title: Synchronous Nesidioblastosis, Endocrine Microadenoma, and Intraductal Papillary Mucinous Neoplasia in a Man Presenting With Hyperinsulinemic Hypoglycemia.
abstract: Herein, we report the first case of concomitant nesidioblastosis, pancreatic neuroendocrine tumor, and intraductal papillary mucinous neoplasia. The combination is significant as each of these pathological entities is independently very rare. The patient was a 33-year-old man who presented with symptomatic hyperinsulinemic hypoglycemia and no risk factors for pancreatic disease. Abdominal imaging showed an isolated 12 mm pancreatic lesion, whilst selective arterial calcium stimulation testing demonstrated multiple territories of insulin excess. He proceeded to subtotal pancreatectomy. Histopathology revealed an endocrine microadenoma, α and β cell nesidioblastosis, and multifocal intraductal papillary mucinous neoplasia. The endocrine microadenoma and nesidioblastosis stained for insulin, suggesting both likely contributed to hypoglycemia. Glucagon immunohistochemistry was also positive, though there were no clinical features of glucagon excess. Hypoglycemia resolved postoperatively. This case and other evidence from the literature suggest that hyperplasia and neoplasia may occur sequentially in the pancreas, and that endocrine and exocrine tumorigenesis may be linked in some individuals. Further study is required to identify a unifying mechanism, and to elucidate potential ramifications in the management of patients with pancreatic neoplasms.
authors.affiliation: From the *Department of Endocrinology, St Vincent's Hospital; †Hormones and Cancer Group, Garvan Institute of Research; ‡Department of Upper Gastrointestinal and Hepatopancreatobiliary Surgery, St Vincent's Hospital, Darlinghurst; §Department of Upper Gastrointestinal and Hepatopancreatobiliary Surgery, Prince of Wales Hospital, Randwick; ∥Faculty of Medicine, University of New South Wales, Randwick; ¶Sydpath, Department of Anatomical Pathology, St Vincent's Hospital; and #Diabetes and Metabolism Division, Garvan Institute of Research, Darlinghurst, NSW, Australia.
authors.forename: Sunita M C
authors.initials: SM
authors.lastname: De Sousa
authors.forename: Koroush S
authors.initials: KS
authors.lastname: Haghighi
authors.forename: Min Ru
authors.initials: MR
authors.lastname: Qiu
authors.forename: Jerry R
authors.initials: JR
authors.lastname: Greenfield
authors.forename: Daniel L T
authors.initials: DL
authors.lastname: Chen
mesh_terms: D000236:Adenoma / Q000150:complications* / Q000473:pathology / Q000601:surgery; D000328:Adult; D001706:Biopsy; D001786:Blood Glucose / Q000378:metabolism; D003937:Diagnosis, Differential; D006801:Humans; D006946:Hyperinsulinism / Q000097:blood / Q000175:diagnosis / Q000209:etiology*; D007003:Hypoglycemia / Q000097:blood / Q000175:diagnosis / Q000209:etiology*; D007150:Immunohistochemistry; D007328:Insulin / Q000097:blood; D008297:Male; D018297:Neoplasms, Cystic, Mucinous, and Serous / Q000150:complications* / Q000473:pathology / Q000601:surgery; D009378:Neoplasms, Multiple Primary; D046768:Nesidioblastosis / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D018358:Neuroendocrine Tumors / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D010186:Pancreatic Function Tests; D010190:Pancreatic Neoplasms / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D011237:Predictive Value of Tests; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D001786:Blood Glucose; D007328:Insulin