Insulinoma

1
Insulinoma

• 95/08/25
• ???

2
Case Base Data

• Name?XX
• Sexfemale
• Age82 y/o
• Chart no 10628043
• Date of admission 95/8/4

3
Chief Complaints

• Dizziness and lightheadness sensation frequency
  in past five months

4
Past History

• H/T with Dilatrend (25 mg) 1 po qd for many
  years
• Denied DM history
• Left femoral fracture s/p ORIF at 804 hospital

5
Present Illness

• Frequent dizziness and lightheadness in past
  five months especially while she felt hunger
  sensation and relief while she took food.
• No body weight loss and good appetite
• Dizziness and conscious disturbance developed on
  95/08/04.
• She was brought to ER for help and blood sugar
  showed 40 mg/dl.

6
Physical Examination (1)

• Vital signs BP 112/60 mmHg
  
• TPR36/70/20
• Conscious levelclear
• Conjunctiva not pale Scleraanicteric
• Light reflex (,)
• Neck supple,JVE(-),LAP(-)
• Chest symmetrical expansion
• breathing sounds bil clear

7
Physical Examination (2)

• HeartRHB,no murmur
• Abdomensoft and flat,no tenderness
• Normoactive bowel sounds
• Extremitiesno lower leg edema
• freely movable

8
Lab Data

• CBC/DC WBC5700 Hb12.8, MCV91.2,
• Platelet196000
• Na/K138.4/4.54 Cr1.4, GOT23, Glucose40

9
Tentative Diagnosis

• Hypoglycemia, cause ?

10
Hospital Course

• Check insulin C-peptide for suspected
  insulinoma and showed insulin (AC)22.6 uIU/ml
  (0.0-15.6), C-peptide3.16ng/ml(0.78-1.8)
• Insulin Antibody0.06 B/F (lt0.06)
• Cortisol (8AM)7.49 ug/dl (6-23)

11

• 8/8 abdomen CT
• 1.Pancreatic tail tumor (1cm),consistent with
  insulinoma
• 2.Status post cholecystectomy
• 3.Hepatic cysts I S5
• 4.Splenic tumor,cyst or solud tumor
• 5.Bilateral renal cysts

12
Abdomen CT
13

• 8/12 Celiac arteriography
• There was a tumor in pancreatic tail (1.2cm)
  and an equivocal tumor in pancreatic head region
  (0.4cm).

14
Angiography
15

• Splenoportal-Venous Sanpli (8/15)
• This procedure was performed via left vein
  apporach percutaneously and transhepatic.
• Multiple bllod sample were obtained from
  different location of splenic vein ,SMV and main
  portal vein

16

• 8/23 Pancreatic tumor and spleen cyst distal
  partial pancreatectomy splenectomy

17
(No Transcript)
18
Insulinoma

• Insulinoma is an uncommon, potentially curable
  cause of hypoglycemia with an estimated incidence
  of 4 cases per million annually.
• Specifically, insulinomas are pancreatic islet
  cell tumors that are often benign but have a
  unique presentation associated with hypoglycemia.

19

• Although the symptoms of hypoglycemia are
  nonspecific, they can be classified into 2 major
  groups noradrenergic symptoms related to
  epinephrine release in response to hypoglycemia
  (pallor, tachycardia, anxiety, perspiration, and
  tremor) and neuroglycopenic symptoms secondary to
  central nervous system glucose deprivation
  (dizziness, headache, confusion, abnormal
  behavior, blurred vision, seizures, and loss of
  consciousness).

20

• Diagnosis of endogenous hyperinsulinemia requires
  the presence of nonsuppressed insulin and
  C-peptide with negative screening for
  sulfonylurea compounds and insulin antibodies.
• The insulin level in a patient with insulinoma is
  generally greater than 6 IU/mL (when measured by
  using radioimmunoassay) when blood glucose level
  is less than 45 mg/dL.

21

• The presence of a hypervascular pancreatic mass
  and a typical picture of endogenous
  hyperinsulinemia are highly suggestive of
  insulinoma in the presence of typical symptoms of
  hypoglycemia.
• More testing is occasionally required in atypical
  cases, including arterial calcium infusion with
  hepatic vein sampling to induce insulin secretion
  and regionalize the tumor before surgical
  intervention.

22
Definition

• An insulinoma is a tumor in the pancreas that
  produces too much insulin

23
Causes, incidence, and risk factors (1)  

• The pancreas is an organ in the abdomen that
  makes the hormone insulin.
• Insulin is required to regulate blood sugar
  levels.
• Tumors of the pancreas that produce too much
  insulin (hyperinsulinemia) are called
  insulinomas.
• High insulin levels cause low blood glucose
  (sugar), also called hypoglycemia.
• The hypoglycemia may be mild, leading to
  symptoms such as anxiety and hunger, or severe,
  leading to seizures, coma, and even death.

24
Causes, incidence, and risk factors (2)

• Insulinomas are rare tumors.
• They usually occur as single, small tumors in
  adults.
• They are very rare in children.
• Most children with hyperinsulinism have multiple
  pockets of overactive insulin-secreting cells in
  the pancreas, rather than a single discrete
  tumor.
• Most insulinomas are not cancer.
• However, about five to ten percent are cancer.
• People with the genetic syndrome called multiple
  endocrine neoplasia Type I (MENI) are at risk for
  developing insulinomas

25
Symptoms

• sweating
• tremor
• rapid heart rate
• anxiety
• hunger
• dizziness
• headache
• clouding vision
• confusion
• behavioral changes
• convulsions
• loss of consciousness

26
(No Transcript)
27
Signs and tests(1)   

• The person's blood may be tested while fasting
  (not eating).
• The person may have
• low blood glucose
• high serum insulin level
• high C-peptide level

28
(No Transcript)
29
Signs and tests(2)

• Other tests may include
• CT scan or MRI of the abdomen to look for a
  pancreatic tumor
• Endoscopic ultrasound to look for a
  pancreatic tumor (when CT or MRI scan is normal)
• Octreotide scan to look for a pancreatic
  tumor (when CT or MRI scan is normal)
• Pancreatic arteriography (when CT or MRI scan
  is normal)
• Pancreatic venous sampling for insulin (when
  CT or MRI scan is normal)

30
Treatment(1) 

• Surgery is the preferred treatment for
  insulinoma.
• The location of the tumor is determined using
  diagnostic testing or surgical exploration.
• Single tumors are removed, but patients with
  multiple tumors usually require partial removal
  of the pancreas (partial pancreatectomy).
• At least 15 of the pancreas is left to prevent
  nutrient malabsorption from lack of pancreatic
  enzymes.

31
Treatment (2)

• If no tumor is found during surgery or a patient
  is not a candidate for surgery, the drug
  diazoxide may be given to lower insulin secretion
  and avoid hypoglycemia.
• A diuretic (water pill) is given with this
  medication to keep the person's body from
  retaining fluid.
• Octreotide has been used to suppress insulin
  secretion in some patients.
• Medication is also used to stabilize the person
  prior to surgery.

32
Prognosis

• In a majority of cases, the tumor is benign and
  surgery is effective.
• However, a severe hypoglycemic reaction or the
  spread of cancerous tumors to other organs can be
  fatal.

33
The End

• Thank you for your attention