The treatment of hyperinsulinemic hypoglycaemia in adults: an update

Davì, Maria Vittoria; Pia, Anna; Guarnotta, Valentina; Pizza, Genoveffa; Colao, Annamaria; Faggiano, Antongiulio

doi:10.1007/s40618-016-0536-3

Cited by 45 publications

(41 citation statements)

References 144 publications

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“…These include ultrasound-guided ethanol ablation, selective chemoembolisation or transcutaneous/ laparascopic radiofrequency ablation (Davi et al 2017). Although favourable outcomes have been reported in case reports or small series, the follow-up of these patients is typically <1 year, with longer term outcomes needed to validate these novel approaches.…”

Section: Local Regional Ablative Therapymentioning

confidence: 99%

Molecular imaging in the investigation of hypoglycaemic syndromes and their management

Pattison¹,

Hicks²

2017

Endocrine-Related Cancer

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There has been recent progress in molecular imaging using a variety of cellular targets for the investigation of adult non-diabetic hypoglycaemic syndromes and its integration into patient management. These targets include peptide receptors (somatostatin receptors (SSTRs) and glucagon-like peptide-1 receptor (GLP-1R)) the amine precursor uptake and decarboxylation system utilising the diphydroxyphenylaline (DOPA) analogue 6-[ 18 F]-l-fluoro-l-3,4-dihydroxyphenylalanine ( 18 F-FDOPA), and glycolytic metabolism with 2-[ 18 F]fluoro-2-deoxy-d-glucose (FDG). Accurate preoperative localisation and staging is critical to enable directed surgical excision or enucleation with minimal morbidity and preservation of residual pancreatic function. Benign insulinoma has near ubiquitous dense GLP-1R expression enabling accurate localisation with radiolabelled-exendin-4 compounds (e.g. 68 Ga-NOTA-exendin-4 PET/CT), whilst the rarer and more difficult to manage metastatic insulinoma typically express SSTR and is preferably imaged with radiolabelled-SSTR analogues such as 68 Ga-DOTA-octreotate (DOTATATE) PET/CT for staging and assessment of suitability for peptide receptor radionuclide therapy (PRRT). Similar to other metastatic neuroendocrine tumours, FDG PET/CT is used in the setting of highergrade metastatic insulinoma to provide important prognostic information that can guide treatment and determine suitability for PRRT. Interestingly, these three tracers appear to represent a spectrum of differentiation, which we conceptually describe as the 'tripleflop' phenomenon, with GLP-1R > SSTR > FDG in benign insulinoma and the opposite in higher-grade disease. This paper will review the clinical syndromes of adult hypoglycaemia (including a practical overview of the differential diagnoses to be considered), comparison of techniques for insulinoma localisation with emphasis on molecular imaging before discussing its implications for management of metastatic insulinoma.

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Section: Local Regional Ablative Therapymentioning

confidence: 99%

Molecular imaging in the investigation of hypoglycaemic syndromes and their management

Pattison¹,

Hicks²

2017

Endocrine-Related Cancer

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“…In pancreatic body and tail lesions, distal pancreatectomy is proposed and for lesions arising from pancreatic head through Whipple procedure (pancreaticoduodenectomy) is the chosen approach. Surgical approach is associated with considerable morbidity (abdominal abscess, wound infection, pancreatic duct injury and fistula, endocrine/exocrine insufficiency, perioperative haemorrhage) and mortality, which limits its indication in high-risk patients (1, 2, 3). …”

Section: Discussionmentioning

confidence: 99%

Endoscopic ultrasound-guided ethanol ablation therapy for pancreatic insulinoma: an unusual strategy

Lages

Paiva

Oliveira

et al. 2017

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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SummaryInsulinomas are the most frequent cause of hyperinsulinaemic hypoglycaemia. Although surgical enucleation is the standard treatment, a few other options are available to high-risk patients who are elderly or present with co-morbidities. We present a case report of an 89-year-old female patient who was admitted to the emergency department due to recurrent hypoglycaemia, especially during fasting. Laboratory work-up raised the suspicion of hyperinsulinaemic hypoglycaemia, and abdominal CT scan revealed a 12 mm nodular hypervascular lesion of the pancreatic body suggestive of neuroendocrine tumour. The patient was not considered a suitable candidate for surgery, and medical therapy with diazoxide was poorly tolerated. Endoscopic ultrasound-guided ethanol ablation therapy was performed and a total of 0.6 mL of 95% ethanol was injected into the lesion by a transgastric approach; no complications were reported after the procedure. At 5 months of follow-up, no episodes of hypoglycaemia were reported, no diazoxide therapy was necessary, and revaluation abdominal CT scan revealed a pancreatic nodular lesion with a size involution of about half of its original volume. The patient is regularly followed-up at the endocrinology clinic and shows a significant improvement in her wellbeing and quality of life.Learning points:Insulinomas are the most frequent cause of hyperinsulinaemic hypoglycaemia.Surgical enucleation is the standard treatment with a few other options available to high-risk patients.Endoscopic ultrasound-guided ethanol ablation therapy is one feasible option in high-risk patients with satisfactory clinical outcomes, significant positive impact on quality of life and low complication rates related to the procedure.

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“…Chemotherapy and peptide receptor radionuclide therapy (PRRT) are also considered important therapeutic options. 6,61 Cytoreductive surgery in advanced malignant insulinoma contributes to improved glycemic control and renders systemic therapy more effective. Therefore, palliative surgery to remove or debulk the primary tumor is recommended.…”

Section: Surgical and Cytoreductive Methodsmentioning

confidence: 99%

“…8 PRRT has been described as a valuable method in the case of refractory hypoglycemia due to malignant insulinoma. 6,8,66 However, this option requires more investigation, as serious side effects are observed. 66 Chemotherapy has been described as an important method to be applied in pNETs.…”

Section: Surgical and Cytoreductive Methodsmentioning

confidence: 99%

“…However, these surveys are limited, as the evaluation of the effects of chemotherapy on patients with all types of pNETs were investigated, while precise data on insulinomas are lacking. 6 conclusIon Insulinoma, as a hormonally active tumor, can cause diagnostic and therapeutic difficulties for physicians. Due to life-threatening hypoglycemia episodes, one of the biggest challenges in treating patients with insulinoma is maintaining the correct glucose blood levels.…”

Section: Surgical and Cytoreductive Methodsmentioning

confidence: 99%

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Glycemic control in patients with insulinoma

Matej¹,

Bujwid²,

Wroński³

2017

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Insulinoma is the most common neuroendocrine tumor of the pancreas. surgical management of insulinomas is considered to be the only curative method. however, effective glycemic control preoperatively and in unresectable insulinomas remains a significant issue. hyperinsulinism, occurring as a result of the hormone-secreting tumor, leads to life-threatening hypoglycemia episodes which require urgent medical treatment. This article discusses current management of hypoglycemia in insulinoma patients, including: education and lifestyle modifications, pharmacotherapy (diazoxide, somatostatin analogs, mTor inhibitor -everolimus), cytoreductive methods and continuous glucose monitoring systems.

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The treatment of hyperinsulinemic hypoglycaemia in adults: an update

Cited by 45 publications

References 144 publications

Molecular imaging in the investigation of hypoglycaemic syndromes and their management

Molecular imaging in the investigation of hypoglycaemic syndromes and their management

Endoscopic ultrasound-guided ethanol ablation therapy for pancreatic insulinoma: an unusual strategy

Glycemic control in patients with insulinoma

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