Treatment with somatostatin analogs and chemoembolization of liver metastases for severe hypoglycemia in malignant insulinomas.

BACKGROUND: Preventing hypoglycemia is of vital importance and a major challenge in patients with severe symptomatic hypoglycemia related to malignant unresectable insulinomas, but there is no consensus treatment. PATIENTS: Five patients with malignant unresectable insulinomas were referred to our department for severe hypoglycemia. At referral the five patients were dependent on iv infusion of glucose solution. Patient 1 had a locally invasive 5-cm insulinoma, patients 2, 3 and 4 had multiple liver metastases and patient 5 had a 2.5-cm pancreatic tumor with multiple liver and lung metastases. Before referral to our department, 4/5 patients had been administered systemic chemotherapy and 3/5 therapeutic doses of radiolabeled octreotide without any benefit on blood glucose levels. Octreoscan scintigraphy was positive in 4 patients (patients 1-4). Diazoxide alone or combined with glucocorticoids had failed to control hypoglycemia. Continuous sc administration of octreotide (up to 1500 μg/day) resulted in normalization of blood glucose levels in patient 1. Chemoembolization of liver metastases normalized blood glucose levels in patient 2, minimized hypoglycemia in patients 3 and 4, and normalized blood glucose levels in patient 5 when followed by subcutaneous administration of octreotide (2000 μg/day). Chemoembolization had to be repeated four times in patient 3 to control blood glucose levels.
CONCLUSION: Chemoembolization of liver metastases and high-dose octreotide in responsive patients (alone or combined with chemoembolization) can control severe hypoglycemia in patients with symptomatic malignant unresectable insulinomas; the efficacy of octreotide can be improved after chemoembolization of liver metastases.