SFEBES2023 Featured Clinical Case Posters Section (10 abstracts)
“A case of metastatic insulinoma: a real challenge to manage”
Dr Muhammad Tahir Chohan 1 , Dr Philip Atherton 1 , Dr Jane Margetts 1 , Dr Peter Littler 1 , Mr Sanjay Pandanaboyana 1 , Dr Ashwin Joshi 2 , Dr David Bishop 2 , Dr Peter Carey 2 , Dr Satish Artham 2 , Dr Rahul Nayar 2 , Dr Anna L Mitchell 1 & Dr Earn H Gan 1
1Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom. 2Sunderland Royal Hospital, Sunderland, United Kingdom
Background: Insulinomas are the commonest functional neuroendocrine tumours (NETs) but metastatic insulinomas are rare (incidence <2%) and their management can be challenging. We report a case of metastatic insulinoma requiring multiple treatment modalities to achieve biochemical control.
Case Presentation: A 77 year old healthy female was admitted with severe spontaneous hypoglycaemia (glucose 1.8mmol/l) due to endogenous hyperinsulinism [insulin 530pmol/l (range 12-50pmol/l); C-peptide 0.58nmol/l (range 0.34-1.8nmol/l)]. Subsequent investigations revealed a well-differentiated grade 2 pancreatic insulinoma (Ki67-12%) with multiple bulky liver metastases. She responded well to diazoxide, but within 3 months her severe hypoglycaemia recurred. Dexamethasone and subcutaneous octreotide were unhelpful. An interval scan showed significant disease progression, therefore NET MDT recommended Lutetium-177 peptide-receptor-radionuclide-therapy (PRRT). Following the first dose, she had hypoglycaemic seizures, requiring two weeks on ITU for continuous 50% dextrose, glucagon infusions and nasogastric feeding. We used Pasireotide as a bridging therapy to step her down from ITU. Pasireotide was stopped after a month and she remained hypoglycaemia-free and completed 4 cycles of PRRT. After PRRT, there was an excellent radiological response. Unfortunately, within 3 months, she had biochemical relapse with severe hypoglycaemia. A trial of low dose Everolimus failed due to neutropenic sepsis. Reintroduction of Pasireotide was not helpful. She remained an inpatient for over 2 months, requiring dextrose and glucagon infusions and continuous PEG feeding. Bland embolisation was ineffective due to her liver disease burden. Following further MDT discussion, we used Theraspheres SIRT (Boston Scientific) (selective internal radiation therapy). Within a week, her hypoglycaemic episodes improved, her infusions were then stopped and she was subsequently discharged from hospital. Her PEG feeds are being weaned and she is in biochemical remission.
Conclusion: The management of metastatic insulinoma is very challenging. Multiple treatment modalities are often required in parallel. PRRT and SIRT both have a role in achieving biochemical control.
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Endocrine Abstracts
ISSN 1470-3947 (print) | ISSN 1479-6848 (online)
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