Korean J Radiol.  2003 Jun;4(2):101-108. 10.3348/kjr.2003.4.2.101.

Selective Intra-Arterial Calcium Stimulation with Hepatic Venous Sampling for Preoperative Localization of Insulinomas

• Sung YM
• Do YS
• Shin SW
• Liu WC
• Choo SW
• Choo IW
• Lee MK

• KMID: 1118812
• DOI: http://doi.org/10.3348/kjr.2003.4.2.101

Abstract

OBJECTIVE
To determine the value of selective intra-arterial calcium stimulation with hepatic venous sampling using serum insulin and C-peptide gradients for the preoperative localization of insulinomas. MATERIALS AND METHODS: Seven consecutive patients [three men and four women aged 15-77 (mean, 42.7) years] with hypoglycemia underwent selective intra-arterial calcium stimulation in conjunction with hepatic venous sampling. Insulin gradients were calculated by an individual blinded to all other preoperative imaging studies and operative findings. In all patients except one, C-peptide gradients were also analyzed. The results were compared with the preoperative findings of ultrasonography, computed tomography, arteriography and endoscopic ultrasonography, as well as with the intraoperative findings of ultrasonography and palpation at surgery. RESULTS: Eight insulinomas (mean diameter, 12.5 mm) were diagnosed after surgery. In six patients, the calcium stimulation test with insulin gradients allowed accurate localization of the pathologic source of insulin secretion. Both C-peptide and insulin gradients substantially increased diagnostic accuracy. In one patient, C-peptide gradients were more helpful than insulin gradients for tumor localization. CONCLUSION: Selective intra-arterial calcium stimulation with hepatic venous sampling is a highly accurate and safe method for the preoperative localization of insulinomas. Additional C-peptide gradients seem to be helpful in assessing tumor location, but further study is needed.

Keyword

Pancreas, neoplasms; Veins, blood sampling; Calcium; Angiography, preoperative

Figure

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  Fig. 1 A 5-French Cobra catheter (arrow) was placed in the right hepatic vein close to its junction with the inferior vena cava through a puncture of the right internal jugular vein. Selective splenic arteriogram shows no abnormal staining.

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  Fig. 2 A 59-year-old woman with an insulinoma of the pancreatic head (patient 2). A. Selective intra-arterial calcium injection demonstrates a 21-fold insulin gradient in the gastroduodenal artery at 30 secs. B. In the same artery, a six-fold C-peptide gradient was also noted at 30 secs. C. Gastroduodenal arteriogram demonstrates tumor blush (arrow) within the pancreatic head.

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  Fig. 3 A 15-year-old youth (patient 3) with an insulinoma of the pancreatic tail. A. In the splenic artery, the insulin gradient peaked at 30 secs. B. In the same artery, the C-peptide gradient also peaked at 30 secs. C. Splenic arteriogram shows tumor staining (arrow) within the pancreatic tail.

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  Fig. 4 A 19-year-old male (patient 4) with two insulinomas of the pancreatic tail. A. Insulin gradients show no significant difference between the GDA 30 secs after calcium stimulation and the SpA at 60 secs. Moreover, after 30 secs, insulin in the gastroduodenal artery decreased gradually, but in the splenic artery a gradual increase was observed. The analyst could not determine the location of the insulinomas. B. In the splenic artery, the C-peptide gradient peaked 60 secs after stimulation but in the gastroduodenal artery, the gradient was not more than 1.0. The analyst localized the tumor to the pancreatic body or tail.

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