Value of intra-arterial calcium stimulated venous sampling for regionalization of pancreatic insulinomas

doi:10.1067/msy.2000.109729

Surgery

Volume 128, Issue 6, December 2000, Pages 903-909

Presented at the 21st Annual Meeting of the American Association of Endocrine Surgeons (jointly hosted with the British Association of Endocrine Surgeons), London, United Kingdom, and Lille, France, May 22-25, 2000.

https://doi.org/10.1067/msy.2000.109729 Get rights and content

Abstract

Background. Intra-arterial calcium stimulation with hepatic venous sampling (ASVS) for insulin gradients has been reported to be the most sensitive preoperative localizing technique for insulinomas. We reviewed our experience with ASVS to localize and guide the treatment of insulinomas over the past decade. Methods. Eighteen patients who underwent ASVS before surgical exploration for insulinoma were studied. The accuracy of ASVS was compared with intraoperative findings and other localizing studies. Results. There were no complications arising from the procedures. A more than 2-fold step-up in insulin level 30 to 60 seconds after injection to at least 1 feeding artery was observed in 16 patients. Fourteen of the 16 solitary tumors (87.5%) were correctly located; 100% (6/6 tumors) at the head and 80% (8/10 tumors) at the body/tail. The overall accuracy of this test was 89%, compared with 11%, 33%, 38%, and 63% of ultrasonography, computed tomography, magnetic resonance imaging, and endoscopic ultrasonography, respectively. Six enucleations and 10 distal resections were performed, which included 2 laparoscopic procedures. The combination of intraoperative ultrasonography with preoperative ASVS identified all tumors. Conclusions. ASVS is the most accurate preoperative localization tool for the localization of insulinomas and, in combination with intraoperative ultrasonography, can enhance surgical success. (Surgery 2000;128:903-9.)

Section snippets

Material and methods

From April 1991 to January 2000, selective intra-arterial calcium injection with hepatic venous sampling for insulin level was performed for preoperative localization of pancreatic insulinoma in 20 patients with documented hypoglycemia in the presence of an inappropriately elevated insulin level during prolonged fasting or spontaneous hypoglycemia. Two patients refused surgical treatment after localization studies. The cases of 18 patients who underwent surgical treatment with histologically

Results

There were 11 men and 7 women (median age, 42.5 years; range, 22-71 years). Two patients with multiple endocrine neoplasia type I (MEN-I) had concomitant hyperparathyroidism; 1 patient was referred for persistent hyperinsulinemia after enucleation of tumor at the head of the pancreas.

The results of all localization studies in these 18 patients are summarized in the Table.

Table. Results of localization studies and clinical data with operative procedure

Case	Age(y)	Gender	USG	CT	MRI	EUS	ASVS	Tumor location

Discussion

Insulinomas are overwhelmingly solitary, small (<2 cm), and benign.² Despite the introduction of sophisticated cross-sectional imaging techniques, the preoperative localization of pancreatic insulinoma remains difficult, and the results of noninvasive imaging techniques have been discouraging.⁵ Endoscopic ultrasonography has a sensitivity of approximately 80%, but it is dependent on operator experience and the size and position of the tumors.⁶ Percutaneous transhepatic venous sampling was found

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Cited by (57)

New Diagnostic Criteria for the Localization of Insulinomas with the Selective Arterial Calcium Injection Test: Decision Tree Analysis
2018, Journal of Vascular and Interventional Radiology
Citation Excerpt :
There were no immediate, short-term, or long-term complications resulting from the SACI test procedure, and there were no hypoglycemic episodes after calcium injection during the SACI test. Initial reports claimed that with the SACI test, insulinomas were accurately localized (7) with a sensitivity of 84%–100% (4,8–10). However, specificity was suboptimal.
To explore optimal diagnostic criteria for localizing insulinomas with the selective arterial calcium injection (SACI) test using decision tree analysis.
A retrospective study included 86 vessels of 18 patients (5 men, 13 women; mean age 67 y; range, 49–73 y) with insulinomas who underwent SACI test between June 2007 and May 2016. Of 27 insulinomas, 7 were found in the head, 13 in the body, and 7 in the tail of the pancreas. Two patients had multiple tumors. To identify optimal diagnostic criteria, decision tree analysis was performed, and sensitivity, specificity, and accuracy of the conventional and the proposed new diagnostic criteria (plasma insulin concentration after calcium injection [ICpost] > 2.0 × plasma insulin concentration before calcium injection [ICpre]) were compared.
The proposed new diagnostic criteria for insulinoma obtained by decision tree analysis were (i) ICpost > 2.7 × ICpre and maximum insulin concentration > 60.3 μIU/mL or (ii) ICpost > 2.7 × ICpre and maximum insulin concentration < 60.3 μIU/mL with ICpre being ≥ 7.5 μIU/mL. Sensitivity, specificity, and accuracy of the new criteria for the SACI test were 100%, 91.4%, and 94.2; sensitivity, specificity, and accuracy of conventional criteria were 100%, 69.0%, and 79.1%.
New diagnostic criteria for localization of insulinomas with the SACI test yielded higher diagnostic performance than conventional criteria.
Operation for insulinomas in multiple endocrine neoplasia type 1: When pancreatoduodenectomy is appropriate
2017, Surgery (United States)
Citation Excerpt :
Thus, there is a need of additional diagnostic tools. Some of these, such as transhepatic portal venous sampling,5,9,21 selective intra-arterial calcium injection test,8,17,22-27 or EUS-guided fine-needle aspiration,28,29 are invasive, not always reliable, and require specific expertise. Therefore, at present it is difficult to establish accurately the localization of the insulinoma in patients with MEN1 and the majority of them undergo operative exploration without establishing the precise site, dimension, and number of them.
Distal pancreatectomy is the most frequent operation for insulinomas complicating multiple endocrine neoplasia type 1 insulinoma, although there are conditions for which a different operative approach might be preferable. In this article, we report the operative experience of a referral center for multiple endocrine neoplasia type 1 insulinoma.
Twelve patients underwent operations between 1992 and 2015: 8 underwent a distal pancreatic resection, and 4 underwent a pancreatoduodenectomy. Enucleation of other macroadenomas present in the remnant pancreas was performed in 9 out of these 12 patients.
Operative complications (2 pancreatic fistulas and 2 cases of pancreatitis) occurred in 4 of the 8 distal pancreatic resections. In 1 patient, reoperation was required to resolve the complications of the first operation. At pathologic analysis, multiple insulinomas were found in 5 patients, lymph-nodal metastasis positive for insulin in 2 patients, multiple nonfunctioning pancreatic tumors in all patients, glucagonoma in 4 patients, and gastrinoma in the duodenum or lymph nodes in 4 patients. All the patients were treated successfully for the hypoglycemic/hyperinsulinemic syndrome with no clinical recurrence at a mean follow-up of 85 months (range 4–242 months). Recurrent nonfunctioning pancreatic tumor macroadenomas in the remnant pancreas occurred in only 1 of the 12 patients, and no progression of the gastrinomas was observed. None of the patients developed diabetes mellitus.
Resection of the most severely affected part of the pancreas, whether left or right, associated with enucleation of concomitant macroadenomas in the preserved pancreas is recommended for the treatment of hypoglycemic/hyperinsulinemic syndrome and to prevent malignant progression of nonfunctioning pancreatic tumors in patients with multiple endocrine neoplasia type 1. If the head of the pancreas is the most affected site and the Zollinger-Ellison syndrome is concomitant, then pancreatoduodenectomy should be preferred over distal pancreatectomy.
Incremental benefit of preoperative EUS for the detection of pancreatic neuroendocrine tumors: A meta-analysis
2015, Gastrointestinal Endoscopy
Current guidelines recommend CT scan or magnetic resonance imaging as the initial imaging modalities for the work-up of suspected pancreatic neuroendocrine tumors (PNETs).
To determine the incremental benefit of preoperative EUS (IB_EUS) for the detection of suspected PNETs after other investigative modalities have been attempted.
This systematic review searched MEDLINE, EMBASE, bibliographies of included articles, and conference proceedings for studies reporting original data regarding the preoperative detection of PNETs. Pooled IB_EUS was calculated by using random effects models. Heterogeneity was explored by using stratified meta-analysis and meta-regression. Evidence of small-study effects was assessed by using funnel plots and the Begg test.
Patients with suspected PNETs.
EUS evaluation.
The pooled IB_EUS for the detection of PNETs after CT scan, with or without additional investigative modalities.
Among 4505 citations identified, we included 17 cohort studies (612 patients). EUS identified PNETs in 97% of cases. Improved PNET identification with EUS was observed in all of the studies. After adjusting for small-study effects, meta-analysis showed that EUS alone could identify PNETs in approximately 1 in 4 patients (adjusted IB_EUS 26%; 95% confidence interval, 17%-37%). The pooled IB_EUS varied based on the study design, study size, type of CT scan used, and the number of modalities used prior to EUS.
The majority of included studies were retrospective. Small-study effects were observed.
Preoperative EUS is associated with an increase in PNET detection after other modalities are attempted.
Pheochromocytoma and multiple endocrine neoplasia syndromes
2014, Pediatric Endocrinology: Fourth Edition
Indication and Surgical Procedures for MEN1-associated Duodenopancreatic Neuroendocrine Neoplasms
2023, Zentralblatt fur Chirurgie - Zeitschrift fur Allgemeine, Viszeral- und Gefasschirurgie
Occult insulinoma with treatment refractory, severe hypoglycaemia in multiple endocrine neoplasia type 1 syndrome; difficulties faced during diagnosis, localization and management; a case report
2022, BMC Endocrine Disorders

View all citing articles on Scopus

^*: Reprint requests: Chung, Yau Lo, FRCS (Edin), FACS, Division of Endocrine Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Pokfulam, Hong Kong, China.

^**: Surgery 2000;128:903-9.

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American Association of Endocrine SurgeonsValue of intra-arterial calcium stimulated venous sampling for regionalization of pancreatic insulinomas*,**

Abstract

Section snippets

Material and methods

Results

Discussion

Mayo Clin Proc

Surgery

Surgery

Clin Radiol

Am J Surg

Pancreatic endocrine disease

Insulinoma: cost-effective care in patients with a rare disease

Ann Intern Med

Pancreatic insulinomas: a 15-year experience

Arch Surg

Localization of endocrine pancreatic tumours

Br J Surg

Localization of pancreatic endocrine tumors by endoscopic ultrasonography

N Engl J Med

Localization of insulinomas to regions of the pancreas by intra-arterial stimulation with calcium

Ann Intern Med

Laparoscopic enucleation of a solitary pancreatic insulinoma

Surg Endosc

American Association of Endocrine Surgeons
Value of intra-arterial calcium stimulated venous sampling for regionalization of pancreatic insulinomas*,**