Endocrine Abstracts

Insulinomas are functional pancreatic tumours which is mostly benign. Malignant disease is rare with variable course. Much remains unknown with regards to clinical trajectory as well as response to treatment to the commonly used agents between a benign or malignant disease. 70-year-old-man, very fit enthusiastic cyclist a month before initial presentation at another hospital with collapse, blood glucose of 2.4 and mild eosinophilia at which point Addison disease was explored. At his second visit with recurrent episodes of light-headedness and confusion especially during fasting, he was diagnosed with hyper-insulinemic hypoglycaemia and abdominal CT scan confirmed a large pancreatic mass in the body and tail with vascular infiltration, regional lymphadenopathy and numerous bilobar hepatic metastasis. He had a liver biopsy which was inconclusive and started on Diazoxide before discharge. He was only home a single night when he developed severe nausea and further severe hypoglycaemia and admitted to our hospital. He was initially managed with titrating dose of diazoxide, anti-emetics, Lanreotide, Acarbose in addition to repeating his biopsy. However, he developed significant fluid overload and electrolyte derangements thus diazoxide was stopped which precipitated further severe hypos despite the other agents. He was therefore restarted on diazoxide at lower dose and with glycaemic stabilisation, he was discharged. He was re-admitted a day after with seizures, severe electrolyte derangements, fluid overload and further severe hypos requiring ITU care. Diazoxide was discontinued and he was started on high dose dexamethasone and verapamil in addition to aforementioned agents and supportive care including IV Dextrose, NG feeding (unable to tolerate) and CGM (difficulty to manage) until hypos became manageable at the ward level with ongoing 6-8 episodes/day. The repeat biopsy confirmed Grade 2 neuroendocrine tumour which are MNF116, synaptophysin and chromogranin positive with Ki67 of 10%, liver MRI showed 15-20% parenchymal volume liver metastasis and delayed functional scan. He was subsequently started on Everolimus with short-lived partial response but still significant hypoglycaemia Dextrose dependent. Admission was also complicated by hospital acquired pneumonia, right arm DVT. Neuroendocrine MDT advised chemotherapy (CAPTEM) which led to significant metabolic control at about 6 weeks of starting and patient discharged after weaning Dextrose on weaning regimen of steroid and NG feeding. This patient has an extensive aggressive resistant insulinoma and despite being tried on multiple agents, sustained and significant metabolic control could not be achieved until chemotherapy was used. He developed multiple complications with significant impact on quality of life.