We report a case of Insulinoma, a rare neuroendocrine tumor with an incidence of approximately four per 5 million. This case demonstrates the characteristic clinical, biochemical and histological features of an insulinoma, a rare benign neuroendocrine tumor where early recognition is important to ensure proper surgical treatment and prevent serious adverse consequences

Bhagavan, Nadhipuram V

Honda, Stacey A A

Tongson-Ignacio, Jane Ellaine F

eVols at University of Hawaii at Manoa

Insulinoma, A Rare NeuroendocrineTumor: A Case ReportAuthors’University of Hawaii Pat hologyResidency ProgramHonolulu, HI 96822 J,E,F.T:Medical Director of Laboratories, Hawaii PermanenteMedical Group. Inc.Honolulu, HI 96819 (S.A.A.H,)- Professor and Chair. Depart-mart of Biochemistry andBiophysics University of Hawaiia: Manoa. John A. Burns Schooo MedicineHonolulu, HI 96822 (N.V,B.)Corresoondence to:Stacey A.A. Honda MD, PhDMedical Director of LaboratoriesHawaii Permanente MedicalGroLp. Inc.3286’ Moanalua RoadHonolulu. HI 96819Abstract\Ve report a case of I usulinoma. a rare neurocndocrinetumor with an incidence of approximately four per5 million. This case demonstrates the characteristicclinical, biochemical and histological features of aninsuhnoma. a rare benign neuroendocrine tumor whereearly recognition is important to ensure proper surgicaltreatment and prevent serious ads cisc consequences.Case ReportA 46 year old female presented to the emergency department with seizures. Her serum glucose level was28mg/dI (70-110 mg/dl). She denied any use of oralhvpoglyceniic agents or insulin intake. The patient wastreated with dextrose infusion with serum glucose les elsranging from 50—60 mgidl. While in the emergencydepartment the patient became sweaty aiid lethargic.Physical examination revealed an obese patient (208Ibs) with normal vital signs, but was otherwise unremarkable. Past medical history’ revealed subtotalthvroidectomy for graves disease. craniotom forcerebel lar hemangioblastoma without any recurrence.and episodes of disorientation hich was thought tobe transient near svncope with undetermined etiologShe was suhsequentl diagnosed with seiture disordercontrol led with medications.The patient was subsequently admitted to the hospitalfor further investigations. During a 24 hour fast, herblood glucose decreased to 4$mgdl. but she was entirelv asvmplomatic. The serum glucose ss ith exercisewas monitored and ranged from 45—50 mg ‘dl. Duringa 36—hour test, the patient remained as mptomatic.The etiology of the hypoglycemia remained unknown.However, approximatels’ thirty minutes after meals. shedeveloped diaphoresis. letharg and mild tremulousness. Blood glucose at that time was 2$ms,dl. Thepatient was treated with dextrose 50 intras enousl\with resolution of ss’mptoms. Thirty’ minutes later. shedeveloped recurrent symptoms with a blood glucoselevel of 35 mg/dl. Again she was given dextrose 50with resolution of symptoms. At this point, the patientss as placed on dextrose 10 overnight with no furthers\ mptoms observed. The following day for the entire24 to 36 hour period, the patient was off ot dextrose I 0and remained asymptomatic. The blood glucose rangedfrom 4$ to 80mg dl. Further testing showed a negative sulfonvlurea screen. normal somaton’iedin—C andwithin normal limits liver ‘unction tests and insulinantibodies 0.4’ tnormal range: I . I or less.The CT scan of the abdomen revealed noes idenceof any lesions in the liver or any evidence for an abdominal tumor that might be a secondary cause forher h perinsulmemic levels. The patieit was subsequently discharged with a diagnosis of postprandialh’poglscemia with the possibility’ of an insulinoma.She svas subsequently’ referred to endocrinology forconsultation and was readmitted fora 72 hour fast. Onthe 40th hourof the fast, she started to develop blurringofvision and her laboratory tests showed the following:Blood glucose of 32 mg/dI (70— 110 mg”dl.Insulinlevel 32jiU/mI (0-221,U/ml ). and C-peptide 3.Sms;mlW.5—3.0( rrigii’nl. The symptoms svere relieved withadministration of Dextrose 50. These studies showing‘fasting, hypoglycemia accompanied by symptoms andreversal of the findings after administration of glucoseare conclusive for an insulinoma.A localization test by’ calcium arterial stimulationtest revealed greater than a 200 fold rise in insLilin inthe superior mesenteric artery. This sugge’ s’ted that thepatient’s insulinoma was located in the uncinate process. The patient underwent exploratory laparotomyenucleating the 1 .5-cm insulinoma that was on thesurface of the uncinate process of the pL1icreIs. lntra—operative ultrasound of the rert of the pancreas foundnoes idence of other lesions. The patient’s symptomsresols ed after the surgery and random serum glucoselevels returned to normal 96mg/dI 60—200 mgdl).Pathologic FindingsThe gross specimen revealed a friable lobulated pinkmass measuring 1.7 x 1.5 x 1.1cm. Histologic examination revealed a well circumscribed tumor nodLilecomposed of endocrine type cells with round uniformnuclei and basophilic cytoplasm .The prtttern of growthwas primarily solid with intervening vascularizedstroma (Figure I ‘. There was noes idence of aty pii orincreased mitotic activity. The lesion appeaied to heseparated from the pancreas by atibroushand Majorityof the tumorcel Is showed positive staining for insulinon imi’nunohistochemical stain (Figure2).i.A’/,’A:: ‘.,, ,ir)iJ sr•.i... ‘,,.‘.,: L,9Self-reporting of Internal MedicineHouse Staff Work Hours3.OE2’ . ‘‘‘ fly) ‘2(1 (/12, :‘.. /ir (Li LiThe views expressed in theabstract manuscnpt are those ofthe author(s) and do not rehectthe official pohcy or position ofrhe Department of the Army.Department of Defense, or theU.S. GovernmentAuthors:Captain. Medical Corps.US Army, Internal MedicineResident. Tripler Army MedicalCenter, Honolulu, HI 96859D.L.S.1Capfain. Medical Corps.US Army. Infernal MedicineResicent. BrooKe Army Medica(Center. Honolulu. HI 96859Program Coordxiator. IniernalMedicine Rewdency. Tr’plerArmy Medica Center. Honolulu.HI 96859 (VH..R.)- Ccone[. Mewcal Corps. USArmy. Director of Health Education and Training. Tripler ArmyMedical Center, Honolulu. HI96859 (B.W.B.)Introduction: Toe 83-tiour sorkucek became areality for resclency programs nationwioe on Jo/v 1.20L3. In this rev!ew oladministrative data. vie examinethe seif-repohing of work hours bva cohort of sitc-ma!fneojcne res,dcnts,Methods: Data was collected from 27 residents intraining at Trip/er Army Medical Center over a 4 monthperiod from September ito December31 2002. Housestaffreported their hours on a daily basis by respondingto an email message, as well as on a monthly basisutilizing the Army’s UCA PEAs (Uniform Chart of AccountEcrsonnelSystem)mandatorymonthly workloadtracking system. Data from the two separate reportingsystems was cornpared for accuracy. completenessand internal consistency.Results: Compliance with daily reporting wasvariable (67-97% with overall compliance rate of86%) but lower when compared with the mandatorymilitary monthly reporting system (95- 100%). Therewere large differences in reporting of average weeklywork hours among individual residents when monthlyreporting was compared to daily reporting of datawith higher averages with monthly data reporting.Weekly totals averaged nearly 12 hours higher whenreported monthly compared to reporting on a dailybasis (p <0.0001). A total of 18 residents reportedthat they worked more than 80 hours per week duringone month using monthly data, while only 7 reportedthat they averaged more than 80 hours with the dailyreporting data When average weekiy hours reportedon a daily basis were compared wrth the total numberof inpatient days worked over the four month penodiusing a simple regression model. there was a sigmA-cant relationship with average hours increas1’ng withincreasrng number of inpatient days worked (adjustedA square = 0 19. p = 0.01).Conclusions: Little internal consistency was foundin the comparison of daily versus monthly work hourreporting, indicating that self-reporting may notprovideaccurate data Complying with the 80-hour workweekis crucial for residency programs to marntain accreditation, and thus programs will need a way to accuratelycapture consistent resident work i]oLJr oata.Furtherstudies are indicated to determine the most’ accurateox of assessing house staff work hours.IntroductionThe Association of’ American Medical ColleeesI A,-\MCi and Acci’editation Council for GraduationMedical Education i ACGMEi have mandated an 80—hour workweek l’or resident physicians in training, andthis has become the accepted standard throughout thecountry as ofJul I .2003. Residencn proc-rams in NewYork have had similar laws regulating resident workhours since July I 989. However, recent studies haveshown that compliance remains a major issue: f. Thereis little scientific data in the literature on the qualityor validity of work hour data or how it is currentlycollected. The typical method used by most programsis resident self—reported hours on an “honor s stem”basis without mechanisms to verify or \ alidate thedata. Ourgoal in this review svas todehne the accuracyof self—reported work hour data from a cohort in anInternal Medicine Residency.MethodsThe Tripler Army Medical Center (TAMC) InternalMedicine Residency program is an ACGME accreditedmilitary residency averaging 24 residents in training.In this retrospective review of administrative data,house staff reported their hours on a daily basis by’responding to an email message. This required roughly’3-4 keystrokes dail to complete. Policy was widelydisseminated through house staff meetings. the housestaff manual and personal communications in additionto daily e—mail. Data from September I to December31 2002 was reviewed. Residents worked a total ofI 25 4—week blocks over this period of ‘s hich 70 wereinpatient rotations ( 565/ of the total . There were 27residents in traIning (7 feniale.i 0 PGY- I. S PGY-2. 9PGY-3 I with an average age of 28 ears ss ho reportedtheir work hours. This data was then compared to theArmy’s UCAPERs (Uniform ChartofAccountyisonnd System) mandatory monthly workload trackingsystem for the same period in an attempt to validatethe usefulness of self—reporting. All Arms personnelare required to enter this data monthly. This monthlyrequirement does not have a specific mandated fi’equenc\ ofdataentr iunstructured monthln repor inc-i.If data was not sd t’—reported. scheduled work hoursss crc used, and it was assumed that house stal’f had Iday off per seek.AbstractCorrespondence to:Bentamln Berg MDDOHET Trinier Army Med:caCenter.1 Jarrett White RoadHonolulu. Hi. 96859H,SV’IAH ML/[/::i’(L .C./,,:“—:(JOy i/I. (2.2(1—14I )ai Iv i oricd data was ad tusted for compl iancessttlt an assumption that as eraee hours svere rouehlvthe same br indis idual residents on days that ssere notreported. Tss o out ot 27 residents did not provide dataas they did not repi nt their ss ork hours on a daily hastsat all. The dail sell-reported data on aserace sseeklyss ork hours was coitipared using simple regressionss nit the total nLimher ob da s \s orked b each residenton inpatient rotatiotis which t picalls account forthe highest as erage ss ecklv work hoursi. Data ssastabulated and statistical analysis was pcrbormed usingMicrosoft Lxcel 200(1.ResultsIndividual compliance ssith daily reporting was variable. ranging from 59—97 ss ith overall compliancerate of 860/ Quartile means for compliance were790/ for the lowest quartile and 94% for 30 quartile(n=25). Compliance with the monthly reporting systemis mandatory. In a less cases where monthly reportswere not submitted in a timely fashion. monthly datawas completed by program staff using scheduledwork hours.There were large differences in reporting of averageweekly work hours among individual residents whenmonthly and daily reporting methods were compared(see figure I ). The range was from +34 to --6 hours perweek. The vast majorit\ of residents (23/25) reportedhigher average hours with monthly reporting than theydid with daily reporting.When adjusted for compliance, aggregated meanhours rising daily reporting were 61.5 per week (standard deviation 8.6) ersus 71 hours per week (std,des. l0.fo ss ith monthl reporting 1 as erage differencess as +9 hours per week) for interns. For residents, theaggregate di lference wits greater svith an avetage of54 hours per v eek ( std. des. 7.0) w ith daily reportingersus 6$ hours per week std. des. 9.61 ss ith monthlteporling for an as erage difference of + 14 hours persveek (see ligure 2). The difference in mean workhours for all house staff was I I .9.Figure 3 shows the number of residents reportingthat the\ worked more than an average of $0 hoursper week h month. A total of I $ residents reportedthat the s orked more than $0 hours per week during a single month using monthl data. ss hile only 7reported that the averaged more than $0 hours withJail \ reported data.Average \\ eekl hours reported on a dat lv basiswere compared with the total number of inpatient daysss orkcd over the tour month period using a simpleregression model. There svas a significant positiverelationship between as erage sveekk svork hours andnumber of inpatient days ss orked (adjusted R square =0.19. P 0.t) I. see Figure 4). There suas no significantrelationship between as erage sveeklv hours reportedona monthly basis and number of inpatient days suorked(p=0.3).Ii1’]rjjJUrLjOLULU NoUnUtgur 1 Average difference in reported weekly w rk h urs f r ndividu I tdemonthly v d ily self-reporttng. September De emb r 200240.035030.025.02001501005000-5,0-10.0J I‘FMonthly90 ii Dailyp<0 0001 p002 p<0,000180706050403020100Figure 2.— Difference in aggregate mean weekly resident work hours. monthly vs. dailyself-reporting. September-December 2002.Residents Interns All6 Monthly6 Daily544Sept Octciie 3— Rcioents reporting over 80 hous pc’ week oy month mo°thIy VS oa lyse reoor:ino September-December 2062Nov DecHVIVLAH VI V.0101+ JOURNAL,, VOL (VI., ,JANUAR15

Insulinoma, a rare neuroendocrine tumor: a case report.

http://evols.library.manoa.hawaii.edu/bitstream/10524/53492/1/2005-01p9-11.pdf

Insulinoma, a rare neuroendocrine tumor: a case report.

Abstract

Similar works

Full text

Available Versions

eVols at University of Hawaii at Manoa