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European Radiology

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01-10-2016 | Computed Tomography

Isoattenuating insulinomas at biphasic contrast-enhanced CT: frequency, clinicopathologic features and perfusion characteristics

Authors: Liang Zhu, Hua-dan Xue, Hao Sun, Xuan Wang, Yong-lan He, Zheng-yu Jin, Yu-pei Zhao

Published in: European Radiology | Issue 10/2016

Abstract

Objectives

We aimed to determine the frequency of isoattenuating insulinomas, to investigate their clinicopathological features and to assess their regional pancreatic perfusion characteristics.

Methods

Institutional review board approval was obtained, and patient informed consent was waived. From July 2010 to June 2014, 170 patients (66 male, 104 female) with endogenous hyperinsulinemic hypoglycemia underwent biphasic contrast-enhanced CT before surgery, and 129 of those patients also received preoperative whole-pancreas CT perfusion. A total of 181 tumours were proved histopathologically after surgery. Enhancement pattern and regional pancreatic perfusion characteristics were analyzed. Clinical features, tumour size and pathological grading were investigated.

Results

The frequency of isoattenuating tumours was 24.9 %. Tumour size and WHO grading was not significantly different between isoattenuating and hyperattenuating tumours. Tumour-free regions had identical blood flow (BF) regardless of their location (p = 0.35). Isoattenuating tumour-harbouring regions had lower BF compared with hyperattenuating tumour-harbouring regions; both showed higher BF compared with tumour-free neighbourhood regions (all p < 0.01). For patients with isoattenuating tumours, the overall hospital stay was longer (p < 0.01).

Conclusions

A substantial subset of insulinomas were isoattenuating on biphasic CT. CT perfusion showed higher BF in tumour-harbouring regions compared to tumour-free regions, providing a clue for tumour regionalization.

Key Points

• About a quarter of all insulinomas were isoattenuating on biphasic contrast-enhanced CT.

• CT perfusion finds tumour-harbouring regions have higher blood-flow compared to tumour-free regions.

• CT perfusion provides important information for tumour regionalization, for isoattenuating tumours.

Soga J, Yakuwa Y, Osaka M (1998) Insulinoma/hypoglycemic syndrome: a statistical evaluation of 1085 reported cases of a Japanese series. J Exp Clin Cancer Res 17:379–388PubMed

Nikfarjam M, Warshaw AL, Axelrod L, Deshpande V, Thayer SP et al (2008) Improved contemporary surgical management of insulinomas: a 25-year experience at the Massachusetts General Hospital. Ann Surg 247:165–172CrossRefPubMedPubMedCentral

Norton JA, Shawker TH, Doppman JL et al (1990) Localization and surgical treatment of occult insulinomas. Ann Surg 212:615–620CrossRefPubMedPubMedCentral

Cirocchi R, Partelli S, Coratti A et al (2013) Current status of robotic distal pancreatectomy: a systematic review. Surg Oncol 22:201–207CrossRefPubMed

Isla A, Arbuckle JD, Kekis PB et al (2009) Laparoscopic management of insulinomas. Br J Surg 96:185–190CrossRefPubMed

Liu Y, Song Q, Jin HT, Lin XZ, Chen KM (2009) The value of multidetector-row CT in the preoperative detection of pancreatic insulinomas. Radiol Med 114:1232–1238CrossRefPubMed

Noone TC, Hosey J, Firat Z, Semelka RC (2005) Imaging and localization of islet-cell tumours of the pancreas on CT and MRI. Best Pract Res Clin Endocrinol Metab 19:195–211CrossRefPubMed

Fiebrich HB, van Asselt SJ, Brouwers AH et al (2012) Tailored imaging of islet cell tumors of the pancreas amidst increasing options. Crit Rev Oncol Hematol 82:213–226CrossRefPubMed

Gouya H, Vignaux O, Augui J et al (2003) CT, endoscopic sonography, and a combined protocol for preoperative evaluation of pancreatic insulinomas. AJR Am J Roentgenol 181:987–992CrossRefPubMed

10.

Fidler JL, Fletcher JG, Reading CC et al (2003) Preoperative detection of pancreatic insulinomas on multiphasic helical CT. AJR Am J Roentgenol 181:775–780CrossRefPubMed

11.

Gusmini S, Nicoletti R, Martinenghi C et al (2007) Arterial vs. pancreatic phase: which is the best choice in the evaluation of pancreatic endocrine tumours with multidetector computed tomography (MDCT)? Radiol Med 112:999–1012CrossRefPubMed

12.

Ichikawa T, Peterson MS, Federle MP et al (2000) Islet cell tumor of the pancreas: biphasic CT versus MR imaging in tumor detection. Radiology 216:163–171CrossRefPubMed

13.

Fendrich V, Bartsch DK, Langer P, Zielke A, Rothmund M (2004) Diagnosis and surgical treatment of insulinoma--experiences in 40 cases. Dtsch Med Wochenschr 129:941–946CrossRefPubMed

14.

Thoeni RF, Mueller-Lisse UG, Chan R, Do NK, Shyn PB (2000) Detection of small, functional islet cell tumors in the pancreas: selection of MR imaging sequences for optimal sensitivity. Radiology 214:483–490CrossRefPubMed

15.

Boukhman MP, Karam JM, Shaver J et al (1999) Localization of insulinomas. Arch Surg 134:818–822, discussion 822-813CrossRefPubMed

16.

Daneshvar K, Grenacher L, Mehrabi A, Kauczor HU, Hallscheidt P (2011) Preoperative tumor studies using MRI or CT in patients with clinically suspected insulinoma. Pancreatology 11:487–494CrossRefPubMed

17.

Graziani R, Brandalise A, Bellotti M et al (2010) Imaging of neuroendocrine gastroenteropancreatic tumours. Radiol Med 115:1047–1064CrossRefPubMed

18.

Antwi K, Fani M, Nicolas G et al (2015) Localization of hidden insulinomas with 68Ga-DOTA-Exendin-4 PET/CT: a pilot study. J Nucl Med 56:1075–1078CrossRefPubMed

19.

Khashab MA, Yong E, Lennon AM et al (2011) EUS is still superior to multidetector computerized tomography for detection of pancreatic neuroendocrine tumors. Gastrointest Endosc 73:691–696CrossRefPubMed

20.

Lin XZ, Wu ZY, Tao R et al (2012) Dual energy spectral CT imaging of insulinoma-Value in preoperative diagnosis compared with conventional multi-detector CT. Eur J Radiol 81:2487–2494CrossRefPubMed

21.

Zhang TP, Zhao YP, Cong L et al (2009) Noninvasive examinations for localization of insulinoma. Zhonghua Wai Ke Za Zhi 47:1365–1367PubMed

22.

Kim JH, Park SH, Yu ES et al (2010) Visually isoattenuating pancreatic adenocarcinoma at dynamic-enhanced CT: frequency, clinical and pathologic characteristics, and diagnosis at imaging examinations. Radiology 257:87–96CrossRefPubMed

23.

Prokesch RW, Chow LC, Beaulieu CF, Bammer R, Jeffrey RB Jr (2002) Isoattenuating pancreatic adenocarcinoma at multi-detector row CT: secondary signs. Radiology 224:764–768CrossRefPubMed

24.

Espana-Gomez MN, Velazquez-Fernandez D, Bezaury P et al (2009) Pancreatic insulinoma: a surgical experience. World J Surg 33:1966–1970CrossRefPubMed

25.

Zhao YP, Zhan HX, Zhang TP et al (2011) Surgical management of patients with insulinomas: result of 292 cases in a single institution. J Surg Oncol 103:169–174CrossRefPubMed

26.

Rha SE, Jung SE, Lee KH et al (2007) CT and MR imaging findings of endocrine tumor of the pancreas according to WHO classification. Eur J Radiol 62:371–377CrossRefPubMed

27.

Van Hoe L, Gryspeerdt S, Marchal G, Baert AL, Mertens L (1995) Helical CT for the preoperative localization of islet cell tumors of the pancreas: value of arterial and parenchymal phase images. AJR Am J Roentgenol 165:1437–1439CrossRefPubMed

28.

Keogan MT, McDermott VG, Paulson EK et al (1997) Pancreatic malignancy: effect of dual-phase helical CT in tumor detection and vascular opacification. Radiology 205:513–518CrossRefPubMed

29.

Rodallec M, Vilgrain V, Couvelard A et al (2006) Endocrine pancreatic tumours and helical CT: contrast enhancement is correlated with microvascular density, histoprognostic factors and survival. Pancreatology 6:77–85CrossRefPubMed

30.

Luo Y, Dong Z, Chen J et al (2014) Pancreatic neuroendocrine tumours: correlation between MSCT features and pathological classification. Eur Radiol 24:2945–2952CrossRefPubMed

31.

Schmid-Tannwald C, Schmid-Tannwald CM, Morelli JN et al (2013) Comparison of abdominal MRI with diffusion-weighted imaging to 68Ga-DOTATATE PET/CT in detection of neuroendocrine tumors of the pancreas. Eur J Nucl Med Mol Imaging 40:897–907CrossRefPubMed

32.

Sotoudehmanesh R, Hedayat A, Shirazian N et al (2007) Endoscopic ultrasonography (EUS) in the localization of insulinoma. Endocrine 31:238–241CrossRefPubMed

33.

Proye C, Malvaux P, Pattou F et al (1998) Noninvasive imaging of insulinomas and gastrinomas with endoscopic ultrasonography and somatostatin receptor scintigraphy. Surgery 124:1134–1143, discussion 1143-1134CrossRefPubMed

34.

Naswa N, Bal CS (2013) Divergent role of (68)Ga-labeled somatostatin analogs in the workup of patients with NETs: AIIMS experience. Recent Results Cancer Res 194:321–351CrossRefPubMed

35.

Sharma P, Arora S, Dhull VS et al (2015) Evaluation of (68)Ga-DOTANOC PET/CT imaging in a large exclusive population of pancreatic neuroendocrine tumors. Abdom Imaging 40:299–309CrossRefPubMed

36.

van Essen M, Sundin A, Krenning EP, Kwekkeboom DJ (2014) Neuroendocrine tumours: the role of imaging for diagnosis and therapy. Nat Rev Endocrinol 10:102–114CrossRefPubMed

37.

Klauss M, Stiller W, Pahn G et al (2013) Dual-energy perfusion-CT of pancreatic adenocarcinoma. Eur J Radiol 82:208–214CrossRefPubMed

38.

Klauss M, Stiller W, Fritz F et al (2012) Computed tomography perfusion analysis of pancreatic carcinoma. J Comput Assist Tomogr 36:237–242CrossRefPubMed

39.

d'Assignies G, Couvelard A, Bahrami S et al (2009) Pancreatic endocrine tumors: tumor blood flow assessed with perfusion CT reflects angiogenesis and correlates with prognostic factors. Radiology 250:407–416CrossRefPubMed

40.

Patlak CS, Blasberg RG, Fenstermacher JD (1983) Graphical evaluation of blood-to-brain transfer constants from multiple-time uptake data. J Cereb Blood Flow Metab 3:1–7CrossRefPubMed

41.

Groothuis DR, Vriesendorp FJ, Kupfer B et al (1991) Quantitative measurements of capillary transport in human brain tumors by computed tomography. Ann Neurol 30:581–588CrossRefPubMed

42.

Sheiman RG, Sitek A (2008) CT perfusion imaging: know its assumptions and limitations. Radiology 246:649, author reply 649-650CrossRefPubMed

43.

Kudo K, Terae S, Katoh C et al (2003) Quantitative cerebral blood flow measurement with dynamic perfusion CT using the vascular-pixel elimination method: comparison with H2(15)O positron emission tomography. AJNR Am J Neuroradiol 24:419–426PubMed

44.

Corcuera-Solano I, McLellan AM, Doshi AH, Pawha PS, Tanenbaum LN (2014) Whole-brain adaptive 70-kVp perfusion imaging with variable and extended sampling improves quality and consistency while reducing dose. AJNR Am J Neuroradiol 35:2045–2051CrossRefPubMed

45.

Tan Z, Miao Q, Li X et al (2015) The primary study of low-dose pancreas perfusion by 640- slice helical CT: a whole-organ perfusion. Springerplus 4:192CrossRefPubMedPubMedCentral

46.

Li HO, Sun C, Xu ZD et al (2014) Low-dose whole organ CT perfusion of the pancreas: preliminary study. Abdom Imaging 39:40–47CrossRefPubMed

Title: Isoattenuating insulinomas at biphasic contrast-enhanced CT: frequency, clinicopathologic features and perfusion characteristics
Authors: Liang Zhu
Hua-dan Xue
Hao Sun
Xuan Wang
Yong-lan He
Zheng-yu Jin
Yu-pei Zhao
Publication date: 01-10-2016
Publisher: Springer Berlin Heidelberg
Published in: European Radiology / Issue 10/2016
Print ISSN: 0938-7994
Electronic ISSN: 1432-1084
DOI: https://doi.org/10.1007/s00330-016-4216-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Isoattenuating insulinomas at biphasic contrast-enhanced CT: frequency, clinicopathologic features and perfusion characteristics

Abstract

Objectives

Methods

Results

Conclusions

Key Points

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objectives

Methods

Results

Conclusions

Key Points

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