title: Malignant insulinoma: spectrum of unusual clinical features.
abstract: BACKGROUND
  Malignant insulinoma occurs in a few patients with insulinoma. Due to the small sample of patients, there are little data regarding their clinical manifestation as well as the preferred treatment modalities. The aims of the current study were to summarize the National Institutes of Health experience during the last two decades and to conduct a critical review of the current literature.
  
  
  METHODS
  The authors identified 10 patients with metastatic insulinoma.
  
  
  RESULTS
  The patients presented with four patterns of clinical behavior. First, four patients presented with lymph node metastasis and, after surgical excision, maintained a prolonged tumor-free survival. Second, four patients presented with metastatic disease to the liver, which appeared years after the initial diagnosis and presumed curative surgery. Third, one patient presented with a large alpha-fetoprotein-secreting liver mass. Finally, 9 of the 10 patients had a prolonged survival. Various treatment modalities were used to control hypoglycemia. Short-term benefits were most often achieved with embolization and diazoxide. Less successful modalities included radiofrequency ablation, radical debulking surgery, verapamil therapy, octreotide therapy, and chemotherapy.
  
  
  CONCLUSIONS
  The current study, as well as others, suggested that metastatic insulinoma may have a variable natural history. After the initial surgical resection, the biology of the tumor, rather than any treatment modality, was most likely the major determinant of long-term survival.
authors.affiliation: Division of Intramural Research, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA. Boaz.Hirshberg@pfizer.com
authors.forename: Boaz
authors.initials: B
authors.lastname: Hirshberg
authors.forename: Craig
authors.initials: C
authors.lastname: Cochran
authors.forename: Monica C
authors.initials: MC
authors.lastname: Skarulis
authors.forename: Steven K
authors.initials: SK
authors.lastname: Libutti
authors.forename: H Richard
authors.initials: HR
authors.lastname: Alexander
authors.forename: Bradford J
authors.initials: BJ
authors.lastname: Wood
authors.forename: Richard
authors.initials: R
authors.lastname: Chang
authors.forename: David E
authors.initials: DE
authors.lastname: Kleiner
authors.forename: Phillip
authors.initials: P
authors.lastname: Gorden
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007003:Hypoglycemia / Q000209:etiology; D007340:Insulinoma / Q000401:mortality / Q000473:pathology / Q000628:therapy; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D013997:Time Factors