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Insulinoma 2012 30 years experience with diagnosis and treatment

Insulinoma 2012 30 years experience with diagnosis and treatment. Jan Škrha 3 rd Department of Internal Medicine, 1 st Faculty of Medicine, Charles University in Prague

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Insulinoma 2012 30 years experience with diagnosis and treatment

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  1. Insulinoma 201230 years experience with diagnosis and treatment Jan Škrha 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University in Prague 27th Symposium of the Federation of the International Danube-Symposia of Diabetes Mellitus, Budapest, 28-30th June, 2012

  2. CAUSE OF HYPOGLYCEMIA According to pathogenesis a) decreased glucose production - lack of contraregulatory hormones - liver or kidney disease, alcohol b) increased glucose utilisation - exogenously caused (DM treatment) - endogenously caused (insulinoma) 2. According to timing of the food ingestion a) fasting hypoglycemia (!!!) b) random hypoglycemia during the day - reactive (functional), postoperative

  3. Hypoglycemia and activation of contraregulatory hormones neurogenic symptoms neuroglycopenic symptoms

  4. HYPOGLYCEMIC SYMPTOMS 1) neurogenic: sweatting, palpitations, tachycardia, (adrenergic) anxiety, tremor 2) neuroglycopenic: a) neurologic: confusion,headache, blurred vision, diplopy, dysarthria, decreased abbility to concentrate, impaired speech and consciousness, cramps, epilepsy b) psychiatric: unusual hesitation, temper changes (depression, euphory) impaired thinking

  5. Characteristics of the patients(3rd Departmrent of Internal Medicine: 1980 – 2012) OrganicFunctional hyperinsulinismhyperinsulinism (n = 125) (n = 30) Males / females32 / 93 (~ 75 % women) 7 / 21 Age (yrs) 52 ± 17 27 ± 5 Durationofthedisease (yrs) 3 (0,1 – 25) 1 (0,5 – 2) BMI (kg/m2) 28,2 ± 5,3 (32 % normal) 24,3 ± 2,9 Bloodpressure – systolic134 ± 17 125 ± 15 (mm Hg) (55 % normal) diastolic79 ± 10 78 ± 6

  6. Fasting test Before After Before After Before After Positive: 100 % 91 % 98 %

  7. Organic hyperinsulinism(3rd Department of Internal Medicine: 1980 – 2012) Imaginating method Finding by surgery Positive Negative Confirmed Removed from positive US 4 (8 %) 47 (92 %) 2 (50 %) 45 (88 %) EU 41 (84 %) 8 (16 %) 33 (83 %) 45 (94 %) CT 27 (30 %) 64 (70 %) 22 (85 %) 86 (95 %) AG 39 (43 %) 52 (57 %) 25 (64 %) 89 (94 %) Localised ~ 70 % of insulinomas before operation

  8. Octreoscan

  9. TREATMENT • surgical • - by laparotomy • - by laparoscopy • conservative • - regimen (diet, activity) • - pharmacological • (diazoxide, octreotide)

  10. Enucleation

  11. Resection (hemipancreatectomy)

  12. INSULINOMA – RESULTS OF TREATMENT(3rd Department of Internal Medicine, 1980-2012) 125 insulinomas / microadenomatosis 115 operated 10 conservatively in 104 removed (90 %) in 11 undiscovered 3 removed 8 conservative (by reoperation) Surgicalsuccess: 93 % Agreementwithpreoperativeexamination : 64 of 81 (79 %)

  13. Histology

  14. Surgical and histological finding • localization (n=115) • Head: 30 % • Body: 28 % • Tail: 42 % • b) histology • Benignadenoma: 103 • Maligncarcinoma: 4 • Uncertainbiologicalactivity: 5 • Multiplemicroadenomatosis: 3

  15. Algorithm of diagnosis in organic hyperinsulinism Clinicalsuspition Biochemical examination Diagnosis confirmed Diagnosis unconfirmed Topographic localisation TREATMENT DIAGNOSIS CT Angiography Endosonography Localisation confirmed Localisation unconfirmed Surgery Insulinomaremoved Insulinoma unremoved Conservative treatment

  16. In differential diagnosis:HYPOGLYCEMIA FACTITIA

  17. HYPOGLYCEMIA FACTITIA Characteristic signs: suspicion on insulinoma uncertainty from clinical picture uncertainty from laboratory findings frequent relationship of the patient to health care providers Attention: IATROGENIC HYPOGLYCEMIA

  18. Insulinoma vs hypoglycemia factitia

  19. Conclusions for clinical practice Hypoglycemia is deleterious for organism and is life threatening • to analyse symptoms (history !) • to confirm hypoglycemia • to elucidate cause of hypoglycemia (confirm diagnosis) • to realize reliable treatment strategy removing hypoglycemia (related to diagnosis and clinical state of the patient)

  20. Collaboration Surgery: Jan Šváb, Ladislav Krušina (†) Biochemistry: Jirina Hilgertová Marcela Jarolímková Pathologist: Jaroslava Dušková Metabolic ward staff: Eva Kotrlíková Gustav Šindelka (†) Imaging: Josef Hořejš, Radan Keil

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