The management of insulin tumours of the pancreas

Abstract

SUMMARY A series of 26 patients diagnosed as having an insulinsecreting, islet-cell tumour of the pancreas is described.Three patients were treated medically, but in the remaining 23 the tumour was found at operation; 1 patient had a carcinoma with hepatic metastases, but in the other 22 the tumour was apparently benign and the subsequent course of these patients has confirmed this conclusion.The BETWEEN 1962 and 1978, 26 patients with an insulinsecreting tumour of the pancreas have been treated at The Middlesex Hospital. Our experience in the management of these patients is reported, with particular emphasis on the results of preoperative angiography in the localization of these tumours, and on the use of diazoxide in the control of hypoglycaemia. The management of patients with this condition is discussed in the light of this experience. 31 Patients and methodsThe present series comprised 16 women and 10 men, their ages ranging from 18 to 70 years (Table I ) . A benign tumour was removed from 22 patients: 1 patient (Case 2) had a carcinoma with metastases and the condition ultimately proved fatal. The 3 remaining patients were treated medically and their tumours are presumably benign.All the patients presented with neurological symptoms, usually attacks of confusion, loss of consciousness or fits.Three patients, following typical, transient attacks occurring intermittently over several months, developed prolonged coma. Two of these (Cases 14 and 16) were admitted in a state of decerebrate rigidity; following maintenance of normoglycaemia with diazoxide a tumour was removed and both have made remarkable recoveries, although they have some permanent impairment of cerebral function. DiagnosisThe diagnosis of hypoglycaemia was based on finding a low blood sugar (<2.2 mmol/l) either after an overnight fast (18 patients) or during prolonged fasting (5 patients). In the other 3 patients the diagnosis was based on the history and on an abnormal blood sugar to serum insulin relationship. The fact that the hypoglycaemia was due to excess insulin was demonstrated by finding a disproportionately high serum insulin for the blood sugar either after overnight or prolonged fasting (Fix. 1).In the first patient in the series the fact that the hypoglycaemia was of islet-cell origin was demonstrated by an intravenous tolbutamide test, but thereafter this test was not used as a diagnostic procedure. DiazoxideDiazoxide was given to 17 patients before operation. The initial dose was 50 mg 8-hourly. In all patients control of the blood sugar level and symptoms was successfully obtained, but to achieve this the dose had to be increased to 450mg daily in several patients, and 1 patient (Case 14) required 1.2 g daily before control was achieved. In 2 patients the drug caused serious fluid retention, leading in one patient (Case 23, 150 mg daily) to left ventricular failure and in the other (Case 17, 450 mg daily) to a pericardial effusion. Both conditions resolved promptly on withdrawal of the drug.In 3 patients (Cases 6 , 18 and 22) ...

Site-specific biology and pathology of gastroenteropancreatic neuroendocrine tumors

“…The highest incidence is found between 40 and 60 years. Women seem to be slightly more frequently affected than men (ratio 6:4) [49,51,52,84,140,141,165].…”

Usefulness of transhepatic portal catheterization in the treatment of insulinomas

“…Operative mortality is much higher (18 per cent) in patients with occult tumour than in those in whom the tumour is felt during the operation (6.7 per cent). Progressive left-to-right resection guided by immediate pathological examination (3) results in an almost total pancreatectomy, the occult tumours usually being in the head of the pancreas (9). In order to overcome these problems various procedures have been proposed.…”

“…This test has been positive in 65. 9 per cent of 170 cases (3). Reports have appeared in which arteriography correctly identified an insulinoma in 38-86 per cent of patients (2).…”

“…Most authors (4, 5, 7, 8, 10) performed TPC in all their patients, whereas failure of a first laparotomy and a negative arteriogram were the indications used by Turner (6) to recommend TPC. Failure of laparotomy and diazoxide therapy were indicators for Le Quesne (9) for TPC.…”

Human insulinoma: Clinical, cellular, and molecular aspects

“…It is generally accepted that the vast majority of insulinomas are benign. The percentages of malignant tumors range from 2.4 to 17.9%, with an average of 8.4% [10][11][12][13][14]. Malignant insulinomas occur in an older age group and have not been reported in children [15].…”