Insulinoma diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Overview

The diagnosis of insulinoma is based on the Whipple's triad, which includes blood glucose < 55 mg/dL, symptoms of hypoglycemia that can be neuroglycopenic (visual disturbances, confusion, weakness, seizures, coma) or adrenergic symptoms (sweating, tremors, palpitations, and hyperphagia) and resolution of symptoms after ingestion/infusion of glucose. It is also diagnosed on the basis of radioimmunoassay (RIA) and Immunochemiluminescent assay (ICMA) in the absence of hypoglycemia causing agents e.g. insulin and oral hypoglycemic agents (e.g. sulfonylureas) by insulin level (>6 μU/mL (43 pmol/L by RIA and ≥ 3 μU/mL by ICMA, glucose level of < 2.5mmol/L (55mg/dL) and C-peptide level of ≥ 200 pmol/L and/or proinsulin level ≥ 25% or ≥ 22pmol/L. The gold standard for the diagnosis of insulinoma is 72-hour fasting test.

Diagnostic Criteria

  1. Hypoglycemia (fasting blood glucose < 55 mg/dL)
  2. Symptoms of hypoglycemia
  3. Improvement of symptoms after glucose infusion
  • The diagnosis of insulinoma is based on the biochemical assay with radioimmunoassay (RIA) and immunochemiluminescent assay (ICMA) in the absence of plasma sulfonylureas (or drug causing hypoglycemia) as below: [5][6]
    • Insulin level > 6 μU/mL (43 pmol/L by RIA and ≥3 μU/ml by ICMA
    • Glucose level < 2.5mmol/L (55 mg/dL)
    • C-peptide level ≥ 200 pmol/L
      • Proinsulin level ≥25% or ≥22pmol/L is also included in some criteria
  • The gold standard for diagnosis classically had been 72-hour fasting test.[6][5]
    • 33% patients develop symptoms in 12 hours, 80% at 24 hours, 90% after 48 hours and 100% after 72 hours of fasting.


Algorithm used commonly[7]
 
 
 
 
 
 
 
 
 
 
 
Suspicion of Insulinoma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Whipple's triad confirmed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
72 hour fast
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MRI/CT
 
 
 
 
 
 
 
 
 
 
Prolonged OGTT or mixed meal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No visible lesion
 
Visible
lesion(s)
 
Unresectable
liver metastasis
 
 
 
No
hypoglycemia
 
 
 
Hypoglycemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No follow up
 
 
 
Differential diagnosis of
postprandial hypoglycemia
 
 
 
 
EUS
 
 
 
 
 
Treat metastatic disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No visible lesion(s)
 
Visible lesion(s)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
GLP-1 Scan or ASVS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No lesion(s)
 
 
Identified lesion(s)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical control
and reevaluation
 
Surgical exploration
(intraoperative US)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Single lesion(s)
 
 
 
 
 
Multiple lesion(s)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Excision
 
 
 
 
 
ASVS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Excision based on ASVS

Abbreviations: EUS: Endoscopic ultrasound, ASVS: Arterial stimulation venous sampling, GLP-1: Glucagon-like-peptide 1, OGTT: Oral glucose tolerance test

References

  1. Whipple AO, Frantz VK (1935). "ADENOMA OF ISLET CELLS WITH HYPERINSULINISM: A REVIEW". Ann. Surg. 101 (6): 1299–335. PMC 1390871. PMID 17856569.
  2. Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER; et al. (2009). "Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 94 (3): 709–28. doi:10.1210/jc.2008-1410. PMID 19088155.
  3. Metz DC, Jensen RT (2008). "Gastrointestinal neuroendocrine tumors: pancreatic endocrine tumors". Gastroenterology. 135 (5): 1469–92. doi:10.1053/j.gastro.2008.05.047. PMC 2612755. PMID 18703061.
  4. Boukhman MP, Karam JH, Shaver J, Siperstein AE, Duh QY, Clark OH (1998). "Insulinoma--experience from 1950 to 1995". West J Med. 169 (2): 98–104. PMC 1305178. PMID 9735690.
  5. 5.0 5.1 Metz, David C.; Jensen, Robert T. (2008). "Gastrointestinal Neuroendocrine Tumors: Pancreatic Endocrine Tumors". Gastroenterology. 135 (5): 1469–1492. doi:10.1053/j.gastro.2008.05.047. ISSN 0016-5085.
  6. 6.0 6.1 Grant CS (2005). "Insulinoma". Best Pract Res Clin Gastroenterol. 19 (5): 783–98. doi:10.1016/j.bpg.2005.05.008. PMID 16253900.
  7. Falconi M, Eriksson B, Kaltsas G, Bartsch DK, Capdevila J, Caplin M, Kos-Kudla B, Kwekkeboom D, Rindi G, Klöppel G, Reed N, Kianmanesh R, Jensen RT (2016). "ENETS Consensus Guidelines Update for the Management of Patients with Functional Pancreatic Neuroendocrine Tumors and Non-Functional Pancreatic Neuroendocrine Tumors". Neuroendocrinology. 103 (2): 153–71. doi:10.1159/000443171. PMC 4849884. PMID 26742109.

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