Insulinoma medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Medical therapy is reserved for those who can't 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-Fluoro Uracil, [[Doxorubicin]][[Bevacizumab]] and [[Capecitabine]] in different combinations.For metastasis mainly going to liver regimens include hepatic artery embolization, radiation, chemoembolization, ethanol ablation [[Radiofrequency ablation]] and [[Cryoablation]]. | |||
==Medical Therapy== | ==Medical Therapy== | ||
*The primary treatment is surgical excision. Medical therapy is reserved for: | *The primary treatment is surgical excision. Medical therapy is reserved for: | ||
Revision as of 15:31, 15 September 2017
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2] Amandeep Singh M.D.[3]
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Overview
Medical therapy is reserved for those who can't 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-Fluoro Uracil, DoxorubicinBevacizumab and Capecitabine in different combinations.For metastasis mainly going to liver regimens include hepatic artery embolization, radiation, chemoembolization, ethanol ablation Radiofrequency ablation and Cryoablation.
Medical Therapy
- The primary treatment is surgical excision. Medical therapy is reserved for:
- Those who can't undergo surgery
- High-risk patients
- Unresectable metastatic disease
- Those who refuse to undergo surgery
- Those who can't 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
- 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
- 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
- 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.
2.2 Children and adolescents- follow the adult regimen
Malignant (metastatic) Insulinoma
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
Liver directed therapy(for metastasis)
- Radiation
- Selective Internal Radiation Therapy
- Peptide Receptor Radionuclide Therapy (PRRT) - cytotoxic doses of radiation are given locally to the site of tumor (also called Radioembolization sometimes)
- Hepatic artery embolization, chemoembolization, and infusion. Infusion consists of:
- Hepatic Artery infusion (HIA) - which is the adminstration of chemotherapeutic agents(high doses of streptozocin and 5-FU) into the hepatic artery. Response rates are 0-100%
- Isolated hepatic perfusion (IHP) which gave rise to minimally invasive, Percutaneous hepatic perfusion. [3]
- Percutaneous ethanol injection/ Ethanol ablation
- Radiofrequency ablation (RFA)
- 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.