Localization and surgical treatment of occult insulinomas.

Management of patients with biochemical evidence of insulinoma and negative preoperative imaging studies (occult) tumors is controversial, varying from primarily medical management to aggressive, blind nearly total pancreatectomy to extirpate the tumor. Since 1982, 12 consecutive patients with occult insulinoma underwent preoperative portal venous sampling (PVS) for insulin followed by surgical exploration with intraoperative ultrasound (IOUS). Eleven of twelve patients (92%) had insulinoma removed and were cured. Portal venous sampling correctly predicted the location of the insulinoma in 9 patients (75%) and that no tumor would be found in another patient. A fourfold insulin gradient in the pancreatic tail of one patient correctly predicted that a distal pancreatectomy would remove the insulinoma despite the fact that neither palpation nor IOUS identified any tumor. Intraoperative ultrasound was the single best method to identify occult tumors because it correctly identified 10 of 11 insulinomas that were found, including five pancreatic head tumors that were not palpable. Palpation identified five insulinomas. Of the 10 tumors that were identified during operation by palpation or ultrasound, IOUS identified significantly more (100% versus 50%, p = 0.03) and guided the successful enucleation of each. The results support the strategy of preoperative PVS and operation with IOUS to localize and remove insulinoma in patients with occult tumors. Most tumors (75%) will be correctly localized to a specific pancreatic region by preoperative PVS and identified by IOUS (83%), allowing simple enucleation and biochemical correction of hypoglycemia. Morbid blind pancreatic resections are no longer indicated and long-term medical management of hypoglycemia should be reserved for the occasional patient (8%) who fails preoperative PVS and operation guided by IOUS.     

Mechanisms of somatostatin action in RINm5F cells in culture: preliminary evidence for possible altered G protein function.

Octreotide (SMS), a somatostatin analogue, is an established antigrowth peptide, but it does not effectively inhibit the growth of insulinoma cells. In order to study the mechanisms that underlie this apparent lack of an antiproliferative effect on insulinoma tumor cells we established the rat insulinoma cell line, RINm5F, in culture. Cells in culture were tested by incubation in media with and without SMS. To study tritiated [3H]-thymidine incorporation into extracted DNA (TTID), 2 muCi/well of 3H was added for 24 hr, and cells were harvested and assayed for TTID (cpm/microgram DNA). Insulin (IRI) and intracellular cAMP (cAMPi) were measured by RIA. To study the effects of SMS on insulin secretion, conditioned media were sampled after 24 hr. To study the effects of cAMPi, conditioned medium was used to extract cAMPi following incubation with SMS for 15 min. Increasing concentrations of SMS had no significant effect on TTID in the presence of 1% FBS. Trypan blue exclusion tests showed > 90% viable cells throughout all stages of these experiments. There were no significant differences in cell numbers and protein content in the presence of SMS. There was a significant decrease in the secretion of insulin and intracellular cAMP levels in response to 50 nM SMS. However, SMS significantly inhibited TTID in RINm5F cells following a 4-hr pretreatment with pertussis toxin (PT) (23553 +/- 1747 vs 20635 [cpm/microgram DNA] +/- 1983 [SEM], P < 0.01). We conclude that the inhibition of insulin secretion by SMS is associated with an attenuation of cAMP formation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Management of islet cell tumors in patients with multiple endocrine neoplasia: a prospective study

As part of a study to manage islet cell tumors in patients with multiple endocrine neoplasia (MEN), patients with MEN I and Zollinger-Ellison syndrome (ZES) underwent surgery if a pancreatic islet cell tumor was identified on imaging studies. Patients with MEN I and either insulinoma or vasoactive intestinal polypeptide tumor (VIPoma) underwent surgery whether or not a tumor was identified. Each patient underwent preoperative portal venous sampling (PVS). Nine patients with MEN I and one with MEN II underwent surgery; seven had ZES, one had insulinoma, one had VIPoma, and one had both insulinoma and ZES. Eight of the nine patients with MEN I had an identifiable hormone gradient on PVS. Islet cell tumors were removed from the pancreas of each patient; two patients also had duodenal wall tumors, and three patients had malignant islet cell tumors. No patient with ZES and MEN I was cured of ZES despite the fact that islet cell tumor was removed from the region of the gastrin gradient in five of six patients. The single patient with MEN II and ZES and the three additional patients with MEN I and either insulinoma or VIPoma were cured by islet cell tumor resection. The results indicate that islet cell tumors in patients with MEN I can be both extrapancreatic and malignant. In patients with MEN I and ZES, ZES cannot be cured by tumor resection, and PVS cannot be used to select patients for curative surgery. It appears that gastrinoma in patients with MEN II, as well as either insulinoma or VIPoma in patients with MEN I, can be cured by islet cell tumor resection.     

Neuroendocrine tumors of the gastroenteropancreatic system--reevaluation using the Capella classification

INTRODUCTION: Neuroendocrine tumors of the gastroenteropancreatic system (GEP) are heterogeneous regarding hormone production, localisation and biological behaviour making the prognostic evaluation of these rare tumors difficult. Capella et al. proposed a new classification that combines for the first time both biological and prognostic characteristics. This study aimed to evaluate the prognostic value of Capella's classification in the patients treated at our hospital. METHODS: 86 from 1975-1999 surgically treated and histologically confirmed neuroendocrine tumors were retrospectively classified as benign (B), uncertain behavior (UB), low grade malignant (LG) or high grade malignant (HG) following the Capella classification. These data were correlated with the long-term outcome of the patients 8.5 (range: 1-24) years after surgery. RESULTS: 43 % of tumors were localised in the pancreas, the others were equally distributed in the remaining GEP. Most tumors were classified as B (42 %) or LG (41 %), few were UB (10 %) or HG (7 %). 61 patients survived free of disease, 25 patients died, 13 of them not tumor related. Tumor related deaths were only observed in 6 patients with inoperable LG- and 6 patients with HG-neuroendocrine tumors within 3 years after surgery. CONCLUSION: The Capella classification reliably reflects the heterogeneity and the biological behaviour of GEP-neuroendocrine tumors and can therefore be recommended for clinical use.     

Rapid reversal of life-threatening hypoglycaemia with a somatostatin analogue (octreotide). A case report

A patient with life-threatening hypoglycaemia caused by metastatic malignant insulinoma is described. Treatment with octreotide (SMS 201-995, Sandostatin; Sandoz) resulted in immediate sustained improvement of the hypoglycaemia despite persistent high levels of insulin. The possible mechanisms of action, other indications and contraindications of octreotide are discussed.     

胰岛素瘤诊治分析：附72例报告

目的:探讨胰岛素瘤的诊断和外科治疗方法。方法:回顾性分析我院31年余诊治的72例胰岛素瘤的临床资料。结果:84.72%有典型的Whipple三联征表现。80.56%血浆免疫反应性胰岛素/血糖(IRI/G)比值>0.3。术前定位诊断方法的阳性率分别为:腹部超声78.13%,CT(平扫或增强)60.97%,多排螺旋CT胰腺灌注100%,MRI 37.50%,内镜超声(EUS)72.73%,选择性动脉造影(DSA)28.57%。术中超声联合扪诊诊断阳性率92.31%。肿瘤最大直径≤2 cm者占88.75%。37.5%的肿瘤位于胰头颈部,27.50%位于胰体部,35.0%位于胰尾部。81.58%的病例可行胰岛素瘤局部剜除术。病理诊断均为胰岛素瘤,65例(90.28%)为功能性胰岛素瘤,7例(9.72%))为无功能性胰岛素瘤;4例(5.56%)为多发性肿瘤,2例(2.78%)恶性倾向,1例(1.39%)合并多发性内分泌肿瘤1型(MEN-1)。结论:Whipple三联征和IRI/G>0.3可作为胰岛素瘤定性诊断的主要依据。应联合应用超声,CT,多排螺旋CT胰腺灌注,MRI,内镜超声和DSA多种方法进行术前定位。术中超声联合扪诊是简单有效的定位诊断方法。肿瘤的局部剜除术是多数胰岛素瘤的最佳手术治疗方式。     

The surgical management of insulinomas in children

Purpose

Insulinomas are rare pediatric tumors for which optimal localization studies and management remain undetermined. We present our experience with surgical management of insulinomas during childhood.

Methods

A retrospective review was performed of patients who underwent surgical management for an insulinoma from 1999 to 2012.

Results

The study included eight patients. Preoperative localization was successful with abdominal ultrasound, abdominal CT, endoscopic ultrasound, or MRI in only 20%, 28.6%, 40%, and 50% of patients, respectively. Octreotide scan was non-diagnostic in 4 patients. For diagnostic failure, selective utilization of 18-Fluoro-DOPA PET/CT scanning, arterial stimulation/venous sampling, or transhepatic portal venous sampling were successful in insulinoma localization. Intraoperatively, all lesions were identified by palpation or with the assistance of intraoperative ultrasound. Surgical resection using pancreas sparing techniques (enucleation or distal pancreatectomy) resulted in a cure in all patients. Postoperative complications included a pancreatic fistula in two patients and an additional missed insulinoma in a patient with MEN-1 requiring successful reoperation.

Conclusions

Preoperative tumor localization may require many imaging modalities to avoid unsuccessful blind pancreatectomy. Intraoperative palpation with the assistance of ultrasound offers a reliable method to precisely locate the insulinoma. Complete surgical resection results in a cure. Recurrent symptoms warrant evaluation for additional lesions.     

Role of intraoperative ultrasonography in the surgical management of insulinomas

The findings in 35 surgically treated patients with insulinoma and 43 tumors of these patients were analyzed to confirm the efficacy of diagnostic modalities and surgical interventions. The rate of accurate preoperative tumor localization was 72% by angiography, 53% by computed tomographic scan, 55% by ultrasonography, and 83% by percutaneous transhepatic portal vein sampling. Extensive operative exposure and palpation detected 81% of the tumors and intraoperative ultrasonography demonstrated 96% of the tumors. Intraoperative ultrasonography was significantly better than any other diagnostic procedure and was able to demonstrate the anatomical relationship of the insulinoma to the essential structures of the pancreas. Intraoperative ultrasonography also helped determine the safest route for enucleating the insulinomas. Five patients (14%) in our series had metastatic diseases; 2 of these patients with metastases beyond the lymph nodes died due to the growth of tumors. The other 33 patients were free of insulinoma syndrome after the removal of the insulinomas. Streptozotocin was used in 1 patient with recurrent malignant insulinoma, with encouraging results.     

Laparoscopic detection and resection of insulinomas

BACKGROUND: Laparoscopic ultrasonography as a diagnostic tool for the localization of islet cell tumors has been described before, but few reports on laparoscopic resection of insulinomas exist. We retrospectively reviewed the results of our experience with laparoscopic detection and the resection of insulinomas to determine its feasibility. METHODS: Between February 1996 and February 1999, 10 patients underwent operation for organic hyperinsulinism at our institution. Patient and clinical characteristics were studied retrospectively. Laparoscopic ultrasonography was performed to localize the insulinoma and then laparoscopic resection was performed. RESULTS: Eight women and 2 men underwent operation for hyperinsulinism. In 6 patients the insulinoma could be resected laparoscopically, either by enucleation (5 patients) or by resection of the pancreatic tail (1 patient). Four procedures were converted to laparotomy for the proximate location of the insulinoma to the portal vein or pancreatic duct (3 procedures) and failure to identify the insulinoma (1 procedure). The overall success rate of preoperative localization of an insulinoma with the use of various imaging techniques was 60% (6/10 patients). Laparoscopic ultrasonography could identify an insulinoma in 90% of the patients (9/10 patients). The median hospital stay was 7 days. CONCLUSIONS: Laparoscopic ultrasonography followed by laparoscopic removal of the insulinoma in patients with clinically manifested hyperinsulinism is a feasible and safe technique with low morbidity and fast postoperative recovery. Preoperative localization studies appear of limited value.     

Laparoscopic management of insulinoma in a child with multiple endocrine neoplasia type 1

The diagnosis and surgical management of insulinomas associated with multiple endocrine neoplasia type 1 (MEN1) pose additional problems in children because of the long-term risk of recurrence of other pancreatic and non-pancreatic tumors. We report a diagnostic confirmation by laparoscopic ultrasound of an insulinoma and its successful removal by laparoscopic enucleation in an 8- year-old boy who was admitted to our hospital with a history of recurrent episodes of absences, headache, and visual and auditive disturbances diagnosed as hyperinsulinism-related hypoglycemia. Magnetic resonance imaging of the pancreas showed a small contrast-enhancing lesion in the body of the pancreas, suspected for insulinoma. MEN1 was genetically proven by direct DNA testing. A pancreatic tumor can arise before the age of 10 in patients with MEN1 and can be surgically treated by a laparoscopical approach.     

Inhibition of growth of human breast carcinomas in vivo by somatostatin analog SMS 201-995: treatment of nude mouse xenografts

Minced tumor fragments were xenografted into subcutaneous tissue of the lateral thoracic regions of young adult, virgin female nude mice to study the effects of somatostatin analog SMS 201-995 on growth of estrogen-dependent (MCF-7) and estrogen-independent (BT-20) human breast carcinomas. When tumors became palpable (6 to 10 days), mice were assigned randomly to receive either SMS (4 to 50 micrograms) or acetate buffer (0.2 ml) subcutaneously twice a day. For MCF-7, mean tumor volume was significantly lower on day 20 and days 30 through 50 in SMS-treated mice than in controls (p less than 0.05), and tumor doubling time was increased from 13.2 to 19.0 days. Calculated growth increment was significantly lower with SMS than with buffer treatment (1.1 +/- 0.1 vs 1.9 +/- 0.2) (p less than 0.001). For BT-20, mean tumor volume of SMS-treated mice was slightly, but not significantly, lower than that of controls; however, calculated growth increment was significantly lower for SMS treatment (3.2 +/- 0.3 vs 3.9 +/- 0.4) (p +/- 0.001), and tumor doubling time was increased from 4.0 to 5.8 days. For MCF-7, flow cytometric DNA analysis of tumor biopsy samples demonstrated a reduced G2 + M phase with SMS treatment. We conclude that SMS slows the growth of both MCF-7 and BT-20 human breast cancer xenografts in nude mice and that SMS may be clinically useful in the management of patients with breast carcinoma.     

Observations on the effect of a somatostatin analog in the Zollinger-Ellison syndrome: implications for the treatment of apudomas

Somatostatin is known to inhibit hormone release and gastrointestinal secretion and hence may be useful in the treatment of amine precursor uptake, decarboxylase tumors. Clinical application has been limited by the short half-life, potency, and specificity of the natural hormone. Our study evaluated the effect of a synthetic analog of somatostatin, SMS 201-995 (Sandoz, Inc., E. Hanover, N.J.) on basal and stimulated gastrin release and gastric acid secretion in 10 patients with the Zollinger-Ellison syndrome. In experiment 1, H2-receptor antagonists were discontinued for 48 hours; SMS 201-995, 1 microgram/kg, was given subcutaneously; gastrin and SMS levels in plasma were determined by radioimmunoassay; and gastric secretion was measured and titrated at 0, 1, 2, 3, 4, 5, 6, 8, 10, 12, 14, 16, and 18 hours. The mean +/- SEM baseline gastrin level (1526 +/- 733 pg/ml) was significantly inhibited for 16 hours (p less than 0.05, paired t test). Gastric secretion was neutralized for as long as 18 hours (p 0.05). In experiment 2, three patients received either a secretin (2 U/kg) or a calcium stimulation test (2 mg/kg) with or without pretreatment with SMS 201-995, 1 microgram/kg, subcutaneously. The mean +/- SEM interpreted change in gastrin (ng X 60 min/ml) without SMS 201-995, 36.8 +/- 11 (secretin), and 129 +/- 30 (calcium) were reduced with SMS 201-995 to -1.1 +/- 0.76 (secretin) and -29 +/- 28 (calcium) (p less than 0.05). In the Zollinger-Ellison syndrome, SMS 201-995 caused significant and long-lasting inhibition of both tumor gastrin release and gastric acid secretion, probably by direct action on both the gastrinoma and the stomach. SMS 201-995 blocks acid secretion and secretin- and calcium-stimulated gastrin release, indicating that SMS 201-995 inhibits peptide secretion by postreceptor mechanisms. SMS 201-995 will be useful in the palliative treatment of apudomas.     

Intraoperative ultrasonographic localization of islet cell tumors. A prospective comparison to palpation.

The purpose of the present study was to evaluate prospectively the value of intraoperative ultrasound scanning (IOUS) in localizing islet cell tumors by comparing results of IOUS to those of palpation during 44 consecutive laparotomies for gastrinoma (36) or insulinoma (8). All patients had preoperative radiographic imaging studies and selective venous sampling for hormones, which guided the subsequent laparotomy. Any suspicious finding by palpation and/or IOUS was resected. Pathologic evidence of islet cell neoplasm served as the reference standard. Five patients were excluded from analysis because neither palpation nor IOUS had suspicious findings and no islet cell tumor was found. Seven pancreatic insulinomas were found in seven patients. IOUS was as sensitive as palpation at localizing insulinomas. Twenty-three pancreatic gastrinomas were found in 19 patients. IOUS was equal to palpation in the ability to localize gastrinomas. Gastrinomas that were successfully imaged by IOUS were significantly larger than gastrinomas that were not imaged. Twelve extrapancreatic gastrinomas were found in nine patients, and palpation was more sensitive than IOUS at localizing these small duodenal wall tumors. Five patients (11%) had their surgical management changed by IOUS. Two patients had pancreatic tumors (one gastrinoma and insulinoma) enucleated that would not have been found without IOUS, and three patients had resections of pathologically proven malignant islet cell tumors based on sonographic findings. All five patients were cured with short follow-up. The present results demonstrate that palpation and IOUS are complementary because IOUS can image tumors that are not palpable and IOUS can provide additional information concerning malignant potential not detected by palpation.     

A prospective evaluation of laparoscopic exploration with intraoperative ultrasound as a technique for localizing sporadic insulinomas

BACKGROUND: Preoperative imaging studies localize insulinomas in less than 50% of patients. Arteriography with calcium stimulation and venous sampling (ASVS) regionalizes greater than 90% of insulinomas but requires specialized expertise and an invasive procedure. This prospective study evaluated laparoscopic exploration with IOUS compared with the other localization procedures in patients with a sporadic insulinoma. METHODS: Between March 2001 and October 2004, 14 patients (7 women and 7 men; mean age, 53) with an insulinoma were enrolled in an IRB-approved protocol. Computed tomography, magnetic resonance imaging, ultrasound scan, and arteriography with calcium stimulation and venous sampling were performed preoperatively. A surgeon, blinded to the results of the localizing studies, performed a laparoscopic exploration with intraoperative ultrasound (IOUS). At the completion of the exploration, the success of laparoscopy for localization was scored, and the tumor was resected. RESULTS: Twelve of 14 tumors were localized successfully before laparoscopy (noninvasive, 7 of 14; invasive, 11 of 14). Laparoscopic IOUS localized successfully 12 of 14 tumors. All lesions were resected, and all patients were cured (median follow-up, 36 months). CONCLUSION: Laparoscopic IOUS identified 86% of tumors. The authors consider laparoscopic IOUS to be equivalent to ASVS in localizing insulinomas. Further study is therefore warranted to determine the role of laparoscopy with IOUS in the localization and treatment algorithm for patients with sporadic insulinoma.     

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目的 总结胰岛素瘤的诊断和治疗经验.方法 回顾性分析北京协和医院1953-2007年诊治404例胰岛素瘤的临床资料.结果 肿瘤直径＜2cm者占79.6%.36.2%的肿瘤位于胰头部,28.2%位于胰体部.35.6%位于胰尾部.18例(4.5%)为恶性胰岛素瘤,34例(9.0%)为多发性肿瘤.96.0%有典型的Whipple三联征.89.6%血胰岛素/血糖比值＞0.3.术前定位检查发现胰岛素瘤敏感性经腹超声检查36.8%,普通平扫CT24.7%,增强CT66.7%,多排螺旋CT胰腺灌注92.7%,MRI 31.6%,生长抑素受体显像33.3%,超声内镜(EUS)79.1%,选择性动脉造影(SAG)84.6%,经皮经肝门静脉置管取血(眦)测定胰岛素88.1%,动脉刺激静脉取血(ASVS)测定胰岛素87.0%.术中定位诊断方法的敏感性细针穿刺活检89.2%,术中超声(包括腹腔镜超声)检查90.0%.73.1%的病例可行肿瘤的局部摘除术.结论 多排螺旋CT胰腺灌注是目前胰岛素瘤术前定位诊断的首选方法.随着微创外科技术在胰腺外科中的应用,对部分条件适宜的病例可选用腹腔镜手术,但对多发胰岛素瘤仍应仔细开腹探查,避免遗漏病灶.     

胰岛素瘤64例的诊断与外科治疗

目的 总结胰岛素瘤的诊断与外科治疗方法.方法 回顾性分析64例胰岛素瘤的临床资料.结果 64例均表现Whipple三联征.术前BUS、CT及强化CT、MRI、DSA诊断阳性率分别为46.9%(30/64),58.2%(23/39),66.7%(18/27),91.7%(11/12).IOUS诊断阳性率为92%(23/25).单个肿瘤58例,多发肿瘤6例.单发者位于胰头19例,其中直径4cm 1例,胰体17例,胰尾22例;多发者6例均为2枚肿瘤,4例位于胰体,2例分别位于胰体和胰尾各1枚.治疗行肿瘤局部切除39例,胰体尾切除13例加作脾切除6例,胰尾切除8例加作脾切除4例,胰体表面肿瘤直径2cm行腹腔镜下单纯肿瘤摘除1例,自左向右分段切除(盲切法)2例,行胰头十二指肠切除1例.良性肿瘤62例,恶性2例.术后胰瘘3例、急性胰腺炎4例均经非手术治愈.64例术后低血糖症状消失.62例良性胰岛素瘤术后随诊1～5年血糖正常,其中2例分别于术后4年和5年复发,再次手术发现胰尾近脾门处分别有直径1cm和1.5cm肿瘤,经胰尾切除后治愈.45例随访8年血糖正常,17例失访.2例恶性胰岛素瘤分别于术后3年和4年复发,因肝转移死亡.结论 Whipple三联征和测定IRI/G＞0.3是定性诊断的依据.术中触诊联合IOUS是最有效的肿瘤定位诊断方法.胰岛素瘤切除术是最佳的治疗方法.     

Anesthetic management of two patients with insulinoma using propofol--in association with rapid radioimmunoassay for insulin

We experienced anesthetic management of two patients with insulinoma in whom frequent hypoglycemic episodes with blood glucose levels of 39-42 mg.dl-1 had been observed. Each patient received epidural analgesia with a catheter inserted at the T 9/10 intervertebral space. Anesthesia was induced with propofol 80-100 mg and fentanyl 200 micrograms. Tracheal intubation was facilitated with vecuronium 6 mg. Anesthesia was maintained with continuous infusion of propofol and epidural anesthesia. Rapid measurements of immunoreactive insulin (IRI) were useful for localization of insulinoma during surgery. Perioperative plasma glucose levels could be maintained within normal ranges by continuous infusion of glucose. Rebound hyperglycemic episodes were not observed, and IRI was reduced after removal of the insulinoma. General anesthesia using propofol and epidural block is a useful choice for the anesthetic management of patients undergoing an operation for removal of an insulinoma.     

Preoperative localization of insulinomas is not necessary.

BACKGROUND: Insulinomas are infrequent but are important to recognize and surgically remove. Several diagnostic tests have been used to increase the chances of operative success. The value of preoperative testing for insulinomas is the subject of this review. STUDY DESIGN: All patients treated at the Cleveland Clinic for insulinoma between 1985 and 1995 were retrospectively reviewed. All patients had biochemical evidence of primary hyperinsulinemia. RESULTS: There were 21 patients, 10 men and 11 women, with a median age of 58 years. Eighteen patients (85%) had a single insulinoma, two patients (10%) had multiple insulinomas, and one patient (5%) had nesidioblastosis. In addition, two patients (10%) had malignant insulinoma. A total of 13 patients (62%) had successful preoperative localization of their tumors, and all of these were found during exploration either by the surgeon (12 patients) or by intraoperative ultrasonography (1 patient). The remaining eight patients (38%) did not have their lesion localized by preoperative tests. In seven patients these tumors were found at operation, three by the surgeon and four by intraoperative ultrasonography. One patient failed preoperative and intraoperative localization and was later diagnosed with nesidioblastosis. Enucleation was performed in 13 patients and distal pancreatectomy in 7; the patient with nesidioblastosis had a negative laparotomy and a subsequent distal pancreatectomy. The mortality and morbidity rates were 0% and 14%, respectively. Only two patients, including the patient with nesidioblastosis, remained symptomatic after operation. CONCLUSIONS: The diagnosis of an insulinoma does not require extensive localization studies before operation. The combination of surgical exploration and intraoperative ultrasonography identified more than 90% of insulinomas. When technically feasible, enudeation is curative and can be accomplished with low morbidity.     

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??Surgical management choice and evaluation on pancreatic endocrine tumor ZHANG Tai-ping, LI Jian, ZHAO Yu-pei. Department of General Surgery??Peking Union Medical College Hospital??Chinese Academy of Medical Sciences, Beijing100730, China
Corresponding author??ZHAO Yu-pei, E-mail??zhao8028@263.net
Abstract Pancreatic neuroendocrine tumor is one of the common tumors in pancreatic surgery. According to the endocrinic disorder caused by the hormone secretion??it is divided into functional and non-functional tumors??such as insulinoma??gastrinoma??non-functioning pancreatic neuroendocrine tumor. The ratio of benign to malignancy varies with the forms of tumors. Hepatic metastasis happens in partial tumors. Surgical management is the most important treatment method??which can cure partial patients. The surgical management method varies with different tumor forms. The specific surgery depends on the tumor form??size??position??the scope of tumor invasion??etc. which includes tumor enucleation??pancreatoduodenectomy??distal pancreatectomy??pancreaticsegmental resection??duodenum-preserving resection of pancreatic head and so on. Laparoscopy is suitable for partial tumors. The prognosis of pancreatic neuroendocrine tumor is much better compared with that of pancreatic ductal adenocarcinoma. Surgery should be positively considered to remove the primary and metastatic tumors to improve the prognosis of patients even with hepatic metastasis.     

Somatostatin analog: effects on hypergastrinemia and hypercalcitoninemia

A somatostatin analog (SMS 201-995) was used to treat symptomatic patients with a residual tumor burden of gastrinoma or medullary thyroid carcinoma and pathologic elevations of circulating marker peptides associated with these neuroendocrine tumors. Possible inhibitory effects of the analog on marker peptides, patients' symptoms, or tumor progression were studied in a dose-response protocol and during several months of self-injection of SMS 201-995. Both patients reported remarkable relief of secretory diarrhea and other symptoms, and serum gastrin was successfully suppressed by increasing doses of the analog. However, no effect was seen in reduction of hypercalcitoninemia. Morphologic imaging of residual tumor showed no progression of medullary thyroid carcinoma during treatment and, in the case of hepatic gastrinoma metastases, remarkable tumor regression was confirmed. No toxicity or glucose intolerance was experienced. Somatostatin analog shows promise for palliative management of endocrinologic symptoms due to neuroendocrine tumors, and an inhibitory effect can be measured in some but not all peptide markers. Further evidence of its negative trophic effect on tumor blood flow may suggest an antineoplastic potential, as well as palliative use of this new treatment.