Advertisement

European Radiology

, Volume 26, Issue 10, pp 3697–3705 | Cite as

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

  • Liang Zhu
  • Hua-dan Xue
  • Hao Sun
  • Xuan Wang
  • Yong-lan He
  • Zheng-yu Jin
  • Yu-pei Zhao
Computed Tomography

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.

Keywords

Insulinoma Multidetector computed tomography Perfusion Sporadic Multiple endocrine neoplasia 

Abbreviations

CT

Computed tomography

MRI

Magnetic resonance imaging

EUS

Endoscopic ultrasound

PET

Positron emission tomography

Notes

Acknowledgments

The scientific guarantor of this publication is Professor Zheng-yu Jin. The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. This study has received funding by the National Natural Science Foundation of China (General Program, No. 81371608). No complex statistical methods were necessary for this paper. Institutional Review Board approval was obtained. Written informed consent was waived by the Institutional Review Board. None of the study subjects or cohorts have been previously reported. Methodology: retrospective, observational, performed at one institution.

References

  1. 1.
    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 17:379–388PubMedGoogle Scholar
  2. 2.
    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 247:165–172CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Norton JA, Shawker TH, Doppman JL et al (1990) Localization and surgical treatment of occult insulinomas. Ann Surg 212:615–620CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Cirocchi R, Partelli S, Coratti A et al (2013) Current status of robotic distal pancreatectomy: a systematic review. Surg Oncol 22:201–207CrossRefPubMedGoogle Scholar
  5. 5.
    Isla A, Arbuckle JD, Kekis PB et al (2009) Laparoscopic management of insulinomas. Br J Surg 96:185–190CrossRefPubMedGoogle Scholar
  6. 6.
    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 114:1232–1238CrossRefPubMedGoogle Scholar
  7. 7.
    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 19:195–211CrossRefPubMedGoogle Scholar
  8. 8.
    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 82:213–226CrossRefPubMedGoogle Scholar
  9. 9.
    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 181:987–992CrossRefPubMedGoogle Scholar
  10. 10.
    Fidler JL, Fletcher JG, Reading CC et al (2003) Preoperative detection of pancreatic insulinomas on multiphasic helical CT. AJR Am J Roentgenol 181:775–780CrossRefPubMedGoogle Scholar
  11. 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 112:999–1012CrossRefPubMedGoogle Scholar
  12. 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 216:163–171CrossRefPubMedGoogle Scholar
  13. 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 129:941–946CrossRefPubMedGoogle Scholar
  14. 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 214:483–490CrossRefPubMedGoogle Scholar
  15. 15.
    Boukhman MP, Karam JM, Shaver J et al (1999) Localization of insulinomas. Arch Surg 134:818–822, discussion 822-813CrossRefPubMedGoogle Scholar
  16. 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 11:487–494CrossRefPubMedGoogle Scholar
  17. 17.
    Graziani R, Brandalise A, Bellotti M et al (2010) Imaging of neuroendocrine gastroenteropancreatic tumours. Radiol Med 115:1047–1064CrossRefPubMedGoogle Scholar
  18. 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 56:1075–1078CrossRefPubMedGoogle Scholar
  19. 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 73:691–696CrossRefPubMedGoogle Scholar
  20. 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 81:2487–2494CrossRefPubMedGoogle Scholar
  21. 21.
    Zhang TP, Zhao YP, Cong L et al (2009) Noninvasive examinations for localization of insulinoma. Zhonghua Wai Ke Za Zhi 47:1365–1367PubMedGoogle Scholar
  22. 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 257:87–96CrossRefPubMedGoogle Scholar
  23. 23.
    Prokesch RW, Chow LC, Beaulieu CF, Bammer R, Jeffrey RB Jr (2002) Isoattenuating pancreatic adenocarcinoma at multi-detector row CT: secondary signs. Radiology 224:764–768CrossRefPubMedGoogle Scholar
  24. 24.
    Espana-Gomez MN, Velazquez-Fernandez D, Bezaury P et al (2009) Pancreatic insulinoma: a surgical experience. World J Surg 33:1966–1970CrossRefPubMedGoogle Scholar
  25. 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 103:169–174CrossRefPubMedGoogle Scholar
  26. 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 62:371–377CrossRefPubMedGoogle Scholar
  27. 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 165:1437–1439CrossRefPubMedGoogle Scholar
  28. 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 205:513–518CrossRefPubMedGoogle Scholar
  29. 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 6:77–85CrossRefPubMedGoogle Scholar
  30. 30.
    Luo Y, Dong Z, Chen J et al (2014) Pancreatic neuroendocrine tumours: correlation between MSCT features and pathological classification. Eur Radiol 24:2945–2952CrossRefPubMedGoogle Scholar
  31. 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 40:897–907CrossRefPubMedGoogle Scholar
  32. 32.
    Sotoudehmanesh R, Hedayat A, Shirazian N et al (2007) Endoscopic ultrasonography (EUS) in the localization of insulinoma. Endocrine 31:238–241CrossRefPubMedGoogle Scholar
  33. 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 1143-1134CrossRefPubMedGoogle Scholar
  34. 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 194:321–351CrossRefPubMedGoogle Scholar
  35. 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 40:299–309CrossRefPubMedGoogle Scholar
  36. 36.
    van Essen M, Sundin A, Krenning EP, Kwekkeboom DJ (2014) Neuroendocrine tumours: the role of imaging for diagnosis and therapy. Nat Rev Endocrinol 10:102–114CrossRefPubMedGoogle Scholar
  37. 37.
    Klauss M, Stiller W, Pahn G et al (2013) Dual-energy perfusion-CT of pancreatic adenocarcinoma. Eur J Radiol 82:208–214CrossRefPubMedGoogle Scholar
  38. 38.
    Klauss M, Stiller W, Fritz F et al (2012) Computed tomography perfusion analysis of pancreatic carcinoma. J Comput Assist Tomogr 36:237–242CrossRefPubMedGoogle Scholar
  39. 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 250:407–416CrossRefPubMedGoogle Scholar
  40. 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 3:1–7CrossRefPubMedGoogle Scholar
  41. 41.
    Groothuis DR, Vriesendorp FJ, Kupfer B et al (1991) Quantitative measurements of capillary transport in human brain tumors by computed tomography. Ann Neurol 30:581–588CrossRefPubMedGoogle Scholar
  42. 42.
    Sheiman RG, Sitek A (2008) CT perfusion imaging: know its assumptions and limitations. Radiology 246:649, author reply 649-650CrossRefPubMedGoogle Scholar
  43. 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 24:419–426PubMedGoogle Scholar
  44. 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 35:2045–2051CrossRefPubMedGoogle Scholar
  45. 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 4:192CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Li HO, Sun C, Xu ZD et al (2014) Low-dose whole organ CT perfusion of the pancreas: preliminary study. Abdom Imaging 39:40–47CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Radiology 2016

Authors and Affiliations

  • Liang Zhu
    • 1
  • Hua-dan Xue
    • 1
  • Hao Sun
    • 1
  • Xuan Wang
    • 1
  • Yong-lan He
    • 1
  • Zheng-yu Jin
    • 1
  • Yu-pei Zhao
    • 2
  1. 1.Department of RadiologyPeking Union Medical College HospitalBeijingChina
  2. 2.Department of General SurgeryPeking Union Medical College HospitalBeijingChina

Personalised recommendations