This case underscores the need to remain vigilant when evaluating a hypoglycemic patient who has unusual imaging characteristics. With the presence of unsuppressed insulin levels accompanying a plasma glucose level of 47 mg/dL, the biochemical picture did suggest endogenous insulin production, according to the guideline criteria. The initial report of a CT of the abdomen described a normal pancreas. However, owing to high suspicion, a multiphase abdominal CT was ordered, which showed a lesion in the pancreatic tail that measured up to 1.8 cm, with extension to the splenic hilum. A 68Ga-DOTA uptake test confirmed the findings.
Ruling out metastatic disease before planning surgical treatment is prudent, especially when surgery is intended to be curative. EUS with biopsy might confirm the presence of a pancreatic mass and a subsequent neuroendocrine tumor but could miss distant metastases. An MRI of the abdomen may not provide any more information than would a CT. A 68Ga-DOTA uptake is comparable to GLP-1R PET/CT and has a high affinity for SSTR2 and SSTR5; thus, it can detect most insulinomas, including metastatic lesions.[9,10]
The follow-up for patients with an insulinoma who do not have MEN1 syndrome should include biochemical testing and imaging studies at 3-6 months after resection.[2] If cured, patients can be followed up as needed if their symptoms recur. Patients with persistent symptoms after surgery might have multiple tumors or MEN1 syndrome, and they should undergo repeat imaging studies.[20] Those with multiple insulinomas or MEN1 should be followed up yearly, even if they continue to be cured after resection.[2]
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