title: Insulinoma case series: Experience of a tertiary care center.
abstract: BACKGROUND
  Insulinomas are usually solitary; benign and encapsulated small lesions and majority of them measure <2 cm in diameter. They pose a challenge for pre-operative localization. Definitive treatment is surgical excision of the tumor. Intra-operative ultrasonography (IOUS), transhepatic portal venous sampling (THPVS) and positron emission tomography (PET) scan can be done for tumors not localized by conventional imaging modalities.
  
  
  METHODS
  A retrospective study of patients diagnosed with insulinoma during the period 2004-2012 (8 years) was done. Biochemical diagnostic criteria used were plasma concentrations of glucose <55 mg/dl with corresponding insulin level >3.0 μU/ml (18 pmol/L) and C-peptide of >0.6 ng/ml (0.2 nmol/L). The localization of the tumor was done by various modalities namely computed tomography (CT), magnetic resonance imaging (MRI), IOUS, PET and portal venous sampling. The initial localizing technique in most of these patients were CT or MRI imaging, or both and those who were not localized by the above modalities were subjected to PET CT or THPVS or intra-operative ultrasound depending on the initial imaging results and patient's consent. All the modalities were not used in the same patient, but the modalities were decided as per the imaging results, patient's consent and affordability for the procedure.
  
  
  RESULTS
  Ninteen cases of insulinoma aged between 10 and 66 years, with a median age of 47 years were included in the analysis. There were 10 males and nine females. Eighty-three percent of patients presented with pre-prandial hypoglycemia (n = 15). Different modalities were employed for pre-operative localization of these patients out of which 5 (26.31%) cases were localized with CT, 5 (26.31) cases with MRI, 5 (26.31%) with THPVS, 1 (5.26%) case with PET CT, 3 (15.78%) of them could not be localized out of which 2 (10.52%) were localized by IOUS and 1 (5.26%) case the lesion could not be localized. Among 19 cases, 12 underwent surgery out of which one patient underwent distal pancreatectomy as tumor was not localized; eight underwent laparoscopic enucleation; three of them required intra-operative exploration and seven of them were not operated, as they did not give consent for surgery. In all the cases, the size of the insulinoma ranged between 1 and 2 cm.
  
  
  CONCLUSIONS
  We report our experience with 19 cases of insulinoma and analyze the role of pre- and intra-operative imaging modalities in the surgical management of insulinomas. Most of our cases were symptomatic, and the most common presentation was with pre-prandial hypoglycemia. THPVS, PET scan and intra-operative ultrasound added to diagnostic sensitivity in some cases not localized by CT or MRI.
authors.affiliation: Department of Endocrinology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India.
authors.forename: Manjunath Ganesh
authors.initials: MG
authors.lastname: Anakal
authors.affiliation: Department of Endocrinology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India.
authors.forename: Pramila
authors.initials: P
authors.lastname: Kalra
authors.affiliation: Department of Endocrinology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India.
authors.forename: Mala
authors.initials: M
authors.lastname: Dharmalingam
authors.affiliation: Department of Radiology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India.
authors.forename: S
authors.initials: S
authors.lastname: Indushekhar
authors.affiliation: Kadri Clinic, Bengaluru, Karnataka, India.
authors.forename: Venkatesh
authors.initials: V
authors.lastname: Rao
authors.affiliation: CDEC, Bengaluru, Karnataka, India.
authors.forename: K M
authors.initials: KM
authors.lastname: Prasanna Kumar
keywords: Hypoglycemia; insulinoma; transhepatic portal venous sampling