Evolving management of insulinoma: Experience at a tertiary care centre

Abstract

Background & objectives:Since our previous study in 2006, several new modalities for localization of cause of endogenous hyperinsulinemic hypoglycaemia such as multiphasic computed tomography (CT), multiphasic magnetic resonance imaging (MRI), endoscopic ultrasound (EUS), intraoperative ultrasound, and intra-arterial calcium infusion with arterial stimulation venous sampling (ASVS) have become available. Therefore, to evaluate the relative usefulness of various imaging modalities to guide future management in terms of diagnosis and patient care, we analyzed presentation and management of patients of endogenous hyperinsulinemic hypoglycaemia.Methods:In this retrospective study, medical records of patients admitted with endogenous hyperinsulinemic hypoglycaemia were retrieved. Data pertaining to clinical features, diagnosis, imaging, surgery and patient outcome were extracted. The localization of insulinoma by preoperative imaging techniques was compared with the findings at surgery to assess the accuracy of localization.Results:Fasting hypoglycaemia was present in all, and post-prandial hypoglycaemia (plasma glucose ≤50 mg/dl within four hours of meal) in 25.8 per cent. Mean duration of symptoms before reaching a diagnosis of hyperinsulinemic hypoglycaemia was 3.9 years. Mean duration of provocative fast was 21.8 h (range 6-48 h). Among the currently used imaging modalities, the sensitivity of localizing tumour was 79.3 per cent for multiphasic CT, 85 per cent for multiphasic MRI and 95 per cent for EUS. EUS detected tumour missed by both CT and MRI. All, except one of the operated patients, were cured by surgery.Interpretation & conclusions:Our results suggest that patients with insulinoma have a varied presentation. Multiphasic contrast-enhanced MRI/CT scan, EUS and ASVS may be complimentary in pre-operative localization.

Diagnosis and Surgical Management of Insulinomas—A 23-Year Single-Center Experience

“…Proper diagnostic and therapeutic management of insulinomas are based on a multidisciplinary team consisting of an endocrinologist, a pancreatic surgeon, radiologists, and endoscopists [ 4 ].…”

“…The can be said of MRI. A conventional MRI can detect insulinoma in about 31% of cases, and multiphasic MRI can detect insulinoma in 85% of patients [ 4 ]. The use of 18 F-fluorodeoxyglucose (18 F-FDG) PET is not helpful in diagnosis due to the low proliferative activities of these tumors.…”

“…Malignant insulinomas are usually larger than 3 cm. Insulinoma can be a part of multiple endocrine neoplasia (MEN I), together with parathyroid and hypophyseal adenoma [ 1 , 2 , 3 , 4 , 5 , 6 , 7 ].…”

“…The diagnosis of insulinomas can be challenging as patients are first examined in neurologic and psychiatric departments due to neuroglycopenic symptoms. A milestone in the diagnosis is the confirmation of Whipple’s triad; symptoms can be provoked by fasting or physical activity, low plasma glucose levels at the time of symptoms, and the immediate relief of symptoms after glucose administration [ 1 , 2 , 3 , 4 ].…”

A rare case of recurrent hypoglycaemia

“…In a study done by Jyotsna VP et al, localization predicted by each pre-operative test was compared to localization at surgery for accuracy. 15 Among non-invasive modalities, multiphasic MRI could localize insulinoma in 85 per cent whereas multiphasic CT in 79 per cent. Three patients in whom insulinoma could not be localized by CT were localized correctly by MRI.…”