Insulinomas are the most common sporadic endocrine tumor of the pancreas.
On imaging, they usually present as small well-defined hypervascular tumors that may be found anywhere in the pancreas.
Account for 40% of syndromic pancreatic endocrine tumors. The overall incidence is of ~0.0003%.
Typically insulinomas present with Whipple's triad consisting of:
- fasting hypoglycemia (<50 mg/dL)
- symptoms of hypoglycemia (due to subsequent catecholamine release)
- immediate relief of symptoms after the administration of IV glucose
As with other endocrine tumors of the pancreas, there is an association with multiple endocrine neoplasia type I (MEN I).
They develop from ductal pluripotent cells into unregulated cells secreting insulin. The beta cells of the islets of Langerhans normally secrete insulin. Approximately 10% of insulinomas are multiple and 10% malignant.
These tumors can be relatively small and multiphase contrast-enhanced thin slice cross-sectional imaging is ideal. Most insulinomas are small (90% are <2 cm at presentation 3) and hypervascular. They may contain calcifications. Malignant tumors tend to be larger. Insulinomas are equally distributed between the head, body, and tail of the pancreas.
They tend to be hyperattenuating on arterial phase and, therefore, dedicated protocols with arterial or pancreatic phase imaging may aid in better detection 6,7. Some may show calcification.
Dynamic MRI with fast gradient echo sequences following a bolus injection of contrast medium may aid in the detection of these tumors 4:
- T1 C+ (Gd): typically shows enhancement, although contrast enhancement may not improve tumor visualization compared with non-contrast images 4
Ga-68 DOTATATE PET-CT
About 80% of insulinomas express the somatostatin receptors 2, and the Ga-68 DOTATATE scans have a high affinity for these receptors and, therefore, have high sensitivity in the detection of these tumors, particularly for low-grade and well-differentiated ones 8-10. The sensitivity of this study has been reported in up to 90% 8, when assessing insulinomas specifically, and ranging between 90-100% for pancreatic neuroendocrine tumors as whole 9.
PET-CT is also useful in excluding additional pancreatic neuroendocrine tumors eventually not detected on CT or MRI, particularly, in inherited syndromes such as MEN1 8.
F-18 FDG PET-CT
Neuroendocrine tumors are slow-growing tumors that usually have slow metabolic activity in their initial stages and, therefore, are not notably avid on F-18 FDG PET-CT 9. Tumors with a higher grade or poorly differentiated tend to show marked uptake 8-10.
- 1. Demos TC, Posniak HV, Harmath C et-al. Cystic lesions of the pancreas. AJR Am J Roentgenol. 2002;179 (6): 1375-88. AJR Am J Roentgenol (full text) - Pubmed citation
- 2. D'onofrio M, Mansueto G, Vasori S et-al. Contrast-enhanced ultrasonographic detection of small pancreatic insulinoma. J Ultrasound Med. 2003;22 (4): 413-7. J Ultrasound Med (full text) - Pubmed citation
- 3. Mcauley G, Delaney H, Colville J et-al. Multimodality preoperative imaging of pancreatic insulinomas. Clin Radiol. 2005;60 (10): 1039-50. doi:10.1016/j.crad.2005.06.005 - Pubmed citation
- 4. Owen NJ, Sohaib SA, Peppercorn PD et-al. MRI of pancreatic neuroendocrine tumours. Br J Radiol. 2001;74 (886): 968-73. Br J Radiol (full text) - Pubmed citation
- 5. Liessi G, Pasquali C, D'andrea AA et-al. MRI in insulinomas: preliminary findings. Eur J Radiol. 14 (1): 46-51. Eur J Radiol (link) - Pubmed citation
- 6. King AD, Ko GT, Yeung VT et-al. Dual phase spiral CT in the detection of small insulinomas of the pancreas. Br J Radiol. 1998;71 (841): 20-3. Br J Radiol (abstract) - Pubmed citation
- 7. Fidler JL, Fletcher JG, Reading CC et-al. Preoperative detection of pancreatic insulinomas on multiphasic helical CT. AJR Am J Roentgenol. 2003;181 (3): 775-80. AJR Am J Roentgenol (full text) - Pubmed citation
- 8. Nockel, Pavel, Babic, Bruna, Millo, Corina, Herscovitch, Peter, Patel, Dhaval, Nilubol, Naris, Sadowski, Samira M., Cochran, Craig, Gorden, Phillip, Kebebew, Electron. Localization of Insulinoma Using 68Ga-DOTATATE PET/CT Scan. (2017) The Journal of Clinical Endocrinology & Metabolism. 102 (1): 195. doi:10.1210/jc.2016-3445 - Pubmed
- 9. Mojtahedi A, Thamake S, Tworowska I, Ranganathan D, Delpassand ES. The value of (68)Ga-DOTATATE PET/CT in diagnosis and management of neuroendocrine tumors compared to current FDA approved imaging modalities: a review of literature. (2014) American journal of nuclear medicine and molecular imaging. 4 (5): 426-34. Pubmed
- 10. Irfan Kayani, Jamshed B. Bomanji, Ashley Groves, Gerard Conway, Sveto Gacinovic, Thida Win, John Dickson, Martyn Caplin, Peter Joseph Ell. Functional imaging of neuroendocrine tumors with combined PET/CT using 68Ga‐DOTATATE (DOTA‐DPhe1,Tyr3‐octreotate) and 18F‐FDG. (2008) Cancer. 112 (11): 2447. doi:10.1002/cncr.23469 - Pubmed
Related Radiopaedia articles
- cystic neoplasm (cystic pancreatic mass differential diagnosis)
- solid neoplasm
- nonepithelial pancreatic neoplasms
- simple pancreatic cyst
pancreatitis (mnemonic for the causes)
- gallstone pancreatitis
- interstitial edematous pancreatitis
- necrotizing pancreatitis
- hemorrhagic pancreatitis
- revised Atlanta classification of acute pancreatitis
- chronic pancreatitis
- Ascaris-induced pancreatitis
- tropical pancreatitis
- autoimmune pancreatitis
- emphysematous pancreatitis
- hypertriglyceridemia-induced pancreatitis
- hereditary pancreatitis
- pancreatitis associated with cystic fibrosis
- pancreaticopleural fistula
- segmental pancreatitis
- acute pancreatitis
- pancreatic atrophy
- pancreatic lipomatosis
- pancreatic trauma