Insulinoma medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{CMG}} {{AE}}{{ADS}} | {{CMG}} {{AE}}{{ADS}} | ||
{{Insulinoma}} | {{Insulinoma}} | ||
==Overview== | ==Overview== | ||
Medical therapy is reserved for those who are unable to undergo the primary surgical therapy. Drugs commonly used for benign insulinoma are [[ | Medical therapy is reserved for those who are unable to undergo the primary surgical therapy. Drugs commonly used for benign insulinoma are [[diazoxide]], [[octreotide]]/lanreotide, [[phenytoin]], [[verapamil]] and [[everolimus]]. For malignant insulinoma, these drugs are used with the [[chemotherapy]] drugs [[streptozocin]], 5 [[fluorouracil]], [[doxorubicin]], [[bevacizumab]] and [[capecitabine]] in different combinations. For [[metastasis]] mainly going to [[liver]] regimens include [[hepatic artery]] [[embolization]], [[Radiation therapy|radiation]], chemo-embolization, [[ethanol]] ablation, [[radiofrequency ablation]], and [[cryoablation]]. | ||
==Medical Therapy== | ==Medical Therapy== | ||
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** Preferred regimen (3): [[Lanreotide]] 120 mg SQ every 4 weeks until [[tumor]] progression. | ** Preferred regimen (3): [[Lanreotide]] 120 mg SQ every 4 weeks until [[tumor]] progression. | ||
*'''1.2 Oral''' | *'''1.2 Oral''' | ||
**Preferred regimen : [[Diazoxide]] 3-8 mg/kg OR 200-300 mg PO q8h for 14-21 days (1200 mg max to be divided in 3 doses and max is 400 mg/dose). <ref name="pmid3019020">{{cite journal |vauthors=Goode PN, Farndon JR, Anderson J, Johnston ID, Morte JA |title=Diazoxide in the management of patients with insulinoma |journal=World J Surg |volume=10 |issue=4 |pages=586–92 |year=1986 |pmid=3019020 |doi= |url=}}</ref><ref name="pmid9497974">{{cite journal |vauthors=Gill GV, Rauf O, MacFarlane IA |title=Diazoxide treatment for insulinoma: a national UK survey |journal=Postgrad Med J |volume=73 |issue=864 |pages=640–1 |year=1997 |pmid=9497974 |pmc=2431498 |doi= |url=}}</ref> | **Preferred regimen : [[Diazoxide]] 3-8 mg/kg OR 200-300 mg PO q8h for 14-21 days (1200 mg max to be divided in 3 doses and max is 400 mg/dose).<ref name="pmid3019020">{{cite journal |vauthors=Goode PN, Farndon JR, Anderson J, Johnston ID, Morte JA |title=Diazoxide in the management of patients with insulinoma |journal=World J Surg |volume=10 |issue=4 |pages=586–92 |year=1986 |pmid=3019020 |doi= |url=}}</ref><ref name="pmid9497974">{{cite journal |vauthors=Gill GV, Rauf O, MacFarlane IA |title=Diazoxide treatment for insulinoma: a national UK survey |journal=Postgrad Med J |volume=73 |issue=864 |pages=640–1 |year=1997 |pmid=9497974 |pmc=2431498 |doi= |url=}}</ref> | ||
** Alternative regimen (1): [[Phenytoin]] 300-600 mg PO q daily. <ref name="MathurGorden2009">{{cite journal|last1=Mathur|first1=Aarti|last2=Gorden|first2=Philip|last3=Libutti|first3=Steven K.|title=Insulinoma|journal=Surgical Clinics of North America|volume=89|issue=5|year=2009|pages=1105–1121|issn=00396109|doi=10.1016/j.suc.2009.06.009}}</ref> | ** Alternative regimen (1): [[Phenytoin]] 300-600 mg PO q daily. <ref name="MathurGorden2009">{{cite journal|last1=Mathur|first1=Aarti|last2=Gorden|first2=Philip|last3=Libutti|first3=Steven K.|title=Insulinoma|journal=Surgical Clinics of North America|volume=89|issue=5|year=2009|pages=1105–1121|issn=00396109|doi=10.1016/j.suc.2009.06.009}}</ref> | ||
**Alternative regimen (2): [[Everolimus]] 10 mg PO q daily until disease progression. | **Alternative regimen (2): [[Everolimus]] 10 mg PO q daily until disease progression. | ||
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**2.1.2 Peptide receptor radionuclide therapy (PRRT): [[cytotoxic]] doses of [[radiation]] are given locally to the site of [[tumor]] (sometimes also called Radio-embolization) | **2.1.2 Peptide receptor radionuclide therapy (PRRT): [[cytotoxic]] doses of [[radiation]] are given locally to the site of [[tumor]] (sometimes also called Radio-embolization) | ||
*2.2 [[Hepatic artery]] [[embolization]], chemo-embolization, and [[infusion]]. Infusion consists of: | *2.2 [[Hepatic artery]] [[embolization]], chemo-embolization, and [[infusion]]. Infusion consists of: | ||
**2.2.1 [[Hepatic artery]] [[infusion]] (HIA): HIA is the administration of [[Chemotherapeutic agent|chemotherapeutic]] agents (high doses of [[streptozocin]] and [[5-FU]]) into the [[hepatic artery]]. Response rates are 0 | **2.2.1 [[Hepatic artery]] [[infusion]] (HIA): HIA is the administration of [[Chemotherapeutic agent|chemotherapeutic]] agents (high doses of [[streptozocin]] and [[5-FU]]) into the [[hepatic artery]]. Response rates are 0 to 100%. | ||
**2.2.2 Isolated hepatic perfusion (IHP): HIP gave rise to minimally invasive, percutaneous hepatic perfusion.<ref name="MathurGorden2009">{{cite journal|last1=Mathur|first1=Aarti|last2=Gorden|first2=Philip|last3=Libutti|first3=Steven K.|title=Insulinoma|journal=Surgical Clinics of North America|volume=89|issue=5|year=2009|pages=1105–1121|issn=00396109|doi=10.1016/j.suc.2009.06.009}}</ref> | **2.2.2 Isolated hepatic perfusion (IHP): HIP gave rise to minimally invasive, percutaneous hepatic perfusion.<ref name="MathurGorden2009">{{cite journal|last1=Mathur|first1=Aarti|last2=Gorden|first2=Philip|last3=Libutti|first3=Steven K.|title=Insulinoma|journal=Surgical Clinics of North America|volume=89|issue=5|year=2009|pages=1105–1121|issn=00396109|doi=10.1016/j.suc.2009.06.009}}</ref> | ||
*2.3 Percutaneous [[ethanol]] injection/ [[Ethanol]] ablation | *2.3 Percutaneous [[ethanol]] injection/ [[Ethanol]] ablation | ||
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[[Category:Endocrinology]] | [[Category:Endocrinology]] | ||
[[Category:Up-To-Date]] | [[Category:Up-To-Date]] | ||
[[Category:Up-To-Date]] | |||
[[Category:Oncology]] | |||
[[Category:Medicine]] | |||
[[Category:Gastroenterology]] | |||
[[Category:Surgery]] | |||
Latest revision as of 02:07, 27 November 2017
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]
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Overview
Medical therapy is reserved for those who are unable to undergo the primary surgical therapy. Drugs commonly used for benign insulinoma are diazoxide, octreotide/lanreotide, phenytoin, verapamil and everolimus. For malignant insulinoma, these drugs are used with the chemotherapy drugs streptozocin, 5 fluorouracil, doxorubicin, bevacizumab and capecitabine in different combinations. For metastasis mainly going to liver regimens include hepatic artery embolization, radiation, chemo-embolization, ethanol ablation, radiofrequency ablation, and cryoablation.
Medical Therapy
- The primary treatment is surgical excision. Medical therapy is reserved for:
- Those who are unable to undergo surgery:
- High-risk patients
- Unresectable metastatic disease
- Those who refuse to undergo surgery:
- Those who are unable to undergo surgery:
- The medical therapy is mainly used to reduce/prevent symptoms of hypoglycemia.
- Pharmacologic medical therapies for insulinoma include diazoxide, octreotide/lanreotide, phenytoin, verapamil, and everolimus.
Benign Insulinoma
1. Adult
- 1.1 Parenteral
- Preferred regimen (1): Octreotide 30 mg IM (depot) every 4 weeks until tumor progression or death.
- Preferred regimen (2): Octreotide 100-500 μg SQ q 8-12h（can be increased to maximum 1500 μg daily）for 1 year.
- Preferred regimen (3): Lanreotide 120 mg SQ every 4 weeks until tumor progression.
- 1.2 Oral
- Preferred regimen : Diazoxide 3-8 mg/kg OR 200-300 mg PO q8h for 14-21 days (1200 mg max to be divided in 3 doses and max is 400 mg/dose).[1][2]
- Alternative regimen (1): Phenytoin 300-600 mg PO q daily. [3]
- Alternative regimen (2): Everolimus 10 mg PO q daily until disease progression.
- Verapamil and Propranolol to control symptoms are used either as alone or in combination.
- Glucocorticoids and glucagon have been used in combination with diazoxide.
2. Pediatric
- 2.1 Neonates and Infants:
- 2.1.1 Oral
- Preferred regimen: Diazoxide
- Initial dose: 10 mg/kg/day divided into 3 equal doses q 8 hours.
- Maintenance dosing range: 8 to 15 mg/kg/day divided into 2 or 3 equal doses every 8 to 12 hours.
- Preferred regimen: Diazoxide
- 2.1.1 Oral
- 2.2 Children and adolescents
- Follow the adult regimen
Malignant (metastatic) Insulinoma
1. Chemotherapy
It is used in the different combination of the following drugs:
- Streptozocin 500 mg/m2/day IV for 5 consecutive days every 6 weeks
- Doxorubicin 40-75 mg/m2 IV every 21 to 28 days
- 5 Fluorouracil(5-FU)
- Temozolamide 200 mg/m2 PO QHS days 10 to 14 of a 28-day treatment cycle (in combination with capecitabine)
- Bevacizumab
- Capecitabine
2. Liver-directed therapy (for metastasis)
- 2.1 Radiation
- 2.2 Hepatic artery embolization, chemo-embolization, and infusion. Infusion consists of:
- 2.2.1 Hepatic artery infusion (HIA): HIA is the administration of chemotherapeutic agents (high doses of streptozocin and 5-FU) into the hepatic artery. Response rates are 0 to 100%.
- 2.2.2 Isolated hepatic perfusion (IHP): HIP gave rise to minimally invasive, percutaneous hepatic perfusion.[3]
- 2.3 Percutaneous ethanol injection/ Ethanol ablation
- 2.4 Radiofrequency ablation (RFA)
- 2.5 Cryoablation
References
- ↑ Goode PN, Farndon JR, Anderson J, Johnston ID, Morte JA (1986). "Diazoxide in the management of patients with insulinoma". World J Surg. 10 (4): 586–92. PMID 3019020.
- ↑ Gill GV, Rauf O, MacFarlane IA (1997). "Diazoxide treatment for insulinoma: a national UK survey". Postgrad Med J. 73 (864): 640–1. PMC 2431498. PMID 9497974.
- ↑ 3.0 3.1 Mathur, Aarti; Gorden, Philip; Libutti, Steven K. (2009). "Insulinoma". Surgical Clinics of North America. 89 (5): 1105–1121. doi:10.1016/j.suc.2009.06.009. ISSN 0039-6109.