Diagnosis and management of insulinoma: current best practice and ongoing developments

Figures & data

Table 1 Symptoms of insulinoma and frequency

Neuroglycopenic symptoms	Adrenergic symptoms
Confusion (80%)	Diaphoresis (69%)
Visual disturbances (59%)	Tremors (24%)
Amnesia or coma (47%)	Palpitations (12%)
Abnormal behavior (36%)	Hyperphagia/weight gain (50%)
Seizures (17%)

Note: Data are from multiple studies.^6,9,11,13

Figure 1 The distribution of the sensitivity rate of preoperative noninvasive and invasive methods in the localization of insulinoma, in all published cases (n=6,222).

Note: Reproduced with permission from Mehrabi A, Fischer L, Hafezi M, et al. A systematic review of localization, surgical treatment options, and outcome of insulinoma. Pancreas. 2014;43(5):675–686.¹⁵
Abbreviations: Angio, angiography; CT, computed tomography; EUS, endoscopic ultrasonography; MRI, magnetic resonance imaging; SACS, selective arterial calcium stimulation; THPVS, transhepatic portal venous sampling; US, ultrasound.

Figure 2 Left hepatic vein insulin concentrations after intra-arterial calcium injections.

Notes: Injections of the superior mesenteric artery, gastroduodenal artery, proper hepatic artery, and mid splenic artery do not show any suspicious areas. However, the increase in insulin concentration after injection into the proximal splenic artery localizes the lesion close to the pancreatic head area, corresponding to the MRI above (Photograph courtesy of Steven K Libutti and National Institutes of Health, Bethesda, MD, USA).
Abbreviations: GDA, gastroduodenal artery; MRI, magnetic resonance imaging; SMA, superior mesenteric artery; R, right; L, left; T, tumor.

Figure 3 The distribution of sensitivity rates of intraoperative modalities in the localization of insulinoma, in all published cases (n=6,222).

Note: Reproduced with permission from Mehrabi A, Fischer L, Hafezi M, et al. A systematic review of localization, surgical treatment options, and outcome of insulinoma. Pancreas. 2014;43(5):675–686.¹⁵
Abbreviations: IOUS, intraoperative ultrasound; IOGM, intraoperative glucose monitoring.

Figure 4 Intraoperative view of insulinoma.

Note: Photograph courtesy of Steven K Libutti.

Figure 5 IOUS placed on insulinoma in Figure 4 to identify the location of the mass in relation to vascular structures and pancreatic duct.

Note: Photograph courtesy of Steven K Libutti.
Abbreviation: IOUS, intraoperative ultrasound.

Figure 6 IOUS of Figures 4 and 5.

Notes: The black arrow is pointing to the pancreatic duct. The yellow lines are showing the insulinoma. Photograph courtesy of Steven K Libutti.
Abbreviation: IOUS, intraoperative ultrasound.

Figure 7 Enucleation of insulinoma seen in Figures 4, 5, and 6.

Note: Photograph courtesy of Steven K Libutti.

Figure 8 Final specimen of insulinoma as shown in Figure 4, 5, 6, and 7.

Note: Photograph courtesy of Steven K Libutti.

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