Metastatic insulinoma managed with radiolabeled somatostatin analog

Abstract

Insulinoma is a rare pancreatic neuroendocrine tumor. Overproduction of insulin and associated hypoglycemia are hallmark features of this disease. Diagnosis can be made through demonstration of hypoglycemia and elevated plasma levels of insulin or C-Peptide. Metastatic disease can be detected through computerized tomography (CT) scans, magnetic resonance imaging (MRI), and positron emission tomography (PET)/CT. Somatostatin receptor scintigraphy can be used not only to document metastatic disease but also as a predictive marker of the benefit from therapy with radiolabeled somatostatin analog. Unresectable metastatic insulinomas may present as a major therapeutic challenge for the treating physician. When feasible, resection is the mainstay of treatment. Prevention of hypoglycemia is a crucial goal of therapy for unresectable/metastatic tumors. Diazoxide, hydrochlorothiazide, glucagon, and intravenous glucose infusions have been used for glycemic control yielding temporary and inconsistent results. Sandostatin and its long-acting depot forms have occasionally been used in the treatment of Octreoscan-positive insulinomas. Herein, we report a case of metastatic insulinoma with very difficult glycemic control successfully treated with the radiolabeled somatostatin analog lutetium ((177)LU).

Figure 1

Low-grade neuroendocrine neoplasia of the pancreas. (a) Strong and diffuse expression of chromogranin A. (b) By immunohistochemistry.

Figure 2

Octreoscan: high uptake in focal areas of the liver, left lower quadrant of the abdomen, and cervicothoracic area.

Figure 3

Octreoscan SPECT/CT prior to radiolabeled somatostatin analog lutetium (¹⁷⁷LU) administration.

Figure 4

Octreoscan SPECT/CT after 1st infusion of radiolabeled somatostatin analog lutetium (¹⁷⁷LU) administration.

Figure 5