Himesh Zaver, MD, Hassan Ghoz, MD, Khaled Alnahha, BS, Ricardo Paz-Fumagalli, MD, Massimo Raimondo, MD, Frank J. Lukens, MD; Mayo Clinic, Jacksonville, FL
Introduction: Insulinomas are a rare, neuroendocrine tumor of the pancreas. We present a unique case of a recurrent insulinoma successfully treated with CT-guided percutaneous ethanol-lipiodol injection.
Methods: An 81 year old female presented to our center with persistent episodes of hypoglycemia during which she reports palpitations, diaphoresis, and confusion. The patient’s past medical history is significant for recurrent hypoglycemia initially due to a 2.5 cm insulinoma at the pancreatic head diagnosed 15 years prior amendable to enucleation therapy. Symptom recurrence 7 years later was significant for a 2 cm neuroendocrine tumor located at the previous surgical bed treated with a pyloric-preserving pancreatoduodenectomy (Whipple procedure). She was symptom free for 7 years prior to reoccurrence for a third time. EUS with fine needle aspiration (FNA) at that time was non-diagnostic and negative for neoplastic immunohistochemistry. On presentation, in our gastrointestinal (GI) clinic patient was hypoglycemic although vitals and physical exam were unremarkable. With concern of reoccurrence of insulinoma, magnetic resonance (MR) abdomen found a 3.8 cm heterogeneous mass posterior and caudal to the pancreatic anastomosis from prior Whipple procedure (Figure 1A). It was decided to proceed with repeat EUS with FNA. EUS was significant for a 3.8 cm, retroperitoneal mass. FNA Biopsy was significant for reoccurrence of insulinoma. The retroperitoneal location and size of the recurrent insulinoma posed a clinically difficult situation to address and focus was placed on symptom management as opposed to tumor removal. EUS with radiofrequency ablation (RFA) was not considered due to the size of the mass, and surgical debulking was ruled out due to the tumor’s retroperitoneal location and patient’s altered post-surgical anatomy. It was decided to proceed with CT-guided percutaneous ethanol-lipiodol injection (Figure 1B). The procedure was successful and the patient was discharged without complications. At follow up 3 months later, the patient reported complete resolution of previous symptoms and repeat MR abdomen showed radiographic evidence of tumor necrosis (Figure 1C). Discussion: Repeat EUS led to expedited diagnosis of a recurrent pancreatic insulinoma and reduced time to treatment. In addition, our case uniquely conveys a successful, alternative approach to addressing symptomatic insulinomas refractory to surgical or medical management, via CT-guided percutaneous ethanol-lipiodol injection.
Figure 1. (A) Contrast-enhanced MRI shows an enlarged, uniformly enhancing porto-caval lymph node metastasis (arrowheads) from pancreatic neuroendocrine tumor. (B) CT scan image after percutaneous injection of lipiodol/ethanol mixture shows extensive distribution of the high radiodensity material within the metastatic lymph node (arrowheads). (C) Contrast-enhanced MRI 3 months after treatment shows extensive zones of lack of enhancement within the treated metastatic lymph node (arrowheads), indicating tumor necrosis.
Disclosures: Himesh Zaver indicated no relevant financial relationships. Hassan Ghoz indicated no relevant financial relationships. Khaled Alnahha indicated no relevant financial relationships. Ricardo Paz-Fumagalli indicated no relevant financial relationships. Massimo Raimondo indicated no relevant financial relationships. Frank Lukens indicated no relevant financial relationships.