What insulinomas are Insulinomas are rare tumours that start in the insulin making cells of the pancreas. These cells are called pancreatic islet cells. Insulinomas are also called islet cell tumours. Insulin is a hormone that controls the amount of sugar in the blood. It helps glucose to move from the blood into body cells. Islet cells also make other hormones. Insulinomas produce insulin. This leads to symptoms of diabetes. Normally, our blood sugar rises when we eat, which signals to the pancreas to produce more insulin. Once the blood sugar has gone back to normal levels the pancreas stops making insulin. When you have an insulinoma the tumour keeps producing insulin. This means your blood sugar level continues to drop. This can lead to dangerously low blood sugar levels. Some insulinomas also produce other hormones such as gastrin. Gastrin is a protein that makes the stomach produce acid to digest food. Most insulinomas are not cancer and 9 out of every 10 insulinomas (90%) are benign tumours. About 1 in 10 people (10%) have more than one tumour. Around 1 out of 10 insulinomas are cancerous (10%).

And in about 1 in 10 people (10%) the cancer has spread to another part of the body when it is diagnosed. These are usually slow growing tumours. They can develop in any part of the pancreas. They are very rare and only 1 to 3 people in every million develop them each year. Insulinomas are a type of neuroendocrine tumour. Neuro means nerve and endocrine means hormone producing. Neuroendocrine tumours (NETs) are tumours that develop in cells that are triggered by nerve cells to produce hormones. Insulinomas belong to a specific group of NETs called gastroenteropancreatic neuroendocrine tumours (GEP NETs). They are also called pancreatic neuroendocrine tumours (pNETs or PETs). Tests to diagnose insulinoma If you have symptoms of a low blood sugar you will have a blood sugar test. This is quick and easy. The doctor or nurse pricks your finger to get some of your blood. They put the blood into a blood sugar testing machine. If your blood sugar is below 2mmol per litre of blood you will have further blood tests to check the levels of insulin and other hormones in your blood.

You may also have blood tests to check for proteins that stop your pancreas making insulin. Other tests you may have include Endoscopic ultrasound MRI scan Endoscopic ultrasound is an ultrasound scan done from inside your body. You have an endoscopy but the endoscope contains a small ultrasound probe. The ultrasound helps the doctor to find areas that might be cancer. They then guide a small needle into the areas to remove a sample of cells ( a biopsy ). Treating insulinoma The main treatment for insulinomas is surgery . This cures most insulinomas. But surgery is not always possible. Some cancerous insulinomas have already spread when they are diagnosed. If you can’t have surgery you will have drug treatment to control your blood sugar levels and other symptoms.

The treatment you have depends on Whether you have one or more tumours Whether the tumour is benign or malignant Whether the tumour has spread to other parts of the body Where in the pancreas the tumours are Your general health Whether you have a familial cancer syndrome Other treatments you may have include The type of surgery you have will depend on Whether you have one or more tumours Where in the pancreas the tumour is The size of the tumour If the tumour is less than 2cm your surgeon may remove just the tumour. They call this enucleation. If the tumour is in the body or tail of the pancreas you may be able to have the operation with a laparoscope. This is also called keyhole surgery. It is a small operation where the surgeon puts a flexible tube filled with optical fibres (a laparoscope) into the body through a small cut. The surgeon looks through the laparoscope to find and remove the tumour. If your tumour is in the head of the pancreas, is larger than 2cm, or you have more than one tumour, you may need to have open surgery. This means having an abdominal operation.

You will also have an ultrasound scan during your operation, to check for other tumours. Some people need to have some or all of their pancreas removed. You may also have nearby organs removed. The types of surgery used include Removing the whole pancreas (total pancreatectomy) Removing the head of the pancreas (pylorus preserving pancreaticoduodenectomy – PPPD) Whipples operation – PPPD with part of your stomach removed Removing the tail of your pancreas (distal pancreatectomy) These are major operations and there are risks with having this type of surgery. But the aim is to try to cure your insulinoma so you may feel it is worth some risks. You can read more about these operations and the possible side effects on the surgery to try to cure pancreatic cancer page . If you have MEN 1 or von Hippel-Landau syndrome, you are more likely to develop more tumours after having one removed. Your surgeon may suggest you have more of your pancreas removed than if you didn’t have a family cancer syndrome. This is to reduce the risk of getting more tumours. You are also more likely to need to have an abdominal operation.

T reating symptoms of insulinoma Some cancerous (malignant) insulinomas are diagnosed when they are already advanced. And some come back after treatment. The most common place for malignant insulinoma to spread to is the liver. Not everyone with a non cancerous (benign) insulinoma can have surgery. This may be because of other medical conditions or the position of the tumour. If surgery is not possible, you will have treatment to control the amount of insulin the tumours are producing. The aim of treatment for insulinomas that can’t be completely removed is to control any symptoms you have rather than cure it. Treatments may include S urgery Your specialist may suggest you have surgery even if your malignant insulinoma can’t be completely removed. Taking away as much of the tumour as possible can help with symptoms because there will be less insulin produced. If a malignant insulinoma spreads to another part of the body, the most common area it goes to is the liver. You may also have surgery to remove tumours in your liver. As this is a major operation and there are risks, you need to think carefully about the benefits. Will it improve your quality of life enough to make it worth having such a big operation?

Your surgeon will talk to you about the risks and benefits and answer any questions you have. Instead of having a major open surgery for a cancer that has spread to your liver you may be able to have radiofrequency ablation, cryotherapy or transarterial chemoembolisation (TACE) to reduce your symptoms. Or you may have selective internal radiotherapy (SIRT). Radiofrequency ablation uses heat made by radio waves to kill cancer cells. Cryotherapy uses a cold probe to destroy cells and tissue by freezing. TACE is when you have chemotherapy injected directly into the area of the tumour in the liver. You also have an injection of another substance which blocks the blood supply to the tumour. This substance may be a gel or tiny plastic beads and helps to keep the chemotherapy around the tumour. SIRT is when microscopic beads that are coated with a radioactive substance called Yttrium-90 are injected into the blood supply to the liver. This is a type of targeted radiotherapy. Before you have surgery you will need to have good control of your insulin levels. You may need to start on one of the drug treatments that control symptoms, for example, diazoxide .

If you have MEN1 and have other symptoms because of that, such as a high calcium level, you will also need treatment to control the symptoms. D rugs and diet to control blood sugar The symptoms of an insulinoma can be difficult to cope with. To help to control your blood sugar you may need to have a high glucose diet. Being aware of the symptoms of a low blood sugar will help you correct it quickly by eating something that contains glucose. T he drug diazoxide helps to control blood sugar by reducing the amount of insulin you make. You take it as a tablet. The possible side effects include feeling or being sick, loss of appetite, and fluid build up in the legs or other parts of the body. Other drug treatments that help control blood sugar are verapamil, diphenylhydantoin [pronounced dye-feen-eye-l-hide-an-toe-in] and steroids. Some tumours have somatostatin receptors and then somatostatin analogue drugs such as octreotide and lanreotide can also reduce the amount of insulin in your body. There is information about somatostatin analogues in the carcinoid section of CancerHelp UK. Research into insulinomas Research is always more difficult with rare conditions.

There are fewer people available to take part in a trial, so it takes longer for the trial to recruit enough people. There is research looking into diagnosing and monitoring these tumours, as well as research into different types of chemotherapy. New biological treatments include drugs like sunitinib (Sutent) , everolimus (Afinitor) and bevacizumab (Avastin) . These types of treatment work on tumours that have particular proteins. A recent phase 3 trial found that people having everolimus for advanced neuroendocrine tumours (NETs) had a longer time before their cancer started growing again compared to people having a dummy drug (placebo). The average time before the tumour started growing again was 11 months, compared to 4.6 months in people having the placebo. Another phase 3 trial comparing sunitinib with a placebo for advanced NETs found that the average time before the cancer started growing again was 11.4 months compared to 5.5 months in people having the placebo. The All Wales Medicines Strategy Group (AWMSG) and the Scottish Medicines Consortium say that sunitinib and everolimus should be available on the NHS.

You should be able to have sunitinib or everolimus if other treatments are not working, and you have pancreatic neuroendocrine tumour that cannot be removed with surgery or has spread to other parts of the body. In England NICE have not looked at these drugs for NET. You may be able to have them through individual funding through your PCT or through the cancer drugs fund if your doctor thinks they would be helpful. We need more research to find out which of these new treatments work best and when to use them. To find out more about trials for neuroendocrine tumours go to our clinical trials database . Coping with insulinoma Coping with a rare condition can be difficult both practically and emotionally. Being well informed about your condition and possible treatments can make it easier to make decisions and cope with what happens. It can also help to talk to people with the same condition. But it can be hard to find someone with a rare tumour. Check out Cancer Chat – Cancer Research UK’s discussion forum. It is a place to share experiences, stories and information with other people who know what you are going through. You might also find our general coping with cancer section helpful.

Insulinoma: MedlinePlus Medical Encyclopedia An insulinoma is a tumor in the pancreas that produces too much insulin. Causes The pancreas is an organ in the abdomen. The pancreas makes several enzymes and hormones, including the hormone insulin. Insulin's job is to reduce the level of sugar (glucose) in the blood by helping it move into cells. Most of the time when your blood sugar level drops too low, the pancreas stops making insulin until your blood sugar returns to normal. Tumors of the pancreas that produce too much insulin are called insulinomas. Insulinomas keep making insulin, even when your blood sugar drops too low. A high blood insulin level causes a low blood sugar level ( hypoglycemia ). Hypoglycemia may be mild, leading to symptoms such as anxiety and hunger. Or it can be severe, leading to seizures, coma, and even death. Insulinomas are rare tumors. They usually occur as single, small tumors in adults. These tumors are very rare in children. Most children with high blood insulin levels have many areas of overactive insulin-releasing cells in the pancreas, instead of a single tumor.

90% of insulinomas are non-cancerous (benign) tumors. People with specific genetic syndromes such as multiple endocrine neoplasia type I are at risk of insulinomas and other endocrine tumors . Symptoms Insulinoma - Symptoms, Diagnosis, Treatment of Insulinoma - NY Times Health Information Back to Top Causes The pancreas is an organ in the abdomen. The pancreas makes several enzymes and hormones, including the hormone insulin. Insulin's job is to reduce the level of sugar (glucose) in the blood by helping it move into cells. Most of the time when your blood sugar level drops too low, the pancreas stops making insulin until your blood sugar returns to normal. Tumors of the pancreas that produce too much insulin are called insulinomas. Insulinomas keep making insulin, even when your blood sugar drops too low. A high blood insulin level causes a low blood sugar level ( hypoglycemia ). Hypoglycemia may be mild, leading to symptoms such as anxiety and hunger. Or it can be severe, leading to seizures, coma, and even death. Insulinomas are rare tumors. They usually occur as single, small tumors in adults.

These tumors are very rare in children. Most children with high blood insulin levels have many areas of overactive insulin-releasing cells in the pancreas, instead of a single tumor. More than 90% of insulinomas are non-cancerous (benign) tumors. People with the genetic syndrome called multiple endocrine neoplasia type I are at risk of insulinomas and other endocrine tumors. Back to Top Treatment Surgery is the recommended treatment for insulinoma. The tumor is first found by tests or surgery. Medication may be used to get patients stable before surgery. If there is a single tumor, it will be removed. If there are many tumors, part of the pancreas will need to be removed (partial pancreatectomy). At least 15% of the pancreas must be left to produce its enzymes for digestion. This may prevent the surgeon from removing the whole insulinoma tumor. In rare cases, the entire pancreas is removed if there are many insulinomas or they continue to come back. Removing the entire pancreas leads to diabetes because there is no longer any insulin being produced. Insulin injections are then required.

If no tumor is found during surgery, or if you are not a candidate for surgery, you may get the drug diazoxide to lower insulin production and prevent hypoglycemia. A diuretic (water pill) is given with this medication to prevent the body from retaining fluid. Octreotide is used to reduce insulin release in some patients. Back to Top When to Contact a Medical Professional Call your health care provider if you develop any symptoms of insulinoma. Convulsions and decreased consciousness are an emergency -- call 911 or your local emergency number right away. Back to Top References Cryer PE. Hypoglycemia. In: Shlomo M, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 12th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 34. Jensen RT, Norton JA. Endocrine tumors of the pancreas and gastrointestinal tract. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease . 9th ed.

Philadelphia, PA: Elsevier Saunders; 2010:chap 32. National Cancer Institute: PDQ Pancreatic neuroendocrine tumors (islet cell tumors) treatment. Bethesda, MD: National Cancer Institute. Date last modified 11/10/2012. Available at: Accessed January 3, 2013. More Information on This Topic News & Features Review Date: 12/22/2012 Reviewed By: Nestoras Mathioudakis, MD, Assistant Professor of Medicine, Division of Endocrinology & Metabolism, Johns Hopkins School of Medicine, Baltimore, MD. Review provided by VeriMed Healthcare Network. Also reviewed by A.D.A.M. Health Solutions, Ebix, Inc., Editorial Team: David Zieve, MD, MHA, David R. Eltz, Stephanie Slon, and Nissi Wang. A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission ( URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M.

is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation ( A.D.A.M. Copyright The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited. Canine Insulinoma Canine Insulinoma Email Article This article will address the canine insulinoma, a cancerous growth that produces an over- abundance of the blood glucose regulating hormone, insulin.

Let's review some terms related to this discussion on canine insulinoma: Cancer - A general term frequently used to indicate any of various types of malignant neoplasms (see below), most of which invade surrounding tissues, may metastasize (see below) to several sites, and are likely to recur after attempted removal and to cause death of the patient unless adequately treated. Neoplasm - An abnormal tissue that grows by cellular proliferation more rapidly than normal and continues to grow after the stimuli that initiated the new growth ceases. Closely related to a tumor. Tumor - An abnormal growth of tissue resulting from uncontrolled progressive multiplication of cells and serving no physiological function. Closely related to a neoplasm. Malignant - Resistant to treatment; occurring in severe form, invades surrounding tissues and is frequently fatal. Benign - Denoting the mild character of an illness or the non-malignant character of a neoplasm. Metastatic - The shifting of a disease, from one part of the body to another. In cancer, the appearance of tumors in parts of the body remote from the origin of the primary tumor. Chemotherapy - Treatment of disease by means of chemical substances or medications.

Exocrine gland - A gland that secretes a substance that ends up outside the body either directly or through a duct. Endocrine gland - A gland that secretes a substance internally as into the bloodstream. What is a canine insulinoma, where is one found and what affect does an insulinoma have on the dog? The canine insulinoma is a cancerous growth located on or within the pancreas of the dog. The pancreas is a secretory organ that serves two main functions; as an exocrine gland and also as an endocrine gland. The exocrine portion of the pancreas produces digestive enzymes that allow the dog to break down proteins, carbohydrates and fats. These enzymes enter the duodenal portion of the small intestine via a small duct where they interact with food particles that are exiting the stomach. The endocrine portion of the pancreas is located in several groups of cells located within the tissue of the pancreas called the Islets of Langerhans. These cells produce several different hormones; the most important for our discussion is insulin. Insulin is the 'truck' that 'carries' sugars, primarily glucose, from the bloodstream into the body's cells where it is used as the fuel that energizes the body, especially the brain.

When blood sugar rises, after eating or in response to a stressful situation, insulin is released to deliver blood sugar to the cells. When the cells of the Islets of Langerhans become cancerous, they increase in numbers and the levels of hormones they produce also increase, in particular the dog's levels of insulin. When the dog's bloodstream receives an abnormally high level of insulin, the dog's available blood sugar is transported from the blood stream into cells markedly reducing the dog's blood sugar. This condition is called hypoglycemia. In response to hypoglycemia, the dog's body will release a number of hormones called catecholamines. These hormones attempt to counteract the hypoglycemia by mobilizing available sugars and sources of sugars. Canine insulinoma's are almost always malignant and often metastatic. What dogs are most commonly affected by insulinomas? The average age when an insulinoma develops in a dog is nine years, with medium- to large-breed dogs most commonly affected. What are the symptoms of insulinoma? Dogs with an insulinoma demonstrate a variety of symptoms including: Ataxia (incoordination) These symptoms are the result of the insulin-induced hypoglycemia.

How is an insulinoma diagnosed? A diagnosis of insulinoma requires several elements. A persistent hypoglycemia is strongly suggestive. Multiple blood samples, fasting and non-fasting, may need to be evaluated. Comparing the levels of insulin and glucose detected in the same blood sample can also be suggestive of an insulinoma. In this case, insulin levels would be above normal and glucose levels below normal. A value called "the amended insulin: glucose ratio" may also be helpful. This test also compares the amount of insulin in the blood stream compared to the glucose levels. With this test, there may be a 'normal' insulin value with an abnormally low level of glucose. Diagnostic imaging may or may not help in the diagnosis of this cancerous growth. Abdominal ultrasound of the pancreas is not typically helpful because of the small size of these cancerous lesions. Ultrasound may be helpful in examining other tissues for the presence of metastasis. Visualizing the pancreas during abdominal surgery is considered the most definitive method of diagnosing an insulinoma. During abdominal surgery, the surgeon will gently palpate the pancreas for the presence of any abnormal growths.

To help the surgeon see the insulinoma in the pancreas, a 1% solution of methylene blue stain mixed with saline is injected intravenously. The cells of the insulinoma will 'take-up' the stain while the surrounding tissue will not. Will a canine insulinoma metastasize? Yes, it is very likely that an insulinoma will spread to other parts of the dog's body. The most common sites for metastases include: Regional lymph nodes Mesentery Spleen As metastatic tumors grow, they often interfere with the function of surrounding structures and organs. For example, if the tumor develops on or near the duodenum, it may block the flow of digestive enzymes from the pancreas and/or bile from the gall bladder. Either of these situations will compromise the health of the dog. Is a canine insulinoma treatable? Yes, this tumor is treatable. Early in the disease process, it is important that hypoglycemia be addressed by feeding several small meals throughout the day to help stabilize the dog's blood sugar. Medication such as corticosteroids can be used to help raise the blood sugar. Diazoxide may be used to inhibit insulin secretion.

Most often, treatment will involve surgically removing the insulinoma. It is critically important that hypoglycemia is controlled during and after surgery. Because the surgeon needs to manipulate the pancreas, the dog will need to be monitored for acute pancreatitis. Pancreatitis can be fatal. If hypoglycemia persists after surgery, the prognosis is not as good. This would indicate that a portion of the insulinoma is still present and chemotherapy should begin. There are several medications that can be used to suppress these tumors and their spread. Streptozocin attacks the beta cells directly, but it can have toxic side effects; toceranib and alloxan are additional options. The primary goal of treatment is to stabilize the dog's blood glucose and avoid hypoglycemia. If the dog is experiencing seizures as a result of the hypoglycemia that cannot be controlled with diet and/or medications, the seizures may need to be controlled with a medication such as phenobarbital. What is the prognosis for a dog with an insulinoma? In most cases the prognosis for dogs with an insulinoma is guarded to poor. This tumor is almost always malignant and metastatic.

Survival rates range from 6-24 months after the disease is diagnosed. Surgery, chemotherapy and diet can reduce the effects of the increase in insulin and the resulting decrease in blood glucose. References and Further Reading Goddard, L. Insulinoma: Why Is My Blood Sugar So Low? British Small Animal Veterinary Congress, Birmingham, United Kingdom, 2011. Nelson, Richard W., Salisbury, Kathleen S. Pancreatic beta cell neoplasia. In Birchard, SJ; Sherding, RG (eds.) Saunders Manual of Small Animal Practice 2nd Edition. W.B. Saunders Co. Philadelphia, PA; 2000: 288-294. Scott-Moncrieff, JC. Logical Approach to Diagnosis and Management of Hypoglycemia. Western Veterinary Conference, Las Vegas, NV 2011. Insulinoma: Causes, Symptoms, and Diagnosis Read This Next What Is an Insulinoma? An insulinoma is a small tumor in the pancreas that produces an excess amount of insulin. In most cases, the tumor isn’t cancerous. Most insulinomas are less than 2 centimeters in diameter.

The pancreas is an endocrine organ located behind your stomach. One of its functions is to produce hormones that control the level of sugar in your bloodstream, such as insulin. Normally, the pancreas stops creating insulin when your blood sugar drops too low. This allows your blood sugar levels to return to normal. When an insulinoma forms in your pancreas, however, it will continue to produce insulin, even when your blood sugar is too low. This can lead to severe hypoglycemia, or low blood sugar. Hypoglycemia is a dangerous condition that can cause blurred vision, lightheadedness, and unconsciousness. It can also be life-threatening. An insulinoma usually needs to be surgically removed. Once the tumor is removed, complete recovery is very likely. What Are the Symptoms of an Insulinoma? People with insulinomas don’t always have noticeable symptoms. When symptoms do occur, they can vary depending on the severity of the condition. Mild symptoms include: jaundice, or yellowing of the skin and eyes What Causes an Insulinoma? Doctors don’t know exactly why people get insulinomas. The tumors typically show up without warning. When you eat food, the pancreas creates insulin.

Insulin is a hormone that helps your body store the sugar from your food. Once the sugar has been absorbed, the pancreas stops producing insulin. This process usually keeps blood sugar levels stable. However, it can be disrupted when an insulinoma develops. The tumor continues to produce insulin even when your blood sugar drops too low. This can lead to hypoglycemia, a serious condition characterized by low blood sugar levels. Who Is at Risk for an Insulinoma? Insulinomas are rare. Most are small and measure less than 2 centimeters in diameter. Only 10 percent of these tumors are cancerous. Cancerous tumors tend to occur more often in people who have multiple endocrine neoplasia type 1. This is an inherited disease that causes tumors in one or more hormonal glands. The risk for insulinoma also seems to be higher for those with von Hippel-Lindau syndrome. This inherited condition causes tumors and cysts to form throughout the body. Insulinomas also tend to affect women more than men. They most commonly develop in people who are between ages 40 and 60. How Is an Insulinoma Diagnosed?

Your doctor will perform a blood test to check your blood sugar and insulin levels. A low blood sugar level with a high insulin level indicates the presence of an insulinoma. The test can also check for: proteins that block the production of insulin medications that cause the pancreas to release more insulin other hormones that affect insulin production Your doctor may order a 72-hour fast if the blood test indicates that you have an insulinoma. You’ll stay in the hospital while you fast so your doctor can monitor your blood sugar levels. They’ll measure your blood sugar levels every six hours at least. You won’t be able to eat or drink anything except water during the fast. You’ll likely have very low blood sugar levels within 48 hours of starting the fast if you have an insulinoma. Your doctor may perform more tests to confirm the diagnosis, including an MRI or CT scan . These imaging tests help your doctor determine the location and size of the insulinoma. An endoscopic ultrasound may be used if the tumor can’t be found using a CT or MRI scan. During an endoscopic ultrasound, your doctor inserts a long, flexible tube into your mouth and down through the stomach and small intestine.

The tube contains an ultrasound probe, which emits sounds waves that produce detailed images of your pancreas. Once the insulinoma is located, your doctor will take a small sample of tissue for analysis. This can be used to determine whether the tumor is cancerous. How Is an Insulinoma Treated? The best treatment for an insulinoma is surgical removal of the tumor. A small part of the pancreas may also be removed if there’s more than one tumor. This typically cures the condition. There are various types of surgery that can be performed to remove the insulinoma. The location and number of tumors determine which surgery will be used. Laparoscopic surgery is the preferred option if there’s only one small pancreatic tumor. This is a low-risk, minimally invasive procedure. During laparoscopic surgery, your surgeon makes several small incisions in your abdomen and inserts a laparoscope through the incisions. A laparoscope is a long, thin tube with a high-intensity light and a high-resolution camera at the front. The camera will display the images on a screen, allowing the surgeon to see inside your abdomen and guide the instruments. When the insulinoma is found, it will be removed.

Part of the pancreas may need to be removed if there are multiple insulinomas. Sometimes, part of the stomach or liver may be removed as well. In rare cases, removing the insulinoma won’t cure the condition. This is usually true when the tumors are cancerous. Treatments for cancerous insulinomas include: radiofrequency ablation, which uses radio waves to kill cancerous cells in the body cryotherapy , which involves the use of extreme cold to destroy cancerous cells chemotherapy , which is an aggressive form of chemical drug therapy that helps destroy cancerous cells Your doctor may also prescribe medications to control blood sugar levels if surgery wasn’t effective. What Is the Long-Term Outlook for People with an Insulinoma? The long-term outlook for people with an insulinoma is very good if the tumor is removed. After surgery, most people recover completely without complications. However, an insulinoma may return in the future. Recurrence is more common in people who have multiple tumors. A very small number of people may develop diabetes after surgery. This usually only occurs when the entire pancreas or a large portion of the pancreas is removed. Complications are more likely in people with cancerous insulinomas.

This is particularly true when the tumors have spread to other organs. The surgeon may not be able to remove all the tumors completely. In this case, more treatment and follow-up care will be necessary. Luckily, only a small number of insulinomas are cancerous. How Can an Insulinoma Be Prevented? Doctors don’t know why insulinomas form, so there’s no known way to prevent them. However, you can reduce your risk of developing hypoglycemia by exercising regularly and maintaining a healthy diet. This diet should largely consist of fruits, vegetables, and lean protein. You can also keep your pancreas healthy by eating less red meat and quitting smoking if you smoke. Ferret Society of Canberra home : 3. health problems : insulinoma insulinoma INSULINOMA (or pancreatic cancer) BODY MECHANISM The pancreas is an organ located within the abdomen, near the spleen and is responsible for secreting various hormones into the bloodstream, as well as pancreatic enzymes into the intestines to aid in digestion. The beta cells within the pancreas, contain cells called the Islets of Langerhans - these are responsible for secreting the hormone, insulin.

Carbohydrates are long strings of sugar, and when a carbohydrate is digested, the sugar (glucose) enters the blood stream, waiting to be used. Insulin is then released from the pancreas in response to the increased ï¿½blood glucoseï¿½ level, in order for the glucose to be utilised by the cells throughout the body. In a healthy animal, blood glucose levels fluctuate moderately depending on when and what was last eaten. Ferrets have a carbohydrate requirement of ZERO, which means they arenï¿½t designed to digest large amounts of carbohydrates or sugar throughout their life, nor release the large amounts of insulin to deal with them. It is thought that the continued consumption of high amounts carbohydrates, over-stimulates the pancreas, and leads to the development of pancreatic neoplasms (cancers) also known as ï¿½insulinomaï¿½. Susan Brown, DVM says, ï¿½If normal beta cells are bombarded with higher than normal levels of glucose (which comes from carbohydrates) they can become hypertrophied (overactive) trying to keep up with insulin demand.

If the high carbohydrate diet continues, the result may be a complete burnout of the cells, which is what happens when a pet or a person develops diet-induced diabetes. However, another possibility is that instead of the cells burning out, they go from hypertrophy to neoplasia (cancer). Neoplasia is an abnormal growth of cells and can be preceded by a hyperplastic condition. I would like to stress that this exact mechanism has not been scientifically proven in ferrets to date, but the scenario is entirely within the realm of possibility.ï¿½ (#1) Other names for insulinoma include: Islet Cell Tumours (named after the Islets of Langerhans), beta cell tumours, pancreatic tumours, insulinomas, or insulinoma tumours. Diabetes is very uncommon in ferrets, so it appears that their bodies react by developing neoplasms rather than burning out. The excess levels of insulin produced by these pancreatic neoplasms (insulinoma) drive too much of the glucose in the blood into the cells of the body, causing a dangerously low blood glucose level known as hypoglycemia.

In the early stages of insulinoma, the bouts of hypoglycemia are sporadic, but as it progresses, the hypoglycemia becomes constant. Dizziness, fatigue, headaches and shakiness are all effects of hypoglycemia that humans have reported, and ferrets probably feel similar. In diabetes, the opposite is true - low levels of insulin production render the bodyï¿½s cells unable to use glucose, resulting in hyperglycemia (high blood glucose level). Glucose is essential for a cellï¿½s survival, and ï¿½glucose starvationï¿½ resulting from hypoglycemia can cause permanent damage ï¿½ especially to sensitive cells such as neurons in the brain.

SUMMARY * neoplasms cause excess insulin production * drives too much glucose from the blood into cells * results in hypoglycemia (low blood sugar) Diabetes * ï¿½burn outï¿½ results in low insulin production * glucose in blood cannot be utilised by cells * results in hyperglycemia (high blood sugar) WORLDWIDE In the USA, it is believed that pancreatic neoplasms (insulinoma) are the most common neoplasm in ferrets (#2), although exact figures are unknown. Most ferrets in the USA are fed primarily on processed foods containing high levels of carbohydrates (mainly ferret or cat biscuits). This is one of the reasons we do not recommend feeding your ferret any processed food, including biscuits. In Australia, insulinoma is still uncommon, but is surfacing more than it once did. This could be due to owners and veterinarians becoming more knowledgeable, but the link between more owners feeding processed foods and our rate of insulinoma cannot be ignored. SYMPTOMS The first thing you will notice with an insulinomic ferret, is that they will stop whatever they are doing and STARE INTO SPACE.

This is because of a sudden drop in their blood sugar level, which makes them feel dizzy. This will only last for several seconds, and they will then continue on their way as if nothing happened. Other symptoms can include * hind leg weakness (although this is a symptom of many problems in ferrets) * lethargy * lack of appetite, and * pawing at the mouth. If left untreated, or if the subtle symptoms are not noticed, it will eventually progress to SEIZURES ï¿½ where the ferret is unresponsive and may twitch. In severe cases, this may progress to screaming seizures ï¿½ the ferret is not screaming in pain, but their vocal chords become active during the seizure - then eventually coma and death. DIAGNOSIS If a ferret is suspected of having insulinoma, a veterinarian can test their blood glucose level, via a blood test.

Normal blood glucose level is in the range of 90-125 mg/dL (4.95 Mmol/L - 6.88 Mmol/L) * see note at end of article about concentration measurements ï¿½Ferrets with blood glucose concentrations lower than 70 mg/dL (3.85 Mmol/L) are suspected of having Insulinoma. In one study of 49 ferrets with confirmed insulinoma, all had blood glucose concentrations lower than 60 mg/dLï¿½ (#3) Ferrets are not usually fasted before a blood test, as ï¿½the majority of insulinomic ferrets will exhibit hypoglycemia without fasting, and may be thrown into a crisis situation following a fastï¿½ (#4) Some vets will diagnose insulinoma without a blood test, based on symptoms and a quick temporary recovery by administration of glucose. EMERGENCY TREATMENT If an insulinomic ferret doesnï¿½t show any initial symptoms, you may be faced with a hypoglycemic seizure (and ferrets usually save their serious illnesses for when the vet hospital is closed, like midnight on a Saturday!).

Raising the blood glucose level of a ferret having a seizure is essential. This is done by applying something with a high sugar content directly to the gums. DO use honey, sugar/water paste, or Karo Syrup (corn syrup) ï¿½ all 3 have high amounts of simple sugars (< 80%) DO apply to the gums with a cotton bud, where it can be absorbed without risk of inhalation into the lungs DO apply every 10 minutes or so, and if possible on the way to the vet. DONï¿½T use Nutripet, as although it smells sweet, it contains only 20% simple sugars DONï¿½T try to get the ferret to drink or put anything down their throat while he/she is seizing ï¿½ this can cause aspiration pneumonia by inhaling the fluid into the lungs. This is an emergency treatment only, so the ferret should be taken to a ferret-knowledgeable vet as soon as possible, to discuss treatment options. TREATMENT The preferred treatment is surgical, where any visible tumours on the pancreas are removed. Part of the pancreas may also be removed (partial pancreatotomy).

Even if a ferret is showing little or no symptoms, an extremely low blood glucose level is often enough for a veterinarian to proceed with surgery (if the ferret is up to the surgery & the owner agrees to proceed) Insulinoma tumours do not usually metastasize (spread to other areas of the body). Complete removal of all tumours is not often possible because they can be microscopic, so the ferret may show symptoms again not long after their surgery. Dr. Bruce Williams says, ï¿½the incidence of recurrence of insulinoma after surgery is high, averaging about 40% over a 10 months spanï¿½ (#4) Although surgery is not always curative, it is the only possibility of a cure, so we recommend attempting it unless the ferret is not able to withstand surgery. For non-surgical candidates, drugs can be given to control the symptoms, however they are not a cure, and have no effect on the neoplasms. Prenisone is a steroid available in either tablet or liquid form.

ï¿½Prednisone achieves its effects by causing breakdown of body protein and reformation into glucose by the liver (a process known as gluconeogenesis) and by decreasing the utilization of glucose by many body tissues.ï¿½ (#4) Prednisone (PRED-nis-own) is converted to Prednisolone (pred-NIS-o-loan) in the liver, so some ferrets may do better on Prednisolone than Prednisone, as it saves this extra step in processing. Side effects can include weight gain, and over a long period, liver damage. Brewerï¿½s yeast (a product containing chromium) used to be recommended to help raise the blood glucose level, however it is no longer recommended, as it actually LOWERS the blood glucose level. PREVENTION A ferretï¿½s natural diet contains virtually no carbohydrates, so providing a diet as close to this as possible (and hence low in carbohydrates) is probably the biggest contribution you can make to preventing insulinoma. Treats with high amounts of sugar and/or carbohydrates (including sultanas and Nutripet) should be avoided or given very sparingly.

Ferrets are often placed on a low-carbohydrate diet AFTER they are diagnosed with insulinoma, however it makes much more sense to provide an appropriate diet to every ferret, in an effort to avoid such problems. REFERENCES 1. ï¿½Rethinking the Ferret Dietï¿½, Dr. Susan Brown, DVM 2. ï¿½Islet Cell Tumor in the Ferretï¿½, Dr. Bruce Williams, DVM 3. ï¿½Ferrets, Rabbits & Rodents: Clinical Medicine & Surgeryï¿½, 1997 4. ï¿½Insulinoma in Ferretsï¿½, Dr. Bruce Williams, DVM CONCENTRATION MEASUREMENTS All concentrations (blood glucose or otherwise) can be measured using weight (grams), or molecule count (moles). Weight Mg / dL (milligrams per decilitre) Traditional unit for measuring Molecule Count Mmol / L (millimoles per litre) SI (Systeme International) world standard unit for measuring blood glucose (used in most places except the USA).

A mole is 6.23 x 10^23 molecules Written by Shona Whaite Pancreatic Cancer (Insulinoma) in Dogs | petMD Pancreatic Cancer (Insulinoma) in Dogs Insulinoma in Dogs Insulinomas are malignant neoplasms -- fast growing cancer cells -- of the beta cells in the pancreas. The beta cells primarily secrete insulin, among other hormones. Insulin produces a variety of effects in the body -- the primary one being to regulate glucose levels throughout the body's cells. Because insulinomas secrete excessive insulin, the blood stream becomes low in glucose (a condition referred to as hypoglycemia), which causes weakness or neurological problems. Symptoms and Types The most common symptom of an insulinoma is physical collapse, or loss of consciousness (syncope). Seizures, extreme weakness, and other neurological abnormalities are also common. Because the insulin is released periodically, symptoms are not consistent and frequency is not necessarily predictable. Diagnosis If your dog should collapse and a blood sample indicates low glucose, insulinoma will be highly suspected and your veterinarian will need to follow through with further tests to confirm it.

However, multiple blood samples may need to be taken over a period of time to determine if there is a persistent low glucose concentration. Your doctor will need to determine the insulin concentration at the lowest glucose concentration. Withold food from your dog before tests are performed is essential for determining true glucose levels - your veterinarian will advise you on the appropriate way to conduct these short term fasts for your dog. An amended insulin:glucose ratio (AIGR) may be useful when your dog's insulin level is low, yet still in the normal range. Insulinoma is still suspected in these type of cases. If the insulin level is inappropriately high for the decreased glucose level, insulinoma may still be present. Ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) can be helpful in determining the extent of the pancreatic tumor and how much it is metastasizing. Typically insulinomas do not metastasize to the lungs; however, chest x-rays may indicate other neoplasias as a cause of persistently decreased glucose. Scintigraphy, a form of imaging using radioactive isotopes to identify abnormal tissue, can also be used to identify the location of primary insulinomas and metastasis.

Treatment If your dog has collapsed or is suffering from seizures because of an insulinoma, medical emergency treatment usually will consist of immediate administration of glucose. For home treatment of sudden collapses or seizures, corn syrup can be given as a temporary solution to increase glucose levels. But medical attention will still be needed, so consulting with a veterinarian is critical. The veterinarian may also give your dog glucose containing fluids and/or steroids to counteract the insulin effects. If your dog's health status, along with imaging of the tumor, indicates potential value from surgery, removal of the tumor will usually be recommended. Hypoglycemia may be resolved by removing the part of the pancreas with the tumor on it. However, if there is significant metastases or functional tumor cells in the remainder of the pancreas, additional treatment will still be necessary. Likewise, if the tumors are generalized, or if there are other health concerns, medical management may be advised as the primary mode of treatment. Prednisolone is a steroid that stimulates formation of glucose and is often a cornerstone of medical treatment. Other medications that might be used to treat insulinoma include: Chemotherapeutic agents, such as streptozocin Dietary management is frequently used in conjunction with other treatments.

In fact, you may be able to minimize the amount of medication, or the need for additional treatments, by feeding your dog small, frequent amounts of moderate protein, low sugar foods, and complex carbohydrate rich foods. Clinically, the most important dietary technique is the frequency of the meals. Essentially, this technique is used to limit the fluctuations in insulin that instigate the hypoglycemic episodes. Controlling symptoms of hypoglycemia is ultimately the goal. Your veterinarian will assist you in developing a workable diet plan for your dog. Living and Management Surgery, along with dietary precautions, can dramatically lessen hypoglycemia and insulinoma symptoms for your dog. However, in many cases continued medical treatment and dietary management will be necessary. Frequent check-ups will be necessary to monitor this condition, and to determine if progress is being made in a positive direction. The success of the treatments will be evaluated and the type of treatment fine-tuned based on your dogs symptoms and whether any of the conditions have recurred. Pancreatic neuroendocrine tumors: What is an insulinoma? This document is available in Spanish What is an insulinoma?

An insulinoma is a tumor, usually benign (non-cancerous), made up of specialized beta islet cells (see below) that constantly secrete insulin, causing hypoglycemia (low blood glucosesugar). Normally, as the glucose rises with eating, the pancreas responds by secreting more insulin, which in turn helps utilize or store the glucose and its blood level drops back down into a safe range. Subsequently, as the glucose level continues to fall toward the lower limit of normal (normal, 60-100mg/dL), the secretion of insulin (by the normal beta cells in the pancreas) stops, and this allows the glucose to remain in the normal range. This type of feedback regulation is the hallmark of endocrine organs (thyroid, parathyroid, endocrine part of the pancreas, pituitary, gonad, and adrenal glands that secrete specific hormones). When an insulinoma is present, insulin regulation is abnormal such that the tumor continues to secrete insulin even though the glucose level may fall to a dangerously low level. Even though insulinoma is the most common pancreatic islet cell tumor, it is very rare, occurring in only 3-4 per million people.

Except in very rare familial (occurring in families, transmitted genetically from parent to child) situations, the exact cause is unknown. Figure 1: Actual insulinoma cut in half, measuring slightly larger than 1 cm (about 1/2 inch). The average age to develop an insulinoma is the mid-40s (range, 10-82 years), and occurs slightly more frequently in females than males. Most are sporadic (occurring "out of the blue" with no known cause) with about 10% occurring as part of the Multiple Endocrine Neoplasia type 1 (MEN 1) syndrome. At least 90% have single, benign, small (less than 2 cm  3/4 of an inch) tumors (Figure 1). Hypoglycemic symptoms are experienced by virtually all patients with insulinoma and can be grouped into 2 categories: neurologic (nervous system) and adrenergic (secretion of adrenalin from the adrenal gland).

Because the brain requires glucose for normal function, a glucose level below 50 mg/dL often results in abnormal brain-related symptoms (neuroglycopenia, Table 1). When the glucose level drops to about 55 mg/dL, this also triggers release of adrenaline by the adrenal glands with resultant adrenergic symptoms (Table 1). While adrenaline may raise the glucose level in normal patients with modestly low glucose levels, it is insufficient to overcome the effect of the continuously secreted insulin by insulinomas. The patient must be rescued from the hypoglycemia by administration of glucose in some form-often taking sugar-containing food or drinks, or intravenous glucose injection (sometimes by emergency medical technicians!). Historically, the three components of 1) symptoms of hypoglycemia, 2) documented plasma glucose of less than 50 mg/dL at the time of hypoglycemic symptoms, and 3) relief of these symptoms with administration of glucose has been referred to as Whipple's triad. It remains an excellent starting point for establishing a diagnosis of insulinoma. Neuroglycopenia Table 1.

Insulinoma Symptoms Figure 2: Commonly used medications may appear extremely similar A. Chlorpropamide (Tolinase™); used in type 2 diabetics to stimulate insulin release from the pancreas to lower blood sugar B. Metoprolol (Lopressor™) 100 mg tablet, used for blood pressure regulation C. Tolbutamide (Orinase™), used in type 2 diabetics to stimulate insulin release from the pancreas to lower blood sugar. D. Metoprolol (Lopressor™) 50 mg tablet, used for blood pressure regulation Because isolated low levels of either glucose or insulin are not sufficient for the diagnosis of insulinoma, and because the symptoms may be profound and dangerous, the standard method to establish the diagnosis is a supervised fast. This may require hospitalization and fasting rarely needing up to 72 hours (the so-called 72-hour fast). Many times, however, it can be performed as an outpatient if the patient is under careful supervision. With the patient fasting, an IV is inserted, the patient is allowed to drink water and non-caffeine containing drinks.

At scheduled intervals and whenever the patient develops the onset of hypoglycemic symptoms, the glucose is checked. When the glucose drops to 50 or below by capillary methods (finger-stick samplereflectance meter glucose, RMG), a standard venous blood sample is taken (Table 2). When insulin is secreted from the pancreas into the bloodstream, it is broken into 2 components: insulin and C-peptide (connecting peptide, which does not have any clinical effect). Both of these are measured to be sure the insulin is coming from the patient, not from an insulin injection (which does not contain C-peptide). In addition, a blood sample is sent to screen for the presence of drugs that might cause release of insulin from a normal pancreas, to be sure this type of drug (typically sulfonylurea drugs used in the management of diabetes) is not responsible for the low glucose. The most common cause of non-insulinoma patient with both low glucose and high insulin is mistakenly taken medication. This typically occurs when 2 people living together get their medications mixed up (Figure 2).

Because measuring insulin in the blood can be difficult, other laboratory studies can also be obtained that indicate high levels of insulin (insulin surrogates). An increase in the glucose level of over 25 mg/dL when glucagon is given IV at the end of the fast when the glucose is low, and a low beta-hydroxybutyrate level are both indicators of high insulin levels with low glucose. Some investigators have noted an insulin to glucose ratio of greater than 0.4 to be helpful. Perhaps most important is to recognize that with a glucose level below 50, no measurable insulin should be present in the bloodstream in a normal individual. CriteriaSimultaneous blood sample Blood glucose level at or below 45 mg/dL Insulin level equal or greater than 3 µU/ml (ICMA technique) C-peptide levels of 200 pmol/L or more Absence of sulfonylurea-class drugs in plasma Table 2. Criteria for Diagnosis of Insulinoma Insulinoma | UCLA Health UCLA Health An insulinoma is a tumor in the pancreas that produces too much insulin.

Alternative Names: Insuloma; Islet cells adenoma Causes, incidence, and risk factors: The pancreas is an organ in the abdomen that makes the hormone insulin. Insulin is required to regulate blood sugar levels. Tumors of the pancreas that produce too much insulin (hyperinsulinemia) are called insulinomas. High insulin levels cause low blood glucose (sugar), also called hypoglycemia. The hypoglycemia may be mild, leading to symptoms such as anxiety and hunger, or severe, leading to seizures, coma, and even death. Insulinomas are rare tumors. They usually occur as single, small tumors in adults. They are very rare in children. Most children with hyperinsulinism have multiple pockets of overactive insulin-secreting cells in the pancreas, rather than a single discrete tumor. Most insulinomas are not cancer. However, about five to ten percent are cancer. People with the genetic syndrome called multiple endocrine neoplasia Type I (MENI) are at risk for developing insulinomas.

Symptoms: CT scan or MRI of the abdomen to look for a pancreatic tumor Endoscopic ultrasound to look for a pancreatic tumor (when CT or MRI scan is normal) Octreotide scan to look for a pancreatic tumor (when CT or MRI scan is normal) Pancreatic arteriography (when CT or MRI scan is normal) Pancreatic venous sampling for insulin (when CT or MRI scan is normal) Treatment: Surgery is the preferred treatment for insulinoma. The location of the tumor is determined using diagnostic testing or surgical exploration. Single tumors are removed, but patients with multiple tumors usually require partial removal of the pancreas (partial pancreatectomy). At least 15% of the pancreas is left to prevent nutrient malabsorption from lack of pancreatic enzymes. If no tumor is found during surgery or a patient is not a candidate for surgery, the drug diazoxide may be given to lower insulin secretion and avoid hypoglycemia. A diuretic (water pill) is given with this medication to keep the person's body from retaining fluid. Octreotide has been used to suppress insulin secretion in some patients. Medication is also used to stabilize the person prior to surgery.

Support Groups: Expectations (prognosis): In a majority of cases, the tumor is benign and surgery is effective. However, a severe hypoglycemic reaction or the spread of cancerous tumors to other organs can be fatal. Complications: cancerous tumor spreading (metastasis) Calling your health care provider: Call your health care provider if symptoms of insulinoma develop. Convulsions and decreased consciousness are emergency symptoms. You & Your Hormones | Endocrine conditions | Insulinoma You & Your Hormones Email article to a friend | Last updated: March 17, 2015 An insulinoma is a type of tumour that occurs in the pancreas. The tumour secretes too much insulin, which causes blood sugar to drop to low levels. What is an insulinoma? Normally, the beta cells within the pancreas secrete insulin in response to rises in blood sugar after a person eats a meal and absorbs the carbohydrates within the meal. The role of insulin is to help the body use the carbohydrates to release energy and to keep blood sugar at normal levels.

An insulinoma is a type of tumour called a neuroendocrine tumour ( NET ) that arises from the beta cells of the pancreas and causes problems by secreting too much insulin. Usually (>90%) these tumours are benign single lesions in the pancreas (ie, they do not spread to other parts of the body). Occasionally, insulinomas may spread and develop secondary tumours beyond the pancreas, most often affecting the liver. These insulinomas are known as malignant. What causes insulinomas? It is unclear why insulinomas occur in most cases, although some occur as part of a genetic condition called multiple endocrine neoplasia type 1 . What are the signs and symptoms of insulinomas? The symptoms of insulinomas can often be vague and non-specific. As insulinomas secrete too much insulin, this means that the blood sugar can drop to levels below normal. This can cause symptoms such as: Sweating Blackouts or seizures These episodes can occur particularly when not eating for long periods (fasting), or first thing in the morning, but may occur at any time. Typically, eating or drinking foods which contain carbohydrate (such as bread, potatoes or pasta) relieves the symptoms. How common are insulinomas?

Insulinomas are rare. It is estimated that one case is diagnosed every year per 250,000 people in the population. In the UK, this translates to approximately 250 new cases a year. Are insulinomas inherited? The majority of patients with insulinomas have not inherited the condition. For one in 14 patients, the insulinoma may be part of an inherited syndrome called multiple endocrine neoplasia type 1. People with multiple endocrine neoplasia type 1 usually have other problems with high blood calcium levels, tumours in the pituitary gland and other tumours in the pancreas. How are insulinomas diagnosed? In order to diagnose an insulinoma, patients suspected of the disease are usually admitted to hospital to undergo a supervised 72-hour fast. During this time, patients are allowed to drink water, but not to eat food. Regular finger-prick tests for blood sugar levels are done. If the blood sugar drops below a certain level, a blood sample to test for glucose, insulin and another substance, C-peptide, is taken. A blood or urine test is also taken to test for any medications that might cause the blood sugar levels to drop.

If the blood test confirms that the blood glucose is below the criteria level, the fast is stopped and the patient is allowed to eat. Computerised tomography (CT) or magnetic resonance imaging (MRI) scans are used to look for insulinomas in the pancreas and liver and to locate their exact position. Insulinomas may not always be straightforward to find on a CT or MRI scan and so one or more of a variety of other localisation techniques may also be used. Specialised nuclear medicine scans such as octreotide or positron emission tomography (PET) scans are also sometimes used to identify insulinomas and to look for any evidence of spread of the tumours. Special ultrasound machines may be used, either attached to a telescope passed, under gentle sedation, through the mouth (endoscopic ultrasound) or during the time of surgery (intra-operative ultrasound). A procedure known as a calcium stimulation test is also sometimes used to confirm that the insulinoma is in the pancreas and actively secreting insulin. This is done in specialist hospitals. It involves placing thin plastic tubes (catheters), under local anaesthetic , into the groin area.

Using small injections of special dye that show up under an X-ray machine, these catheters are threaded into the blood vessels that supply the pancreas with blood. Then a small amount of calcium solution, which is harmless to patients, is injected into the blood vessels, and blood tests are taken to measure the levels of insulin secreted by the pancreas. This test usually takes about 1 hour to perform. If multiple endocrine neoplasia type 1 is suspected, a blood test to look for defects in the gene responsible for this disease can be carried out. Genetic specialists will talk through the implications of genetic testing, which is usually performed in outpatient clinics. How are insulinomas treated? Benign insulinomas are usually removed by surgery with the intention being to remove the tumour fully and achieve a long-term cure and normal life expectancy. The surgery takes place as an inpatient in specialist hospitals and is completed by a specialist pancreatic surgeon with support from the endocrine (hormone specialist) team. The extent of the surgery depends on the location and size of the tumour. Sometimes it is possible to do a smaller operation that cuts out only the insulinoma (enucleation).

However, in some cases it may also be necessary to remove larger portions of the pancreas in a more complicated operation. If the low blood sugar levels are troublesome, medication may be used to increase blood sugar levels before the operation. Commonly used drugs include diazoxide and somatostatin analogues. Patients should also be given dietary advice to ensure a frequent supply of carbohydrates to try and prevent blood sugar levels dropping. For example, small meals can be taken more frequently, eg, five to six times a day. A food additive such as guar gum can also be used to lengthen the time the body can absorb carbohydrates. How to manage a low blood sugar acutely and activities to avoid whilst at risk of a low blood sugar should be explained to all patients. There are a range of different treatment options for malignant insulinomas. Surgery may still be utilised although the intent would not be curative but instead to significantly reduce the amount of tumour present to reduce the symptoms and challenges of a recurrent low blood sugar. Diazoxide and the somatostatin analogues may be used in this setting to control symptoms. The somatostatin analogues may also be used to control tumour growth.

Other options that may be considered include radiolabelled somatostatin analogue therapy, chemotherapy or relatively new drugs called Everolimus or Sunitinib. Are there any side-effects to the treatment? In most cases, surgery is successful and the patient does not experience any side-effects. Occasionally, surgery can cause side-effects including excessive bleeding, infections and pain. If a large part of the pancreas is removed, the surgery may cause blood sugar levels to rise, causing excessively high levels of blood sugar ( diabetes mellitus ). This isbecause there is insufficient insulin being secreted by the pancreas. In addition, if the part of the pancreas that makes digestive enzymes is damaged then replacement enzymes may need to be prescribed. Other side-effects are specific to the individual drug. The commonest agent, diazoxide, has the following side effects: diabetes mellitus, nausea, vomiting, ankle swelling, dizziness and excessive growth of body hair (if taken for prolonged periods). What are the longer-term implications of insulinomas? If the insulinoma is benign and has been removed by surgery, the outcome is good and patients are usually cured of the condition.

If the insulinoma is malignant and has spread to the liver, the symptoms of low blood sugar may continue to be a problem, and long-term treatment with the aim of stabilising tumour growth, may be required. Patients with frequent episodes of low blood sugar should not drive or operate heavy machinery.

Question: An Insulinoma is a tumour of which organ of the body?
Answer: Pancreas