Recurrent hypoglycemia caused by malignant insulinoma: Chemoembolization as therapeutical option

History and Clinical Findings: A 73-year-old previously healthy woman prese nted with recurrent weakness, vertigo and perioral paresthesia of 3 months' duration. Physical examination on admission was unremarkable and revealed a patient in good condition. Investigations: Recurrent episodes of fasting hypoglycemia let us to procee d with a fasting test. The test was stopped after 24 hours when the patient became presyncopal and was found to have a blood sugar value of 2.2 mmol/l (accompanied by inadequately increased values for proinsulin, insulin and C-peptide). Ultrasound and computertomography of the abdomen showed a huge inhomogeneous mass in the tail of pancreas and multiple lesions in the live r, respectively. Core needle biopsies revealed typical histopathological fi ndings of a neuroendocrine carcinoma. Treatment and Course: Eight cycles of chemotherapy were given using strepto zotocin/doxorubicin for three cycles and streptozotocin/5-fluorouracil for the remaining therapy over a period of 16 months resulting in a reduction i n size of liver metastases and improvement of symptoms. Following 6 months without any therapy new episodes of severe hypoglycemia and progression of the liver metastases occurred. Despite seven further cycles of chemotherapy and additional treatment with diazoxide/octreotide the patient remained hy poglycemic and continuous glucose infusions became necessary. Therefore, ch emoembolization of the liver with streptozotocin/5-fluorouracil and lipiodo l (R) -emulsion was performed. This resulted in a significant improvement o f symptoms and the patient could subsequently be discharged. The patient di ed 4 months later. Conclusion: Chemoembolization is an effective possibility in the palliative treatment of advanced malignant insulinoma.