Metastatic Insulinoma: Presentation, Diagnosis, and Multimodal Treatment

Clinical Features

• Whipple's triad: hypoglycemia symptoms + plasma glucose <55 mg/dL + relief with glucose.
• Neuroglycopenic: confusion, seizures, coma.
• Adrenergic: sweating, tremor, palpitations, hunger.

Diagnostic Workup

• Fasting test (72‑hr) with simultaneous glucose, insulin, C‑peptide, proinsulin, β‑hydroxybutyrate, sulfonylurea screen.
• Imaging: multiphasic CT/MRI abdomen, Ga‑68 DOTATATE PET/CT for metastasis.

Treatment

• Surgery: Resection of primary + debulking metastases if feasible (only curative chance).
• Medical: Diazoxide, octreotide/lanreotide, everolimus, sunitinib, PRRT (Lu‑177 DOTATATE).
• Liver‑directed: Embolization, radioembolization, ablation.

Prognosis

5‑year survival ~50% with aggressive multimodal therapy; highly variable based on burden, grade, and resectability.