经病理证实的胰岛素瘤患者26例临床资料分析

Clinical data of 26 patients with insulinoma confirmed by pathology

目的通过分析近15年收治的26例胰岛素瘤患者的临床特征,探讨胰岛素瘤易误诊的原因,总结其临床特征、诊断及预后因素。方法回顾性分析2004年1月至2018年8月南京鼓楼医院经手术病理确诊的26例胰岛素瘤患者的临床资料。根据低血糖时患者症状分成两组,分析以神经性低血糖为首发症状和其他低血糖症状患者临床特征的差异;根据肿瘤直径将患者分成两组,分析直径<2 cm和≥2 cm患者临床特征的差异。结果26例患者中,17例(65.38%)患者以神经性低血糖为首发症状,23例(88.46%)患者有典型的Whipple三联征表现。组间比较显示,以神经性低血糖为首发症状组肿瘤直径小于其他低血糖症状组[(1.75±0.89)cm vs(2.86±1.52)cm,P=0.027];饥饿试验中,前者胰岛素水平稍高于后者[(33.58±22.67)μIU/ml vs(18.06±8.90)μIU/ml,P=0.104],血糖水平稍低于后者[(2.06±0.52)mmol/L vs(2.27±0.46)mmol/L,P=0.374],但差异均无统计学意义。26例患者中,肿瘤直径≥2 cm者10例,有4例(40.00%)出现局部浸润;肿瘤直径<2 cm者16例,均无局部浸润及远处转移。19例患者的饥饿试验结果显示:当血糖低于3.0 mmol/L时,19例患者同步胰岛素浓度≥3μIU/ml,16例患者胰岛素释放指数>0.3。在病理报告提供了分级结果的20例患者中,G1级14例(14/20),其中1例(1/14)出现局部浸润;G2级6例(6/20),其中3例(3/6)出现局部浸润。结论胰岛素瘤患者的临床表现多不典型,常以神经精神症状就诊,症状发作时典型的Whipple三联征有助于诊断;对于症状不典型患者,72 h饥饿试验具有重要诊断价值。胰岛素瘤大部分是良性的,对于少数恶性者,饥饿试验时的血糖水平、胰岛素水平以及病理学分级可为预后提供重要指导意义。

Objective By analyzing the clinical characteristics of 26 cases of insulinoma in recent 15 years,to explore the causes of insulinoma misdiagnosis and summarize the clinical characteristics,diagnosis and prognostic factors.Methods A retrospective analysis was performed in the clinical data of 26 patients with insulinoma confirmed by surgery and pathology treated in Nanjing Drum Tower Hospital from January 2004 to August 2018.According to their symptoms at the time of hypoglycemia,the patients were divided into two groups to analyze the difference in clinical characteristics between patients with neurohypoglycemia as the first symptom(group A,n=17)and those with other causes of hypoglycemia symptoms(group B,n=9).According to tumor diameter,the patients were divided into two groups to analyze the differences in clinical characteristics between patients with diameter less than 2 cm and those with diameter more than or equal to 2 cm.Results Among the 26 patients with insulinoma,there were 17 cases(65.38%)with neurohypoglycemia as first symptom and 23 cases(88.46%)with typical Whipple traid.The diameter of the tumor in group A was smaller than that in group B[(1.75±0.89)cm vs(2.86±1.52)cm,P=0.027].In the starvation test,the insulin level increased[(33.58±22.67)μIU/ml vs(18.06±8.90)μIU/ml,P=0.104],and the blood glucose level[(2.06±0.52)mmol/L vs(2.27±0.46)mmol/L,P=0.374]decreased slightly in group A compared with group B,but there were no significant differences between two groups.Local tumor invasion occurred in 4(4/10)of the 10 patients with diameter greater than or equal to 2 cm,and there were no local invasion or distant metastasis in 16 patients with diameter less than 2 cm.The results of starvation test in 19 patients showed that when the blood glucose level was lower than 3.0 mmol/L,the synchronous insulin concentration was greater than or equal to 3μIU/ml in 19 patients,and the insulin release index was greater than 0.3 in 16 patients.The report of pathological grading system showed thatthere were 14 patients with G1(14/20),and 6 patients with G2(6/20).Local invasion occurred in one patient with G1 and three patients with G2.Conclusion The clinical manifestations of patients with insulinoma are often atypical,and the patients are often presented with neuropsychiatric symptoms.Typical Whipple triad is helpful for diagnosis in the onset of symptoms.For the patients with atypical symptoms,72-hour hunger test has important diagnostic value.Insulinoma is mostly benign.For the patients with malignant insulinoma,the glucose level,insulin level during the 72-hour hunger test,and pathological grade can provide important guidance for the prognosis.