Endocrine Abstracts

Background: The gold-standard therapeutic approach for benign insulinoma is surgery. If surgery is not feasible, minimally invasive ablative procedures by interventional radiology can lead to partial or complete remission of hormone hypersecretion and tumour control.

Summary: 72-year-old woman, admitted with recurrent hypoglycaemia with whipple triad symptoms and presyncopal attacks for 5 weeks, relieved by eating carbohydrates. Investigations showed high insulin and c-peptide levels at low glucose level of 1.9mmol/l. MEN-1 screen showed normal calciumand prolactin levels. CT abdomen showed focal arterial enhancement in the head of pancreas (13 mm). Hypoglycaemia improved with Diazoxide, but patient developed lower limb oedema (side effect of diazoxide). So Bendroflumethiazide was prescribed to reduce oedema. Surgical treatment was discussed in NET MDT and Pancreaticoduodenectomy was offered as enucleation of insulinoma was not an option as the lesion was deep-seated. However the patient was high risk of mortality rate (10%), for the surgery because of high BMI (>50) and short neck. Therefore Trans-arterial embolization of Gastroduodenal artery for pancreatic head neoplasm was offered. Diazoxide stopped a day prior to procedure and procedure remained uneventful. She didn’t have further hypoglycaemia during 6 month follow up. Libre2 CGM, Ambulatory glucose profile (self-funded) showed normal blood sugars. From literature there is a small risk of recurrence ~16% after chemoembolization and hence further surveillance was considered. Her follow up image after 3 months showed complete resolution of the lesion. A planned yearly follow up with imaging surveillance was considered. She was advised to check capillary blood sugars if she develops any hypoglycaemia symptoms.

Conclusion: It is important to involve Multidisciplinary team (endocrinologist, physicians, surgeon, dietician and radiologist) to decide best treatment options for insulinoma. Minimally invasive ablative procedure can lead to complete remission of hormone hypersecretion and tumour control in patients with a high risk for surgery.

References: 1. C Mele et al. J Endocrinol Invest 2018 Feb;41(2):153-162. 2. Emily Brown et al. Clin Endocrinol (Oxf) 2018 May;88(5):615-624. 3. Anee D Carbonaeeries et al. HPB (Oxford). 2021 Dec;23(12):1799-1806. 4. Peiman Habibollahi, Harrison X Bai, Sreeja Sanapudi et al. Pancreas 2020 Jul;49(6):763- 67. 5. European Neuroendocrine Tumor Society (ENETS) 2023 Guidance Paper for Functioning Pancreatic Neuroendocrine Tumour Syndromes. https://doi.org/10.1111/jne.13318