A 60-year expirience in the treatment of pancreatic insulinoma in the Military Medical Academy, Belgrade, Serbia.

BACKGROUND/AIM: Insulinomas are rare benign tumors in the most cases and the most frequent endocrine tumors of the pancreas. A wide spectrum of clinical manifestations in patients with insulinoma is the reason for difficult recognition of the disease with a long period of time between the onset of symptoms and the diagnosis. Diagnostic procedures include Whipple's triad, 72-hour fast test and topographic assessment. The only currative therapy for patients with insulinoma is operative treatment. METHODS: This retrospective study included 42 patients with diagnosis of insulinoma treated in our institution in a 60-year period. In all the patients a demographic and clinical data, types of biochemical methods for diagnosis, and diagnostic procedures for insulinoma localization were analyzed. Tumor size and localization, surgical procedures, postoperative complications and outcome were assessed. RESULTS: A study included 42 patients, 29 women and 13 men. The median age at diagnosis was 43 years. Median time between the onset of symptoms and diagnosis was 3 years. The most common clinical symptoms and signs were disturbance of consciousness and abnormal behavior in 73%, confusion and convulsions in 61% of patients. The diagnosis of insulinoma was estimated by Whipple's triad and 72-hour fast test in 14 patients. Determination of insulinoma localization was assessed by angiography in 16 (36%) of the patients, by ultrasound (US) in 3 of 16 (18.8%) patients, by abdominal computed tomography (CT) in 8 of 18 (44.5%) patients, and magnetic resonance imaging (MRI) in 2 of 8 (25%) patients. Insulinoma was found in 13 of 13 (100%) patients by arterial stimulation with venous sampling (ASVS) and in 13 of 14 (93%) patients by endoscopic ultrasound (EUS). Of the 42 patients, 38 (90.5%) underwent operative procedure. Minimal resection was performed in 28 (73.6%) of the patients [tumor enucleation in 27 (71%) and central pancreatectomy in one (2.6%) of the patients], and the major resection was performed in 9 (23.6%) of the operated patients [distal splenopancreatectomy in 8 (21%) and pancreaticoduodenectomy in one (2.6%) patient]. The overall mortality rate in postoperative period was 2.6% (one patient). CONCLUSION: A combination of ASVS and EUS as diagnostic procedures ensures high accuracy for preoperative determination of insulinoma localization. Minimal resection such as enucleation shoud be performed whenever it is possible.

Possibilities of nontoxic autonomous thyroid nodules treatment by percutaneous ethanol injection.

BACKGROUND/AIM: According to the current principles, autonomous functional thyroid nodules are treated by surgery or by radioiodin therapy. Ultrasound guided percutaneous ethanol injection into solid tumors of the soft tissues was a starting point in attempts to treat the thyroid nodules by the same method. The aim of the study was to assess the efficiency of percutaneous injection in treating solitary, nontoxic, autonomous thyroid nodules of up to 15 mL volume. METHODS: In 25 patients with solitary nontoxic autonomous thyroid nodules diagnosed by tehnetium-99m scanning as an intensive area having a complete supremacy in the paranodal tissue, an ultrasound guided percutaneous ethanol injection was applied. The procedure was carried out repeatedly once a week until the reduction in nodule size to 50% of the initial size was achieved. RESULTS: An average size of the nodule before curing was 9.68 +/- 5.01 mL. An average quantity of the injected ethanol was 9.52 +/- 5.08 mL, ie 1.06 +/- 0.48 mL/mg of the tissue. The regression of the nodule size in the successfully (deltavol% u -57.09 +/- 13.75%, p < 0.001) and partly successfully cured (deltavol du = -48.45 +/- 14.35%, p < 0.05) was statistically significant compared to the size before the treatment. After ceasing ethanol injection, 18 months later, a further size regression (deltavol% = -79.20 +/- 9.89%) compared to the initial one (p < 0.001) was noticed. Soon, after the procedure was finished, a statistically significant concentration increase of Thyroid Stimulating Hormone (TSH) was noticed compared to the initial values (0.18 +/- 0.16 vs 0.34 +/- 0.31 mU/L, p < 0.01). According to the given criteria, in two female patients satisfactory results were not achieved, but, a year later, in one of them the nodule was not seen by repeated scintigram. The number and frequency of side effects were insignificant. CONCLUSION: Repeated percutaneous ethanol injections into nontoxic solitary autonomous thyroid nodules result in disappearing of authonomy. The regression of the nodule size of more than 50% compared to its initial volume, as well as the increase in concentration of TSH for more than 50% are the signs of a successful treatment.

[Personal experience in diagnosis and localization of pheochromocytoma]. / Feohromocitom--nasa iskustva u dijagnostici i lokalizaciji.

INTRODUCTION: Pheochromocytomas are most commonly tumours of adrenal medullary origin. Pheochromocytoma by definition produces and secretes catecholamines. Similar tumours that do not secrete active substances of any kind are called non functioning paragangliomas. The hallmark clinical manifestation of pheochromocytoma is hypertension accompanied with various signs and symptoms in excess of catecholamines or other bioactive substances. The early diagnosis of pheochromocytoma is important not only because it offers the possibility of curing hypertension but also because unrecognised pheochromocytoma is a potentially lethal condition. The aim of this article is to stress the specify of the clinical finding, diagnostical values of the laboratory tests and possibilities of morphological localizing techniques in a series of 98 patients with surgically proven pheochromocytoma. RESULTS: Over the period from 1954 to 2002 pheochromocytoma was diagnosed and surgically treated in 98 patients. The diagnosis was confirmed at operation except in patients who refused operation or continued the examination in other Clinical wards. There were 59 females and 48 males (F:M = 1.23:1), the age ranged from 7 to 64 years with the pick incidence in the second and third decades of life in males and the third and fourth decades of life in females. The basic clinical characteristic was hypertension which was found in 94% of patients with an approximately equal frequency of fixed and paroxysmal hypertension cases. The most often accompanning manifestations were headache (62%), perspiration (61%) and palpitations (65%). A high level of vanyl mandelic acid (VMA) and free catecholamines in 24-hour urine collection confirmed the diagnosis in 94% of cases. In boderline cases we performed dynamic tests, the most relevant among them being the test with phentolamin. It was positive in 95% of patients. Retropneumothomography contributed to a successful localisation of tumour in 83% of cases. Computed tomography (CT) was performed in 69 patients and was positive in 97% of them. Magnetic resonance imaging (MRI) localized the tumour in all 16 patient in whom it was performed. The whole body MIBG-J-131 (metaiodobenzylguanidine) scanes were positive in 92% (45/49) and false negative in the remainder of 8% (4/49) of cases. Selective angiography was performed in 40 patients and in all it was positive. DISCUSSION: Although pheochromocytomas were among the first recognized adrenal tumours, the prompt and safe diagnosis is mandatory up to date. The average annual incidence has been estimated by several epidemiologic studies to range from 0.8 to between 1.55 and 2.1 million persons per year. It is reported that it is curable cause of hypertension in 0.1% to 1% of cases. Pheochromocytoma has been classified as a "10% tumour" because various studies have shown that each of the characteristics mentioned bellow occurs with a frequency of approximately 10%: bilateral, extra-adrenal, multiple, malignant, familial and occurring in children. Our series of patients has a similar distribution: pheochromocytoma was in 9.2% of patients extra-adrenal, in 7.1% bilateral, in 9.2% multiple and in 4.08% malignant. Hypertension was the constant finding in 94% of our patients. Three clinical patterns of hypertenson have been observed. The first is paroxysmal hypertension, and the others are fixed or combinations of fixed and paroxysmal hypertension. According to our experience there were the equal incidence of all forms of hypertension. We noticed, like others, when the triad of headache, sweating and palpitations is accompanied by hypertension, the diagnosis of pheochromocytoma can be made with specify and sensitivity over 93%. In absence of this finding the diagnosis can be excluded with certainty of 99%. As a specify of the clinical finding, we mention two patients with manifestations of hypercorticism, two patients with pheochromocytoma of the urinary bladder, and four with MEN syndrome (one with MEN 2A and three with MEN 2B). For confirming the diagnosis the most relevant laboratory test was the higher level of VMA and free catecholamines in 24-hour urine collections. Once pheochromocytoma has been diagnosed by biochemical analyses, the anatomic location of the tumour or tumors must be determined. Currently, the best approach is to obtain MIBG-J-131 scan and then to perform MRI or CT of the abdomen and other areas identified on MIBG scan in order to provide more accurate spatial information. With this approach the great majority of pheochromocytomas can be localized. CONCLUSION: There is no classic picture, no stereotype for pheochromocytoma, although the history and physical finding are helpful. Patients come to the clinician in a variety of ways and settings. They may have classic attacks of hypertension accompanied with headache, perspiration and paplpitations or they may have identical symptoms and physical findings as the patients with primary hypertension. On the other hand, they may have signs and symptoms of diabetes mellitus, hyperthyroidism, hypercalcaemia, congestive heart failure, myocardial infarction, malignant hypertension or a variety of other conditions. Rarely, they have no complaints at all. Once the diagnosis was made, spatial localizing of the tumour or tumours, and surgical treatment are necessary. Unrecognized disease may be fatal.