Insulinoma medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Associate Editor(s)-in-Chief: Amandeep Singh M.D.[4] Parminder Dhingra, M.D. [5]

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Overview

The predominant therapy for insulinoma is surgical resection. Supportive therapy for insulinoma includes octerotide, endoscopic ultrasound guided alcohol ablation, radiofrequency ablation, embolization, diazoxide and chemotherapy.

Medical Therapy

The medical therapy of insulinoma include:

• Octreotide
• Endoscopic ultrasound guided alcohol ablation
• Radiofrequency ablation (RFA)
• Embolization
• Diazoxide
• Combination chemotherapy
  • Doxorubicin AND Streptozotocin
  • Fluorouracil AND Streptozotocin (when doxorubicin is contraindicated)

Overview

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

OR

Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

OR

The majority of cases of [disease name] are self-limited and require only supportive care.

OR

[Disease name] is a medical emergency and requires prompt treatment.

OR

The mainstay of treatment for [disease name] is [therapy].

OR   The optimal therapy for [malignancy name] depends on the stage at diagnosis.

OR

[Therapy] is recommended among all patients who develop [disease name].

OR

Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

OR

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

OR

Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

OR

Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

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
• The medical therapy is mainly used to reduce/prevent symptoms of hypoglycemia
• Pharmacologic medical therapies for insulinoma include Diazoxide, Octreotide/Lanreotide, and Phenytoin

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)
  • Alternative regimen(1): Phenytoin 300-600 mg PO q daily
  • 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)

• Hepatic artery embolization, chemoembolization, and infusion. Infusion consists of
  • Hepatic Artery infusion (HIA) - which is adminsitration of chemotherapeutic agents(high doses of streptozocin and 5-FU) into hepatic artery. Response rates are 0-100%
  • Isolated hepatic perfusion (IHP) which gave rise to minimally invasive, Percutaneous hepatic perfusion.

• Radiofrequency ablation (RFA)
• Cryoablation