Pomegranate peel, chokeberry leaves and Ironwort extract as novel natural inhibitors of amylin aggregation and cellular toxicity in pancreatic β cells

ObjectiveTo report the clinical signs, histopathology results, and prognostic factors for outcomes following excision for feline insulinoma (INS).Study designRetrospective study.Sample populationTwenty client‐owned cats.MethodsMedical records from 2006 to 2020 were reviewed by Veterinary Society of Surgical Oncology members for cats with hypoglycemia resulting from INS, with surgical excision and follow up. Clinical signs and histopathology results were summarized. Factors potentially related to disease‐free interval (DFI), disease‐related death (DRD), and overall survival time (OST) were analyzed with a Cox proportional hazards regression analysis.ResultsAll cats were hypoglycemic on presentation with neurologic signs in 18 out of 20 and inappropriate insulin levels in 12/13. Excision of insulinomas resulted in immediate euglycemia or hyperglycemia in 18 cats. Eighteen cats survived to hospital discharge. The median time to death or last postoperative follow up was 664 days (range: 2‐1205 days). Prognostic factors included age at presentation (for DFI); time to postoperative euglycemia (for DRD); preoperative and postoperative serum blood glucose concentrations; metastasis at the time of surgery (DFI and DRD), and histopathologic tumor invasion (for OST). The median OST for all cats was 863 days. The 1‐, 2‐ and 3‐year survival rates were 75%, 51%, and 10%, respectively.ConclusionExcision of insulinoma resulted in euglycemia or hyperglycemia in most cats. Negative prognostic factors included young age, low serum glucose concentrations, metastasis at time of surgery, tumor invasion, and shorter time to euglycemia.Clinical significanceSurgical excision resulted in survival times comparable to those of canine INS.

Chronic wounds are wounds that recur or fail to heal by six weeks and cost the United States $150 million through prolonged and frequent hospital visits. Chronic wounds can be caused by poor blood circulation, compromised immune systems, and limited mobility. Current treatments include daily dressing changes that maintain moist wound environments, surgical debridement, skin grafts, and vacuum assisted wound closure. There is a need for an accelerated wound therapy that is inexpensive, nonsurgical, and reduces the patient’s discomfort.Insulin treatments have shown promise in wound healing because it is the main initiator of the mitogen-activated protein kinase – extracellular signal-regulated kinases (MAPK-ERK) pathways and the phosphoinositide 3-kinase – protein kinase B (PI3K-Akt) pathway. This leads to the stimulation of haptotactic migration, collagen production, cell proliferation and a reduction in apoptosis. Pilot studies in the lab showed accelerated healing in a chronic wound model by using RIN-m, which are insulin secreting cells (ISCs) derived from pancreatic rat tumor cells. The results showed that wounds that were treated with ISCs closed at day 28 of the study, while the wounds treated by the controls did not close during the 35-day study. Since cancer cells also promote growth and resist apoptosis it is necessary to establish that these results stem from the insulin treatment and not the use of cancer cells. The goal of this present study is to evaluate the effects of cell lines derived from RIN-m, namely RIN-5F and RIN-14B, which secrete only insulin and somatostatin respectively. These cells were combined with prepolymer solutions to create polyethylene glycol diacrylate (PEGDA) hydrogels. Conditioned media were used in an insulin ELISA to determine insulin concentrations. The conditioned media was also used to perform scratch assays using HaCaT keratinocytes to model an in vitro wound and monitor the rate of scratch closure. The ELISA showed that the cell bioactivity and insulin release were not impeded by encapsulation, with the insulin concentrations at expected levels. RIN-5F had high levels of insulin secretion, and RIN-14B had low levels of insulin secretes. Since RIN-14B secretes somatostatin, which suppresses insulin, these results are expected. The experimental groups treated with RIN-5F conditioned media had the smallest gap area at the end of the 48 hour study than the experimental groups treated with RIN-14B conditioned media in the scratch assay. Since the RIN-5F experimental groups stimulated keratinocytes to close gaps faster than the RIN-14B experimental groups, it strongly suggests that the results of the wound healing, both in these experiments and in previous lab work, stem from the insulin treatment and not simply the use of cancer cells.

Insulinomas (INS) are the most common human and canine functioning pancreatic neuroendocrine tumours. The long-term prognosis for malignant INS is poor, because micrometastases are frequently missed during surgery. As human and canine malignant INS share clinical and histopathological features, dogs have been proposed as models for INS research. Using RNA-sequencing, we conducted a pilot study to better understand the underlying molecular mechanisms of canine INS. Normal canine pancreas and lymph node control tissues were compared with primary INS and INS-metastatic lymph nodes, revealing more than 3,000 genes differentially expressed in normal pancreas compared to primary INS. Only 164 genes were differentially expressed between primary INS and INS-metastatic lymph nodes. Hierarchical clustering analysis demonstrated similar genetic profiles in normal pancreas and early clinical stage primary INS, whereas late clinical stage primary INS resembled the genetic profile of INS-metastatic lymph nodes. These findings suggest that markers of malignant behaviour could be identified at the primary site of the disease. Finally, using the REACTOME pathways database, we revealed that an active collagen metabolism, extracellular matrix remodelling, beta-cell differentiation and non-beta-cell trans-differentiation might cause disease progression and hyperinsulinism in INS, identifying major pathways worthy of future research in this currently poorly controlled disease.

Malignant insulinoma, a very rare cause of pediatric hypoglycemia.

C-peptide suppression test (CPS) was shown to diagnose the cause of hyperinsulinemic hypoglycemia, i.e. insulinoma, as effectively as supervised 72-hour fast test with less time consuming and cost. In the conventional CPS, regular insulin (RI) is used to induce hypoglycemia that subsequently suppresses endogenous insulin secretion. As RI is measurable in plasma insulin (PI) assay, plasma C-peptide (PCP) but not PI response is therefore used for assessment of endogenous insulin secretion in CPS using RI. As rapid acting insulin analogs (RA) are not measurable in a selected PI assay, both PCP and PI levels can be used to assess endogenous insulin secretion if an RA is used instead of RI in CPS. There is no study on PI and PCP responses to RA in insulinoma. This study aimed to examine efficacy of modified CPS, so-called insulin and C-peptide suppression test (ICPS) by using an RA (insulin aspart) in the diagnosis of insulinoma. Ten patients, 7 with histopathological proven insulinoma (IN) and 3 with non-insulinoma (non-IN), underwent ICPS. Blood samples were collected for measurement of plasma glucose (PG), PCP, and PI using a Roche Cobas 8000 module e602 which does not measure insulin aspart at before and every 10-20 minutes during intravenous infusion of insulin aspart at the rate of 0.05-0.075 unit/kg/hr. The test was terminated if the patients had a PG level of <40 mg/dL. There was no difference in baseline biochemical data between two groups. At the end of the test, IN had significantly higher PCP level (range: 0.60-10.20 vs. 0.31-0.48 ng/mL and median: 4.67 vs. 0.47 ng/mL; p = 0.017), lower percentage of PCP suppression (range: 2.10-53.10% vs. 63.08-91.24% and mean: 24.78 ± 19.4% vs. 73.17 ± 15.7%; p = 0.005), higher PI level (range: 1.13-113.70 vs. 0.22-0.73 µIU/mL and median: 21.29 vs. 0.49 µIU/mL; p = 0.017) and lower percentage of PI suppression (range: -14.63-81.32% vs. 88.14-96.10% and mean: 28.45 ± 36.2% vs. 93.31 ± 4.5%; p = 0.003) than did the non-IN. No overlapping of these parameters was observed between IN and non-IN. Using the same cut-off levels as the supervised 72-hour fast test, the insulin criterion (≥3 µIU/mL) in ICPS had a sensitivity of 86% and a specificity of 100% and the C-peptide criterion (≥0.6 ng/mL) in ICPS had a sensitivity of 100% and a specificity of 100%. There was a high correlation of 89% between using PCP and PI responses. In conclusion, ICPS using an RA is effective in the diagnosis of insulinoma.

Insulinoma is a rare but common functional neuroendocrine tumor that secretes an excess amount of insulin resulting in mostly fasting hypoglycemia but can also cause postprandial hypoglycemia. It usually presents with neuroglycopenic and autonomic sympathetic symptoms that resolve following the administration of dextrose. The patients may remain symptomatic from 1 week to as long as several decades before diagnosis. Insulinoma presenting with psychiatric symptoms has been documented in case/case series reports. Laboratory findings of elevated insulin and C-peptide level in the presence of hypoglycemia and absence of plasma sulfonylurea are suggestive of the diagnosis. Localization of the tumor is essential preoperatively. Surgery usually cures most of the patients, but a minority will have a recurrence especially with malignant insulinoma. The manuscript presents a case of insulinoma presenting with psychiatric symptoms without sympathetic symptoms that led to the delay of the diagnosis for 3 months as initially thought to be related to psychiatric problems. Pancreatic insulinoma was localized by computed tomography (CT) scan and confirmed with endoscopic ultrasound (EUS). The patient underwent successful resection of the tumor, and her symptoms were completely resolved. J Med Cases. 2020;11(5):142-144 doi: https://doi.org/10.14740/jmc3477

Correction to: A Man With Whipple’s Triad Secondary to a Malignant Insulinoma

Инсулинома - сложности диагностики

Сложности диагностики инсулиномы

Objective To investigate the clinical characteristics, biochemical parameters, radiographic features and prognosis of malignant insulinomawith liver metastasis. Methods We retrospectively analyzed the clinical data of 4 cases of malignant insulinomaswith liver metastasis recruited in Peking Union Medical College Hospital from December 2016 to December 2018. Related literature were reviewed in this article. Results All the 4 cases manifested as Whipple triad with hypoglycemic symptoms gradually aggravated. They all met the criteria for the typical hyperinsulinemic hypoglycemia. Three patients had liver metastasis at the time of diagnosis. Qualitative diagnosis indicated that the ratio of fasting proinsulin to insulin was increased. All 4 patients undertook various radiographic examination. The sensitivity of pancreatic enhanced magnetic resonance imaging (MRI) was the highest in diagnosing primary pancreatic tumor and liver metastases (4/4). Abdominal ultrasound was not sensitive to primary pancreatic tumor (1/4), but sensitive to liver metastases (3/4). All 4 patients underwent insulinoma resection, of which 3 received hepatic metastases resection. Postoperative pathology finding was consistent with liver metastasis of neuroendocrine tumors. Ki-67 index was 1%-15%. Tumor grade was G1 in 2 patients, and G2 in the other 2 patients. Taken together the findings in the literature, it suggested that the increase of proinsulin/insulin ratio is of great significance in the diagnosis of malignant insulinoma. In the treatment of malignant insulinoma with hepatic metastasis, surgical resection of primary tumor and hepatic metastases yielded relative optimal prognosis. Conclusion The increase of proinsulin/insulin ratio is of great clinical significance in the diagnosis of malignant insulinoma. Enhanced pancreatic MRI is the most sensitive for both primary tumor and liver metastases. Surgical removal of primary and metastatic lesions is the most effective treatment to improve prognosis of malignant insulinoma with liver metastasis. Key words: Malignant insulinoma; Liver metastasis; Proinsulin/insulin ratio

The present study investigated whether melatonin influences the expression/oligomerization of amylin with endoplasmic reticulum (ER) stress in rat insulinoma INS-1E cells. No change in cell survival after exposure to thapsigargin- and tunicamycin-combined melatonin treatment or melatonin-only treatment was observed when compared with the normal control cells. With thapsigargin-only or combined tunicamycin-melatonin treatments, phosphorylation of extracellular signal-regulated kinase (ERK) was significantly increased compared with control and melatonin-only treatments. A significant increase was observed in the levels of ER stress markers, namely, phosphorylated inositol-requiring protein 1α (p-IRE1α), CCAAT enhancer binding proteins (C/EBP)-homologous protein, p-eukaryotic translation initiation factor 2α and cleaved caspase-12, in the thapsigargin-combined melatonin-treated cells as compared with the tunicamycin-combined or only melatonin treatment. The melatonin-only treatment resulted in increased levels of amylin expression/oligomerization in 15-25 kDa and insulin proteins, compared with the thapsigargin- and tunicamycin-combined melatonin treatments. Treatment with ER stress inhibitor 4-phenylbutyric acid (4-PBA) did not suppress amylin expression/oligomerization or insulin production with thapsigargin or tunicamycin treatment. Levels of cleaved caspase-12 were significantly decreased in the thapsigargin- or tunicamycin-4-PBA combination treatments. Therefore, whether melatonin regulates the amylin expression/oligomerization in thapsigargin- or tunicamycin-combined with Bafilomycin A1 (autophagy inhibitor) or MG132 (proteasome inhibitor) treatments were investigated. Amylin expression/oligomerization with melatonin treatment was significantly decreased in the thapsigargin- or tunicamycin-combined Bafilomycin A1 or MG132 treatments. Since these outcomes are involved in cell viability, they indicate that increased cell death leads to decreased amylin expression/oligomerization, however, the effects of melatonin treatment on amylin expression/oligomerization induce proliferation of pancreatic β cells and improve the cellular functions of pancreatic β cells.

Objective To investigate the application value of augmented reality (AR) technology in pancreatoduodenectomy (PD). Methods The retrospective and descriptive study was conducted. The clinicopathological data of 3 male patients who underwent PD in Tsinghua University Affiliated Beijing Tsinghua Changgung Hospital from June 2018 to February 2019 were collected. The 3 patients were aged from 52 to 63 years, with a median age of 57 years. Digital imaging and communication standard format data of enhanced computed tomography (CT) scan were collected, the three-dimensional (3D) images of abdominal arteries, portal vein, descending duodenum, pancreatic body and tail, pancreatic head, common bile duct, and pancreatic duct were reconstructed. The results were imported into the AR software. Optical tracking based on two-dimensional codes and manual interactive rigid registration were adopted for intraoperative navigation. Observation indicators: (1) surgical and postoperative conditions; (2) postoperative pathological examination; (3) follow-up. Follow-up using outpatient examination or telephone interview was conducted to detect survival of patients and tumor metastasis and recurrence up to June 2019. The measurement data with skewed distribution were expressed as M (range). Count data were expressed as absolute numbers. Results (1) Surgical and postoperative conditions: all the 3 patients underwent PD with AR technology as intraoperative navigation successfully. The operation time, volume of intraoperative blood loss, and duration of postoperative hospital stay were 6 hours (range, 5-8 hours), 700 mL (range, 300-900 mL), 11 days (range, 9-12 days). There was no perioperative death or complication occured. After surgery, the patients who underwent PD combined with superior mesenteric vein (SMV) resection and reconstruction had patent SMV on the enhanced computed tomography examination. (2) Postoperative pathological examination: results of pathological examination showed 1 case of intraductal papillary mucinous neoplasm (IPMN) of the pancreas with invasive adenocarcinoma (neoplasm invading SMV), 1 case of insulinoma, and 1 case of periampullary neuroendocrine carcinoma, respectively. (3) Follow-up: 3 patients were followed up for 4-12 months, with a median follow-up time of 6 months. During the follow-up, the patient with IPMN of the pancreas and invasive adenocarcinoma had liver metastasis at 3 months after surgery, and received chemotherapy at other hospital. After 4 cycles of chemotherapy, the metastatic nodule shrank, and the patient was still in follow-up up to deadline of follow-up. Other 2 patients had no recurrence or metastasis. Conclusion AR technique assisted PD is safe and feasible, which is helpful to indentify vascular branches and tracks. Key words: Pancreatic neoplasms; Augmented reality technology; Three-dimensional reconstruction; Pancreatoduodenectomy; Surgical navigation

Nesidioblastosis is a rare cause of persistent hyperinsulinemic hypoglycemia in adults. It is difficult to distinguish between nesidioblastosis and insulinoma based on clinical manifestations, and traditional imageology cannot improve the diagnostic rate. The final diagnosis relies on the histopathologic evaluation. The pathogenesis of nesidioblastosis is unknown, it may be related to gene mutation, gastric bypass operations or special hormonal situation. The preferred treatment of nesidioblastosis is surgery, but the resection volumes remain undefined. Key words: Nesidioblastosis; Adults; Hyperinsulinemic hypoglycemia; Pancreactomy

Objective To analyze the relationship between the changes of fasting plasma level of leptin and obesity in patients with insulinoma before operation. Methods From January 2003 to May 2008, 40 patients with insulinoma diagnosed at Peking Union Medical College Hospital were selected. Preoperative fasting plasma samples of them were collected. From January 2003 to May 2008, the plasma samples of 28 volunteers matched with age, gender and body weight matched with the patients were collected as the controls. All the subjects were divided into overweight-obesity group and normal weight group according to their body mass index (BMI). Plasma levels of leptin of all the subjects were measured by enzyme linked immunosorbent assay(ELISA). The Mann-Whitney U test and the correlation coefficient test were used for statistical analysis. Results The plasma leptin level of patients with insulinoma was 0.35 ng/mL (0.25 ng/mL to 1.13 ng/mL), which was higher than that of the control group (0.29 ng/mL, 0.25 ng/mL to 1.15 ng/mL), and the difference was statistically significant (U=324.50, P=0.003). In the normal-weight group, the plasma leptin level of the patients with insulinoma was 0.35 ng/mL (0.27 ng/mL to 0.62 ng/mL), which was higher than that of the control group (0.28 ng/mL, 0.25 ng/mL to 0.37 ng/mL), and the difference was statistically significant (U=28.000, P=0.001). While in the overweight-obesity group, the plasma leptin levels of the patients with insulinoma and the controls were 0.35 ng/mL (0.25 ng/mL to 1.13 ng/mL) and 0.34 ng/mL (0.26 ng/mL to 1.15 ng/mL), respectively, and the difference was not statistically significant (U=153.500, P=0.525). Plasma leptin levels in both the patients with insulinoma and the controls, were correlated with BMI (r=0.355, P=0.025; r=0.571, P=0.001, respectively). Conclusion Preoperative fasting plasma level of leptin increase in patients with insulinoma which is correlated with BMI. Key words: Insulinoma; Obesity; Leptin; Insulin; Body mass index; Pancreatic neuroendocrine tumor

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Objective To synthesize 18F-fluoro-L-3, 4-dihydroxyphenylalanine (18F-FDOPA) and evaluate its biodistribution and kinetics in mice, in order to explore its feasibility for insulinoma detection. Methods 18F-FDOPA was synthesized by a three-step nucleophilic reaction. Radiolabeling yield, radiochemical purity and stability in vitro were analyzed. Normal mice were scarified at 2, 5, 15, 30, 60 and 120 min postinjection to measure radioactive counts in main organs. Biodistribution and kinetics were evaluated by dynamic microPET in normal mice. The insulinoma tumor (INS-1) model was established and dynamic microPET was performed immediately after intravenous injection and stopped at 60 min. Region of interest (ROI) was drawn to access time-activity curve (TAC) in main organs and insulinoma. Results 18F-FDOPA was prepared with radiochemical yield of (11.0±0.4)%, radiochemical purity of (99.3±0.2)%. The radiochemical purity was still >99% after being stored for 120 min at room temperature. Predominant uptake of 18F-FDOPA was in the kidneys, and was cleared rapidly in blood. Pancreas showed stable uptake from 20 to 50 min, which was (5.98±0.71) percentage activity of injection dose per gram of tissue (%ID/g) at 20 min and (4.62±0.47) %ID/g at 50 min postinjection, respectively. 18F-FDOPA showed high affinity to tumor tissue of insulinoma ((11.42±0.70) %ID/g) at 2 min. Conclusions 18F-FDOPA could be easily synthesized in short total reaction time with high radiochemical purity and stability. Early phase imaging of 18F-FDOPA may be helpful for insulinoma detection. Key words: Levodopa; Isotope labeling; Fluorine radioisotopes; Insulinoma; Positron-emission tomography; Mice

Objective To investigate the clinical efficacy of middle segment pancreatectomy (MSP) in treatment for pancreatic neck and body tumors. Methods From Jan. 2000 to Dec. 2016, the clinicopathological data of 26 patients with pancreatic neck or body tumors were analyzed retrospectively. Results All of the 26 patients received middle segment pancreatectomy. 14 cases had serous or mucinous cystadenomas. The tumor diameter was 2.3 to 5.6 cm (averaging from 3.8 cm) . 9 cases had solid pseudopapillary tumors. The tumor diameter was 3.3 to 5.0 cm (averaging from 3.6 cm) ; One case had insulinoma and the diameter was 2.0 cm. Two cases had nonfunctional pancreatic neuroendocrine tumors, and the diameter was 2.1 and 2.4 cm. The post-complication morbidity rate was 53.8%. The main post-complications of the group were pancreatic fistula (9 cases,34.2%) , intra-abdominal infection (1 case, 3.8%) , delayed gastric emptying (2 cases, 7.6%) , lymphatic fistula (1 case, 3.8%) , and abdominal infection (1 case, 3.8%) . All of the 26 patients healed after surgery without undergoing surgery again. There were no mortality during perioperative period. All patients were followed up for 6 to 60 months. All of the 26 patients had good life quality, without new-onset diabetes or cancer recurrence during the follow-up period of 6 to 60 months after operation. Conclusion Middle segment pancreatectomy is safe and feasible in treatment of benign or low-graded malignant pancreatic neck and body tumors and is capable of preserving pancreatic endocrine and exocrine function. Key words: Pancreatic tumors; Middle segment pancreatectomy; Complication

Objective To study the component ratios of pancreatic carcinoma, and prognosis of patients with the different pathological types. Methods The data of 92 011 pancreatic carcinoma patients who were diagnosed by the definite pathological method from 2004 to 2014 were extracted from the US SEER database. The life table was used to calculate the 1-, 3- and 5-year survival rates. The Kaplan-Meier was used to construct the survival curves of the patients. The Cox univariate analysis was applied to evaluate the HR of the different pathological types, and the χ2 test and independent sample t-test were used to evaluate the baseline data. Results The overall 5-year survival of 92 011 pancreatic carcinoma patients was 7.6%. The median survival time was 8.8 months and the component ratios of the pancreatic ductal adenocarcinoma (PDAC), pancreatic epithelium cancer bedside the PDAC, neuroendocrine tumors, undifferentiated carcinoma, mesenchymal carcinoma and rare cancer unclassified were 85.78%, 6.40%, 6.67%, 0.97%, 0.10% and 0.08%, respectively. The differences were statistically significant between the baseline data such as age, gender, race and position (P<0.05). The overall 5-year survivals of the PDAC, pancreatic epithelium cancer beside the PDAC, neuroendocrine tumors, undifferentiated carcinoma, mesenchymal carcinoma and rare cancer unclassified were 4.2%, 13.4%, 49.2%, 5.0%, 29.2% and 24.5%, respectively, and the median survival times were 5 months, 7 months, 58 months, 2 months, 26 months and 7 months respectively. The distant metastasis rate of neuroendocrine carcinoma was the lowest (35.0%). The undifferentiated carcinoma was the most prone to distant metastases (65.2%). Basically, half of the other types of pancreatic cancer had metastasis at the time of diagnosis. In pancreatic epithelium cancer beside the PDAC, the high to low 5-year survival rates were solid pseudopapillary carcinoma (87.3%), cystadenocarcinoma (36.8%), intraductal papillary mucinous neoplasm (36.5%), acinar cell carcinoma (20.0%), and pancreatic adenocarcinoma mixed with other subtypes (19.7%). The incidence of the other types of pancreatic carcinoma was less than 8%, such as mucinous carcinoma, squamous cell carcinoma, adenosquamous carcinoma and signet ring cell carcinoma. In neuroendocrine tumor, the 5-year survival rate of insulinoma (77.1%) was higher than those of neuroendocrine tumor (malignant) (NET, 62.0%) and neuroendocrine carcinoma (NEC, 46.5%). Conclusion The prognosis of pancreatic carcinoma was poor, and the pathological types had a significant impact on the prognosis of the patients. Key words: Pancreatic carcinoma; Prognosis; Pathological types; Surveillance, epidemiology, and end results (SEER)

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)