Download PDF
CC BY 4.0 · World J Nucl Med 2024; 23(04): 312-316
DOI: 10.1055/s-0044-1788735
Case Report

Aggressive Metastatic Insulinoma in a Patient of Diabetes Mellitus with Documentation on Dual-Tracer PET-CT ([68Ga]Ga-DOTATATE and [18F]FDG): Clinical Benefits with Combined Chemo-PRRT Approach

Yeshwanth Edamadaka
1   Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Mumbai, Maharashtra, India
2   Homi Bhabha National Institute, Mumbai, Maharashtra, India
,
Rahul V. Parghane
1   Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Mumbai, Maharashtra, India
2   Homi Bhabha National Institute, Mumbai, Maharashtra, India
,
Sandip Basu 
1   Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Mumbai, Maharashtra, India
2   Homi Bhabha National Institute, Mumbai, Maharashtra, India
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Insulinoma is a relatively uncommon pancreatic neuroendocrine tumor, with approximately 10% of the cases being malignant. Diabetes mellitus (DM) with concurrent insulinoma is very rare and the diagnosis of such condition is easily missed as it can be misconstrued as improved glycemic control. Therefore, persistent hypoglycemic symptoms even after stopping antidiabetic medications may be considered for insulinoma. Herein, we present a patient with DM and pancreatic insulinoma with extensive hepatic and skeletal metastases on dual-tracer positron emission tomography/computed tomography (PET/CT) ([68Ga]Ga-DOTATATE and [18F]fluorodeoxyglucose). Given the extensive disease, the patient was treated with a combination of peptide receptor radionuclide therapy (PRRT) and chemotherapy (capecitabine and temozolomide). During therapy, patient showed early clinical and imaging response for insulinoma leading to unmasking of poor glycemic control necessitating requirement of insulin administration for DM. The patient did not experience any life-threatening hypoglycemia during the chemo-PRRT treatment and showed an improvement in quality of life. Unfortunately, the disease progressed at the 4th cycle, 10 months after the initiation of PRRT. We conclude that combined chemo-PRRT may be considered an effective treatment option for patients with metastatic insulinoma and DM owing to its favorable imaging response and effective symptom control.

Keywords

insulinoma - pancreatic neuroendocrine tumor - diabetes mellitus - peptide receptor radionuclide therapy - chemo-PRRT - [68Ga]Ga-DOTATATE-PET/CT and [18F]FDG-PET/CT scans


Publication History

Article published online:
24 July 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Anderson CW, Bennett JJ. Clinical presentation and diagnosis of pancreatic neuroendocrine tumors. Surg Oncol Clin N Am 2016; 25 (02) 363-374
    CrossrefPubMedSearch in Google Scholar
  • 2 Parghane RV, Ostwal V, Ramaswamy A. et al. Long-term outcome of “Sandwich” chemo-PRRT: a novel treatment strategy for metastatic neuroendocrine tumors with both FDG- and SSTR-avid aggressive disease. Eur J Nucl Med Mol Imaging 2021; 48 (03) 913-923
    CrossrefPubMedSearch in Google Scholar
  • 3 Sitani K, Parghane RV, Talole S, Basu S. Long-term outcome of indigenous 177Lu-DOTATATE PRRT in patients with metastatic advanced neuroendocrine tumours: a single institutional observation in a large tertiary care setting. Br J Radiol 2021; 94 (1117) 20201041
    CrossrefPubMedSearch in Google Scholar
  • 4 Sada A, Yamashita TS, Glasgow AE. et al. Comparison of benign and malignant insulinoma. Am J Surg 2021; 221 (02) 437-447
    CrossrefPubMedSearch in Google Scholar
  • 5 Peltola E, Hannula P, Huhtala H. et al. Long-term morbidity and mortality in patients diagnosed with an insulinoma. Eur J Endocrinol 2021; 185 (04) 577-586
    CrossrefPubMedSearch in Google Scholar
  • 6 Kane LA, Grant CS, Nippoldt TB, Service FJ. Insulinoma in a patient with NIDDM. Diabetes Care 1993; 16 (09) 1298-1300
    CrossrefPubMedSearch in Google Scholar
  • 7 Kunieda T, Yamakita N, Yasuda K. Insulinoma in a patient with type 2 diabetes mellitus proved at autopsy. Endocr Pract 2012; 18 (06) 1038
    CrossrefPubMedSearch in Google Scholar
  • 8 Pavel M, Öberg K, Falconi M. et al; ESMO Guidelines Committee. Electronic address: clinicalguidelines@esmo.org. Gastroenteropancreatic neuroendocrine neoplasms: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2020; 31 (07) 844-860
    CrossrefPubMedSearch in Google Scholar
  • 9 Brown E, Watkin D, Evans J, Yip V, Cuthbertson DJ. Multidisciplinary management of refractory insulinomas. Clin Endocrinol (Oxf) 2018; 88 (05) 615-624
    CrossrefPubMedSearch in Google Scholar
  • 10 Maggio I, Mollica V, Brighi N. et al. The functioning side of the pancreas: a review on insulinomas. J Endocrinol Invest 2020; 43 (02) 139-148
    CrossrefPubMedSearch in Google Scholar
  • 11 Rogers JE, Lam M, Halperin DM, Dagohoy CG, Yao JC, Dasari A. Fluorouracil, doxorubicin with streptozocin and subsequent therapies in pancreatic neuroendocrine tumors. Neuroendocrinology 2022; 112 (01) 34-42
    CrossrefPubMedSearch in Google Scholar
  • 12 Tovazzi V, Ferrari VD, Dalla Volta A, Consoli F, Amoroso V, Berruti A. Should everolimus be stopped after radiological progression in metastatic insulinoma? A “cons” point of view. Endocrine 2020; 69 (03) 481-484
    CrossrefPubMedSearch in Google Scholar
  • 13 Zandee WT, Brabander T, Blažević A. et al. Symptomatic and radiological response to 177Lu-DOTATATE for the treatment of functioning pancreatic neuroendocrine tumors. J Clin Endocrinol Metab 2019; 104 (04) 1336-1344
    CrossrefPubMedSearch in Google Scholar
  • 14 Friebe L, Freitag MT, Braun M. et al. Peptide receptor radionuclide therapy is effective for clinical control of symptomatic metastatic insulinoma: a long-term retrospective analysis. J Nucl Med 2024; 65 (02) 228-235
    CrossrefPubMedSearch in Google Scholar
  • 15 Kumar S, Melek M, Rohl P. Case report: hypoglycemia due to metastatic insulinoma in insulin-dependent type 2 diabetes successfully treated with 177 Lu-DOTATATE. Front Endocrinol (Lausanne) 2022; 13: 906012
    CrossrefPubMedSearch in Google Scholar
  • 16 Magalhães D, Sampaio IL, Ferreira G. et al. Peptide receptor radionuclide therapy with 177Lu-DOTA-TATE as a promising treatment of malignant insulinoma: a series of case reports and literature review. J Endocrinol Invest 2019; 42 (03) 249-260
    CrossrefPubMedSearch in Google Scholar