Doherty G M, Doppman J L, Shawker T H, Miller D L, Eastman R C, Gorden P, Norton J A
Surgical Metabolism Section, National Cancer Institute, National Institutes of Health, Bethesda, Md 20892.
Surgery. 1991 Dec;110(6):989-96; discussion 996-7.
Since 1982, 25 consecutive patients with benign sporadic (non-multiple endocrine neoplasia type I) insulinomas have been studied. Most were referred because either the tumor was not identified at the referring institution or the diagnosis was unclear. Each patient suffered severe neuroglycopenic symptoms for a median of 24 months before diagnosis of insulinoma, and 32% had hypoglycemic seizures. Eighteen patients (72%) had a confirmed weight gain. Each patient underwent a supervised fast until 72 hours or the onset of significant neuroglycopenic symptoms (median duration 16 hours), with serum levels of glucose (median 35 mg/dl; range 24 to 46 mg/dl), insulin (median 21 microU/ml; range 11 to 230 microU/ml), C-peptide (median 2.5 ng/ml; range 1.0 to 7.2 ng/ml), and proinsulin fraction (median 55%; range 14% to 86%) measured at the termination of the fast. Preoperative imaging with ultrasonography, computed tomography, magnetic resonance, and angiography visualized tumor in a minority of patients (26%, 17%, 25%, and 35%, respectively); in 48% of patients one or more imaging study results was positive. Selective portal venous sampling for insulin was the most informative localizing test (77% positive; no false-positive results). Tumor was resected for cure in 24 of 25 patients. Intraoperative ultrasonography identified nonpalpable tumor in seven patients and was crucial to the achievement of this high rate of surgical cure. We conclude that the diagnosis of insulinoma can be made by the results of a supervised fast, portal venous sampling is the most sensitive preoperative test for localizing insulinomas, and intraoperative ultrasonography is essential for intraoperative detection of insulinomas.
自1982年以来，我们对25例连续性散发性（非多发性内分泌肿瘤I型）良性胰岛素瘤患者进行了研究。大多数患者是因为在转诊机构未发现肿瘤或诊断不明确而被转诊的。每位患者在胰岛素瘤诊断前均出现严重的神经低血糖症状，中位时间为24个月，32%的患者发生过低血糖惊厥。18例患者（72%）体重增加得到证实。每位患者均接受了72小时的监测性禁食，直至出现明显的神经低血糖症状（中位持续时间16小时），禁食结束时测定血清葡萄糖（中位值35mg/dl；范围24至46mg/dl）、胰岛素（中位值21μU/ml；范围11至230μU/ml）、C肽（中位值2.5ng/ml；范围1.0至7.2ng/ml）和胰岛素原比例（中位值55%；范围14%至86%）。术前超声、计算机断层扫描、磁共振成像和血管造影等影像学检查仅在少数患者中发现肿瘤（分别为26%、17%、25%和35%）；48%的患者一项或多项影像学检查结果为阳性。选择性门静脉胰岛素取样是最具诊断价值的定位检查（阳性率77%；无假阳性结果）。25例患者中有24例接受了肿瘤切除以达到治愈目的。术中超声在7例患者中发现了触诊不到的肿瘤，对于实现如此高的手术治愈率至关重要。我们得出结论，胰岛素瘤的诊断可通过监测性禁食的结果做出，门静脉取样是术前定位胰岛素瘤最敏感的检查，术中超声对于术中检测胰岛素瘤至关重要。
