Insulinomas: localization with selective intraarterial injection of calcium.
ABSTRACT To facilitate the noninvasive preoperative localization of islet cell tumors less than 15 mm in diameter, the authors examined the use of calcium as an insulin secretagogue in an arterial stimulation venous sampling (ASVS) technique. In four patients with episodic hypoglycemia, calcium gluconate (0.01-0.025 mEq Ca2+/kg) was injected directly into branches of the celiac plexus (gastroduodenal, splenic, and hepatic arteries) and the superior mesenteric artery. In all patients, serum levels of insulin rose abruptly in blood samples taken from the right hepatic vein 30 and 60 seconds after the infusion of calcium into the artery supplying the tumor; injection into an artery not supplying the tumor did not result in a similar rise. Accurate localization of the insulinomas was verified at surgery in three patients. In the fourth patient, who did not undergo surgery, arteriographic results were positive for insulinoma at the predicted site. On the basis of these results, the authors believe noninvasive ASVS may replace invasive portal venous sampling as the most effective method for the localization of occult insulinomas.
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ABSTRACT: The endogenous hyperinsulinemia hypoglucemic syndrome (EHHS) can be caused by an insulinoma, or less frequently, by nesidioblastosis in the pediatric population, also known as non insulinoma pancreatic hypoglycemic syndrome (NIPHS) in adults. The aim of this paper is to show the strategy for the surgical treatment of ehhs. A total of 19 patients with a final diagnosis of insulinoma or NIPHS who were treated surgically from january 2007 until june 2012 were included. We describe the clinical presentation and preoperative work-up. Emphasis is placed on the surgical technique, complications and long-term follow-up. All patients had a positive fasting plasma glucose test. Preoperative localization of the lesions was possible in 89.4% of cases. The most frequent surgery was distal pancreatectomy with spleen preservation (9 cases). Three patients with insulinoma presented with synchronous metastases, which were treated with simultaneous surgery. There was no perioperative mortality and morbidity was 52.6%. Histological analysis revealed that 13 patients (68.4%) had benign insulinoma, 3 malignant insulinoma with liver metastases and 3 with a final diagnosis of SHPNI. Median follow-up was 20 months. All patients diagnosed with benign insulinoma or NIPHS had symptom resolution. The surgical treatment of EHHS achieves excellent long-term results in the control of hypoglucemic symptoms.Cirugía Española 01/2014; · 0.87 Impact Factor
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ABSTRACT: Background Although fasting hypoglycemia has historically been considered the hallmark of insulinoma, postprandial hypoglycemia has also been occasionally reported as the predominant feature. We report a rare case of an insulinoma diagnosed in an individual presenting exclusively with postprandial hypoglycemia without fasting hypoglycemia. Case Report A 47-year-old woman with medical history of migraine, depression, hypercholesterolemia, iron deficiency anemia, and peptic ulcer disease presented with complaints of frequent episodes of dizziness, blurring of vision, and anxiety over the past 4 months. These episodes usually occurred 1-2 hours after eating and resolved with ingestion of sugary foods. Home glucometer readings during typical symptoms were 47-64 mg/dL. Physical exam revealed a healthy-appearing middle-aged female with BMI of 28. Laboratory data after an overnight fast showed serum blood glucose 77mg/dL and AM cortisol 9.6 (5-25 µg/dl). Hemoglobin A1C, thyroid function tests, IGF-1, liver function tests, and kidney function were in normal range. She was instructed to bring a typical meal to the clinic for monitoring of postprandial glucose levels. Three hours after ingestion of the meal, she developed typical adrenergic symptoms during which laboratory analysis revealed a serum glucose level of 44 mg/dL, C-peptide of 2.9 (0.8-3.1ng/ml), insulin level of 32 (0-17 µIU/lt), negative sulfonylurea screen, and insulin antibodies. She was treated with 15 grams of oral glucose, which alleviated her symptoms. Medical therapy with acarbose was attempted, but did not lead to significant reduction in hypoglycemic events. CT abdomen/pelvis confirmed the presence of a tumor in the tail of the pancreas. The patient subsequently underwent partial pancreatectomy, splenectomy, and lymph node resection, with resolution of symptoms. Histopathological analysis confirmed insulinoma. Conclusions We present a rare case of an insulinoma in the setting of verified postprandial hypoglycemia with elevated insulin and C-peptide levels. Although insulinomas typically present with fasting hypoglycemia, it is important to consider insulinoma in the differential diagnosis of patients presenting exclusively with postprandial hypoglycemia.The American journal of case reports. 01/2014; 15:488-91.
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ABSTRACT: Occult insulinomas are tumors which are not identified by conventional tests. Selective arterial calcium stimulation and hepatic venous sampling (ASVS) can be used to identify the pancreatic segment where the tumor is located. We report the case of a patient with clinically proven insulinoma detected only by ASVS. The details of the procedure are also discussed.Radiologia Brasileira 06/2004; 37(3):223-225.