What are the guidelines for treatment of insulinoma?

Updated: May 31, 2020
  • Author: Zonera Ashraf Ali, MBBS; Chief Editor: Neetu Radhakrishnan, MD  more...
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Answer

National Comprehensive Cancer Network (NCCN) guidelines recommend resection as the primary treatment for most localized pancreatic neuroendocrine tumors (NETs). Exceptions include patients with life-limiting comorbidities or high surgical risk. In addition, observation may be appropriate for incidentally discovered tumors < 1 cm, depending on the site. [39]

Prior to surgery, NCCN recommends that symptoms of hormonal excess be treated with octreotide or lanreotide; however, such treatment is contraindicated in patients with insulinoma because of the potential for fatal complications. Specific recommendations vary by tumor subtype.Cholecystectomy is recommended during surgical resection if treatment with octreotide or lanreotide is planned, due to the increased rate of biliary problems associated with long-term use of these agents. [39]

Additional NCCN recommendations for insulinoma treatment include the following [39] :

  • Stabilize glucose levels with diet and/or diazoxide; everolimus may be considered

  • Primary treatment is enucleation; consider laparoscopic resection for solitary tumors

  • Deeper or invasive tumors or those with proximity to the main pancreatic duct require pancreatoduodenectomy if located in the head and laparoscopic distal pancreatectomy if in a distal location, with preservation of the spleen for smaller tumors

European Neuroendocrine Tumor Society guidelines include the following minimal consensus statements on treatment of insulinomas [61] :

  • Surgery remains the preferred treatment whenever possible, but medical treatment is needed prior to surgery, in recurrent cases, and in malignant insulinomas.
  • In additional to diazoxide, frequent small meals, somatostatin analogs, and the mTOR inhibitor everolimus has been effective in controlling hypoglycemia; sunitinib also has been effective in a few patients. In malignant insulinomas, peptide receptor–targeted radiotherapy (PRRT) or chemoembolization can help control the hypoglycemia.
  • Surgical exploration for possible cure should be performed in all patients with insulinomas if non-resectable metastatic disease is not present, with or without MEN1.
  • A laparoscopic approach is generally recommended in patients with sporadic disease with imaged tumors.
  • In the uncommon patient who is not thought to be a surgical candidate, successful treatment of localized insulinomas with ablative therapy, either endoscopically directed or percutaneously with radiologic direction, has been reported but further data are required. Successful use of EUS-directed ablation using ethanol injection or CT-guided radiofrequency ablation has also been reported.

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