Tumor-induced hypoglycemia is a serious disorder most commonly caused by insulinoma or non-islet cell tumor hypoglycemia (NICTH). The hypoglycemia can be severe and refractory to conventional therapy, leading to significant morbidity and mortality. The objective of this work is to describe a series of challenging cases in which refractory, tumor-induced hypoglycemia was shown to respond to the use of pasireotide, a second-generation somatostatin receptor ligand. We describe the clinical and biochemical features of three patients with tumor-induced hypoglycemia due to an occult insulinoma, malignant insulinoma, and non-islet cell tumor hypoglycemia. In these three individuals, the hypoglycemia remained refractory to guideline-recommended medical therapy, such as diazoxide, non-pasireotide somatostatin analogs, and glucocorticoids. Pasireotide was substituted in order to attenuate the refractory hypoglycemia for each patient. The addition of pasireotide led to prompt improvement in the frequency and severity of hypoglycemic episodes for each tumor-induced hypoglycemia patient. We demonstrate the successful treatment of three individuals with refractory, tumor-induced hypoglycemia with pasireotide. We offer the first-reported use of pasireotide for the successful treatment of non-malignant insulinoma and non-islet cell tumor hypoglycemia.
Background
Methods that aim to accurately measure and predict breast development can be utilized in gender-affirming treatment planning, patient education, and research.
Objectives
The authors sought to evaluate whether three-dimensional (3D) stereophotogrammetry accurately measures transfeminine breast volume changes on a masculine frame when simulating anticipated changes in soft tissue after gender-affirming surgical therapy. Then, we describe the innovative application of this imaging modality in a transgender patient to illustrate the potential role of 3D imaging in gender-affirming surgical care.
Methods
A 3D VECTRA scanner (Canfield, Fairfield, NJ) was used to measure anthropometric breast measurements. Postoperative changes in breast volume were simulated on a cardiopulmonary resuscitation (CPR) mannequin using 450cc MENTOR breast implants (Mentor Worldwide LLC, Irvine, CA). To demonstrate the ability of the VECTRA to accurately simulate transfeminizing augmentation in practice, we describe its use in a 30-year-old transgender female with a 2-year history of gender-affirming hormone therapy, presenting for gender-affirming surgical care.
Results
In the mannequin, mean breast volumes were 382 cc on the right (range 375–388 cc), and 360 cc on the left (range 351–366 cc). The average calculated difference in volume between the two sides was 22 cc (range 17–31 cc). There were no instances where the left side was calculated to be larger than the right or where the calculated size was smaller than the actual implant size.
Conclusions
The VECTRA 3D camera is a reliable and reproducible tool for preoperative assessment, surgical planning, and simulating breast volume changes after gender-affirming surgery.
There has been an increasing prevalence of individuals presenting for treatment of gender dysphoria over the past several years. This growing population includes transgender children referred to pediatric clinics. Transgender children meeting diagnostic criteria for gender dysphoria, with supportive mental health care, may be treated with gonadotropin releasing hormone (GnRH) agonists and cross sex hormones. The treatment for these children requires ongoing maintenance and monitoring and therefore follow-up in the adult care setting. As is the case with other conditions that require long term treatment, these youth need a formal transition from pediatric to adult clinical care. The period of transition of care is critical and if not executed properly exposes the adolescent to risks of complications, and loss of follow-up. The proper clinical transfer is especially important for transgender youth in the setting of increased psychosocial and mental health issues. The transition of care for transgender adolescents has not been formally studied but given a growing population seeking treatment for gender dysphoria, it will need to be systematically assessed to determine the best outcomes to measure.
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