A 67-year-old man with intractable hypoglycaemia due to a malignant pancreatic insulinoma with multiple hepatic metastases is reported. Continuous intravenous infusion of dextrose was necessary to prevent life-threatening hypoglycaemia; high-dose parenteral octreotide was ineffective and oral diazoxide was associated with intolerable gastrointestinal side-effects. Preoperative imaging failed to identify the primary tumour with certainty. At laparotomy, the tumour was located in the pancreas and excised. Intraoperative cryotherapy was administered to hepatic metastases inducing localised ice-ball formation and subsequent necrosis of the lesions. These interventions led to prompt resolution of the hypoglycaemia with normalisation of plasma concentrations of islet B-cell products. In an effort to consolidate the beneficial effects of surgery, chemotherapy was instituted post-operatively using the islet B-cell toxin streptozotocin. In an innovative therapeutic approach, the drug was infused via the hepatic artery for 5 consecutive days at a reduced dose calculated to induce an insulitis in the residual hepatic metastases analogous to that described in murine models of diabetes. The chemotherapy was well tolerated although the course of treatment was curtailed by problems with catheter placement. Nonetheless, the patient has, to date, remained well and free from hypoglycaemia during more than 3 years of follow-up. These therapeutic strategies appear to merit further evaluation.
Endocrine-Related Cancer (1996) 3 341-345
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