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Surgical Management of Insulinomas
Surgical Management of Insulinomas
Objective: To analyze the characteristics and out- plasia type 1. Surgical procedures included 106 enucle-
comes following enucleation and pancreatic resections ations (54%) and 92 pancreatic resections (46%). Mor-
of insulinomas. tality was nil. Rate of clinically significant pancreatic fistula
was 18%. Enucleations had a higher reoperation rate com-
Design: Retrospective cohort study; prospective data- pared with pancreatic resections (8.5% vs 1%; P=.02).
base. Multiple endocrine neoplasia type 1 was significantly as-
sociated with younger age at onset (P⬍.005) and higher
Settings: Academic, tertiary, and referral centers. rates of malignancies and multiple lesions. Median fol-
low-up was 65 months. Six patients (3%; 5 patients had
Patients: Consecutive patients with insulinomas (symp-
neuroendocrine tumors grade G2) developed tumor re-
toms of hyperinsulinism and positive fasting glucose test)
currence. Four patients (2%) died of disease. New exo-
who underwent surgical treatment between January 1990
and December 2009. crine (1.5%) and endocrine (4%) insufficiencies were as-
sociated only with pancreatic resections.
Main Outcome Measures: Operative morbidity, tu-
mor recurrence, and survival after treatment. Conclusions: Outcomes following surgical resection of
insulinomas are satisfactory, with no mortality and good
Results: A total of 198 patients (58.5% women; me- functional results. Recurrence is uncommon (3%), and
dian age, 48 years) were identified. There were 175 (88%) it is more likely associated with neuroendocrine tumors
neuroendocrine tumors grade G1 and 23 (12%) neuro- grade G2. Insulinomas in multiple endocrine neoplasia
endocrine tumors grade G2. Malignant insulinomas de- type 1 are at higher risk for being malignant and multi-
fined by lymph node/liver metastases were found in 7 pa- focal, requiring pancreatic resections.
tients (3.5%). Multiple insulinomas were found in 8% of
patients, and 5.5% of patients had multiple endocrine neo- Arch Surg. 2012;147(3):261-266
I
NSULINOMAS , THE MOST COM - atic and blind pancreatic resections were
mon functioning endocrine performed,7,8 high-resolution imaging tech-
neoplasms of the pancreas, are niques and endoscopic ultrasound cur-
Author Affiliations: characterized clinically by hypo- rently allow high preoperative detection
Department of Surgery,
glycemic symptoms resulting rates, which is essential in planning the
Policlinico GB Rossi, University
of Verona, Verona (Drs Crippa, from neuroglycopenia and catechol- most appropriate surgical strategy.9-18
Boninsegna, Partelli, Pederzoli, amine response.1,2 They usually present as Tumor enucleation is largely per-
and Falconi); Department of a small, well-demarcated, solitary nodule formed to treat insulinomas.3,5 Although
Surgery, IRCCS Ospedale S. that may arise in any part of the gland, with associated with a high risk for postopera-
Raffaele, Vita e Salute an incidence peak in the fifth decade of tive complications, this procedure has the
University, Milan (Drs Zerbi, life.1-3 Approximately 5% to 10% of pa- advantage of preserving healthy pancre-
Capitanio, Balzano, and tients with insulinomas have multiple en- atic parenchyma with a low risk for post-
Di Carlo); and Department of docrine neoplasia type 1 (MEN 1), and operative pancreatic insufficiency.19,20
Surgery, Ospedale Sacro these patients frequently have multiple le- However, when the lesion is embedded
Cuore-Don Calabria, Negrar
sions and are at higher risk for malig- deep in the pancreatic tissue or is close to
(VR) (Drs Crippa, Boninsegna,
Partelli, and Falconi), Italy. nancy.3-6 Still, more than 90% of sporadic the main pancreatic duct, enucleation
Dr Zerbi is now with Pancreatic insulinomas are benign tumors, being should be avoided and formal pancreatic
Surgery Section, IRCCS treatable by surgical operation.1,3 resections performed. The rate of enucle-
Ospedale Humanitas, University While in the past preoperative local- ations and pancreatic resections for insu-
of Milan, Rozzano, Italy. ization of insulinoma could be problem- linomas varies among different studies, and
Pancreatic
Overall Enucleation Resection
Variable (N = 198) (n = 106) (n = 92) P Value
Tumor site
Head/uncinate process 69 (35) 56 (53) 13 (14)
Body/tail 123 (62) 49 (46) 74 (80.5) ⬍.001
Entire gland 6 (3) 1 (1) 5 (5.5)
Intraoperative ultrasound 70 (35.5) 39 (37) 31 (34) .65
Laparoscopic procedure 13 (6.5) 6 (5.5) 7 (7.5) .78
Duration of surgery, median (range), min 180 (70-540) 180 (70-280) 240 (90-540) ⬍.001
Intraoperative blood transfusions 20 (10) 3 (3) 17 (18.5) ⬍.001
Mortality 0 (0) 0 (0) 0 (0)
Overall morbidity 103 (52) 50 (47.2) 53 (57.5) .14
Abdominal complications 93 (47) 47 (44.3) 46 (50) .43
Overall pancreatic fistula 83 (42) 44 (42) 39 (42) .90
Grade A pancreatic fistula 48 (24) 22 (21) 26 (28) .13
Grades B and C pancreatic fistulas 35 (18) 22 (21) 13 (14)
Pancreatitis 11 (5.5) 6 (5.5) 5 (5.5) .91
Hemorrhage 6 (3) 4 (3.5) 2 (2) .49
Abdominal collection 26 (13) 17 (16) 9 (10) .13
Delayed gastric emptying 1 (0.5) 0 (0) 1 (1) .29
Overall nonsurgical complications 18 (9) 7 (6.5) 11 (12) .18
Sepsis 9 (4.5) 4 (3.5) 5 (5.5) .59
Pulmonary complications 13 (6.5) 4 (3.5) 9 (10) .08
Hospital LOS, median (range), d 12 (4-57) 10.5 (7-57) 12 (4-53) .44
Reoperation 10 (5) 9 (8.5) 1 (1) .02
Readmission 6 (3) 4 (3.5) 2 (2) .51
Abbreviations: DOD, dead of disease; G, grade; MEN, multiple endocrine neoplasia; NET, neuroendocrine tumor; TTR, time to recurrence; UBB, uncertain biological
behavior; WDEC, well-differentiated endocrine carcinoma.
Overall morbidity was 52% with no mortality. No sta- Nikfarjam et al,5 with an R1 rate of 13% and no recur-
tistically significant differences were found between rences in this group.
enucleations and pancreatic resections in regard to pan- Interestingly, insulinomas in the setting of MEN 1 have
creatic fistula and abdominal complications, despite a a specific clinicopathologic profile, showing a more ag-
higher reoperation rate in the enucleation group. More- gressive biological behavior. Multiple endocrine neopla-
over, the rate of pancreatic insufficiency following enucle- sia type 1 insulinomas were associated with an earlier age
ation was nearly absent as in other series.19,20,26 at onset and higher rates of malignant neoplasms and mul-
In this cohort, 6 patients developed tumor recur- tiple lesions. The optimal management of patients with
rence; of these, 5 patients had NET grade G2. Interest- MEN 1 is debated. Although some researchers have sug-
ingly, 2 of these patients had undergone enucleation with gested a systematic subtotal pancreatectomy associated
no lymph nodes excised (NX status), and they devel- with enucleation of pancreatic head lesions,41,42 it is un-
oped liver metastases. It could be supposed that the lack clear whether this aggressive approach may eventually
of nodal samples led to an erroneous pathologic diagno- decrease the risk for tumor recurrence.3,4,6 In this series
sis. Enucleation as well as other parenchyma-sparing pro- among patients with MEN 1, there was only 1 local re-
cedures may lack adequate lymph node sampling, re- currence after an R0 spleen-preserving distal pancreatec-
sulting in a possible tumor understaging.38 Remarkably, tomy for a NET grade G1 pT2NX that was successfully
NX rates were 87% for enucleation, 75% for MP, and 70% treated with pancreaticoduodenectomy. It is likely that
for spleen-preserving distal pancreatectomy. Whenever this tumor represents a new primary rather than a real
enucleation or other parenchyma-sparing procedures are recurrence. Since insulinomas in MEN 1 are at higher risk
carried out, lymph node sampling of peripancreatic nodes for being malignant and multifocal, pancreatic resec-
should be performed to increase the oncologic effective- tions instead of enucleation should be performed, but the
ness of these procedures. performance of routine subtotal pancreatectomy seems
The combination of preoperative imaging, intraop- unjustified.43
erative ultrasound, and palpation allowed localizing in- In conclusion, insulinomas are commonly well-
sulinomas in all 198 patients, thus avoiding blind pan- differentiated nonmetastatic and unifocal tumors. A com-
creatic resections. Preoperative localization of the tumor bination of endoscopic ultrasonography with high-
is of paramount importance when planning the most ap- resolution imaging techniques can identify nearly 100%
propriate surgical management for these patients.9,15,39 of insulinomas, optimizing the surgical strategy and avoid-
Currently, the combination of biphasic thin section he- ing blind resections. About half of patients will require
lical computed tomography and endoscopic ultrasonog- a pancreatic resection; and in high-volume centers, both
raphy has an almost 100% sensitivity in localizing insu- surgical resections and enucleations are safe, with no mor-
linomas. 5,10-12,16,17,39 Pathologic characteristics of tality and acceptable morbidity. Recurrence is uncom-
insulinomas in this series were similar to the findings re- mon (3%), and it is more likely associated with NET grade
ported by others.1,3,5,21,24 The overall median tumor size G2. Lymph node sampling should be carried out when-
was 15 mm and most insulinomas were NET grade G1. ever a parenchyma-sparing procedure is performed to de-
Danforth and colleagues40 found a correlation between crease the risk for tumor understaging. Insulinomas in
size and malignancy (median size of 47 mm in a group MEN 1 are at higher risk for being malignant and mul-
of 62 patients). We confirm this data because malignant tifocal, thus requiring pancreatic resections.
insulinomas had a median size of 45 mm with a median
Ki67 value of 8%. Finally, in this cohort, R1 resection Accepted for Publication: October 1, 2011.
was found in 9 patients (4.5%) but none of them devel- Correspondence: Massimo Falconi, MD, Department of
oped tumor recurrence. Similar data are provided by Surgery, Chirurgia Generale B, Policlinico GB Rossi, Uni-