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home - Pancreas - Pancreatic Cancers - Insulinoma Written by Dr Sebastian Zeki
Knowledge


Knows the presentation investigation and staging of pancreatic
cancer

Recognises the importance of considering and being able to identify
uncommon pancreatic tumours (such as neuroendocrine or
intrapapillary mucinous tuours)

Knows the range of potential therapies and recognises the factors
that make such tumours potentially operable or inoperable

Knows the prevalence and natural history of benign cysts/serous
cystadenoma and potentially malignant cystic lesions

Knows the options for palliative treatment
Skills
Shows ability to sequence investigations appropriately
Understands value of multi-disciplinary team
Recognises the importance of considering possibility that the tumour
is unusual

Behaviours
Communicates effectively within the multi-disciplinary team and with
the patient and their family

Insulinoma

Insulinoma (60% of all pancreatic endocrine neoplasms) Patient survival The overall survival is the same as the general population but is worse in the patients with malignant insulinomas although they can have a prolonged survival.The risk of recurrence is 6%. Treatment Surgical removal of the insulinoma is the treatment of choice.Diazoxide (which diminishes insulin secretion and is given in divided doses of up to 1200 mg/day) is sometimes used for controlling hypoglycemia.side effects include oedema and hirsutism.Verapamil and phenytoin are alternatives. Diagnosis and Tumour LocalizationPatients have high insulin levels after 72 hour fast.Do MRI/ CT (CT sensitivity 40%) first.If nothing found on initial imaging, do EUS (sensitivity 85%).Spiral CT 111-In-pentetreotide imaging (misses 40% insulinomas), and 18F-DOPA PET are alternatives-.Lesions are difficult to pick up with octreotide scan (scant somatostatin receptors).Arterial stimulation (with calcium- this stimulates insulinomas rather than B cells) with hepatic venous sampling are alternatives when an insulinoma cannot be localized by noninvasive means.May need to rely on intraoperative localisation.Accuracy can be improved with the addition of single photon emission computed tomography (SPECT).Malignant insulinomas are rare, and behaviour may not correspond to histology. Fasting hypoglycemia, with discrete episodes of neuroglycopenic symptoms +/- sympathoadrenal (autonomic) symptoms.The hypoglycemia in persons with insulinoma is primarily due to reduced hepatic glucose output rather than increased glucose utilization .Evidence suggests that insulinomas arise from cells of the ductular/acinar system of the pancreas rather than from neoplastic proliferation of islet cells Increased insulin in presence of hypoglycaemia possibly related to a variant of insulin mRNA with increased translation efficiency.Incidence — 4 cases per million per year.Age - 40-50Sex- M=FSymptoms — Amnesia for hypoglycemia is common.The median duration of symptoms before diagnosis was less than 1.5 years, but may be symptomatic for years.Usually misdiagnosed20% have MEN1 Tumor distribution — Insulinomas can be single or multiple, and benign or malignant (15%) Clinical Features: In addition to general treatment for islet cells Written by Dr Sebastian Zeki

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