Recurrent Insulinoma Syndrome with Metastatic Glucagonoma

J Clin Pathol: first published as 10.1136/jcp.36.9.1076 on 1 September 1983. Downloaded from

J Clin Pathol 1983;36:1076-1080

Recurrent insulinoma syndrome with metastatic glucagonoma

PJS DUNN*, MC SHEPPARDt, DA HEATHt, G SLANEYt From the Departments of *Pathology, tMedicine and tSurgery, University of Birmingham, Queen Elizabeth Hospital, Birmingham B15 2 TH

SUMMARY A case is reported of a patient who presented with symptomatic hypoglycaemia and who had three pancreatic tumours resected over the ensuing eight years. Immunocytochemistry demonstrated two of these to be insulinomas and the third to be a glucagonoma. In addition metastatic spread of cells positive for glucagon had occurred to a lymph node and multiple nodules staining positively for glucagon were present in the remainder of the pancreas.

Pancreatic endocrine tumours are uncommon but of by a pancreatic pseudocyst but he remained normog- great interest because of the variety of clinical syn- lycaemic, even after a 24-hour fast. dromes which they produce. Sensitive After six asymptomatic years without treatment immunocytochemical studies have shown that many he again presented with hypoglycaemia and inap- of these tumours are composed of several cell types propriately raised serum insulin concentrations (glu-copyright. and are multihormonal.4 5 0 cose 2-9, 1-5 mmoL/l, insulin 35, 38 mU/l). He was Transformation from one syndrome to another treated with diazoxide 100 mg tds. Transhepatic has been reported9 and presumed to be due to portal vein sampling revealed a large "step-up" in change in type of the dominant cell in a mixed serum insulin at the level of the head of pancreas. At tumour. We report a case of recurrent insulinoma surgery (1981) a 2*5 cm tumour was removed from syndrome with metastatic glucagonoma, shown by the head of the pancreas. Immediately postopera- immunocytochemistry to be due to the coexistence tively his blood glucose rose to within the normal of insulinoma and glucagonoma. The importance of range but on the second postoperative day it in immunocytochemistry accurately defining the returned to the preoperative concentration and he http://jcp.bmj.com/ nature of these tumours is emphasised. subsequently required continued diazoxide treatment. Repeat transhepatic portal vein sampling Case report confirmed persistently high insulin concentrations in veins draining the head of pancreas and selective A 24-year-old caucasian man (date of birth 7.8.58) arteriography demonstrated a tumour in the head. presented in June 1974 with a grand mal convulsion, Further surgery (1982) was undertaken and hypoglycaemia and inappropriately raised serum another tumour was identified in the head of

pan- on October 3, 2021 by guest. Protected insulin concentrations (corresponding glucose and creas adjacent to the superior mesenteric vein. A insulin values were 1*7, 2*3, 1-7, 1*7 mmolI and 39, pancreatico-duodenectomy was performed. Post- 38, 32, 20 mU/l respectively). In addition mild operatively the patient has remained asymptomatic hypercalcaemia was noted (2-88 mmol/1) which was and normoglycaemic with no treatment. unresponsive to hydrocortisone administration. Raised parathyroid hormone (PTH) concentrations Material and methods were subsequently documented and his father was noted to have mild hypercalcaemia with high PTH Multiple sections of formalin-fixed paraffin- concentrations, suggesting a multiple endocrine embedded tissue from all three surgical specimens adenopathy syndrome, type I. At laparotomy in were examined using haematoxylin and eosin, August 1974 a tumour in the tail of the pancreas was aldehyde fuchsin, congo red and lead haematoxylin removed. His postoperative course was complicated stains and by the Grimelius silver impregnation technique.' In addition serial sections from the same Accepted for publication 27 April 1983 blocks were examined by means of the PAP method 1076 J Clin Pathol: first published as 10.1136/jcp.36.9.1076 on 1 September 1983. Downloaded from

Recurrent insulinoma syndrome with metastatic glucagonoma 1077

'A) '

W\,v b nsa Fig. 1 Tumour removed from tail ofpancreas in 1974. Fig. 2 Tumour removed from head ofpancreas in 1981. Immunocytochemical demonstration ofinsulin in the Immunocytochemical demonstration ofglucagon in the majority of tumour cells. Unlabelled antibody-enzyme majority oftumour cells. Unlabelled antibody-enzyme method using guinea-pig anti-insulin antiserum as first method using rabbit antiglucagon antiserum as first layer. layer. x 575. x 575. of Stemberger et al,2 after treatment with trypsin,3 were unstained by aldehyde fuchsin or lead using antisera to insulin, glucagon, and somatosta- haematoxylin. No amyloid was demonstrable. tin. The antisera were used at the following dilu- Immunocytochemistry showed the majority of cells tions: guinea pig anti-insulin (Immuno-nuclear to contain insulin-positive granules (Fig. 1) with copyright. Corp., PO Box 285, Stillwater, Minnesota, USA) occasional cells staining for somatostatin. The two 1/500; rabbit antiglucagon (Mercia Brocades, cell types appeared distinct in serial sections Brocades House, Pyrford Road, West Byfleet, Sur- examined. No positive staining for glucagon was rey) 1/500; rabbit antisomatostatin (Immuno- observed in any of the sections examined. A few nuclear Corp., PO Box 285, Stillwater, Minnesota, cells failed to react with any of the antisera used. USA) 1/800. The second and third stages were performed using sheep antirabbit (RIA UK, 3 Manor 1981 Place, Athenaeum Street, Sunderland) and rabbit The second tumour removed was a cystic mass 2 cm

PAP complex (Mercia Brocades). Appropriate con- x 2 cm x 1*5 cm containing straw-coloured fluid. A http://jcp.bmj.com/ trols were performed, using the specific antibodies small amount of exocrine pancreatic tissue was after prior absorption with an excess of the corres- attached at one pole. Microscopy showed similar ponding antigen as a first layer, non-immune serum cells to the first tumour arranged in a gyriform pat- as first layer, and by omission of 3,3'diaminoben- tern around numerous blood vessels. A thin capsule zidine tetrahydrochloride from the incubation of hyaline collagen was present, with areas of medium for the peroxidase reaction. infiltration by tumour. Mitoses were not seen.

Routine histological staining reactions were identi- on October 3, 2021 by guest. Protected PATHOLOGICAL FINDINGS cal to the 1974 tumour but the immunohistochemi- The findings are described separately for the three cal reactions were quite distinct. No positive staining tumours, identified by the year of removal. was obtained with anti-insulin or antisomatostatin, but almost all the tumour cells showed moderate to 1974 strong staining with antiglucagon (Fig. 2). This was a 2 cm diameter ovoid mass with no attached pancreatic tissue. Microscopy showed a cel- 1982 lular tumour composed of irregular sheets and broad This specimen consisted of pylorus, duodenum, and trabeculae of cuboidal basophiic cells with large the head of the pancreas. Within the head of the uniform open nuclei. Occasional mitotic figures pancreas and extending to the anterior border there were observed. The cells were arranged around a was a firm congested clearly defined nodule 2 cm rich sinusoidal vascular network and a thin fibrous diameter. The pancreatic tissue was otherwise capsule was present. Many cells showed silver- unremarkable macroscopically. Several small positive granules by the Grimelius technique but peripancreatic lymph nodes were identified. Micros- J Clin Pathol: first published as 10.1136/jcp.36.9.1076 on 1 September 1983. Downloaded from

1078 Dunn, Sheppard, Heath, Slaney

Fig. 3 Main tumour removed with head ofpancreas in 1982 showing gyriform pattern. Haematoxylin and eosin. x 92. Fig. 5 Metastatc deposit in peripancreatic lymph node removed with head ofpancreas in 1982. Haematoxylin and eosin. x 92.

.4 :I q:k ..I copyright. * C,-

w ~~~~.. http://jcp.bmj.com/

Fig. 4 Main tumour removed with head ofpancreas in 1982. Immunocytochemical demonstration ofinsulin in the majority of the tumour cells. Unlabelled antibody-enzyme method using guinea-pig anti-insulin antiserum as first layer. x 575. Fig. 6 Metastatic deposit in peripancreatic lymph node on October 3, 2021 by guest. Protected copy of the tumour showed identical appearances to removed with head ofpancreas in 1982. Immunocytochemical demonstration ofglucagon in all of the previous specimen apart from the absence of a the tumour cells. Unlabelled antibody-enzyme method using clearly defined capsule (Fig. 3). Silver-positive rabbit antiglucagon as first layer. x 230. granules were again demonstrable and aldehyde fuchsin and lead haematoxylin were negative. tical to the main tumour. Three of the six were Immunocytochemistry showed the majority of cells encapsulated. A further area of tumour was to contain insulin (Fig. 4) with a few staining posi- identified within the subcapsular sinus of a peripan- tively for somatostatin. No glucagon-containing cells creatic lymph node (Fig. 5). All six nodules and the could be identified in multiple sections examined. lymph node metastasis were strongly positive for Examination of tissue from elsewhere in the glucagon (Fig. 6) and negative for both insulin and excised pancreas revealed six discrete irregular somatostatin. endocrine cell nodules varying in size from 0 1 cm to The pancreatic islets in the intervening pancreas 0-5 cm. The cellular morphology of all six was iden- were irregular in outline and many were hyperplas- J Clin Pathol: first published as 10.1136/jcp.36.9.1076 on 1 September 1983. Downloaded from

Recurrent insulinoma syndrome with metastatic glucagonoma 1079

Fig. 7 Edge ofmain tumour removed with head of pancreas in 1982 showing silver-reactive cells. Unstained cells at centre are exocrine pancreatic tissue. Silver impregnation after Grimelius. x 600.

tic with diameters up to 450 ,um. Columns of endoc- criteria for diagnosis of insulinoma and its removal rine cells appeared to infiltrate between the exocrine was followed by a long period of remission. The cells. Within these large irregular islets the normal second tumour, although accompanied by a clinical arrangement of central B cells and peripheral A and insulinoma syndrome, showed marked positive D cells was preserved. Clusters of endocrine cells staining for glucagon and was entirely negative for were also seen in close apposition to small ductules. insulin. Resection was not accompanied by relief of copyright. These clusters contained all three cell types appar- symptoms and it would seem reasonable to regard ently randomly arranged. The exocrine pancreatic this as a glucagonoma. The symptoms of excess tissue was unremarkable. glucagon secretion were probably masked by the presence of a further small insulinoma not detected Discussion at that time. This insulinoma presumably grew and constituted the main tumour removed at the time of The accepted classification of pancreatic endocrine pancreaticoduodenectomy. This third operation was tumours has been complicated by the demonstration again accompanied by relief of symptoms and the of the mixed nature of many of these neoplasms.4 '° tumour showed positive staining for insulin and was http://jcp.bmj.com/ It has been suggested that the name given to an negative for glucagon, and could therefore be individual tumour should depend on an appreciation confidently labelled an insulinoma. The metastasis of the clinical, biochemical, and immunocytochemi- found in a lymph node, staining strongly for cal features of the case.5 However, it would seem glucagon only, was presumably metastatic from the worth retaining the terms insulinoma, glucagonoma, glucagonoma previously removed and might be etc., in view of the recorded differences in biological interpreted as evidence of the usual malignant behaviour.4 behaviour of glucagonomas. on October 3, 2021 by guest. Protected This case is presented as one of recurrent Despite the heterogeneity revealed by insulinoma syndrome complicated by the unex- immunohistochemistry, all the tumour tissue pected discovery of metastatic glucagonoma. Recur- examined showed identical staining reactions using rent or multiple insulinomas6 are rare and most are conventional techniques. Aldehyde fuchsin is a rec- associated with one of the multiple endocrine neop- ognised stain for B cells but no positive staining was lasia syndromes.5 Malignancy as shown by metas- obtained with the tumour tissue removed in 1974 or tasis, probably the only reliable criterion, is also a 1982. Others have reported aldehyde-fuchsin posi- rare complication of insulinoma, approximately 5% tive staining of insulinomas in only about three- in two large series.64 In contrast glucagonoma is quarters of the cases examined,8 possibly because much more often malignant, in more than 80% of less insulin is stored in the tumour cells as compared cases in one series.5 with normal B cells. Likewise, the Grimelius silver The first tumour removed from this patient impregnation technique specifically demonstrates fulfilled the clinical and immunocytochemical the A and PP cells of the normal pancreas. However J Clin Pathol: first published as 10.1136/jcp.36.9.1076 on 1 September 1983. Downloaded from

1080 Dunn, Sheppard, Heath, Slaney Creutzfeldt5 reports Grimelius-positive granules in formed and a possibly misleading concept of the 40% of 50 insulinomas investigated and quotes likely future symptomatology had been postulated. another series in which four of 11 insulin producing tumours were positive. In this case argyrophilic In addition to the above studies immunocytochemi- granules were present in all three primary tumours cal staining of the tissue specimens was performed in (Fig. 7). the Department of Histochemistry, Royal Post- Although none of the usual features of hyper- graduate Medical School. These examinations also glucagonaemia was seen in this case,' future confirmed positive staining for insulin in the tumour glucagonoma symptoms might be anticipated in from 1974, glucagon in the tumour from 1981 and view of the likelihood of recurrent disease due to insulin in the tumour from 1982. We are very grate- metastatic glucagon-producing tumour. The value of ful to Dr Julia M Polak for performing these inves- immunocytochemical studies is emphasised in this tigations. We are also grateful to Professor LH case as an indication of future behaviour and a guide Blumgart and Dr DJ Allison of the Royal Post- to which serum hormone concentrations should be graduate Medical School for their help in managing monitored for evidence of recurrence. The trans- the patient. We wish to thank Mr J Gregory for formation of a case of insulinoma syndrome into a skilled technical assistance and Miss A Wright for glucagonoma syndrome has been previously typing the manuscript. MCS is in receipt of a Well- reported by Ohneda et al.9 This case appeared to be come Trust Senior Lectureship. due to an alteration in the predominant cell type in a mixed endocrine cell tumour. Our case appears to References be one of coexistence of two functionally distinct tumours with different biological behaviours. 'Grimelius L. A Silver nitrate stain for alpha 2 cells in human pancreatic islets. Acta Soc Med upsal 1968;73:243-70. The relation between insulinoma and 2 Sternberger LA. Immunocytochemistry 2nd ed New York: John glucagonoma is obscure in view of the occurrence of Wiley & Sons, 1979. mixed tumours. In this case the two tumour types 3 Curran RC, Gregory J. The unmasking of antigens in paraffin appear to be distinct. One possibility is that pro- sections of tissue by trypsin. Experientia 1977;33:1400-1. 4 Heitz PU, Kasper M, Polak J, Kloppel G. Pancreatic endocrinecopyright. longed hyperinsulinaemia induced a secondary A tumours. Hum Pathol 1982;13:263-71. cell hyperplasia leading to neoplasia. However there Creutzfeldt W. Endocrine tumours of the pancreas. In: Volk BW, is no evidence of hyperplasia of A cells alone and Wellman KF, eds. The diabetic pancreas. London: Balli6re- the multiple small glucagon-producing tumours in Tindall, 1977:551-90. 6 Service JF, Dale AJD, Elveback RL, Jiang NS. Insulinoma, clini- this case are probably metastatic. In view of the cal and diagnostic features of 60 consecutive cases. Mayo Clin postulated origin of pancreatic endocrine tumours Proc 1976;51:417-29. from multipotent stem cells in the ductular Matheson LN, Bloom SR, Warn AP, Salmon PR, Cox BA. A epithelium rather than from the islets,'0 it would glucagonoma syndrome. Lancet 1974;ii: 1-5. Creutzfeldt W. Endocrine tumours of the pancreas. Monogr seem more likely that these tumours are different Pathol 1980;21:208-30. http://jcp.bmj.com/ expressions of an increased tendency to endocrine Ohneda A, Otsuki M, Fujiya H, Yaginuma N, Kokubo T, Ohtari cell neoplasia. The usual mixed nature of these H. A malignant insulinoma transformed into a glucagonoma tumours supports this view. The presence of islet syndrome. Diabetes 1979;28:962-9. Larsson LI. Endocrine pancreatic tumours. Hum Pathol hyperplasia and nesidioblastosis might be regarded 1978;9:401-15. as further evidence of a tendency towards endocrine Larsson LI. Two distinct types of islet abnormality associated cell proliferation, although others have regarded with endocrine pancreatic tumours. Virchows Arch [Pathol these features as being due to the tumours." Anat] 1977;376:209-19. This report again illustrates the difficulty in clas- on October 3, 2021 by guest. Protected sifying these tumours without immunocytochemis- Requests for reprints to: Dr PJS Dunn, Department of try. Indeed this case had been regarded as one of Pathology, The Medical School, Birmingham B15 2TJ, malignant insulinoma before these studies were per- England.