Localization of Insulinomas to Regions of the Pancreas by Intraarterial Calcium Stimulation: The NIH Experience

Guettier, Jean Marc; Kam, Anthony; Chang, Richard; Skarulis, Monica C.; Cochran, Craig; Alexander, H. Richard; Libutti, Steven K.; Pingpank, James F.; Görden, Phillip

doi:10.1210/jc.2008-1986

Cited by 149 publications

(138 citation statements)

References 35 publications

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“…Selective intra-arterial injection of the pancreatic arteries with calcium and hepatic venous sampling for insulin, first introduced 17 years ago (18), correlates anatomy with function, and in many series, it appears to be the most sensitive method for regionalisation of insulinoma. In a previous series of 25 surgically proven sporadic insulinomas, calcium stimulation correctly regionalised 88% of tumours, compared to MRI in 43% and CT in only 17% (19), and this high diagnostic accuracy was maintained in a recent update on a further 45 patients (20).…”

Section: Introductionmentioning

confidence: 81%

“…In another series of 39 sporadic cases of insulinoma, the accuracy of CT scanning was 35% with a false negative rate of 49% and a false positive localisation rate of 16%. For MRI, the accuracy was 30% with a false negative rate of 57% and a false positive rate of 13% (20). While some small radiological series have suggested greater sensitivity for both CT and MRI (13,15), in general, the low accuracy of cross-sectional imaging has in part driven the development of more invasive methods.…”

Section: Discussionmentioning

confidence: 99%

“…The success of the investigation relies on several assumptions, including that the tumour will have a dominant arterial supply, that calcium evokes a characteristic response of coordinated discharge of vesicles from the entire syncytium of tumour cells, and that the remainder of the b-cells will be suppressed from the chronic hormone hypersecretion. As well as the theoretical advantage of corroboration of structure and function, accuracy rates are reported to be very high, with figures of 93% (21) and 89% (20) being quoted. However, it should be pointed out that to be accurate this is regionalisation rather than true localisation.…”

Section: Discussionmentioning

confidence: 99%

“…In the absence of anatomic variants, a positive response following injection into the CHA, GDA or SMA predicts a lesion in the head of the pancreas, while a positive response following splenic artery injection predicts a lesion in the body or tail of the pancreas. When a positive response was seen in more than one artery, by convention, the territory with the greatest insulin rise was used to predict regionalisation (20).…”

Section: Functional Localisationmentioning

confidence: 99%

“…It therefore remains instructive to review the information collected by centres with the experience of managing these rare neuroendocrine tumours. Recent case series have been published examining both secular trends in the presentation and diagnosis of insulinoma (21), and have also reported on the relative accuracy of several methods of localisation (20). We have previously reported that MRI appears to be increasingly accurate in demonstrating small pancreatic tumours (22).…”

Section: Introductionmentioning

confidence: 99%

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Diagnosis and localisation of insulinoma: the value of modern magnetic resonance imaging in conjunction with calcium stimulation catheterisation

Druce¹,

Muthuppalaniappan²,

O’Leary³

et al. 2010

European Journal of Endocrinology

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Context: Preoperative localisation of insulinoma improves cure rate and reduces complications, but may be challenging. Objective: To review diagnostic features and localisation accuracy for insulinomas. Design: Cross-sectional, retrospective analysis. Setting: A single tertiary referral centre. Patients: Patients with insulinoma in the years 1990-2009, including sporadic tumours and those in patients with multiple endocrine neoplasia syndromes. Interventions: Patients were identified from a database, and case notes and investigation results were reviewed. Tumour localisation by computed tomography (CT), magnetic resonance imaging (MRI), octreotide scanning, endoscopic ultrasound (EUS) and calcium stimulation was evaluated. Main outcome measure(s): Insulinoma localisation was compared to histologically confirmed location following surgical excision. Results: Thirty-seven instances of biochemically and/or histologically proven insulinoma were identified in 36 patients, of which seven were managed medically. Of the 30 treated surgically, 25 had CT (83.3%) and 28 had MRI (90.3%), with successful localisation in 16 (64%) by CT and 21 (75%) by MRI respectively. Considered together, such imaging correctly localised 80% of lesions. Radiolabelled octreotide scanning was positive in 10 out of 20 cases (50%); EUS correctly identified 17 lesions in 26 patients (65.4%). Twenty-seven patients had calcium stimulation testing, of which 6 (22%) did not localise, 17 (63%) were correctly localised, and 4 (15%) gave discordant or confusing results. Conclusions: Preoperative localisation of insulinomas remains challenging. A pragmatic combination of CT and especially MRI predicts tumour localisation with high accuracy. Radionuclide imaging and EUS were less helpful but may be valuable in selected cases. Calcium stimulation currently remains useful in providing an additional functional perspective.European Journal of Endocrinology 162 971-978

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Section: Introductionmentioning

confidence: 81%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Functional Localisationmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Diagnosis and localisation of insulinoma: the value of modern magnetic resonance imaging in conjunction with calcium stimulation catheterisation

Druce¹,

Muthuppalaniappan²,

O’Leary³

et al. 2010

European Journal of Endocrinology

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Interventional radiology in the management of hepatopancreatobiliary malignancy and surgical complications

Huang

Wallace

2016

Laparoscopic Liver, Pancreas, and Biliary Surgery

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Surgery for multiple endocrine neoplasia type 1-related insulinoma: long-term outcomes in a large international cohort

Beek¹,

Nell²,

Verkooijen

et al. 2020

British Journal of Surgery

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Background Insulinomas are found in 10–15 per cent of patients with multiple endocrine neoplasia type 1 (MEN1) and lead to life‐threatening hypoglycaemia. Surgical outcome and the optimal surgical strategy for MEN1‐related insulinoma are unknown. Methods Patients with MEN1‐related insulinomas were identified in 46 centres in Europe and North America between 1990 and 2016. Insulinomas were considered localized if the lesion was in the pancreatic head or body/tail. Patients with pancreatic neuroendocrine tumours throughout the pancreas were suspected of having multifocal insulinoma. The primary outcome was postoperative hypoglycaemia, defined as persistent hypoglycaemia, or recurrent hypoglycaemia caused by a new insulinoma or insulin‐producing liver metastases. Hypoglycaemia‐free survival was estimated by the Kaplan–Meier method. Results Ninety‐six patients underwent resection for MEN1‐related insulinoma. Sixty‐three and 33 patients had localized and multifocal insulinomas respectively. After a median follow‐up of 8 (range 1–22) years, one patient (1 per cent) had persistent disease and six (6 per cent) had developed recurrent disease, of whom four had a new insulinoma. The 10‐year hypoglycaemia‐free survival rate was 91 (95 per cent c.i. 80 to 96) per cent. Of those with localized disease, 46 patients underwent pancreatic resection and 17 enucleation. One of these patients had persistent disease and one developed recurrent insulinoma. Among patients with multifocal disease, three developed new insulinomas and two developed insulin‐producing liver metastases. Conclusion Surgery for MEN1‐related insulinoma is more successful than previously thought.

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Localization of Insulinomas to Regions of the Pancreas by Intraarterial Calcium Stimulation: The NIH Experience

Abstract: The CaStim has remained vastly superior to abdominal US, CT, or MRI over time as a preoperative localizing tool for insulinomas. The utility of the CaStim for this purpose and in this setting is thus validated.

Cited by 149 publications

References 35 publications

Diagnosis and localisation of insulinoma: the value of modern magnetic resonance imaging in conjunction with calcium stimulation catheterisation

Diagnosis and localisation of insulinoma: the value of modern magnetic resonance imaging in conjunction with calcium stimulation catheterisation

Interventional radiology in the management of hepatopancreatobiliary malignancy and surgical complications

Surgery for multiple endocrine neoplasia type 1-related insulinoma: long-term outcomes in a large international cohort

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