A lady presented with recurrent attacks of giddiness and abdominal pain since three months. Endoscopy was normal. Her fasting blood glucose level was 40 mg and insulin levels were elevated. CT abdomen showed a well defined 8mm enhancing lesion in the head of pancreas, with no other abnormal findings. The treatment plan should be-
Ans is 'a' i.e. Enucleation "Enucleation is usually sufficient to remove the entire tumor as these are typically benign lesions. More extensive resections are required for complete excision of malignant insulinomas, which are typically much larger (approximately 6 cm), and in patients with MEN-I or multifocal disease. These patients may require subtotal pancreatectomy, with enucleation of lesions in the head of the pancreas or pancreaticoduodenectomy with local resections of tumors in the body or tail. Tumor debulking may be useful even if all disease is not removed since some residual disease may not be functional."-Maingot's 11/e chapter 42 Demonstration of inappropriately elevated levels of plasma insulin and fasting hypoglycaemia suggest the diagnosis of insulinoma. Since most insulinomas are benign and in this patient the insulinoma is well defined, quite small in size, an enucleation would be sufficient. Streptozotocin selectively destroys pancreatic islet cells by inhibiting DNA synthesis. It is the chemotherapeutic agent of choice for metastatic insulinomas.
Enucleation
Enucleation with radiotherapy
Whipple's operation
Administration of streptozotocin