Hypoglycemia in pancreatic adenocarcinoma with suspected concomitant insulinoma: A case report
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Copyright (c) 2026 Karla Nicole Aguirre Ordóñez, Noemi Bautista Litardo
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
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https://doi.org/10.33821/810Keywords:
insulinoma, pancreatic adenocarcinoma, hypoglycemia, neuroendocrine tumor, case reportAbstract
Introduction: The coexistence of insulinoma and pancreatic adenocarcinoma is an extremely rare condition, reported in only a few cases worldwide. It poses a diagnostic challenge because persistent hypoglycemia in pancreatic neoplasms may be underestimated or attributed to the patient’s overall clinical condition. Case presentation: We report the case of a 58-year-old woman diagnosed with pancreatic adenocarcinoma, who initially presented with recurrent episodes of severe hypoglycemia. Biochemical evaluation revealed hypoglycemia associated with hyperinsulinemia and elevated C-peptide levels. Octreotide scintigraphy demonstrated uptake in the pancreas and liver, suggesting the presence of a functional neuroendocrine neoplasm. However, histopathological analysis identified only adenocarcinoma, without confirmation of a neuroendocrine tumor. Despite two lines of chemotherapy and symptomatic management with Octreotide, Diazoxide, and glucagon, the clinical course was unfavorable. The clinical presentation was consistent with endogenous hyperinsulinemic hypoglycemia, which raised suspicion of a probable insulinoma coexisting with pancreatic adenocarcinoma. Discussion: This scenario requires considering differential diagnoses, including paraneoplastic causes and other etiologies of hypoglycemia in oncology patients. The lack of histopathological confirmation represents a significant limitation. Conclusion: This case highlights the importance of not underestimating hypoglycemia in patients with pancreatic neoplasms and of considering endocrine etiologies when the clinical presentation is not fully explained by the primary tumor.
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Treiber G, Igaz P. Insulinoma. En Practical Clinical Endocrinology. Cham: Springer; 2021. pp. 459-65. https://doi.org/10.1007/978-3-030-62011-0_46
Hofland J, Refardt JC, Feelders RA, Christ E, de Herder WW. Approach to the patient: Insulinoma. J Clin Endocrinol Metab. 2024;109(4):1109-18. https://doi.org/10.1210/clinem/dgad641
Berkovic MC, Ulamec M, Marinovic S, Balen I, Mrzljak A. Malignant insulinoma: Can we predict the long-term outcomes? World J Clin Cases. 2022;10(16):5124-32. https://doi.org/10.12998/wjcc.v10.i16.5124
Palani G, Stortz E, Moheet A. Clinical presentation and diagnostic approach to hypoglycemia in adults without diabetes mellitus. Endocr Pract. 2023;29(4):286-94. https://doi.org/10.1016/j.eprac.2022.11.010
Athanasopoulos PG, Polymeneas G, Dellaportas D, Mastorakos G, Kairi E, Voros D. Concurrent insulinoma and pancreatic adenocarcinoma: Report of a rare case and review of the literature. World J Surg Oncol. 2011;9:7. https://doi.org/10.1186/1477-7819-9-7
Li JH, Tang CJ, Hennessey J V. A rare case of pancreatic adenocarcinoma and subsequent metastatic insulinoma causing severe hypoglycemia. Case Rep Intern Med. 2016;3(4):22. https://doi.org/10.5430/crim.v3n4p22
Negahi A, Zare-Mirzaie A, Negahban H, Soleymani S, Jaliliyan A, Agah S. Concurrent pancreatic ductal adenocarcinoma and poorly differentiated neuroendocrine carcinoma: A case report and review of the literature. Int J Surg Case Rep. 2025;131:111320. https://doi.org/10.1016/j.ijscr.2025.111320
Kurakawa KI, Okada A, Manaka K, Konishi T, Jo T, Ono S, et al. Clinical characteristics and incidences of benign and malignant insulinoma using a national inpatient database in Japan. J Clin Endocrinol Metab. 2021;106(12):3477-86. https://doi.org/10.1210/clinem/dgab559
Chatterjee R, Ali B, Nguyen SH, Chen R, Sada YH. Malignant insulinoma arising from nonfunctioning pancreatic neuroendocrine tumor. ACG Case Rep J. 2023;10(1):e00954. https://doi.org/10.14309/crj.0000000000000954
Buddhavarapu VS, Dhillon G, Grewal HS, Soles B, Halbur L, Surani S, et al. Transformation of pancreatic nonfunctioning neuroendocrine tumor into metastatic insulinoma: A rare case report. Clin Case Rep. 2023;11(11). https://doi.org/10.1002/ccr3.8152
Mehta S, Banker A, Shah J V. Malignant insulinoma: Diagnostic difficulties and treatment strategies in a case of persistent hypoglycemia. Cureus. 2024;16(11). https://doi.org/10.7759/cureus.74700
Erhamamc? S, Sager S, Asa S, Uslu L, Akgun E, Sonmezoglu K. Malignant insulinoma: 18F-DOPA and 68Ga-DOTATATE PET/CT and treatment with 177Lu-DOTATATE. Rev Esp Med Nucl Imagen Mol. 2020;39(6):383-6. https://doi.org/10.1016/j.remn.2019.12.002
Tomita T. Significance of chromogranin a and synaptophysin in pancreatic neuroendocrine tumors. Bosn J Basic Med Sci. 2020;20(3):336-46. https://doi.org/10.17305/bjbms.2020.4632
Wiese D, Humburg FG, Kann PH, Rinke A, Luster M, Mahnken A, et al. Changes in diagnosis and operative treatment of insulinoma over two decades. Langenbecks Arch Surg. 2023;408(1):321. https://doi.org/10.1007/s00423-023-02974-6
Zhang C, Zhang • Hui, Huang W. Endogenous hyperinsulinemic hypoglycemia: Case series and literature review. Endocrine. 2020;80:40-6. https://doi.org/10.1007/s12020-022-03268-5
Karamanolis NN, Kounatidis D, Vallianou NG, Alexandropoulos K, Kovlakidi E, Kaparou P, et al. Paraneoplastic hypoglycemia: An overview for optimal clinical guidance. Metabol Open. 2024;23:100305. https://doi.org/10.1016/j.metop.2024.100305
Kalista KF, Rahma HCN, Tahapary DL, Nababan SH, Jasirwan COM, Kurniawan J, et al. Persistent hypoglycemia in patients with liver cancer. Endocrinol Diabetes Metab Case Rep. 2024;2024(3). https://doi.org/10.1530/EDM-23-0077
Baba H, Yamada Y, Tada K, Kuboyama Y, Fukuzawa K, Iwaki K, et al. Pancreatic mixed acinar-neuroendocrine carcinoma with intraductal growth: A case report with radiologic–pathologic correlations. Radiol Case Rep. 2023;18(12):4422-30. https://doi.org/10.1016/j.radcr.2023.09.032
Sakaguchi R, Yamada R, Nose K, Tanaka T, Murashima Y, Tsuboi J, et al. Pancreatic mixed acinar-neuroendocrine-ductal carcinoma: A case report and literature review. Intern Med. 2023;62(22):3347-53. https://doi.org/10.2169/internalmedicine.1298-22
Koch R, McGarrah PW, Vella A, Shah P, Hobday TJ, Sonbol MB, et al. Comparative efficacy of systemic therapies in malignant insulinoma. Endocr Relat Cancer. 2025;32(6). https://doi.org/10.1530/ERC-25-0091
Ito T, Jensen RT. Perspectives on the current pharmacotherapeutic strategies for management of functional neuroendocrine tumor syndromes. Expert Opin Pharmacother. 2021;22(6):685-93. https://doi.org/10.1080/14656566.2020.1845651
Rouf S, Boujtat K, Harroudi T El, Latrech H. Balancing efficacy and adverse reactions using everolimus in a patient with metastatic malignant insulinoma: Case report. Int J Clin Pharmacol Ther. 2024;62(6):278-83. https://doi.org/10.5414/CP204503
Tovazzi V, Ferrari VD, Dalla Volta A, Consoli F, Amoroso V, Berruti A. Should everolimus be stopped after radiological progression in metastatic insulinoma? A “cons” point of view. Endocrine. 2020;69(3):481-4. https://doi.org/10.1007/s12020-020-02368-4
Das S, Al-Toubah T, Strosberg J. Chemotherapy in neuroendocrine tumors. Cancers (Basel). 2021;13(19):4872. https://doi.org/10.3390/cancers13194872
Capdevila J, Ducreux M, García Carbonero R, Grande E, Halfdanarson T, Pavel M, et al. Streptozotocin, 1982–2022: Forty Years from the FDA’s Approval to Treat Pancreatic Neuroendocrine Tumors. Neuroendocrinology. 2022;112(12):1155-67. https://doi.org/10.1159/000524988
