Case Of Malignant Insulinoma Research Articles

Tissue Is the Issue - A Case of Malignant Insulinoma

Introduction: Insulinomas are rare, functioning pancreatic neuroendocrine tumors, predominantly benign (90%). Most are sporadic, but they can occur as part of inherited disorders. Large size insulinomas are more likely to be malignant. 68Gallium (Ga)-DOTATATE scan is an essential tool in diagnosis and treatment of pancreatic neuroendocrine tumors. However, tissue diagnosis is the ultimate prognosis predictor and treatment guide.Clinical Case: An 80-year-old man presented with left ankle fracture after a syncopal episode. In the past several months he reported multiple episodes of lightheadedness. He denied history of diabetes. Past medical and surgical history included prostate cancer, gastroesophageal reflux disease and bilateral orchiectomy for undescended testes. His left ankle appeared swollen, otherwise the exam was unremarkable: he was well-nourished, the abdomen was soft and nontender, there were no palpable masses. He was noted to have several episodes of hypoglycemia. Hypoglycemia work up included negative sulfonylurea screen, plasma glucose 51 mg/dl (60-99 mg/dl), insulin of 31 uIU/ml (3-25 uIU/ml), proinsulin 85.4 pmol/L (<8 pmol/L), C peptide 3.4 ng/ml (1.1-4.4 ng/ml). Abdominal Computed Tomography with contrast showed a 4.7 x 3.1 cm exophytic mass in the body of pancreas, a 5.3 x 5 cm mass in the head of pancreas and multiple ill-defined hepatic lesions concerning for metastatic disease. 68Ga-DOTATATE scan revealed an avid pancreatic mass and multiple avid foci throughout the liver suspicious for metastatic disease. Octreotide and intravenous dextrose were started for the treatment of persistent hypoglycemia. He underwent Whipple procedure and resection of the metastatic liver lesions. Postoperatively hypoglycemia resolved. The pathology revealed large cell pancreatic neuroendocrine carcinoma with areas of well differentiated tumor and multiple liver metastatic neuroendocrine carcinoma, Ki-67 of 50-80% was reported in the primary tumor and metastatic lesions.Discussion: Metastatic insulinomas carry a significant morbidity and mortality risk. Surgical resection to decrease tumor burden can reduce the risk of hypoglycemia. Histopathology is essential in treatment decision making. Surprisingly our patient’s pathology revealed poorly differentiated neuroendocrine carcinoma, changing the prognosis and treatment. Treatment with platinum-based chemotherapy and etoposide is the standard of care for aggressive neuroendocrine neoplasms. Despite hypoglycemia resolution following surgery and good DOTATATE uptake by the well differentiated neuroendocrine tumor portion, our patient’s prognosis remained poor in view of the high-grade carcinoma. Due to complicated hospital course, and decreased functional status patient was not a candidate for chemotherapy immediately post hospital discharge.

2407 Clinical Challenges of Diagnosis and Management: A Case of Malignant Insulinoma With Hepatic Metastasis

INTRODUCTION: Insulinoma is a rare type of neuroendocrine tumor, about 4 cases per 1 million person-years. It can present at varied sites of body and metastasize extensively and progress rapidly. We present a case of rare and complicated duodenal insulinoma with significant hepatic metastases requiring integrated diagnostic workup and multidisciplinary management with specialties- gastroenterology, pulmonary, oncology, endocrinology and interventional radiology. CASE DESCRIPTION/METHODS: 70 year old male with PMHx. of tobacco who presented with fall. When EMS arrived, patient was found to be hypoglycemic. Noted to have increased liver enzymes, CT of Abdomen showing multiple liver lesions and heterogenous lesion near or arising from the distal stomach/pylorus. Due to refractory hypoglycemia, he was started on D20W on a high rate. GI performed EGD which showed large penetrating duodenal ulcer at posterior wall of duodenal bulb and biopsy showed reactive changes but negative for intestinal metaplasia. IR guided Liver Biopsy was performed which showed Metastatic Neuroendocrine tumor, grade 3. Immunostains reveal neoplastic cells positive for synaptophysin. Ki67 show high proliferation (up to 50%). B-OH gastrin level, VIP, proinsulin were normal, insulin and c-peptide were interestingly low. Also, ACTH sim test was negative. Chromogranin was elevated. On repeat EGD with EUS and biopsy obtained directly from duodenal bulb was consistent with neuroendocrine tumor diagnosis. Also, Octreoscan scan did not display of Octreoscan uptake. Given this finding and the high KI-67 index, the hepatic metastases were thought likely somatostatin receptor negative. IR decided to perform embolization. IR angiography, showed very large hyper vascular tumor occupying the entire left and anterior right lobe of the liver and 2/3 left hepatic artery. It did persist despite left, right gastric artery and 2/3 left hepatic artery embolization. Later, patient was weaned off dextrose drip and blood sugars stabilized. Patient discharged home with follow up with IR, gastroenterology and Oncology team. DISCUSSION: This is rare case of hepatic metastatic insulinoma with paradoxical negative diagnostic parameters and atypical location, successfully diagnosed by EUS endoscope and liver biopsy and managed by multidisciplinary specialties.

A Case of Malignant Insulinoma with Uncontrolled Blood Glucose Level where a Debulking Surgery was Useful

A Case of Malignant Insulinoma with Uncontrolled Blood Glucose Level where a Debulking Surgery was Useful

Malignant Metastatic Insulinoma in a Dog

Background: Insulinomas are tumors of the pancreatic islet beta cells that secreting insulin. They are malignant neoplasms and rarely seen in dogs. Because insulinomas secrete excessive insulin and hypoglycemia occur. The most common clinical symptoms are seizures, extreme weakness, and other neurological abnormalities. The tumors typically release insulin episodically, with clinical signs being seen intermittently as a result. These are most often associated with prolonged starvation or prolonged periods of exertion. Insulinoma occurs most often in middle-aged and older dogs, averaging nine years in age. They affect both sexes and are more likely in larger breeds. The most commonly afflicted breeds are German Shepherds, Irish Setters, Boxers, Golden Retrievers and Terriers. Case: In this study, a case of malignant insulinoma with multiorgan metastasis in a 7-year-old hunting dog that brought to the clinic with complaints of constipation and inappetence were evaluated by clinical, cytological, histopathological and immunohistochemical fndings. Owner stated that the animal suffers from constipation for 4 days, but no vomitus or nervous symptoms were present. Clinical efforts not solved the constipation. For to the defnitive diagnosis the dog decided to underwent laparotomy. After a midline abdominal approach multiple whitish, hard and irregular metastatic tumoral masses were observed in different abdominal organs. Because of the poor prognosis and according to owner’s acceptance the dog euthanatized at the same time. At necropsy, a bloody serous fluid approximately 500 mL was found in the abdominal cavity. The intestines were hyperemic and hemorrhagic in some areas. A hemorrhagic 9x5x3 cm in diameter mass was observed on the pancreas. Mesenterial adhesions were formed due to mass between duodenum and jejunum. The mass was moderately hard and cut surface was bloody, necrosis was observed in some areas. At the gross examination, whitish color, various sized and multiple metastatic masses were noted in spleen, liver, lymph nodes and lungs. Before formalin fxation, impression smears were made from the pancreatic mass. In cytological preparations of the lesion, epithelial cells in different shapes and sizes were observed. At the histopathological examination, the tumor mass consisted of anaplastic, pleomorphic cells that have pale cytoplasm, vesicular nucleus and prominent nucleolus. Diffuse necrotic areas were noted in the mass. Similar metastatic masses were seen in liver, spleen, lungs and kidneys. The tumor cells were positive for insulin and negative for glucagon immunohistochemically. Discussion: Insulinomas generally caused nervous symptoms due to hypoglycemia. Metastasis may occur in some cases and generally lymph node metastasis occurs. Spleen metastasis are very rare in insulinoma cases. The mean age of the occurrence of insulinoma is generally older than 9-year-old. In this case, a case of malignant insulinoma with multiorgan metastasis and caused constipation due to intestinal adhesions in a dog was presented with clinical and pathological fndings. Best of the author’s knowledge insulinoma as a cause of constipation not previously reported in a dog. The aim of this study was to report a case of metastatic insulinoma without neurological symptoms but constipation in a 7 years old hunting dog by clinical, pathological, cytological and immunohistochemical fndings. Keywords: Malignant insulinoma, constipation, cytology, histopathology, immunohistochemistry, dog.

A case of malignant insulinoma: successful control of glycemic fluctuation by replacing octreotide injections with octreotide LAR injections

A 73-year-old woman with malignant insulinoma was treated with 100 μg/day octreotide for unresected insulinoma and liver metastases. The daily administration of the drug induced hyperglycemia after dinner in addition to existing fasting hypoglycemia possibly because this drug suppressed both insulin and glucagon secretion and its blood concentration was unstable. After replacing a daily injection of octreotide with a monthly injection of octreotide long-acting repeatable (LAR), blood glucose levels stabilized within the normal range. The findings of the present study showed that octreotide LAR could be useful for the long-term treatment of unresectable insulinomas.

A Case of Malignant Insulinoma Metastasized to Liver after Partial Pancreatectomy due to Insulinoma 10 Years before

Malignant insulinomas are very rare endocrine tumours with a variable clinical course. Here, a case of a malignant insulinoma, resected from the tail of the pancreas 10 years previously, which was found to have hepatic metastasis, is reported. A pancreatic mass, without evidence of metastasis, has been found using an abdominal CT scan and intra-operative ultrasonography 10 years previously. Recently, the patient has suffered from dizziness, sweating and an altered mentality. Hyperinsulinemia was diagnosed from the biochemical laboratory finding. An abdominal CT scan and intra-operative abdominal sonography showed multiple hepatic metastasis, without local recurrence in pancreas. Therefore, a partial hepatic segmentectomy was performed. Immunohistochemical staining of the postoperative specimen was strongly positive for insulin. The postoperative biochemical response was normalized, and the patient experienced no further hypoglycemic symptom (J Kor Soc Endocrinol 21:68~73, 2006).

Abstract #104: A Real Estate Agent with Episodes of Confusion: A Case of Malignant Insulinoma

Abstract #104: A Real Estate Agent with Episodes of Confusion: A Case of Malignant Insulinoma

Streptozotocin treatment for malignant insulinoma.

A CASE of malignant insulinoma was treated with streptozotocin intravenously and by coeliac axis infusion. Treatment was repeated over a period of two years, and the total dose was 82.5g. Several clinical remissions of hypoglycaemia were obtained despite the persistence of abnormally elevated plasma insulin levels. At necropsy tumour metastases within the liver were not necrotic. Severe medial degeneration of the lower abdominal aorta was present but the relationship of this change to intra-arterial infusion of the drug could not be established.