title: Selective Arterial Calcium Stimulation With Hepatic Venous Sampling Differentiates Insulinoma From Nesidioblastosis.
abstract: BACKGROUND
  In adult patients with endogenous hyperinsulinemic hypoglycemia and negative or inconclusive noninvasive imaging, insulinoma and non-insulinoma pancreatogenous hypoglycemic syndrome (NIPHS) resulting from diffuse nesidioblastosis must be considered in the differential diagnosis. It is not known whether the biochemical results of selective arterial calcium stimulation (SACST) with hepatic venous sampling can differentiate insulinoma from diffuse nesidioblastosis.
  
  
  OBJECTIVE
  To determine the specificity of SACST with hepatic venous sampling in differentiating insulinoma from diffuse nesidioblastosis.
  
  
  METHODS
  Retrospective review (January 1996 to March 2014).
  
  
  METHODS
  Tertiary referral center.
  
  
  METHODS
  A total of 116 patients with biochemical evidence of endogenous hyperinsulinemic hypoglycemia and negative or inconclusive noninvasive imaging who were subsequently shown at surgery to have insulinoma (n = 42) or nesidioblastosis (n = 74) after undergoing SACST with hepatic venous sampling.
  
  
  METHODS
  SACST with hepatic venous sampling before pancreatic exploration.
  
  
  METHODS
  Receiver operating characteristic curves were generated from the biochemical results of SACST to determine the specificity of the maximum hepatic venous insulin concentration (mHVI) and the relative-fold increase in hepatic venous insulin concentration (rHVI) over baseline after calcium injection from the dominant artery in differentiating insulinoma from nesidioblastosis.
  
  
  RESULTS
  The mHVI (21.5-fold; P < .001) and rHVI (3.9-fold; P < .001) were significantly higher in the insulinoma group compared to the nesidioblastosis group. The areas under the receiver operating characteristic curve for mHVI and rHVI were excellent (0.94; P < .0001) and good (0.83; P < .0001), respectively, for differentiating insulinoma from nesidioblastosis. mHVI cutoffs of > 91.5 and > 263.5 μIU/mL were 95 and 100% specific for insulinoma, respectively. A 19-fold increase in rHVI over baseline was 99% specific for insulinoma.
  
  
  CONCLUSIONS
  These data suggest that the mHVI and rHVI at SACST may be useful in differentiating insulinoma from nesidioblastosis with high specificity in patients with hyperinsulinemic hypoglycemia and negative or inconclusive noninvasive imaging.
authors: Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905.
authors: Scott M
authors: SM
authors: Thompson
authors: Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905.
authors: Adrian
authors: A
authors: Vella
authors: Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905.
authors: Geoffrey B
authors: GB
authors: Thompson
authors: Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905.
authors: Kandelaria M
authors: KM
authors: Rumilla
authors: Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905.
authors: F John
authors: FJ
authors: Service
authors: Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905.
authors: Clive S
authors: CS
authors: Grant
authors: Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905.
authors: James C
authors: JC
authors: Andrews
mesh_terms: D000328:Adult; D000368:Aged; D015992:Body Mass Index; D002118:Calcium / Q000494:pharmacology*; D003937:Diagnosis, Differential; D005260:Female; D006503:Hepatic Veins; D006801:Humans; D006946:Hyperinsulinism / Q000175:diagnosis / Q000209:etiology; D007003:Hypoglycemia / Q000175:diagnosis / Q000209:etiology; D007340:Insulinoma / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D046768:Nesidioblastosis / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery; D010190:Pancreatic Neoplasms / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery; D012372:ROC Curve; D012189:Retrospective Studies
chemical_list: D002118:Calcium