Hospital Muenster, Muenster, Germany
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jamie K Capal
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Division of Neurology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - David Neal Franz
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Division of Neurology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - David Rodriguez-Buritica
- Division of Medical Genetics, Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
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Kessoku T, Kobayashi N, Yoneda M, Kasai Y, Ozaki A, Okubo N, Iwaki M, Kobayashi T, Yoshihara T, Kurita Y, Honda Y, Tokuhisa M, Ishiki H, Hibiya T, Fujii S, Nakajima A, Ichikawa Y. Case Reports: Transformation of End-Stage Neuroendocrine Tumors With Uncontrollable Liver Metastasis Into a Novel or Additional Functional Phenotype. Front Oncol 2020; 10:555963. [PMID: 33102220 PMCID: PMC7544986 DOI: 10.3389/fonc.2020.555963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/26/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Neuroendocrine tumors (NETs) are rare, but their worldwide incidence is gradually increasing. NETs are generally heterogeneous; however, in rare cases, they have been shown to change their phenotype (i.e., nonfunctional to functional or one functional phenotype to the addition of another functional phenotype). Here, we present two cases of liver metastatic NETs with phenotype transformation at the advanced stage that led to life-threatening events. Case presentation: A 73-year-old woman had a small intestinal nonfunctional NET with liver metastasis. After uncontrollable liver metastasis at the advanced stage, she developed duodenal perforation with hypergastremia. The patient was treated with octreotide and proton pump inhibitors and underwent endoscopic closure for duodenal perforation, but her general condition gradually deteriorated, and she died 2 weeks after duodenal perforation. Another patient, a 50-year-old man, had a functional NET (gastrinoma) with liver metastasis and duodenal ulcer. After uncontrollable liver metastasis at the advanced stage, he developed hypoglycemia. Although octoreotide and diazoxide were administrated for hyperalimentation, his hypoglycemia was uncontrollable, and he died after 4 months owing to general deterioration. Conclusion: The present cases show that advanced NETs with treatment-uncontrollable liver metastasis can transform their phenotype, specifically from a nonfunctional NET into a functional NET, and from one functional NET into the addition of another functional NET. These experiences suggest that the presence of treatment-resistant liver metastasis might be a hallmark of the potential to gain novel functions.
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Affiliation(s)
- Takaomi Kessoku
- Department of Palliative Medicine, Yokohama City University Hospital, Yokohama, Japan.,Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | | | - Masato Yoneda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuki Kasai
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Anna Ozaki
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Naoki Okubo
- Department of Oncology, Yokohama City University Hospital, Yokohama, Japan
| | - Michihiro Iwaki
- Department of Palliative Medicine, Yokohama City University Hospital, Yokohama, Japan
| | - Takashi Kobayashi
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tsutomu Yoshihara
- Department of Palliative Medicine, Yokohama City University Hospital, Yokohama, Japan.,Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yusuke Kurita
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yasushi Honda
- Department of Palliative Medicine, Yokohama City University Hospital, Yokohama, Japan.,Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Motohiko Tokuhisa
- Department of Oncology, Yokohama City University Hospital, Yokohama, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Takashi Hibiya
- Department of Pathology, Yokohama City University Hospital, Yokohama, Japan
| | - Satoshi Fujii
- Department of Pathology, Yokohama City University Hospital, Yokohama, Japan.,Department of Molecular Pathology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yasushi Ichikawa
- Department of Oncology, Yokohama City University Hospital, Yokohama, Japan
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7
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Keen F, Iqbal F, Owen P, Christian A, Kumar N, Kalhan A. Metastatic insulinoma presenting 14 years after benign tumour resection: a rare case and management dilemma. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200065. [PMID: 33434180 PMCID: PMC7576662 DOI: 10.1530/edm-20-0065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 07/13/2020] [Accepted: 08/25/2020] [Indexed: 12/11/2022] Open
Abstract
SUMMARY We present a 60-year-old woman who underwent successful surgical resection (partial pancreatectomy) for a low grade non-functioning pancreatic neuroendocrine tumour (pNET), with no biochemical or radiological features of recurrence on follow-up visits for 5 years. Fourteen years after the initial surgery, she developed spontaneous severe hypoglycaemic episodes which required hospitalisation, with subsequent investigations confirming the diagnosis of a metastatic insulin-secreting pNET (insulinoma). Medical management of her severe spontaneous hypoglycaemic episodes remained challenging, despite optimum use of diazoxide and somatostatin analogue therapy. Based on a discussion at the regional neuroendocrine tumour multidisciplinary team meeting, she underwent an elective hepatic trans-arterial embolization which was unfortunately unsuccessful. She ended up requiring an emergency right hemihepatectomy and left retroperitoneal mass resection which finally stabilised her clinical condition. LEARNING POINTS Ours is only the seventh case report of a previously benign pNET presenting as a functional insulin secreting metastatic tumour. However, it is the first case report, in which the metastatic functional pNET presented after such a long hiatus (14 years). There is currently no clear consensus regarding the length of follow-up of non-functional pNET which are deemed cured post-surgical resection, with most guidelines advocating a median follow up of 5 years (1). The delayed presentation in our case suggests additional considerations should be made regarding optimal post-operative surveillance duration based on the age of the patient, location of the tumour, lymph node spread and Ki-67 index. Hepatic artery embolization and/or partial hepatectomy remains a treatment option for pNET patients with significant hepatic metastasis.
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Affiliation(s)
- F Keen
- Department of Diabetes and Endocrinology, Royal Glamorgan Hospital, Llantrisant, UK
| | - F Iqbal
- Morriston Hospital, Swansea, UK
| | - P Owen
- Department of Diabetes and Endocrinology, Royal Glamorgan Hospital, Llantrisant, UK
| | | | - N Kumar
- University Hospital of Wales, Cardiff, UK
| | - A Kalhan
- Department of Diabetes and Endocrinology, Royal Glamorgan Hospital, Llantrisant, UK
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8
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Clover T, Abdelkader A, Guru Murthy GS. Transformation of a non-secretory neuroendocrine tumor to insulinoma after treatment with Sunitinib: A case report and review of the literature. J Oncol Pharm Pract 2018; 25:1516-1519. [PMID: 30089432 DOI: 10.1177/1078155218791309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We report a case of a non-secretory neuroendocrine tumor which transformed into an insulin secreting tumor after treatment with Sunitinib. To our knowledge, this has only been described in three other cases worldwide. Previously reported case series find transformation of non-secretory neuroendocrine cancers into secretory lesions occurs in 3.4-6.8% of cases. Sunitinib is known to have the potential to lower blood glucose and induce epigenetic changes in cells of various types. We hypothesize that the mechanism for Sunitinib-induced transformation in cancer phenotype is through epigenetic changes in DNA expression within the tumor cells.
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Affiliation(s)
- Todd Clover
- 1 Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, USA.,2 Department of Pathology, Medical College of Wisconsin, Milwaukee, USA
| | - Amrou Abdelkader
- 1 Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, USA.,2 Department of Pathology, Medical College of Wisconsin, Milwaukee, USA
| | - Guru Subramanian Guru Murthy
- 1 Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, USA.,2 Department of Pathology, Medical College of Wisconsin, Milwaukee, USA
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9
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Dimitriadis GK, Weickert MO, Randeva HS, Kaltsas G, Grossman A. Medical management of secretory syndromes related to gastroenteropancreatic neuroendocrine tumours. Endocr Relat Cancer 2016; 23:R423-36. [PMID: 27461388 DOI: 10.1530/erc-16-0200] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/26/2016] [Indexed: 12/14/2022]
Abstract
Although recent epidemiological evidence indicates that the prevalence of non-functioning gastroenteropancreatic (GEP) neuroendocrine tumours (NETs) is rising, a significant number of GEP-NETs still present with symptoms related to the secretion of biologically active substances leading to the development of distinct clinical syndromes. In the past, these syndromes were associated with substantial morbidity and mortality due to the lack of specific therapies; however, since the introduction of long-acting somatostatin analogues and medications such as proton pump inhibitors, their control has been greatly improved. As a result, nowadays, the main cause of morbidity and mortality in GEP-NETs is mostly directly related to tumour growth and the extent of metastatic disease. However, in some patients with functioning tumours and extensive disease, control of the secretory syndrome still remains problematic, necessitating the employment of several cytoreductive techniques, which may not always be sufficient. Recently, new agents directed against tumour growth, or exerting increased binding activity to receptors expressed in these tumours, or interfering with the synthetic pathway of some of the compounds secreted by these tumours, have been developed. Since there are no specific guidelines addressing the totality of the management of the secretory syndromes related to GEP-NETs, this review aims at critically analysing the medical management of previously recognised secretory syndromes; it also addresses areas of uncertainty, assesses the newer therapeutic developments and also addresses recently described but poorly characterised secretory syndromes related to GEP-NETs.
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Affiliation(s)
- Georgios K Dimitriadis
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK Division of Translational and Experimental MedicineWarwick Medical School, University of Warwick, Coventry, UK Division of Endocrinology and Investigative MedicineImperial College London, Hammersmith Campus, London, UK
| | - Martin O Weickert
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK Division of Translational and Experimental MedicineWarwick Medical School, University of Warwick, Coventry, UK Centre for Applied Biological and Exercise SciencesCoventry University, Coventry, UK
| | - Harpal S Randeva
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK Division of Translational and Experimental MedicineWarwick Medical School, University of Warwick, Coventry, UK Centre for Applied Biological and Exercise SciencesCoventry University, Coventry, UK
| | - Gregory Kaltsas
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK Division of PathophysiologyNational and Kapodistrian University of Athens Medical School, Athens, Greece Oxford Center for DiabetesEndocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Ashley Grossman
- Oxford Center for DiabetesEndocrinology and Metabolism, University of Oxford, Oxford, UK
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10
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Abstract
OBJECTIVES Pancreatic neuroendocrine tumors (PNETs) are known to have heterogeneity in terms of their ability to produce multiple hormones. The aim of this study was to evaluate the heterogeneity of PNETs from the viewpoint of hormonal expression. METHODS The expressions of 4 representative hormones, gastrin, insulin, glucagon, and somatostatin, in both primary and metastatic lesions, were analyzed by immunohistochemical staining in 20 patients with metastatic PNETs (6 gastrinomas, 1 insulinoma, 1 glucagonoma, and 12 nonfunctioning PNETs [NF-PNETs]). Metastatic sites included lymph nodes in all 20 patients and liver metastasis in 7 patients (2 gastrinomas and 5 NF-PNETs). RESULTS There were 6 PNETs with multiple hormone secretion (30%), and positive expression of 1 or more hormones was found in 9 of 12 patients whose primary tumors were diagnosed as NF-PNETs. The positive concordance rate of the hormonal expression pattern between primary tumors and metastatic lymph nodes and between primary tumors and hepatic metastasis were 50% and 11%, respectively. Three patients had metastatic lesions with positive hormonal expression, whereas their primary tumors were negative. CONCLUSIONS Hormonal expressions are often different between the primary tumors and metastatic sites of PNETs.
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11
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Arslan MS, Ozbek M, Karakose M, Tutal E, Ucan B, Yilmazer D, Dilli A, Gultekin SS, Cakal E, Delibasi T. Transformation of nonfunctioning pancreatic tumor into malignant insulinoma after 3 years: an uncommon clinical course of insulinoma. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 59:270-2. [PMID: 26154097 DOI: 10.1590/2359-3997000000049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 01/14/2015] [Indexed: 11/22/2022]
Abstract
A 62-year-old man admitted to our outpatient clinic with two months of recurrent life threatening hypoglycemia episodes. He was diagnosed as malignant insulinoma with multiple metastases of liver and peripancreatic lymph nodes. Liver biopsy specimen was demonstrated grade 2 neuroendocrine tumor compatible with clinical and radiological results. He was followed under the treatment of continuous intravenous glucose infusion during the diagnostic procedures. He had a pancreatic lesion history measured 20 x 12 mm in diameter via the abdominal tomography examination approximately two years before the diagnosis. Unusual course of this case suggests the transformation of nonfunctioning pancreatic neuroendocrine tumor into functional insulin secreting tumor with metastases. The patient was found inoperable and started on chemotherapy.
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Affiliation(s)
- Muyesser Sayki Arslan
- Department of Endocrinology and Metabolism, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Mustafa Ozbek
- Department of Endocrinology and Metabolism, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Melia Karakose
- Department of Endocrinology and Metabolism, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Esra Tutal
- Department of Endocrinology and Metabolism, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Bekir Ucan
- Department of Endocrinology and Metabolism, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Demet Yilmazer
- Department of Pathology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Alper Dilli
- Department of Radiology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Salih Sinan Gultekin
- Department of Nuclear Medicine, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Erman Cakal
- Department of Endocrinology and Metabolism, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Tuncay Delibasi
- Department of Endocrinology and Metabolism, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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12
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Nahmias A, Grozinsky-Glasberg S, Salmon A, Gross DJ. Pancreatic neuroendocrine tumors with transformation to insulinoma: an unusual presentation of a rare disease. Endocrinol Diabetes Metab Case Rep 2015; 2015:150032. [PMID: 26113980 PMCID: PMC4477235 DOI: 10.1530/edm-15-0032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 05/29/2015] [Indexed: 12/12/2022] Open
Abstract
Approximately 35% of the pancreatic neuroendocrine tumors (pNETs) are functional, the most common of which is an insulinoma. Rarely can initially nonfunctioning tumor undergo biological transformation to a hormone-secreting tumor with subsequent changes in the clinical picture. We present here three unique patients with long-standing pNETs who developed life-threatening hyperinsulinemic hypoglycemia along with tumor progression. In two of the patients, everolimus (Afinitor) was administered in an attempt to control both tumor growth and hypoglycemia. In two cases everolimus therapy resulted in the abolishment of hypoglycemia and induced significant tumor regression; however these beneficial responses were transient. These cases highlight the exceptional ability of pNETs to change biological behavior in parallel with disease progression. Our experience concurs with recently published studies demonstrating the utility of everolimus for the control of both hypoglycemia and tumor progression.
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Affiliation(s)
- Avital Nahmias
- Neuroendocrine Tumor Unit, Endocrinology and Metabolism Service, Hadassah-Hebrew University Medical Center , Jerusalem , Israel
| | - Simona Grozinsky-Glasberg
- Neuroendocrine Tumor Unit, Endocrinology and Metabolism Service, Hadassah-Hebrew University Medical Center , Jerusalem , Israel
| | - Asher Salmon
- Department of Oncology, Hadassah-Hebrew University Medical Center, Kiryat Hadassah , Jerusalem, POB 12000 , 91120, Israel
| | - David J Gross
- Neuroendocrine Tumor Unit, Endocrinology and Metabolism Service, Hadassah-Hebrew University Medical Center , Jerusalem , Israel
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13
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de Mestier L, Hentic O, Cros J, Walter T, Roquin G, Brixi H, Lombard-Bohas C, Hammel P, Diebold MD, Couvelard A, Ruszniewski P, Cadiot G. Metachronous hormonal syndromes in patients with pancreatic neuroendocrine tumors: a case-series study. Ann Intern Med 2015; 162:682-9. [PMID: 25984844 DOI: 10.7326/m14-2132] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (PNETs) may evolve and cause hormonal hypersecretion-related symptoms that were not present at the initial diagnosis, termed metachronous hormonal syndromes (MHSs). Their setting, characteristics, and outcomes are not well-described. OBJECTIVE To describe MHSs in patients with sporadic PNETs. DESIGN Retrospective, multicenter study. SETTING 4 French referral centers. PATIENTS Patients with PNETs who developed MHSs related to hypersecretion of insulin, gastrin, vasoactive intestinal peptide, or glucagon between January 2009 and January 2014. MEASUREMENTS Tumor extension, biological markers, and treatments at initial PNET diagnosis and MHS onset. Pathologic specimens were evaluated centrally, including Ki-67 index and hormone immunolabeling. RESULTS Of 435 patients with PNETs, 15 (3.4%) were identified as having MHSs involving the hypersecretion of insulin (5 patients), vasoactive intestinal peptide (5 patients), gastrin (2 patients), or glucagon (4 patients). Metachronous hormonal syndromes developed after a median of 55 months (range, 7 to 219) and in the context of PNET progression, stability, and tumor response in 8, 6, and 1 patients, respectively. The median Ki-67 index was 7% (range, 1% to 19%) at PNET diagnosis and 17.5% (range, 2.0% to 70.0%) at MHS onset. Immunolabeling of MHS-related peptides was retrospectively found in 8 of 14 of pathologic PNET specimens obtained before MHS diagnosis. Median survival after MHS onset was 28 months (range, 3 to 56). Seven patients with MHSs died during follow-up, all due to PNETs, including 4 patients with insulin-related MHSs. LIMITATION Retrospective data collection and heterogeneity of pathologic specimen size and origin. CONCLUSION Metachronous hormonal syndromes were identified more often in the context of PNET progression and increased Ki-67 indices. Patients with insulin-related MHSs may have decreased survival rates. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Louis de Mestier
- From Robert-Debré University Hospital, Reims, France; Beaujon University Hospital, Clichy, France; Edouard-Herriot University Hospital, Lyon, France; Angers University Hospital, Angers, France; and Xavier-Bichat University Hospital, Paris, France
| | - Olivia Hentic
- From Robert-Debré University Hospital, Reims, France; Beaujon University Hospital, Clichy, France; Edouard-Herriot University Hospital, Lyon, France; Angers University Hospital, Angers, France; and Xavier-Bichat University Hospital, Paris, France
| | - Jérôme Cros
- From Robert-Debré University Hospital, Reims, France; Beaujon University Hospital, Clichy, France; Edouard-Herriot University Hospital, Lyon, France; Angers University Hospital, Angers, France; and Xavier-Bichat University Hospital, Paris, France
| | - Thomas Walter
- From Robert-Debré University Hospital, Reims, France; Beaujon University Hospital, Clichy, France; Edouard-Herriot University Hospital, Lyon, France; Angers University Hospital, Angers, France; and Xavier-Bichat University Hospital, Paris, France
| | - Guillaume Roquin
- From Robert-Debré University Hospital, Reims, France; Beaujon University Hospital, Clichy, France; Edouard-Herriot University Hospital, Lyon, France; Angers University Hospital, Angers, France; and Xavier-Bichat University Hospital, Paris, France
| | - Hedia Brixi
- From Robert-Debré University Hospital, Reims, France; Beaujon University Hospital, Clichy, France; Edouard-Herriot University Hospital, Lyon, France; Angers University Hospital, Angers, France; and Xavier-Bichat University Hospital, Paris, France
| | - Catherine Lombard-Bohas
- From Robert-Debré University Hospital, Reims, France; Beaujon University Hospital, Clichy, France; Edouard-Herriot University Hospital, Lyon, France; Angers University Hospital, Angers, France; and Xavier-Bichat University Hospital, Paris, France
| | - Pascal Hammel
- From Robert-Debré University Hospital, Reims, France; Beaujon University Hospital, Clichy, France; Edouard-Herriot University Hospital, Lyon, France; Angers University Hospital, Angers, France; and Xavier-Bichat University Hospital, Paris, France
| | - Marie-Danièle Diebold
- From Robert-Debré University Hospital, Reims, France; Beaujon University Hospital, Clichy, France; Edouard-Herriot University Hospital, Lyon, France; Angers University Hospital, Angers, France; and Xavier-Bichat University Hospital, Paris, France
| | - Anne Couvelard
- From Robert-Debré University Hospital, Reims, France; Beaujon University Hospital, Clichy, France; Edouard-Herriot University Hospital, Lyon, France; Angers University Hospital, Angers, France; and Xavier-Bichat University Hospital, Paris, France
| | - Philippe Ruszniewski
- From Robert-Debré University Hospital, Reims, France; Beaujon University Hospital, Clichy, France; Edouard-Herriot University Hospital, Lyon, France; Angers University Hospital, Angers, France; and Xavier-Bichat University Hospital, Paris, France
| | - Guillaume Cadiot
- From Robert-Debré University Hospital, Reims, France; Beaujon University Hospital, Clichy, France; Edouard-Herriot University Hospital, Lyon, France; Angers University Hospital, Angers, France; and Xavier-Bichat University Hospital, Paris, France
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14
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Yoshioka M, Shibata S, Uchinami H, Watanabe G, Miyazawa H, Iida M, Yoshida M, Yoshioka T, Nanjo H, Yamamoto Y. The transformation of a nonfunctioning islet cell tumor of the pancreas into a proinsulinoma under conditions of lung metastasis. Intern Med 2015; 54:785-90. [PMID: 25832942 DOI: 10.2169/internalmedicine.54.3772] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report the first case of a nonfunctioning islet cell tumor that transformed into a proinsulinoma during the process of metastasis to the lungs. This phenomenon was confirmed in a 69-year-old woman with an advanced pancreatic islet cell tumor and multiple liver metastases who later developed multiple lung metastases. She underwent pancreatic resection followed by the administration of chemotherapy and survived for seven years. Although the patient initially had hyperglycemia due to diabetes mellitus, she conversely began to manifest hypoglycemic attacks 63 months postoperatively with the concomitant development of multiple lung metastases. An autopsy revealed that only the tumor in the lungs produced proinsulin; no other hormones were detected.
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Affiliation(s)
- Masato Yoshioka
- Department of Gastroenterological Surgery, Akita University Graduate School of Medicine, Japan
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15
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Abstract
Insulinoma is a rare pancreatic neuroendocrine tumor that is usually described as benign, sporadic, and very small (<2 cm). However, there have been rare case reports of insulinoma presenting as a giant tumor. We describe 3 cases of giant insulinomas, all of which developed liver metastases. The patients were aged 38, 63, and 67 years. Clinically, all patients presented with Whipple's triad associated with a large mass located in the pancreatic tail. The tumors ranged in size from 10 to 15 cm. On microscopic examination, the tumors were well differentiated with amyloid deposition ranging between 20% and 30%. Immunohistochemically, all 3 tumors showed strong diffuse expression of chromogranin and synaptophysin, whereas they were only focally positive for insulin. One patient developed liver recurrence 3 years after resection of the primary tumor yet remained asymptomatic without treatment. Another patient with liver recurrence underwent right hepatectomy and has been free of disease for 2 years. The third patient died of metastatic disease 13 years after initial surgery. Giant insulinomas are characterized by focal expression of insulin and high rates of liver metastases. Long-term follow-up is mandatory in these patients, as recurrence is expected after primary surgery.
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16
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Ohn JH, Kim YG, Lee SH, Jung HS. Transformation of nonfunctioning pancreatic neuroendocrine carcinoma cells into insulin producing cells after treatment with sunitinib. Endocrinol Metab (Seoul) 2013; 28:149-52. [PMID: 24396670 PMCID: PMC3811707 DOI: 10.3803/enm.2013.28.2.149] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 04/17/2013] [Indexed: 11/11/2022] Open
Abstract
We report a rare case of severe hypoglycemia after sunitinib treatment for pancreatic neuroendocrine carcinoma. We describe the initial clinical presentation, laboratory results, pathologic findings, and managment in a patient with a nonfunctioning pancreatic neuroendocrine carcinoma with liver metastases who developed life threatening hypoglycemia after 2 months of sunitinib therapy. A 46-year-old woman presented to the emergency department with loss of consciousness from hypoglycemia. Serum C-peptide and insulin levels at fasting state revealed that the hypoglycemia resulted from endogenous hyperinsulinemia. She had been diagnosed with nonfunctioning pancreatic neuroendocrine carcinoma based on a biopsy of metastatic cervical lymph node and was being treated with sunitinib, a small molecule tyrosine kinase inhibitor. Immunohistochemical stain of the metastatic liver mass demonstrated that the initially nonfunctioning neuroendocrine carcinoma cells had changed into insulin-producing cells after sunitinib therapy. Transarterial chemoembolization of the liver masses and systemic chemotherapy with streptozotocin/adriamycin relieved the hypoglycemia. A nonfunctioning pancreatic neuroendocrine carcinoma was transformed into an insulin-producing tumor after treatment with sunitinib, causing endogenous hyperinsulinemia and severe hypoglycemia.
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Affiliation(s)
- Jung Hun Ohn
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yeong Gi Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Se-Hoon Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hye Seung Jung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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17
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Koshy AA, Gordon IO, Van Ha TG, Kaplan EL, Philipson LH. Metastatic Insulinoma Following Resection of Nonsecreting Pancreatic Islet Cell Tumor: A Case Report and Review of the Literature. J Investig Med High Impact Case Rep 2013; 1:2324709612473274. [PMID: 26425568 PMCID: PMC4528785 DOI: 10.1177/2324709612473274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 56-year-old woman presented to our clinic for recurrent hypoglycemia after undergoing resection of an incidentally discovered nonfunctional pancreatic endocrine tumor 6 years ago. She underwent a distal pancreatectomy and splenectomy, after which she developed diabetes and was placed on an insulin pump. Pathology showed a pancreatic endocrine neoplasm with negative islet hormone immunostains. Two years later, computed tomography scan of the abdomen showed multiple liver lesions. Biopsy of a liver lesion showed a well-differentiated neuroendocrine neoplasm, consistent with pancreatic origin. Six years later, she presented to clinic with 1.5 years of recurrent hypoglycemia. Laboratory results showed elevated proinsulin, insulin levels, and c-peptide levels during a hypoglycemic episode. Computed tomography scan of the abdomen redemonstrated multiple liver lesions. Repeated transarterial catheter chemoembolization and microwave thermal ablation controlled hypoglycemia. The unusual features of interest of this case include the transformation of nonfunctioning pancreatic endocrine tumor to a metastatic insulinoma and the occurrence of atrial flutter after octreotide for treatment.
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