• Humans
• Male
• Hypoglycemia/etiology
• Hypoglycemia/diagnosis
• Adult
• Paraneoplastic Syndromes/diagnosis
• Paraneoplastic Syndromes/etiology
• Insulin-Like Growth Factor I/metabolism
• Insulin-Like Growth Factor II/metabolism

• ASVS
• functioning neuroendocrine tumor
• hyperinsulinemic hypoglycemia
• insulinoma
• nesidioblastosis
• pancreas
• selective intraarterial calcium stimulation

• Humans
• Insulinoma/diagnostic imaging
• Pancreatic Neoplasms/diagnostic imaging
• Female
• Male
• Middle Aged
• Adult
• Calcium Gluconate/administration & dosage
• Angiography/methods
• Aged
• Calcium/metabolism
• Injections, Intra-Arterial
• Insulin/administration & dosage
• Retrospective Studies

• 18F-DOPA
• PET/MRI
• carbidopa
• children
• hyperinsulinism
• insulinoma

• Exendin-4
• PET/CT
• enucleation
• hypoglycemia
• insulinoma

• Insulinoma
• Psychiatric disorders
• Schizophrenia
• isCGM

• NEN
• calcitonin
• insulinoma
• procalcitonin
• proinsulin

• Humans
• Insulinoma/blood
• Insulinoma/diagnosis
• Insulinoma/metabolism
• Calcitonin/blood
• Middle Aged
• Pancreatic Neoplasms/blood
• Pancreatic Neoplasms/diagnosis
• Insulin/blood
• Procalcitonin/blood
• Male
• Female

• Ablation
• Alcohol
• Ethanol
• Insulinoma

• Adult
• Female
• Humans
• Aged
• Male
• Insulinoma/diagnostic imaging
• Insulinoma/surgery
• Insulinoma/complications
• Ethanol/therapeutic use
• Pancreatic Neoplasms/surgery
• Pancreatic Neoplasms/pathology
• Hypoglycemia/etiology
• Ultrasonography
• Endosonography/methods

• c-peptide
• high serum insulin and c-peptide
• pancreatic insulinoma
• proinsulin
• severe hypoglycemia

• Amplified feedback system
• Diabetic distress
• Divine punishment
• Psychopathology

• Humans
• Male
• Insulinoma/diagnosis
• Insulinoma/epidemiology
• Insulinoma/pathology
• Pancreatic Neoplasms/epidemiology
• Hypoglycemia/etiology
• Pancreas/pathology
• Hyperinsulinism

• endoscopic-ultrasound-guided ethanol ablation (EUS-EA)
• endoscopic-ultrasound-guided radiofrequency ablation (EUS-RFA)
• pancreatic neuroendocrine tumor (PanNET)

• Humans
• Neuroendocrine Tumors/surgery
• Endoscopy
• Genetic Testing
• Medical Oncology
• Pancreatic Neoplasms/surgery

• Case report
• Hypoglycaemia
• Insulinoma
• Neuroendocrine tumour
• Seizure

Insulinoma is an insulin-secreting tumor that causes hypoglycemia due to inappropriately high insulin secretion. The Whipple's triad, which comprises indications of hypoglycemia (tremor, sweating, irritability, uneasiness, and weakness), plasma glucose concentration <55 mg/dL (3.0 mmol/L), and resolution of symptoms after administration of glucose, is utilized for the determination of insulinoma. In this report, we present the case of a thin, lean, adult male with a BMI of 22, who presented with repetitive episodes of tremor, sweating, weariness, and perplexity that occurred amid fasting and settled with meals, fulfilling Whipple's triad criteria for the determination of insulinoma. The episodes frequently led to seizures. Supervised fasting was carried out, which revealed raised C-peptide levels, low blood glucose, and negative sulfonylurea screen. A computed tomography (CT) scan localized the tumor, and surgical resection was planned.

• autoimmune
• genetic
• hyperkinetic
• infectious
• metabolic
• movement disorders
• treatable

Insulinoma is a pancreatic neuroendocrine tumor that causes hyperinsulinemic hypoglycemia. Symptomatic hypoglycemia related to hepatic insulinoma metastases may be addressed with liver-directed therapies such as hepatic artery embolization.

This work aimed to determine the safety and effectiveness of bland hepatic artery embolization (HAE) for palliation of symptomatic hypoglycemia in patients with hepatic insulinoma metastases refractory to medical management.

An institutional review board–approved retrospective review was undertaken of all patients with a tissue (n = 18) or imaging (n = 2) diagnosis of hepatic insulinoma metastases and symptomatic hyperinsulinemic hypoglycemia refractory to medical management who underwent bland HAE at a single center between January 1, 1998 and November 1, 2020. Twenty patients (10 women, 10 men; mean age, 56 years; range, 18-84 years) were identified who individually underwent 1 (n = 7), 2 (n = 5), 3 (n = 5), 4 (n = 2), or 5 (n = 1) HAEs, for an overall total of 45 HAEs. Post-HAE hypoglycemia recurrence was defined as onset of adrenergic symptoms (eg, sweating, weakness, tremor), neuroglycopenic symptoms (eg, confusion, loss of consciousness), and/or documented serum glucose of less than 50 mg/dL, in the absence of an alternative explanation. Median time to first hypoglycemia recurrence, hypoglycemia-free survival (HFS), and overall survival (OS) were calculated using Kaplan-Meier method.

Before HAE, all patients experienced adrenergic or neuroglycopenic symptoms alleviated by glucose intake, and 60% (n = 12) of patients had documented serum glucose of less than 50 mg/dL within 1 week of the first treatment. Median post-HAE follow-up was 9.4 months (mean, 26 months; range, 0.1-190 months). Postprocedural hypoglycemic symptom relief after the first HAE was reported in 100% (n = 20) of patients before discharge or at follow-up. Post-HAE hypoglycemia recurrence occurred in 60% (n = 12) of patients with a median time to first hypoglycemia recurrence of 2 months (mean, 14 months; range, 0.2-60 months). After the first HAE, median HFS was 14.5 months, and median OS was 16 months. One patient experienced labile postprocedure blood glucose levels requiring intensive care unit admission for intravenous dextrose. Otherwise, no major procedure-related complications occurred.

Bland HAE is a safe, effective, and repeatable procedure for palliation of symptomatic hypoglycemia in patients with hepatic insulinoma metastases refractory to medical management.

• PVA
• bland hepatic artery embolization
• polyvinyl alcohol particles
• transarterial chemoembolization
• transcatheter arterial
• treatment refractory hyperinsulinemic hypoglycemia

• Diazoxide
• Ga68-DOTANOC PET-CT
• insulinoma
• seizures

• NENs
• carcinoid syndrome
• insulinoma
• neuroendocrine tumors

• endocrine cancer
• endocrinology
• epilepsy and seizures
• general surgery

• ADCY5
• ATP1A3
• PRRT2
• SLC2A1
• cAMP
• cerebellum
• episodic ataxia
• ketogenic diet
• paroxysmal dyskinesia
• triheptanoin

Insulinomas are the most common type of functioning endocrine neoplasms of the pancreas presenting hypoglycemic symptoms. Patients characteristically develop symptoms while fasting, but some patients have reported symptoms only in the postprandial state. Repeated and prolonged hypoglycemic episodes can reduce the awareness of adrenergic symptoms, and patients may have amnesia, which delays diagnosis.

We describe a case of a 24-year-old underweight patient who showed hypoglycemic symptoms for almost 6 years. Although patients with insulinoma characteristically develop symptoms while fasting, this young man had hypoglycemic symptoms up to one hour postprandially, especially after high-sugar meals and after physical activity. The fasting tests and imaging methods performed at local hospitals were evaluated as negative for abnormal results. However, brown adipose tissue exhibited increased metabolic activity, and some muscle groups had histological changes as indicated by positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography. Glycogen deficiency was also histologically confirmed. The patient’s symptoms progressed over the years and occurred more frequently, i.e., several times a month, and the patient had reduced awareness of adrenergic symptoms. The follow-up fasting test was positive, and the imaging results showed a tumor in the head of the pancreas. The patient underwent laparotomy with enucleation of the insulinoma.

Weight gain and fasting hypoglycemia are not necessarily characteristics of insulinoma. In prolonged cases, adrenergic symptoms can be suppressed.

• Brown adipose tissue
• Glycogen deficit
• Hypoglycemia
• Insulinoma
• Underweight
• Case report

Pancreatic neuroendocrine tumors (pNETs) are a heterogeneous group of tumors with complicated treatment options that depend on pathological grading, clinical staging, and presence of symptoms related to hormonal secretion. With regard to diagnosis, remarkable advances have been made: Chromogranin A is recommended as a general marker for pNETs. But other new biomarker modalities, like circulating tumor cells, multiple transcript analysis, microRNA profile, and cytokines, should be clarified in future investigations before clinical application. Therefore, the currently available serum biomarkers are insufficient for diagnosis, but reasonably acceptable in evaluating the prognosis of and response to treatments during follow-up of pNETs. Surgical resection is still the only curative therapeutic option for localized pNETs. However, a debulking operation has also been proven to be effective for controlling the disease. As for drug therapy, steroids and somatostatin analogues are the first-line therapy for those with positive expression of somatostatin receptor, while everolimus and sunitinib represent important progress for the treatment of patients with advanced pNETs. Great progress has been achieved in the combination of systematic therapy with local control treatments. The optimal timing of local control intervention, planning of sequential therapies, and implementation of multidisciplinary care remain pending.

• Pancreatic neuroendocrine tumor
• Serum biomarkers
• Staging
• Grading
• Management
• Therapy

• Ablation Techniques/methods
• Antineoplastic Agents/pharmacology
• Antineoplastic Agents/therapeutic use
• Biomarkers, Tumor/blood
• Chemotherapy, Adjuvant/methods
• Combined Modality Therapy
• Cytoreduction Surgical Procedures
• Disease-Free Survival
• Humans
• Lymph Node Excision
• Molecular Targeted Therapy/methods
• Neoplasm Grading
• Neoplasm Staging
• Neuroendocrine Tumors/blood
• Neuroendocrine Tumors/diagnosis
• Neuroendocrine Tumors/mortality
• Neuroendocrine Tumors/therapy
• Pancreas/pathology
• Pancreas/surgery
• Pancreatectomy/methods
• Pancreatic Neoplasms/blood
• Pancreatic Neoplasms/diagnosis
• Pancreatic Neoplasms/mortality
• Pancreatic Neoplasms/therapy
• Patient Care Team
• Prognosis
• Progression-Free Survival
• Somatostatin/analogs & derivatives
• Somatostatin/therapeutic use
• Treatment Outcome

Insulinomas, neuroendocrine tumors arising from pancreatic beta cells, often show overexpression of the glucagon‐like peptide‐1 receptor. Therefore, imaging with glucagon‐like peptide analog exendin‐4 can be used for diagnosis and preoperative localization. This review presents an overview of the development and clinical implementation of exendin‐based tracers for nuclear imaging, and the potential use of exendin‐4 based tracers for optical imaging and therapeutic applications such as peptide receptor radionuclide therapy or targeted photodynamic therapy.

• GLP-1 receptor
• exendin-4
• insulinoma
• peptide receptor radionuclide therapy (PRRT)
• positron emission tomography (PET)
• single-photon emission computed tomography (SPECT)
• targeted photodynamic therapy (tPDT)
• theranostics

• diabetes mellitus
• hyperglycemia
• hypoglycemia
• pancreatectomy

• Animals
• Diabetes Mellitus/etiology
• Diabetes Mellitus/veterinary
• Dog Diseases/surgery
• Dogs
• Female
• Insulinoma/surgery
• Insulinoma/veterinary
• Male
• Neoplasm Recurrence, Local/veterinary
• Pancreatic Neoplasms/surgery
• Pancreatic Neoplasms/veterinary
• Postoperative Complications/veterinary
• Retrospective Studies
• Survival Analysis
• Treatment Outcome

• Mars Petcare
• Royal Canin
• Mars Petcare
• Royal Canin

• Adénome hypophysaire
• Hyperparathyroïdie primaire
• Multiple endocrine Neoplasia type 1
• Neuroendocrine tumor
• Néoplasie endocrinienne multiple de type 1
• Pituitary adenoma
• Primary hyperparathyroidism
• Tumeur neuroendocrine

• Adrenal Insufficiency/etiology
• Aged
• Humans
• Hydrocortisone/administration & dosage
• Hyperinsulinism/etiology
• Hypoglycemia/etiology
• Hypogonadism/etiology
• Insulinoma/complications
• Insulinoma/diagnosis
• Male
• Pancreatic Neoplasms/complications
• Pancreatic Neoplasms/diagnosis

Insulinomas are pancreatic endocrine tumors of rare incidence worldwide, the vast majority are of single occurrence and benign. These may not always present with the clear symptoms described in the literature and may be overlooked because their neuroglycopenic characteristics present in a fashion similar to some psychiatric conditions.

A 50-year-old Hispanic man referred severe psychomotor symptoms, described as anxiety, aggressiveness, agitation, weakness, diaphoresis, and decreased visual acuity. Laboratory testing performed during his last episode revealed increased insulin levels and C-peptide among other findings. Imaging, biopsy, and histopathologic analysis confirmed an insulinoma was the cause of the symptoms, proving the importance of ruling out organic causes of altered mental status prior to consideration of psychiatric disorders.

It is of critical importance to rule out organic causes of altered mental status prior to consideration of psychiatric disorders, as unusual diseases may be overlooked by physicians and be detrimental to the patient’s progress.

• Altered mental status
• Insulinoma
• Neuroendocrine tumor

• IGF-2 induced hypoglycemia
• gastrointestinal stromal tumor
• hepatocellular carcinoma
• hypoglycemia
• non-islet cell hypoglycemia

• U54 GM115428 NIGMS NIH HHS

• DOTATOC
• continuous glucose monitoring
• flash glucose monitoring
• hypoglycemia
• hypoglycemia unawareness
• insulinoma

• Awareness
• Blood Glucose/analysis
• Blood Glucose Self-Monitoring/methods
• Delayed Diagnosis
• Exercise
• Female
• Humans
• Hypoglycemia/diagnosis
• Hypoglycemia/etiology
• Insulinoma/complications
• Insulinoma/diagnosis
• Middle Aged
• Pancreatic Neoplasms/complications
• Pancreatic Neoplasms/diagnosis
• Postprandial Period
• Unconsciousness/etiology

• Biomarkers/blood
• Cells, Cultured
• Chromogranin A/blood
• Female
• Glucagon/blood
• Humans
• Intestinal Neoplasms/blood
• Intestinal Neoplasms/diagnosis
• Male
• Middle Aged
• Neuroendocrine Cells/metabolism
• Neuroendocrine Tumors/blood
• Neuroendocrine Tumors/diagnosis
• Neuroendocrine Tumors/diagnostic imaging
• Pancreatic Neoplasms/blood
• Pancreatic Neoplasms/diagnosis
• Pancreatic Polypeptide/blood
• Protein Precursors/blood
• Sensitivity and Specificity
• Stomach Neoplasms/blood
• Stomach Neoplasms/diagnosis
• Tomography, Emission-Computed, Single-Photon/methods

• Ablation
• Electroporation
• Embolization
• Ethanol
• Insulinoma
• Microwave
• Radiofrequency
• Ultrasound

• Ablation Techniques/methods
• Catheter Ablation
• Humans
• Insulinoma/therapy

• hypoglycemia
• insulin
• neuroendocrine tumor
• pancreatic polypeptide

• anti-epileptic drug
• continuous glucose monitoring
• epilepsy
• hypoglycemia
• insulinoma
• misdiagnosis

• Adult
• Delayed Diagnosis
• Early Diagnosis
• Epilepsies, Partial/complications
• Epilepsies, Partial/drug therapy
• Epilepsies, Partial/physiopathology
• Female
• Humans
• Insulinoma/diagnosis
• Insulinoma/physiopathology
• Insulinoma/surgery
• Pancreatectomy
• Pancreatic Neoplasms/diagnosis
• Pancreatic Neoplasms/surgery
• Treatment Outcome

• Carcinoid
• Ectopic ACTH
• Functional
• GEP NEN
• Gastrinoma
• Gastroenteropancreatic
• Hormonally active
• Insulinoma
• Neuroendocrine neoplasm
• Syndrome
• VIP
• Whipple´s triad
• Zollinger ellison

• Gastrointestinal Neoplasms/diagnosis
• Gastrointestinal Neoplasms/metabolism
• Humans
• Neuroendocrine Tumors/diagnosis
• Neuroendocrine Tumors/metabolism
• Pancreatic Neoplasms/diagnosis

Insulinomas are the most common cause of hypoglycemia resulting from endogenous hyperinsulinism. Traditionally, inappropriately elevated levels of insulin in the face of hypoglycemia are the key to diagnosis. However, contradictory levels of insulin and C-peptide do not necessarily exclude the diagnosis. A 50-year-old female was brought to our emergency department because of conscious disturbance on the previous night. She had no history of diabetes mellitus, and was not using any medications or alcohol. Laboratory data showed low sugar, a significantly low insulin level, and elevated C-peptide. After admission, she had multiple episodes of spontaneous hypoglycemia after overnight fasts without discomfort. It was considered that a neuroendocrine tumor was the source of her hypoglycemia. CT scan of the abdomen revealed a 1.1cm hypervascular nodule in the pancreatic tail. Elective laparoscopic distal pancreatectomy was incorporated into her treatment course. A 1.2×1.0cm homogenous well-encapsulated tumor was resected. We monitored her glucose levels in the outpatient clinic every month for a period of six months. She did not have another episode of spontaneous hypoglycemia.

Insulinoma is a rare diagnosis in the general population with estimates of 1 in 250,000 people per year. Reports of these pancreatic islet cell tumors are even more unusual in children and adolescents. Chronic hypoglycemia due to an insulinoma often presents with neuroglycopenic symptoms that can easily be overlooked, especially in adolescents where nonspecific complaints are common. This may result in delayed diagnosis with prolonged periods of untreated hypoglycemia and associated complications. The rarity of pediatric insulinoma, vagueness of presenting symptoms, and challenge of tumor localization make insulinoma a true diagnostic quandary for clinicians.

In this report, we present a 15-year-old female who visited her primary care provider complaining of intermittent episodes of altered mental status including fatigue, irritability, and poor concentration. Her outpatient management included routine laboratory studies, drug screening, electroencephalogram (EEG), valproic acid initiation, CT scan of the abdomen, and endoscopic ultrasound with documentation of hypoglycemia, but otherwise inconclusive results. The patient was admitted to a tertiary children’s hospital with severe refractory hypoglycemia 8 months after the initial evaluation. A serum critical sample was obtained and magnetic resonance imaging (MRI) of the abdomen performed which confirmed the presence of a pancreatic mass ultimately identified as an insulinoma. She went on to have surgical resection of her tumor resulting in complete resolution of her hypoglycemia and associated symptoms.

Within this report we demonstrate the importance of being vigilant for fasting hypoglycemia secondary to insulinoma even when the patient presents with nonspecific symptoms such as fatigue, irritability, or problems with concentration. If these neuroglycopenic complaints are unnoticed or misdiagnosed, patients with a potentially curable disease are put at risk of neurologic injury, or even death, due to untreated severe hypoglycemia.

• Adolescent
• Altered mental status
• Child
• Epilepsy
• Hyperinsulinism
• Hypoglycemia
• Insulinoma

• Pancreatic neuroendocrine tumors
• VIPoma
• gastrinoma
• glucagonoma
• insulinoma
• somatostatinoma

• 72-Hour supervised fast test
• Insulin autoimmune syndrome
• Insulinoma
• Non-insulinoma pancreatogenous hypoglycemia syndrome
• Non-islet cell tumor hypoglycemia
• Postprandial hypoglycemia (reactive hypoglycemia)
• Spontaneous hypoglycemia

• Adult
• Blood Glucose
• Diagnosis, Differential
• Female
• Humans
• Hypoglycemia/diagnosis
• Hypoglycemia/therapy
• Insulin/blood
• Insulinoma/diagnosis
• Male
• Middle Aged
• Pancreatic Neoplasms/diagnosis
• Postprandial Period

• Gastrinoma
• Insulinoma
• Laparoscopic pancreas resection
• Pancreatic neuroendocrine tumors
• Robotic pancreas resection

• Aged
• Diagnosis, Differential
• Female
• Humans
• Insulinoma/diagnosis
• Male
• Middle Aged
• Pancreatic Neoplasms/diagnosis
• REM Sleep Behavior Disorder/diagnosis

• Adolescents
• Children
• Etiology
• Hyperphagia
• Overeating

• Accidents, Traffic
• Adult
• Humans
• Hypoglycemia/etiology
• Insulinoma/diagnosis
• Insulinoma/surgery
• Male
• Pancreatic Neoplasms/diagnosis
• Pancreatic Neoplasms/surgery
• Robotic Surgical Procedures
• Unconsciousness/etiology

A 24-year-old female with type 1 diabetes mellitus presented with hemiparesis induced by hypoglycemia. She was hospitalized because she has noticed a weakness of her right hand and leg three days after childbirth. On physical examination she had an expressive dysphasia and right side hemiparesis with facial drop. Hypoglycemia is rarely associated with hemiparesis and it is often overlooked, especially when it happens in patients at higher risk of other diseases frequently associated with hemiparesis. Although sporadical cases of hypoglycemia-induced hemiparesis were reported, the clear pathophysiology behind this is not well determined. However, any individual case is important in order to increase the awareness of hypoglycemia as an important etiology of this condition.