Intractable hypoglycaemia in a patient with advanced carcinoid syndrome successfully treated with hepatic embolization

Abstract

A male patient presented at the age of 54 years with metastatic pancreatic neuroendocrine tumour (net). He was managed with interferon and multiple courses of MIBG therapy which controlled his disease for about seven years. He then developed symptomatic hypoglycaemia which resolved with the introduction of somatostatin analogue treatment and further therapeutic MIBG. However, three years later he was admitted to hospital with severe and intractable hypoglycaemia, which persisted despite treatment with dietary manipulation, diazoxide, longacting octreotide injections, intravenous infusion of dextrose and octreotide and everolimus. Bland hepatic embolization was attempted as a last resort and resulted in prompt and dramatic improvement of his condition with no hypoglycaemia for five months. we recommend that hepatic embolization should be considered in patients with advanced and metastatic nets accompanied by refractory hypoglycaemia, with the aim of symptomatic relief and palliation, and possibly some survival benefit.

Treatment of symptomatic neuroendocrine tumor syndromes: recent advances and controversies

“…This approach has been particularly considered in patients with hepatic symptoms or refractory malignant F-NET syndromes[17, 20, 21, •22, 68, 71]. In general TACE/TAE result in a symptomatic response in 50–100% of patients and numerous series as well as case reports have documented their control of symptoms in patients with both carcinoid syndrome and F-pNET syndromes[17, 20, 21, •22, 68, 71, 72, •73, 74, 75, •76, 77, •78]. …”

“…These palliative effects included not only effects on tumor growth/size but also symptomatic improvement in patients with carcinoid syndrome[105–109]. 131 I-MIBG treatments have also been used in occasional patients with refractory F-pNET syndromes[•73, 110–112]. Therapy with 131 I-MIBG is gernally well tolerated but can include pancytopenia, thrombocytopenia, nausea and emesis.…”

“…Both studies and case reports have reported the successful use in patients with carcinoid syndrome of the control of the symptoms of the hormone-excess state by using: everolimus[•38]; PRRT[•56, 57, 66, 95, •96, •148]; liver-directed therapies including TACE/TAE[70, 72, •73, 77, 95, 98, 149]; radioembolization[70, 150, 151]; RFA[80, 81, 83, 95, 152]; by increasing the dosage of octreotide/Lanreotide in refractory cases[94, 97, 153–155]; use of cytoreductive surgery[23, 95, 156–160]; use of 131 I-MIBG[95, 105, 106, 108, 110, •161, 162–164]; with the use of the tryptophan hydroxylase inhibitor, Telotristat[108, 113, 114, ••116, •117, 118, 119] and with pasireotide in octreotide resistant cases[•122]. …”

“…Included in the recent literature are reports of the control of the symptoms of the insulinoma hormone-excess state by using: everolimus[•39, 40–46, 170, 171]; tyrosine kinase inhibitor sunitinib[•50]; PRRT[44, 55, 58–60, •61, •76, 170, 172]; liver directed therapies including TACE/TAE[44, 70, 72, •73, 74 75, •76, 172–17444, 70, 172]; RFA and use of ablative treatment(ethanol, microwave of primary/metastases[81, 83–87, •89, 90, 92, •93, 175, •176, 177, 178]; by increasing the dosage of octreotide/Lanreotide in refractory cases[153, 155]; use of cytoreductive surgery[157, 158, 160, 172, 174]; use of 131 I-MIBG[•111] and with pasireotide in octreotide resistant cases[125].…”