Insulinoma
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Figure 1
Intraoperative ultrasound demonstrating insulinoma in posterior head of the pancreas with the pancreatic duct coursing over and deflected by the tumour.
Figure 2
New prototype CT scan, coronal (a) and sagittal (b) images showing insulinoma (circled) obscured by splenic artery on original CT scan.
Figure 3
Subselective arterial catheterization with calcium stimulation and venous sampling to regionalize insulinoma. A catheter has been threaded into the gastroduodenal artery and a separate catheter placed into the right hepatic vein to sample the venous effluent seconds after calcium stimulation of the blood supply feeding the insulinoma depicted in the head of the pancreas.
Figure 4
Longitudinally cut gross specimen of pancreas showing typical multiple tumours in a patient with MEN-1 syndrome.
Although rare, insulinomas are the most common functioning islet cell tumour of the pancreas. Recognition of the key neuroglycopenic symptoms should trigger the initial investigation. Biochemical proof of endogenous hyperinsulinemic hypoglycemia establishes the diagnosis. Several options are available for imaging and localizing these tumours including ultrasonography, computed tomography, and intra-arterial calcium stimulation with venous sampling. The tumours are usually small, single, benign, well-circumscribed, and evenly distributed throughout the pancreas. This tumour may be a part of the multiple endocrine neoplasia type 1 (MEN-1) syndrome, in which case the tumours are almost always multiple. Surgical treatment is the only curative method, traditionally accomplished with enucleation or partial pancreatic resection. Patients are almost invariably cured lifelong with complete excision of a benign insulinoma. The most recent developments in this area are the recognition of noninsulinoma pancreatogenous hypoglycemia syndrome as a cause of organic hypoglycemia, and the development of laparoscopic techniques to excise these tumours.
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