Insulinoma after sleeve gastrectomy: A case report.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has been proposed as an effective and durable treatment for severe obesity and glucose metabolism disorders, and its prevalence has increased from 5% to 37% since 2008. One common complication after bariatric surgery is a postprandial hyperinsulinemic hypoglycemic state. While rare, insulinomas can cause this state, where symptoms are more common in the fasting state; thus, evaluation of insulin secretion is needed. Until now, there have been no reports of insulinoma after LSG. CASE SUMMARY: We describe the case of a 43-year-old woman who was referred to the obesity clinic 2 years after LSG was performed. She had symptoms of hypoglycemia predominantly in the fasting state and documented hypoglycemia of less than 30 mg/dL, which are compatible with Whipple's triad. Initially, dumping syndrome was suspected, but after a second low fasting plasma glucose was documented, a 72-h fasting test was performed that tested positive. Computed tomography and endoscopic ultrasound were performed, identifying the presence of a homogeneous hypoechoic semioval tumoral lesion in the pancreas. The diagnosis was compatible with insulinoma. After laparoscopic enucleation of the insulinoma, the symptoms and hypoglycemia disappeared. The histopathological report described a well-differentiated grade 2 neuroendocrine tumor with positive chromogranin and synaptophysin and Ki67 immunopositivity in 4% of the neoplastic cells. CONCLUSION: Insulinoma after LSG is a rare condition, and clinicians must be aware of it, especially if the patient has hypoglycemic symptoms during the fasting state.

Metastases of ductal carcinoma of the breast in the esophagus. Case report / Metástasis de carcinoma ductal de mama en esófago. Reporte de un caso

Background: Invasive breast cancer is the most common carcinoma in women, 23% of all cancers in the world. It is classified according to its histological pattern and expression of immunohistochemical markers; 75% are ductal type. The incidence of metastases is 10 to 80% of the cases according to their immunophenotype, the main sites of metastases are bone, visceral and brain. Clinical case: A 64 years old lady with a history of radical left mastectomy due to unspecified breast cancer in 2000, received chemotherapy, radiation therapy and tamoxifen. After her discharge from hospital, the patient remained unattended. In 2014 she started with dysphagia, in 2016 was documented esophageal stricture by panendoscopy, three endoscopic dilations were performed, in the last one she presented incidental perforation. An esophagectomy was performed; the pathological study reported metastasis of ductal carcinoma of the breast. Conclusions: Ductal carcinoma of the breast rarely metastasizes to the digestive tract but, its probability must have this and insist on monitoring of patients after their cancer treatment.

Introducción: el cáncer de mama es la neoplasia maligna más común en mujeres, 23% a nivel mundial. Se clasifica según su patrón histológico y expresión de marcadores de inmunohistoquímica; hasta 75% son de tipo ductal. La incidencia de metástasis es de 10 a 80% según su inmunofenotipo, ocurren principalmente en hueso, vísceras y cerebro. Caso clínico: mujer de 64 años, con antecedente de mastectomía radical izquierda por carcinoma de mama no especificado en el 2000, recibió quimioterapia, radioterapia y tamoxifeno. Posterior a su alta hospitalaria la paciente permaneció sin vigilancia. En el 2014 inició con disfagia a sólidos, en el 2016 se documentó estenosis esofágica por panendoscopía, le realizaron tres dilataciones endoscópicas, en la última con perforación incidental. Se realizó esofagectomía; el estudio de patología reportó metástasis de carcinoma ductal de mama. Conclusiones: el carcinoma ductal de mama raramente da metástasis a tubo digestivo, no obstante, su probabilidad se debe tener presente e insistir en la vigilancia de las pacientes después de concluir su tratamiento contra el cáncer.

Multicentric insulinoma associated with multiple endocrine neoplasia type 1: One case report / Insulinoma multicéntrico asociado a neoplasia endócrina múltiple tipo 1: reporte de un caso

Background: Pancreatic neuroendocrine tumors may be associated with multiple endocrine neoplasia type 1 (MEN1) in 15-25% of cases, and up to 10% develop insulinomas, which are the most frequent cause of persistent hyperinsulinemic hypoglycemia in adults. The objective is to show a clinical case that presents this association. Clinical case: 36-year-old patient with seizures associated with fasting hypoglycemia of 36 mg/dL. The patient presented high levels of insulin, peptide C, proinsulin, hypercalcemia, hypophosphatemia and parathyhroid hormone. Ultrasound sonography test showed hypoechoic lesion in the pancreatic tail of 2.3 cm. Tomography showed a 10 mm hypodense lesion at pancreatic head. Scintigram showed hypercaptating parathyroid tissue. Magnetic resonance did not show evidence of pituitary adenoma. We carried out a tumor enucleation of the pancreatic head and distal partial pancreatectomy with histopathological diagnosis of well-differentiated low-grade multifocal neuroendocrine tumor (five tumors); two tumors were immunoreactive to insulin. After surgery, glucose level was normalized (105 mg/dL). Patient underwent parathyroidectomy with a report of adenoma of the parathyroid gland. Conclusion: The multicentricity of pancreatic neuroendocrine tumors related to parathyroid neoplasia suggests the diagnosis of MEN1. Genetic molecular studies should be performed to confirm this and provide the patient with a correct diagnosis, targeted treatment and adequate genetic counseling.

Introducción: Los tumores neuroendócrinos pancreáticos pueden estar asociados a neoplasia endócrina múltiple tipo 1 (NEM 1) en el 15-25% de los casos; de estos, hasta el 10-30% desarrollan insulinomas, que son la causa más frecuente de hipoglucemia hiperinsulinémica persistente en adultos. El objetivo de este reporte es mostrar un caso clínico que presenta esta asociación. Caso clínico: Paciente de sexo masculino de 36 años con crisis convulsivas asociadas a hipoglucemia en ayuno de 36 mg/dL. El paciente presentó niveles altos de proinsulina, insulina, péptido C, calcemia y hormona paratiroidea e hipofosfatemia. El ultrasonido (USG) mostró lesión hipoecogénica de 2.3 cm en la cola del páncreas. En la tomografía se observó lesión hipodensa de 10 mm en la cabeza del páncreas. El gammagrama mostró tejido paratiroideo hipercaptante. La resonancia magnética no presentó indicios de adenoma hipofisario. Se hizo enucleación de tumor de cabeza de páncreas y pancreatectomía parcial distal con diagnóstico histopatológico de tumor neuroendócrino bien diferenciado de bajo grado multifocal (cinco tumores); dos tumores fueron inmunorreactivos a insulina. Después de la cirugía se normalizaron los niveles de glucosa (105 mg/dL). Se sometió al paciente a paratiroidectomía con reporte de adenoma de la glándula paratiroides. Conclusión: La multicentricidad de los tumores neuroendócrinos pancreáticos relacionados con neoplasia paratiroidea sugiere el diagnóstico de NEM tipo 1. Deben realizarse estudios moleculares genéticos para confirmarlo y ofrecer al paciente un diagnóstico certero, un tratamiento dirigido y una adecuada asesoría genética.