合并肝转移的恶性胰岛素瘤四例并文献复习  

Clinical characteristics of malignant insulinoma with liver metastasis:4 cases report and literature review

作　　者：池玥 袁涛 段炼 平凡 Chi Yue;Yuan Tao;Duan Lian;Ping Fan(Department of Endocrinology,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences,National Health Commission Key Laboratory of Endocrinology,Beijing 100730,China)

机构地区：[1]中国医学科学院北京协和医院内分泌科国家卫生健康委员会内分泌重点实验室,100730

出　　处：《中华糖尿病杂志》2019年第12期803-808,共6页CHINESE JOURNAL OF DIABETES MELLITUS

基　　金：中国医学科学院中央级公益性科研院所基本科研业务费专项资金(2017PT32020,2018PT32001)。

摘　　要：目的探讨合并肝脏转移恶性胰岛素瘤的临床、生化、影像学特点以及预后。方法回顾性分析北京协和医院2016年11月至2018年11月收治的4例合并肝脏转移的恶性胰岛素瘤患者的临床诊治过程并文献复习。结果4例患者均以Whipple三联征起病,低血糖症状进行性加重且符合典型的高胰岛素性低血糖。3例患者在初次就诊时已伴有肝转移,定性诊断提示空腹胰岛素原/胰岛素比值升高。影像学定位诊断方面胰腺增强磁共振成像(MRI)对于胰腺原发灶及肝转移灶的敏感性最高(阳性率均为4/4);腹部B超对胰腺原发灶敏感性较差(阳性率1/4),但对肝转移灶较为敏感(阳性率3/4)。4例患者均行胰岛素瘤切除术,其中3例行肝多发转移灶切除术。术后病理均符合神经内分泌肿瘤肝转移,Ki-67指数为1%~15%。病理分级其中2例为G1,2例为G2。结合分析国外文献提示胰岛素原/胰岛素比值升高对诊断恶性胰岛素瘤有重要意义,即使合并肝转移的恶性胰岛素瘤治疗方式中,仍以行原发灶及肝转移灶的手术切除预后相对最好。结论胰岛素原/胰岛素比值升高对诊断恶性胰岛素瘤有较大临床价值。胰腺增强MRI对于判断原发灶及肝转移灶敏感性最高。手术切除原发灶及转移病灶仍是最能改善合并肝转移的恶性胰岛素瘤预后的治疗措施。Objective To investigate the clinical characteristics,biochemical parameters,radiographic features and prognosis of malignant insulinomawith liver metastasis.Methods We retrospectively analyzed the clinical data of 4 cases of malignant insulinomaswith liver metastasis recruited in Peking Union Medical College Hospital from December 2016 to December 2018.Related literature were reviewed in this article.Results All the 4 cases manifested as Whipple triad with hypoglycemic symptoms gradually aggravated.They all met the criteria for the typical hyperinsulinemic hypoglycemia.Three patients had liver metastasis at the time of diagnosis.Qualitative diagnosis indicated that the ratio of fasting proinsulin to insulin was increased.All 4 patients undertook various radiographic examination.The sensitivity of pancreatic enhanced magnetic resonance imaging(MRI)was the highest in diagnosing primary pancreatic tumor and liver metastases(4/4).Abdominal ultrasound was not sensitive to primary pancreatic tumor(1/4),but sensitive to liver metastases(3/4).All 4 patients underwent insulinoma resection,of which 3 received hepatic metastases resection.Postoperative pathology finding was consistent with liver metastasis of neuroendocrine tumors.Ki-67 index was 1%-15%.Tumor grade was G1 in 2 patients,and G2 in the other 2 patients.Taken together the findings in the literature,it suggested that the increase of proinsulin/insulin ratio is of great significance in the diagnosis of malignant insulinoma.In the treatment of malignant insulinoma with hepatic metastasis,surgical resection of primary tumor and hepatic metastases yielded relative optimal prognosis.Conclusion The increase of proinsulin/insulin ratio is of great clinical significance in the diagnosis of malignant insulinoma.Enhanced pancreatic MRI is the most sensitive for both primary tumor and liver metastases.Surgical removal of primary and metastatic lesions is the most effective treatment to improve prognosis of malignant insulinoma with liver metastasis.

关 键 词：恶性胰岛素瘤 肝转移 胰岛素原/胰岛素比值 

分 类 号：R73[医药卫生—肿瘤]