PROINSULIN-PREDOMINANT PANCREATIC NEUROENDOCRINE TUMOR-INDUCED HYPOGLYCEMIA AFTER ROUX-EN-Y GASTRIC BYPASS SURGERY

Overview

Journal AACE Clin Case Rep

Specialty Endocrinology

Date 2020 Jan 23

PMID 31967066

Citations 2

Authors

Khary Edwards

Lori De La Portilla

Faryal S Mirza

Pooja Luthra

Affiliations

Soon will be listed here.

Abstract

Objective: To present a case of recurrent hypoglycemia following Roux-en-Y gastric bypass (RYGB) surgery whose etiology was determined to be a proinsulin-predominant pancreatic neuroendocrine tumor (a proinsulinoma).

Methods: A case report along with a brief discussion and review of the pertinent literature is presented.

Results: The patient is a 62-year-old female who presented with symptomatic hypoglycemia 11 years after RYGB surgery. Initial workup revealed low insulin levels with elevated proinsulin levels. A 72-hour fast confirmed the presence of proinsulin-induced hypoglycemia secondary to a pancreatic neuroendocrine tumor (PNET). She underwent distal pancreatectomy with splenectomy and a PNET tumor was successfully removed with resolution of her symptoms.

Conclusion: Hypoglycemia after RYGB surgery is a well-established syndrome. While there are several etiologies for this, PNETs (including proinsulinomas) should be considered in the differential diagnosis in this population. Proinsulinomas are an increasingly recognized cause of hypoglycemia. Proinsulin levels must always be included as part of the workup of hypoglycemia in an adult.

Citing Articles

Intraoperative selective arterial calcium injection test to confirm complete resection of a proinsulinoma.

Sakamoto A, Ogawa K, Iwata M, Ito C, Shine M, Matsui T J Surg Case Rep. 2022; 2022(7):rjac249.

PMID: 35919694 PMC: 9341228. DOI: 10.1093/jscr/rjac249.

Metastatic insulinoma presenting after bariatric surgery in a patient diagnosed with MEN1.

Poku C, Amjed H, Kazi F, Samarasinghe S Clin Case Rep. 2022; 10(2):e05419.

PMID: 35145695 PMC: 8818282. DOI: 10.1002/ccr3.5419.

References

van Beek A, Emous M, Laville M, Tack J . Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management. Obes Rev. 2016; 18(1):68-85. DOI: 10.1111/obr.12467. View

Yao J, Hassan M, Phan A, Dagohoy C, Leary C, Mares J . One hundred years after "carcinoid": epidemiology of and prognostic factors for neuroendocrine tumors in 35,825 cases in the United States. J Clin Oncol. 2008; 26(18):3063-72. DOI: 10.1200/JCO.2007.15.4377. View

Tamm E, Bhosale P, Lee J, Rohren E . State-of-the-art Imaging of Pancreatic Neuroendocrine Tumors. Surg Oncol Clin N Am. 2016; 25(2):375-400. PMC: 4808582. DOI: 10.1016/j.soc.2015.11.007. View

Service G, Thompson G, Service F, Andrews J, Collazo-Clavell M, Lloyd R . Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med. 2005; 353(3):249-54. DOI: 10.1056/NEJMoa043690. View

Service F, Natt N . The prolonged fast. J Clin Endocrinol Metab. 2000; 85(11):3973-4. DOI: 10.1210/jcem.85.11.6934. View

Kitabchi A . Proinsulin and C-peptide: a review. Metabolism. 1977; 26(5):547-87. DOI: 10.1016/0026-0495(77)90099-3. View

Service F, OBrien P . Increasing serum betahydroxybutyrate concentrations during the 72-hour fast: evidence against hyperinsulinemic hypoglycemia. J Clin Endocrinol Metab. 2005; 90(8):4555-8. DOI: 10.1210/jc.2005-0033. View

Salehi M, Vella A, McLaughlin T, Patti M . Hypoglycemia After Gastric Bypass Surgery: Current Concepts and Controversies. J Clin Endocrinol Metab. 2018; 103(8):2815-2826. PMC: 6692713. DOI: 10.1210/jc.2018-00528. View

Fadini G, Maran A, Valerio A, Meduri F, Pelizzo M, Miotto D . Hypoglycemic syndrome in a patient with proinsulin-only secreting pancreatic adenoma (proinsulinoma). Case Rep Med. 2011; 2011:930904. PMC: 3135210. DOI: 10.1155/2011/930904. View

10.

Wiesli P, Schmid C, Perren A, Pfammatter T, Spinas G, Keller U . Hypoglycemia in response to glucose and glucagon in insulinoma patients with a negative prolonged fast: functional and morphological properties. J Endocrinol Invest. 2005; 27(9):832-8. DOI: 10.1007/BF03346277. View

11.

Mulla C, Storino A, Yee E, Lautz D, Sawnhey M, Moser A . Insulinoma After Bariatric Surgery: Diagnostic Dilemma and Therapeutic Approaches. Obes Surg. 2016; 26(4):874-81. PMC: 4814298. DOI: 10.1007/s11695-016-2092-5. View

12.

Won J, Tseng H, Yang A, Tang K, Jap T, Kwok C . Intra-arterial calcium stimulation test for detection of insulinomas: detection rate, responses of pancreatic peptides, and its relationship to differentiation of tumor cells. Metabolism. 2003; 52(10):1320-9. DOI: 10.1016/s0026-0495(03)00200-2. View

13.

Chia C, Saudek C . The diagnosis of fasting hypoglycemia due to an islet-cell tumor obscured by a highly specific insulin assay. J Clin Endocrinol Metab. 2003; 88(4):1464-7. DOI: 10.1210/jc.2002-021543. View

14.

Kartalis N, Mucelli R, Sundin A . Recent developments in imaging of pancreatic neuroendocrine tumors. Ann Gastroenterol. 2015; 28(2):193-202. PMC: 4367208. View

15.

Goldfine A, Patti M . How common is hypoglycemia after gastric bypass?. Obesity (Silver Spring). 2016; 24(6):1210-1. PMC: 5079518. DOI: 10.1002/oby.21520. View

16.

Thakker R, Newey P, Walls G, Bilezikian J, Dralle H, Ebeling P . Clinical practice guidelines for multiple endocrine neoplasia type 1 (MEN1). J Clin Endocrinol Metab. 2012; 97(9):2990-3011. DOI: 10.1210/jc.2012-1230. View

17.

Ro C, Chai W, Yu V, Yu R . Pancreatic neuroendocrine tumors: biology, diagnosis,and treatment. Chin J Cancer. 2012; 32(6):312-24. PMC: 3845620. DOI: 10.5732/cjc.012.10295. View

18.

Murtha T, Lupsa B, Majumdar S, Jain D, Salem R . A Systematic Review of Proinsulin-Secreting Pancreatic Neuroendocrine Tumors. J Gastrointest Surg. 2017; 21(8):1335-1341. DOI: 10.1007/s11605-017-3428-8. View

19.

Rodriguez A, Canto M, Makary M . Endoscopic localization and tattooing of a proinsulinoma for minimally invasive resection. Pancreas. 2011; 40(3):474-7. DOI: 10.1097/MPA.0b013e318205e926. View

20.

Iglesias P, Diez J . Management of endocrine disease: a clinical update on tumor-induced hypoglycemia. Eur J Endocrinol. 2014; 170(4):R147-57. DOI: 10.1530/EJE-13-1012. View