Syptoms of Hypoglycemia and Forgetfulness Revealed 10 Tiny Tumors Hidden in the Pancreas

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A lady, who had received "insulinoma resection" two years ago, suffered from hypoglycemia and forgetfulness again. It turned out that there were still as many as 10 tiny tumors in the pancreatic tissue.

Recently, the Department of Endocrinology and Metabolism, combined with the Dept. of Radiology, Ultrasound, and Nuclear Medicine at Shanghai General Hospital successfully located multiple tiny insulinomas hidden in the patient's pancreas by using a series of new imaging technique, and performed "laparoscopic subtotal pancreatectomy" for the patient to successfully remove the pancreatic tissue containing multiple islet tumors. The patient has recovered and discharged.

Mrs. Chen, 59 years old, was diagnosed as "pancreatic occupying lesion; hypoglycemia" two years ago because of hypoglycemia symptoms such as palpitation, dizziness and cold sweat. She underwent "open pancreatic tumor resection" and removed four tiny islets tumors.

In April this year, Mrs. Chen came to Prof. Fang Liu, director of the Endocrinology and Mtabolism Dept. at Shanghai General Hospital, for help because her right fingers were numb. After physical examination and consultation, Prof. Liu found that Ms. Chen was obese and had obvious memory loss. Her fasting blood glucose was 3.0 mmol / L, and her insulin level was higher than normal. Considering hypoglycemia and combining with her past medical history, Prof. Liu suspected that there might still exists insulinoma, so she immediately arranged her to receive further evaluation in ward.

The Endocrinological team monitored the patient's blood glucose dynamically. It was found that her blood glucose fluctuated between 2.5-5.0 mmol / L, and there was severe hypoglycemia (< 2.8 mmol / L) at night and before dawn. In addition, she represented memory loss, slow response, weak apprehension and emotional instability.

The medical team also improved the relevant examinations for the patient according to the standardized procedure for hypoglycemia diagnosis and discrimination. The results showed that Mrs. Chen had no obvious deficiency of glucose elevating hormones such as cortisol, thyroid hormone and pituitary hormone. She had hypoglycemia (1.8 mmol / L) over 5 hours after starvation test. At this time, the insulin release index was as high as 1.44 (normal below 0.3). At this evidence, Ms. Chen was confirmed the recurrent hypoglycemia, and her corresponding decline in intelligence and memory are caused by insulinoma.

The function diagnosis was clear, but where is the insulinoma? The patient had undergone insulinoma resection 2 years ago. Why did she still have insulinoma? Is it because the adenoma was not completely removed in the previous operation?

In order to find the "hide and seek" insulinoma in the patient’s body, Prof. Liu organized MDT discussion and consultation. In addition to the conventional enhanced CT / MRI of the pancreas, the multiple disciplinary team not only performed contrast-enhanced ultrasound for Mrs. Chen, but also used the new technology of Nuclear imaging - "18F octreotide PET / CT dual imaging technology" to assist in topical diagnosis.

Under the careful and accurate scanning technique, the insulinoma had no way to hide. The multiple small tumors were revealed in the neck, body and tail of Mrs. Chen's pancreas, with a volume ranging from 0.3 * 0.5cm2 to 0.7 * 0.8cm2, and their numbers adding up to as many as 10!

After fully communicating with her family members about her condition, stabilize her blood sugar and control blood lipid and blood pressure, the MDT team transferred Mrs. Chen to the ward in North campus. The surgeon team led by prof. Jiang Long, director of the pancreatic surgery department took over her follow-up care.

Due to the wide-distributed multiple insulinomas in Mrs. Chen's pancreas, which are scattered in the neck, body and tail of the pancreas, and the patient's poor condition, the operation is speculated to be very difficult. In order to make the surgery less traumatic, after fully discussion, Prof. Long’s team decided to overcome the obstacles and perform subtotal pancreatectomy for Mrs. Chen through laparoscopic minimally invasive surgery.

The surgery team drilled three 1cm holes in Ms. Chen's abdomen and operated through laparoscope. Not Surprisingly, the omentum tissue in her abdominal cavity is widely adhered to the abdominal wall, the lower edge of the liver and the gastric wall, and the spleen is also adhered to the left hepatic edge and the anterior wall of the stomach, which was a great challenge to the general surgeon. After carefully separating the adhesions, the surgical team successfully removed the pancreatic tissue containing multiple insulinomas guided from the accurate positioning by laparoscopic ultrasound. After the surgery, the patient's hypoglycemia alarm was quickly removed and the blood sugar returned to normality. Soon after, she was discharged from the hospital with the assistance of the Endocrinologists. The follow-up results of dynamic blood glucose monitoring proved that Mrs. Chen had no hypoglycemic episode later.

It is reported that insulinoma is a type of islet endocrine tumors derived from pancreatic islet insulin-secreting  cells, its prevalence is very low in Chinese population. In previous reports, more than 90% of insulinoma were single, and multiple insulinomas are extremely rare.

Insulinoma can continue to secrete excessive insulin, causing a series of symptoms, mainly hypoglycemia. Over time, it will damage brain tissue, cause consciousness disorder and mental abnormality, and even threaten life in serious cases.

Prof. Liu reminded that although more than 95% of insulinomas are benign tumors, if not diagnosed and treated in time, long-term low glucose level may cause irreversible damage to brain function. Surgical resection is the only way to cure insulinoma. Through the early diagnosis and successful surgery, most of the patients will back to healthy and live long.

Correspondent: Chenyan Li, Yang Hu