Impacto del PET/CT en el diagnóstico de insulinoma / Impact of PET/CT in the Diagnosis of Insulinoma

Introducción: La tomografía de emisión de positrones es una técnica diagnóstica no invasiva que permite tomar imágenes del organismo que muestra el metabolismo de los órganos del cuerpo. Objetivo: Destacar el valor de la PET/CT en el diagnóstico imagenológico prequirúrgico del enfermo. Presentación de caso: Se presentó un paciente masculino de 39 años sin antecedentes de importancia, con un cuadro de hipoglucemias severas de 5 años de evolución, a pesar de los múltiples estudios imagenológicos se incluyó la ecoendoscopía digestiva, lo que no fue posible evidenciar la lesión tumoral. Se le realiza PET/CT cuyo resultado fue crucial para localizar el tumor, se le dio al paciente la oportunidad de un tratamiento quirúrgico y la demostración anatomopatológica de insulinoma. Conclusiones: Los insulinomas son tumores pancreáticos poco frecuentes que provocan hiperinsulinismo endógeno y son difíciles de visualizar debido a su tamaño por las técnicas de imágenes convencionales, por lo que el PET/CT es un estudio bastante efectivo para localizar la lesión tumoral, y así realizar un procedimiento quirúrgico(AU)

Introduction: Positron emission tomography is a non-invasive diagnostic technique, allowing images of the body to be taken that show the metabolism of the body's organs. Objective: To highlight the value of PET/CT in the pre-surgical imaging diagnosis of the patient. Case presentation: We report the case of a 39-year-old male patient with no significant medical history, but a 5-year history of severe hypoglycemia. Despite multiple imaging studies, digestive ultrasound endoscopy was included, which was not possible to demonstrate the tumor lesion. PET/CT was performed, the result of which was crucial in locating the tumor. The patient was given the opportunity for surgical treatment and the pathological demonstration of insulinoma. Conclusions: Insulinomas are rare pancreatic tumors that cause endogenous hyperinsulinism and are difficult to visualize due to their size using conventional imaging techniques, therefore PET/CT is a fairly effective study to locate the tumor lesion, and thus perform a surgical procedure(AU)

Endoscopic ultrasound-guided ethanol ablation for the management of a symptomatic pancreatic insulinoma.

INTRODUCTION: pancreatic insulinoma is a sporadic, usually benign, frequently solitary tumor that is smaller than 20 mm. When it is functioning, patients present with symptoms of hypoglycemia secondary to insulin hypersecretion. The diagnosis is clinical, with biochemical and radiological confirmation. Surgery is the management of choice, although endoscopic ultrasound-guided ablation is currently being developed. MATERIAL AND METHODS: we present a prospective case series of pancreatic insulinoma patients with symptoms of severe hypoglycemia, who were treated with endoscopic ultrasound-guided ethanol ablation as an alternative to surgical management. RESULTS: technical and clinical success was achieved in all cases and there were no complications associated with the procedure. CONCLUSION: the treatment of symptomatic insulinoma by endoscopic ultrasound-guided ethanol ablation could be a safe and effective alternative to surgical management in non-surgical patients or those who refuse surgery.

Hipoglucemia tumoral dependiente y no dependiente de células ß-pancreáticas, un reto diagnóstico / Tumor and non-tumor mediated hypoglycemia by pancreatic beta cells, a diagnostic challenge

La hipoglucemia es una urgencia médica frecuente que en la mayoría de los casos es secundaria al uso de fármacos hipoglucemiantes, orales o inyectados, indicados en pacientes con diabetes mellitus. No obstante, puede presentarse en forma espontánea y severa relacionándose con múltiples condiciones clínicas, incluyendo las neoplasias. Ante una hipoglucemia de origen paraneoplásico se deben reconocer los mecanismos fisiopatológicos que la generan y establecer el diagnóstico oportuno y preciso para disminuir las complicaciones propias de este síndrome clínico. Presentamos dos pacientes con cuadro de hipoglucemia refractaria al manejo médico inicial, de aparición similar con patologías diferentes. El primer caso corresponde a un paciente con insulinoma y el segundo con un hemangiopericitoma.

Hypoglycemia is a common medical emergency which is mostly secondary to the use of oral or injected hypoglycemic drugs indicated in patients with diabetes mellitus. However, it can present spontaneously and severely in relation to multiple clinical conditions, including neoplasms. When faced with hypoglycemia associated with paraneoplastic disorders, the pathophysiological mechanisms of hypoglycemia must be recognized and a timely and accurate diagnosis must be established in order to diminish complications inherent to this clinical syndrome. We herein present two patients with hypoglycemia refractory to initial medical management, sharing similar appearance with other pathologies. The first case corresponds to a patient with an insulinoma and the second to a patient with a hemangiopericytoma.

Evaluation of the Influence of the Conjugation Site of the Chelator Agent HYNIC to GLP1 Antagonist Radiotracer for Insulinoma Diagnosis.

BACKGROUND AND OBJECTIVE: Radiotracer diagnosis of insulinoma, can be done using somatostatin or glucagon-like peptide 1 (GLP-1). Performance of GLP-1 antagonists tends to be better than of agonists. METHODS: We investigated the uptake of the antagonist exendin (9-39), radiolabeled with technetium- 99m. Two different sites of the biomolecule were selected for chelator attachment. RESULTS: HYNIC-ßAla chelator attached to serine (C- terminus) of exendin, was associated with higher tumor uptake than to aspartate (N- terminus). CONCLUSION: The chelator position in the biomolecule influenced receptor uptake.

A freeze-dried kit formulation for the preparation of Lys(27)(99mTc-EDDA/HYNIC)-Exendin(9-39)/99mTc-EDDA/HYNIC-Tyr3-Octreotide to detect benign and malignant insulinomas.

About 90% of insulinomas are benign and 5%-15% are malignant. Benign insulinomas express the glucagon-like peptide-1 receptor (GLP-1R) and low levels of somatostatin receptors (SSTR), while malignant insulinomas over-express SSTR or GLP-1R in low levels. A kit for the preparation of Lys(27)((99m)Tc-EDDA/HYNIC)-Exendin(9-39)/(99m)Tc-EDDA/HYNIC-Tyr(3)Octreotide was formulated to detect 100% of insulinomas. The formulation showed radiochemical purity of 97±1%, high stability in human serum, and GLP-1R and SSTR affinity. The biodistribution and imaging studies demonstrated properties suitable for its use as a target-specific agent for the simultaneous molecular imaging of GRP-1R- and/or SSTR-positive tumors.

Insulinoma, a propósito de dos casos / Insulinoma, a propos of two cases

El Insulinoma es el tumor neuroendocrino pancreático más frecuente. Se manifiesta por signos adrenérgicos y de neuroglucopenia. Su diagnóstico se confirma documentando la existencia de hipoglucemia junto a una inapropiada secreción de insulina. Se desarrollan a partir de las células de los islotes de Langerhans. Tanto los funcionantes como los no funcionantes son embriológica e histológicamente muy similares y sólo difieren en su capacidad para producir o no hormonas. Presentamos 2 casos de insulinomas cuya localización tumoral no fue posible con técnicas de imagen convencionales, pero sí con ultrasonografía transoperatoria. La evolución fue favorable con remisión total de los síntomas(AU)

Insulinoma is the most common neuroendocrine pancreatic tumor. It manifests with adrenergic and neuroglycopenia signs. Its diagnosis is confirmed by documenting the existence of hypoglycemia together with inadequate insulin secretion. They developed from Langerhans islet cells and both functioning and non-functioning ones are embryologically and histologically very similar and just differ in their capacity to produce hormones or not. Here are two insulinoma cases where tumoral location was not possible with the conventional imaging techniques but with transoperative ultrasonography. The progression was favorable with total remission of symptoms(AU)

Utilidad de la ecografía intraoperatoria para la resección de un insulinoma en la cabeza del páncreas / Usefulness of intraoperative echography for resection of a insulinoma located in the head of pancreas

El insulinoma es la neoplasia más frecuente entre los tumores neuroendocrinos del páncreas. En el presente trabajo se describe el cuadro clínico, los exámenes de laboratorio e imaginológicos y los aspectos quirúrgicos y complicaciones de una paciente con diagnóstico clínico de insulinoma, sin evidencias por imágenes preoperatorias. La cirugía se indicó sobre la base de las evidencias clínicas y analíticas de hipoglucemia e hiperinsulinemia, y la realización de una laparotomía exploradora donde no se encontró lesión alguna con la palpación directa del páncreas. Se utilizó la ecografía intraoperatoria y se localizó un nódulo de 0,8 cm de diámetro en la cabeza de este órgano. Tras la enucleación se presentó, como complicación posoperatoria, una fístula pancreática de bajo gasto que remitió espontáneamente. El diagnóstico histológico fue de insulinoma benigno. La paciente presentó reversión clínica de los síntomas, además de la normalización de los valores de glucemia, comparados con los preoperatorios(AU)

The insulinoma is the more frequent neoplasms among the neuroendocrine tumors of pancreas. The aim of present paper is to describe the clinical picture, laboratory and imaging examinations and the surgical features as well as the complications in a patient diagnosed with insulinoma without evidences by preoperative images. Surgery was prescribed on the base of clinical and analytic evidences of hypoglycemia and hyperinsulinism and the carrying out of an exploratory laparatomy without any lesion with direct palpation of pancreas. Intraoperative echography was used to locate a 0,8 cm nodule in the head of pancreas. After enucleation the only postoperative complication was a low-flow pancreatic fistula with a spontaneous remission. The histological diagnosis was a benign insulinoma. Patient had a clinical reversion of symptoms in addition to normalization of glycemia values, compared to those intraoperative(AU)

[Laparoscopic surgical treatment of insulinomas with the use of intraoperative ultrasonography]. / Tratamento cirúrgico videolaparoscópico de insulinomas utilizando ultra-sonografia intra-operatória.

BACKGROUND: Insulinoma are insulin productive tumors originated from the pancreatic beta cells with an incidence of 4/1 million persons. It is more prevalent between the 5th and 6th decade, in women (2:1) and from the endocrine pancreatic tumor is the more frequent (50% to 60%). Insulinoma behave as a benign tumor when the diameter is inferior to 2 cm. The diagnosis is mainly clinical and laboratorial. Surgery is the unique treatment with potential cure. AIM: The present observation reports the use of simultaneous laparoscopic resection associated to intraoperative ultrasonography. METHODS: Five patients were studied (3 man and 2 women) with age from 20 to 53 years old, clinically diagnosed with insulinoma. After image work out it was proposed nuclear resection of the insulinoma by laparoscopic technique associated to intraoperative ultrasonography. RESULTS: The patients had a complete remission of tumor related hypoglycemia and one patient developed a pancreatic fistula and other a pancreatic pseudocist with good postoperative resolution. CONCLUSIONS: The videolaparoscopic approach for the surgical treatment of insulinoma is feasible. The intraoperative ultrasonography helps to identify the lesions and check their complete resection with low complication rate.

[Clinical experience in 37 cases of insulinoma]. / Experiencia clinica sobre 37 casos de insulinoma.

Insulinoma is the most frequent pancreatic islet cell tumor. Clinical manifestations include adrenergic and neuroglycopenic symptoms. Diagnosis is established through demonstration of inappropriately elevated insulin serum concentrations in the presence of hypoglycemia. The aim of this study is to show our experience in the management of insulinoma. Since 1988, 23 women (48 +/- 18 years) and 14 men (45 +/- 19 years) were studied. Seventy three percent of them suffered mainly from neuroglucopenic symptoms while 27% referred adrenergic signs. Mean duration of symptoms before diagnosis was 2.7 +/- 2 years. Mean fasting serum glucose was 32.4 +/- 8.7 mg/dl, insulin 38.2 +/- 39.7 microU/ml (RIA, n=11) or 23.8 +/- 18.1 microU/ml (chemoluminescence, n=26) and C-peptide 1.15 +/- 1.60 nmol/l (n=14). Twenty one patients developed clinical and/or biochemical hypoglycaemia within 9.0 +/- 5.2 hours of supervised fast. Preoperative localization was performed in 73% by imaging techniques, arterial calcium stimulation and/or intraoperative ultrasonography and palpation by the surgeon. Thirty six patients were operated on by conventional surgery in 25, or laparoscopic approach in 11 cases. In 22 patients, a solitary tumor was excised (61.1%). Six cases presented multiple insulinomas. Five patients had malignant insulinomas. In one case, a pattern of nesidioblastosis was found and 2 patients presented unspecific findings. In 3 patients another tumour (glucagonoma) was found (1 of them with MEN 1). One patient was treated with verapamil with good clinical response. Mean postoperative follow up was 60.4 +/- 59.9 months.

Experiencia clinica sobre 37 casos de insulinoma / Clinical experience in 37 cases of insulinoma

El insulinoma es el tumor neuroendocrino pancreático más frecuente. Se manifiesta por signos adrenérgicos y de neuroglucopenia. Su diagnóstico se confirma documentando la existencia de hipoglucemia junto a una inapropiada secreción de insulina. Desde 1988 fueron estudiados 23 mujeres (48 ± 18 años) y 14 varones (45 ± 19 años) con diagnóstico de insulinoma. La evolución de la enfermedad hasta el diagnósticofue de 2.8 ± 2.1 años. Veintisiete pacientes (73%) presentaron principalmente síntomas de neuroglucopenia, y el 27% refirió síntomas adrenérgicos. El laboratorio mostró glucemia en ayunas 32.4 ± 8.7 mg/dl, insulina (RIA) 38.2 ± 39.7 μU/ml (n=11), insulina (quimioluminiscencia) 23.8 ± 18.1 μU/ml (n=26), péptido C1.15 ± 1.6 nmol/l (n=14). El test de ayuno prolongado fue diagnóstico a las 9.0 ± 5.2 horas (n=21). La localizaciónpreoperatoria fue posible en el 73% por imágenes, arteriografía con estimulación de calcio y/o ecografía intraoperatoria. Once casos fueron operados por laparoscopia, y el resto por vía convencional. El diagnósticofue confirmado por histología e inmunohistoquímica. Veintidos pacientes (61.1%) presentaron insulinomas únicos(16 en cuerpo y cola, 6 en la cabeza y proceso uncinado), 6 eran portadores de insulinomas múltiples, 5 deinsulinomas malignos, 1 de nesidioblastosis del adulto y en 2 casos los hallazgos fueron incaracterísticos. En 3 pacientes se halló un glucagonoma asociado (1 de ellos con NEM1). Una paciente no fue operada recibiendotratamiento con verapamilo, con buena respuesta clínica. El seguimiento postquirúrgico fue de 60.4 ± 59.9 meses (AU)

Insulinoma is the most frequent pancreatic islet cell tumor. Clinical manifestations include adrenergic and neuroglycopenic symptoms. Diagnosis isestablished through demonstration of inappropriately elevated insulin serum concentrations in the presence ofhypoglycemia. The aim of this study is to show our experience in the management of insulinoma. Since 1988,23 women (48 ± 18 years) and 14 men (45 ± 19 years) were studied. Seventy three percent of them sufferedmainly from neuroglucopenic symptoms while 27% referred adrenergic signs. Mean duration of symptoms beforediagnosis was 2.7 ± 2 years. Mean fasting serum glucose was 32.4 ± 8.7 mg/dl, insulin 38.2 ± 39.7 μU/ml(RIA, n= 11) or 23.8 ± 18.1 μU/ml (chemoluminescence, n=26) and C-peptide 1.15 ± 1.60 nmol/l (n=14). Twenty one patients developed clinical and/or biochemical hypoglycaemia within 9.0 ± 5.2 hours of supervised fast. Preoperative localization was performed in 73% by imaging techniques, arterial calcium stimulation and/or intraoperative ultrasonography and palpation by the surgeon. Thirty six patients were operated on by conventional surgery in 25, or laparoscopic approach in 11 cases. In 22 patients, a solitary tumor was excised (61.1%). Six cases presented multiple insulinomas. Five patients had malignant insulinomas. In one case, a pattern of nesidioblastosis was found and 2 patients presented unspecific findings. In 3 patients another tumour(glucagonoma) was found (1 of them with MEN 1). One patient was treated with verapamil with good clinicalresponse. Mean postoperative follow up was 60.4 ± 59.9 months (AU)

Experiencia clinica sobre 37 casos de insulinoma / Clinical experience in 37 cases of insulinoma

El insulinoma es el tumor neuroendocrino pancreático más frecuente. Se manifiesta por signos adrenérgicos y de neuroglucopenia. Su diagnóstico se confirma documentando la existencia de hipoglucemia junto a una inapropiada secreción de insulina. Desde 1988 fueron estudiados 23 mujeres (48 ± 18 años) y 14 varones (45 ± 19 años) con diagnóstico de insulinoma. La evolución de la enfermedad hasta el diagnósticofue de 2.8 ± 2.1 años. Veintisiete pacientes (73%) presentaron principalmente síntomas de neuroglucopenia, y el 27% refirió síntomas adrenérgicos. El laboratorio mostró glucemia en ayunas 32.4 ± 8.7 mg/dl, insulina (RIA) 38.2 ± 39.7 μU/ml (n=11), insulina (quimioluminiscencia) 23.8 ± 18.1 μU/ml (n=26), péptido C1.15 ± 1.6 nmol/l (n=14). El test de ayuno prolongado fue diagnóstico a las 9.0 ± 5.2 horas (n=21). La localizaciónpreoperatoria fue posible en el 73% por imágenes, arteriografía con estimulación de calcio y/o ecografía intraoperatoria. Once casos fueron operados por laparoscopia, y el resto por vía convencional. El diagnósticofue confirmado por histología e inmunohistoquímica. Veintidos pacientes (61.1%) presentaron insulinomas únicos(16 en cuerpo y cola, 6 en la cabeza y proceso uncinado), 6 eran portadores de insulinomas múltiples, 5 deinsulinomas malignos, 1 de nesidioblastosis del adulto y en 2 casos los hallazgos fueron incaracterísticos. En 3 pacientes se halló un glucagonoma asociado (1 de ellos con NEM1). Una paciente no fue operada recibiendotratamiento con verapamilo, con buena respuesta clínica. El seguimiento postquirúrgico fue de 60.4 ± 59.9 meses (AU)

Insulinoma is the most frequent pancreatic islet cell tumor. Clinical manifestations include adrenergic and neuroglycopenic symptoms. Diagnosis isestablished through demonstration of inappropriately elevated insulin serum concentrations in the presence ofhypoglycemia. The aim of this study is to show our experience in the management of insulinoma. Since 1988,23 women (48 ± 18 years) and 14 men (45 ± 19 years) were studied. Seventy three percent of them sufferedmainly from neuroglucopenic symptoms while 27% referred adrenergic signs. Mean duration of symptoms beforediagnosis was 2.7 ± 2 years. Mean fasting serum glucose was 32.4 ± 8.7 mg/dl, insulin 38.2 ± 39.7 μU/ml(RIA, n= 11) or 23.8 ± 18.1 μU/ml (chemoluminescence, n=26) and C-peptide 1.15 ± 1.60 nmol/l (n=14). Twenty one patients developed clinical and/or biochemical hypoglycaemia within 9.0 ± 5.2 hours of supervised fast. Preoperative localization was performed in 73% by imaging techniques, arterial calcium stimulation and/or intraoperative ultrasonography and palpation by the surgeon. Thirty six patients were operated on by conventional surgery in 25, or laparoscopic approach in 11 cases. In 22 patients, a solitary tumor was excised (61.1%). Six cases presented multiple insulinomas. Five patients had malignant insulinomas. In one case, a pattern of nesidioblastosis was found and 2 patients presented unspecific findings. In 3 patients another tumour(glucagonoma) was found (1 of them with MEN 1). One patient was treated with verapamil with good clinicalresponse. Mean postoperative follow up was 60.4 ± 59.9 months (AU)

Laparoscopic distal pancreatectomy for insulinoma with preservation of the spleen.

We report on a successful laparoscopic distal pancreatectomy due to insulinoma, preserving the spleen and the splenic vessels in a 29-year-old male patient who presented with repeated syncope due to hypoglycemia. The ultrasound exam did not show the pancreatic lesion; it was only the angiotomography of the pancreas that revealed a 3-cm mass located at the transition from the body to the tail of the pancreas. The laparoscopic distal pancreatectomy was performed using a harmonic scalpel (Ethicon EndoSurgery/UltraCision), without mechanical suturing. There were no intra- or postoperative complications or hypoglycemias during the 6 months of follow-up. When it is performed by experienced laparoscopic surgeons, this is a technically feasible procedure, safe for the treatment of benign lesions of the pancreas body and tail.

[Identification of insulinomas by endoscopic ultrasonography]. / Identificação dos insulinomas pela ecoendoscopia.

BACKGROUND: The aim of this study is to compare EUS and the others diagnostics tests in the correct localization of insulinomas. METHODS: We prospectively investigated 30 patients with endoscopic ultrasound with a clinical diagnosis of insulinomas prior to surgical exploration. They were submitted to abdominal ultrasonography, spiral computed tomography and four patients were submitted to magnetic ressonance before EUS. Surgery was the gold standard for tumor localization. RESULTS: Twenty-six tumors were benign (86.6%) and four were malign (13.4%). The median size tumors detected by EUS was 1.5 cm. The overall sensitivity of EUS in identifying insulinomas was 86.6% compared to 33% for CT, 40% to MRI and 90.9% to IUS. In 12 patients we were able to perform EUS-guided fine needle aspiration. Insulinoma was diagnosed in ten cytological specimens (83.3%). Tumors located in the head and body of the pancreas were seen by EUS in all patients, respectively but those located in the tail were diagnosed only in 55.5% of the cases. CONCLUSIONS: EUS has a high sensibility in the identification and localization of pancreatic insulinomas and should replace traditional methods of image when clinical suspicion is high.

Manejo anestésico de un paciente operado en dos oportunidades de un insulinoma múltiple / Anesthetic managemet of a twice operated patient for multiple insulinoma

Nuestro objetivo es describir el manejo anestésico de una paciente intervenida en dos oportunidades de un insulinoma múltiple. La presentación clínica fue la tríada de Whipple, y el diagnóstico se confirmó por la dosificación de péptido C y por el test de ayuno. La tomografía axial (TAC) y la resonancia nuclear (RNM) fueron normales, pero la ecografía abdominal y la TAC helicoidal dinámica confirmaron la presencia del tumor. El hallazgo de un insulinoma en una paciente de 16 años llevó al diagnóstico presuntivo de síndrome de neoplasias endocrinas múltiples tipo I (MEN I). La paciente se intervino con anestesia general balanceada monitorizándose estrictamente la glicemia. La reposición se efectuó con soluciones glucosadas ajustando el ritmo de infusión a los valores de glicemia, lográndose un buen control metabólico. La localización intraoperatoria del tumor se realizó por ecografía, y la resección completa del nódulo se confirmó por biopsia extemporánea. La aparición de hipoglicemia severa en el postoperatorio inmediato llevó al diagnóstico de una neoplasia múltiple, reforzando el planteo de un síndrome MEN I. El diagnóstico del segundo tumor se confirmó por la TAC helicoidal dinámica y la arteriografía. Un aspecto discutido en el trabajo es el costo beneficio de la localización preoperatoria del insulinoma. Previo a la segunda operación se medicó a la paciente con diazóxido. La utilización de soluciones glucosadas para evitar la hipoglicemia severa durante la intervención genera controversia, pues impide el uso de la hiperglicemia rebote como indicador de la resección tumoral completa. (AU)

Tumores neuroendocrinos no funcionantes de páncreas / Pancreatic islet cell tumors

Antecedentes: Dentro del capítulo de las neoplasias de páncreas, los tumores insulares no funcionantes son los menos frecuentes. Generalmente son de diagnóstico tardío, de comportamiento biológico maligno en un 80 por ciento de los casos y presentan una tasa de sobrevida a los 5 años de 40 a 60 por ciento. Objetivo: Analizar la experiencia en este tipo de tumores en los últimos 10 años. Material y métodos: Desde enero de 1987 a enero de 1997 se operaron 23 pacientes con tumores insulares de páncreas, de los cuales 10 casos eran no funcionantes, 8 mujeres y 2 varones con una edad promedio de 49,5 años. El tiempo promedio transcurrido entre el comienzo de los síntomas y el diagnóstico fue de 1.5 años. El síntoma más frecuente fue el dolor abdominal. Todos fueron evaluados por ecografía y TAC. Ecoendoscopía en 5 casos, ecografía intraoperatoria en 5, RNM en 3 y angioresonancia en 1. En un caso localmente avanzado se realizó punción diagnóstica preoperatoria. Resultados: Nueve pacientes fueron resecados con criterio curativo, siendo un caso irresecable. Se realizaron una duodenopancreatectomía y 8 esplenopancreatectomías corporocaudales. El promedio de internación fue de 13 días. No se registró mortalidad perioperatoria. La tasa de morbilidad fue del 20 por ciento. El diagnóstico histológico fue tumor insular en los 10 casos, 8 de los cuales fue carcinoma insular. Al momento del análisis 4 pacientes se encontraban vivos y libres de enfermedad, 4 murieron a los 49, 50, 60 y 62 meses y dos fueron perdidos del seguimiento a los 18 y 24 meses. Conclusiones: Debido al comportamiento biológico maligno de estos tumores, la resección es la mejor opción independientemente del tamaño tumoral. Sin embargo, debido a que poseen mejor pronóstico que el adenocarcinoma, siempre se debe realizar diagnóstico histológico en los tumores considerados irresecables (AU)

[Magnetic resonance diagnosis of insulinoma]. / Diagnóstico de insulinoma por resonancia magnética.

OBJECTIVE: The purpose of this report is to highlight the use of the magnetic resonance imaging in the detection of very small tumors of the pancreas. BACKGROUND: The computed axial tomography and angiography have been the traditional methods in the detection of neoplasms of the pancreas, mostly vascular lesions, both lacking the tissue characterization and contrast; the magnetic resonance scan was performed to rule out a pancreatic tumor in a 37 year old female patient with hypoglycemia, previously treated for seizures. RESULTS: A 1.0 cm nodular hypointense lesion was seen in the union of the body and the tail of the pancreas, confirmed by surgery and pathology as an insular cell tumor. CONCLUSION: Given its axial and tissue contrast resolution, as demonstrated in our case, the magnetic resonance imaging has became the gold standard in the identification of very small tumors of the pancreas.