Adenocarcinoma of the pancreas associated with hypoglycemia.Case report and review of the literature

Abstract

The occurrence of profound hypoglycemia in a patient with metastatic adenocarcinoma of the pancreas is reported. In contrast to the four previously reported cases, no suggestion of excess insulin production was found. Metabolic studies in this patient suggest both increased peripheral glucose utilization and decreased hepatic glucose production as contributing factors which promoted the hypoglycemia.Cancer 43:2457-2464, 1979.YPOGLYCEMIA IS K N O W N to occur in asso-H ciation with a number of nonislet cell tumors.22 An understanding of the mechanism responsible for the hypoglycemia in this diverse group of tumors is lacking.16 Hypoglycemia has previously been reported to occur with adenocarcinoma of the p a n~r e a s .~.~~.~~ In this subgroup, it has been attributed to excess insulin production secondary to changes in adjacent pancreatic t i s s~e .~~-~~-~~ We wish to report a fifth case of adenocarcinoma of the pancreas associated with profound hypoglycemia, but in which no evidence could be found for excess insulin. CASE REPORTA 67-year-old black woman with known metastatic adenocarcinoma of the pancreas was transferred to the Medical College of Virginia Hospital after having presented to a local hospital emergency room "weak and confused" with marked hypoglycemia. The patient had been in excellent health throughout life until five months earlier when, because of weight loss, abdominal distress, and jaundice, she was hospitalized for evaluation culminating in an exploratory laparotomy. At laparotomy a hard mass (10 mm x 15 mm) was found in the head of the pancreas which on histologic review was noted to be adenocarcinoma of the pancreas. Because of biopsy-proven lymph node and liver involvement, only palliative surgery was done with a gastrojejunostomy and cholecystojejunostomy. T h e postoperative period was unremarkable and the patient was started on a regimen of 4000 rads to the head of the pancreas in combination with weekly 5-fluorouracil ( 1 5 mg/kg iv).T h e patient tolerated the above regimen during the four months followingsurgery. During the fifth month her husband became aware of gradual changes in her behavior with increasing confusion and lethargy. When this progressed to unresponsiveness, the patient was brought to the emergency room.On the admission physical examination, the patient was noted to be a cachectic, elderly black female who was tachypneic, nondiaphoretic and responding only to painful stimuli. Pertinent findings included a 2 cm x 2 cm hard fixed lymph node in the left supraclavicular space and an enlarged liver (14 cm span in right midclavicular line). Other than the state of consciousness, the neurologic exam was within normal limits with no focal defects.In the emergency room, blood samples were immediately drawn following which two ampules of 50% dextrose in water (50 g glucose) were administered intravenously. Initial laboratory studies revealed a plasma glucose of 16 mg/dl accompanied by an electrolyte pattern suggestive of a metabolic acidosis. N o ketones were noted in the ser...