Rev Med UAS
Vol. 12: No. 1. Enero-Marzo 2022
ISSN 2007-8013

Ninety-one-year-old female with severe hypoglycemic events secondary to an insulinoma: A case report and review of literature

Mujer de noventa y un años con eventos hipoglucémicos severos secundarios a un insulinoma: Reporte de un caso y revisión de la literatura

Hector Navarro-Chavez, MD1, Julio Garza-Vega, MD1, Victor Segura-Ibarra, MD, PhD2,3,Marisa G. Frausto-Alejos, MD2, Eduardo Flores-Villalba, MD, MSc1,2,3,*

  1. ISSSTE, Hospital Regional de Monterrey, Departamento de Cirugía, Monterrey, Nuevo León, México.
  2. TEC Salud, Escuela de Medicina y Ciencias de la Salud, Departamento de Cirugía, Monterrey, Nuevo León, México.
  3. TEC de Monterrey, Escuela de Ingeniería y Ciencias, Departamento de Manufactura Avanzada, Monterrey, Nuevo León, México.

*Autor de correspondencia:Dr. Eduardo Flores-Villalba
Escuela de Medicina y Ciencias de la Salud TEC de Monterrey,
Monterrey 64849, México. Phone: +52 8358-2000 Ext. 5126
Email: eduardofloresvillalba@tec.mx

DOI http://dx.doi.org/10.28960/revmeduas.2007-8013.v12.n1.007

Texto Completo PDF

Recibido 29 de junio 2021, aceptado 06 de julio 2021

ABSTRACT
Neuroendocrine tumors are a vast group of neoplasms. Insulinomas are the most frequent functioning pancreatic neuroendocrine tumors. Therapeutic gold standard is surgery without which most patients have a fatal outcome due to hypoglycemia. Herein we report a case of a 91-year-old female, with a 3 month history of asthenia and adynamia, which progressed to several neuroglycopenic events, leading to hospitalization. An abdominal CT-scan reported 1.8 x 1.4 cm pancreatic tumor. Labs reported proinsulin 40.5 pM/L. Laparoscopic enucleation was performed. 3 months later she presented a pancreatic pseudocyst treated successfully by endoscopy. Insulinomas, are considered to have low-malignant potential, it is a rare endocrinal tumor and there is minimal mention about a consensus for optimal surgical treatment. Insulinoma remains an exclusion diagnosis after analyzing other differentials. Correct utilization of pre-operative imaging is critical in pre-surgical planning to choose the appropriate surgery.
Keywords: Laparoscopy; Insulinoma; Whipple’s triad; Neuroendocrine tumor.

RESUMEN
Los tumores neuroendocrinos son un extenso grupo de neoplasias, siendo el insulinoma el tumor neuroendocrino pancreático funcionante más frecuente. El estándar de oro terapéutico es quirúrgico, sin el cual la mayoría de pacientes obtiene un desenlace fatal por hipoglucemia. Reportamos el caso de una femenina de 91 años, con 3 meses de evolución de astenia y adinamia, que progresó a eventos neuroglucopénicos, y posterior hospitalización. El TC abdominal reportó un tumor pancreático de 1.8 x 1.4 cm. Los laboratorios reportaron proinsulina 40.5 pM/L. Se realizó enucleación laparoscópica. 3 meses después presentó un pseudoquiste pancreático, tratado satisfactoriamente mediante endoscopia. El insulinoma es considerado de bajo potencial maligno, es un tumor endocrino raro y hay poca información sobre un consenso para el tratamiento quirúrgico óptimo. Es un diagnóstico de exclusión después de analizar otros diferenciales. El uso correcto de imágenes preoperatorias es fundamental en la planeación y elección de la cirugía apropiada.
Palabras Clave: Laparoscopia; Insulinoma; Triada de Whipple; Tumor neuroendocrino.

REFERENCIAS

  1. Yao JC, Hassan M, Phan A, Dagohoy C, Leary C, Mares JE, et al. One hundred years after "carcinoid": epidemiology of and prognostic factors for neuroendocrine tumors in 35,825 cases in the United States. J Clin Oncol. 2008 Jun 20;26(18):3063-72. doi: 10.1200/JCO.2007.15.4377.
  2. Service FJ, McMahon MM, O'Brien PC, Ballard DJ. Functioning insulinoma--incidence, recurrence, and long-term survival of patients: a 60-year study. Mayo Clin Proc. 1991 Jul;66(7):711-9. doi: 10.1016/s0025-6196(12)62083-7.
  3. Mathur A, Gorden P, Libutti SK. Insulinoma. Surg Clin North Am. 2009 Oct;89(5):1105–21.
  4. Halfdanarson TR, Rabe KG, Rubin J, Petersen GM. Pancreatic neuroendocrine tumors (PNETs): incidence, prognosis and recent trend toward improved survival. Ann Oncol. 2008 Oct;19(10):1727-33. doi: 10.1093/annonc/mdn351.
  5. Agha RA, Borrelli MR, Farwana R, Koshy K, Fowler AJ, Orgill DP; SCARE Group. The SCARE 2018 statement: Updating consensus Surgical CAse REport (SCARE) guidelines. Int J Surg. 2018 Dec;60:132-136. doi: 10.1016/j.ijsu.2018.10.028.
  6. Pearse AG. The APUD concept and hormone production. Clin Endocrinol Metab. 1980; 9:211–22.
  7. Mahdi M, Almehman B, Nassan S, Binyahib S. Pancreatic insulinoma causing hypoglycemic episodes. J Pediatr Surg Case Rep 2020 Jun. doi: 10.1016/j.epsc.2020.101466
  8. Brandi ML, Gagel RF, Angeli A, Bilezikian JP, Beck-Peccoz P, Bordi C, et al. Guidelines for diagnosis and therapy of MEN type 1 and type 2. J Clin Endocrinol Metab. 2001 Dec;86(12):5658-71. doi: 10.1210/jcem.86.12.8070.
  9. Triponez F, Dosseh D, Goudet P, Cougard P, Bauters C, Murat A, et al. Epidemiology data on 108 MEN 1 patients from the GTE with isolated nonfunctioning tumors of the pancreas. Ann Surg 2006 Feb;243(2):265-72. doi: 10.1097/01.sla.0000197715.96762.68.
  10. Whipple AO, Frantz VK. Adenoma of islet cells with hyperinsulinism: a review. Ann Surg 1935 Jun;101(6):1299-335. doi: 10.1097/00000658-193506000-00001.
  11. Harrington MG, McGeorge AP, Ballantyne JP, Beastall G. A prospective survey for insulinomas in a neurology department. Lancet. 1983 May 14;1(8333):1094-5. doi: 10.1016/s0140-6736(83)91923-2.
  12. Guettier JM, Lungu A, Goodling A, Cochran C, Gorden P. The role of proinsulin and insulin in the diagnosis of insulinoma: a critical evaluation of the Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2013 Dec;98(12):4752-8. doi: 10.1210/jc.2013-2182.
  13. Khashab MA, Yong E, Lennon AM, Shin EJ, Amateau S, Hruban RH, et al. EUS is still superior to multidetector computerized tomography for detection of pancreatic neuroendocrine tumors. Gastrointest Endosc. 2011 Apr;73(4):691-6. doi: 10.1016/j.gie.2010.08.030.
  14. Finlayson E, Clark OH. Surgical treatment of insulinomas. Surgical Clin North Am. 2004; 84:775–85.
  15. Câmara-de-Souza AB, Toyoshima MTK, Giannella ML, Freire DS, Camacho CP, Lourenço DM, et al. Insulinoma: A retrospective study analyzing the differences between benign and malignant tumors. Pancreatology. 2018 Apr;18(3):298–303.
  16. Sosa JA, Bowman HM, Gordon TA, Bass EB, Yeo CJ, Lillemoe KD, et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg. 1998 Sep;228(3):429-38. doi: 10.1097/00000658-199809000-00016.
  17. Howell DA, Elton E, Parsons WG. Endoscopic management of pseudocysts of the pancreas. Gastrointest Endosc Clin N Am. 1998 Jan;8(1):143-62.
  18. Cherkasov M, Sitnikov V, Sarkisyan B, Degtirev O, Turbin M, Yakuba A. Laparoscopy versus laparotomy in management of abdominal trauma. Surg Endosc. 2008 Jan;22(1):228-31. doi: 10.1007/s00464-007-9550-z.
  19. Hochwald SN, Zee S, Conlon KC, Colleoni R, Louie O, Brennan MF, et al. Prognostic factors in pancreatic endocrine neoplasms: an analysis of 136 cases with a proposal for low-grade and intermediate-grade groups. J Clin Oncol. 2002 Jun 1;20(11):2633-42. doi: 10.1200/JCO.2002.10.030.