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					Basic Data

 24 y/o
 Sex: Female
 Admission date: 960711,970411
Chief complain

 Drowsiness, weakness, fall down episodes
 and muscle spasm when fasting which last
 for 5 years
Present Illness

 No history of DM, HTN
 before taking breakfast but improved after
 eating, then 2 hours later arose again
 In NTUH , supressed cortisol with high
 ACTH was found , abdominal angio
 showed multiple insulinoma
Personal history

 Insulinoma diagnosed at NTUH
Lab 960713

 Insulin Ab:0.05

 5mm slice upper abdomen CT couldn’t
 find the lesion
 Celiac angiography found blood supply
 enhancement from the distal pancreatic
 artery in pancreatic tail.
 The other mass couldn’t be found, intra-
 operative ultrasound was used to check
 other small insulinomas
1*1 cm mass
1*1 cm mass
 Insulinoma: Whipple triad, celiac angiography,
 pancreatic CT, likely
    Enteropancreatic tumors
       Gastrin normal, no PU, gastrinoma not likely
       No watery diarrhea, VIPoma not likely
       Insulin high, hypoglycemia, C-peptide high, insulinoma
 PTH, prolactin level normal, tumor of parathyroid
 or pituitary gland not likely
 One 1×1 ×1 cm mass at pancreas head ,one 0.7
 ×0.5 ×0.5cm at head , one 0.8 ×0.7 ×0.5 at body ,
 one 0.4 ×0.3 ×0.5 at tail.
 Tumor cell arranged in nest , trabecular
 patterns , separated by fibrous tissue
 The tumors are well encapsulated. The tumor
 cells have abundant eosinophilic cytoplasm and
 small and bland-looking nuclei without evident
 mitotic activity
 The morphologic changes are compatible with
 insulinoma clinically

 Insulinoma: incidence: estimated at 1 to 4
 new cases per million persons per year
 Estimates of malignancy (metastases)
 range from 5% to 30%
 About 5% of cases are associated MEN1
 are more likely multiple and malignant
Symptoms and signs

 recurrent headache, lethargy, diplopia,
 and blurred vision, particularly with
 exercise or fasting
 Severe hypoglycemia may result in
 seizures, coma, and permanent
 neurological damage
 palpitations, tachycardia, sweating,
 nausea are not as common
Whipple triad:
  symptoms and signs of hypoglycemia,
  concomitant plasma glucose level of 45 mg/dL
  or less,
  symptom relieved after administration of
Serum insulin levels of 10 µU/mL (normal
<6 µU/mL)
Glucose less than 40 mg/dL
C-peptide exceeding 2.5 ng/mL (normal
<2 ng/mL)
Proinsulin levels greater than 25% (or up
to 90%) that of immunoreactive insulin
Screening for sulfonylurea negative

 most commonly affected, the parathyroid,
 pancreas, and pituitary glands
 Primary hyperparathyroidism
 Pituitary tumors
   Growth hormone-secreting

 Enteropancreatic tumors
  Gastrinoma (Zollinger-Ellison syndrome)
    Most common
Diagnostic imaging

 CT , MRI , angiography are standard, but
 usually missed when tumor <1.5 cm
 EUS with high sensitivity
 Most reliable: intra-operative ultrasound

 Definitive management is surgical removal
 Food control and diazoxide or
 somatostatin for initial management.
 Combination chemotherapy is used
 Patient with MEN1 need aggressive
 treatment: usually subtotal pancreactomy
 due to high possibility of recurrence of

 Most patients with benign insulinomas can
 be cured with surgery
 Persistent or recurrent hypoglycemia after
 surgery tends to occur in patients with
 multiple tumors
 About 2 percent of patient develop DM
 after surgery