64-year-old woman • hot flashes, facial flushing, excessive sweating, and palpitations • daily headaches • history of hypertension • Dx?

► hot flashes, facial flushing, excessive sweating, and palpitations ► daily headaches ► history of hypertension.

Successful Long-Term Medical Management of Unresectable Insulinomas.

In this paper, we present two patients with unresectable insulinomas and a literature review. Patient 1: A 58-year-old woman was diagnosed at age 42, with an insulinoma in the pancreatic tail and hepatic metastasis. She underwent distal pancreatectomy, splenectomy, hepatic wedge resection, and chemoembolization, with resolution of her symptoms. By age 48, her symptoms returned, with new hepatic metastasis. She started long-acting octreotide, with subsequent resolution of her symptoms. She has since had an unremarkable clinical course. Patient 2: A 48-year-old female was diagnosed at age 37. Numerous imaging modalities and two exploratory surgeries did not localize a mass. A distal pancreatectomy did not resolve her symptoms. She tried several medications before her symptoms were finally controlled with low-dose prednisone. She has continued prednisone and diazoxide treatment for the past decade, which controls her symptoms, along with diet modification. In conclusion, while prednisone is not standard therapy, it can control symptoms in patients with unresectable insu-linoma. Providers should be aware of available and emerging medical options. Patients with unresectable insulinomas will likely have better long-term survival rates than those quoted in historical literature. Additional studies are needed to elucidate survival rate and the long-term efficacy of medical therapies.

Diarrhea as an Initial Presentation in Patients with Medullary Thyroid Cancer: Delaying the Diagnosis.

Tumoral secretion of various molecular factors, such as calcitonin (Ct), can cause diarrhea in patients with medullary thyroid cancer (MTC). We report 3 patients (age 26-38 years, serum Ct levels ranging from 2,890 to 52,894 ng/L) with chronic diarrhea, and the diagnosis of MTC was delayed. Diarrheal symptoms improved after thyroid surgery. Two patients with elevated Ct had no diarrhea. The link between tumor humoral secretion and diarrhea is not well established in patients with MTC. Diarrhea is more common in patients with metastatic disease and improves after resection of the tumor. Diarrhea may result from elevated circulating levels of Ct or other substances, such as prostaglandins or serotonin. Other proposed mechanisms include decreased absorption in the colon secondary to gastrointestinal motor disturbances. In conclusion, MTC should be considered when evaluating chronic diarrhea.