1. Darshika Christie-David Endocrinology AT, Westmead Hospital Hidden Hypos, or How many tumours can a Koala bear?

2. Case of JP, now age 21 Age 14 Symptomatic hypoglycemia Occurred during physical education - became dazed, sweaty and unable to complete simple tasks. Episodes accompanied by hunger, recover after eating Preventative measures by the family were frequent snacks, and energy drinks prior to sports.

3. Investigated by a paediatric endocrinologist as investigations identified that a plasma BGL 0.9 mmol/L with an elevated insulin level.

4. Prolonged Fast BGL of 0.8mmol/L at 15 hours - asymptomatic Insulin level very elevated at 81 mIU/L (0-16) Free fatty acid 0.4 mmol/l (0.8 – 1.0) Beta hydroxybutyrate <0.18 umol/l (20-270) Metabolic screen at the time of hypoglycemia showed no amino acid or organic acid abnormalities

5. Investigations for Endogenous Hyperinsulinism Abdominal Ultrasound, CT scan and MRI consistently showed a 2.5cm mass lesion in the region of the pancreatic neck. MRI showed a second lesion 1.1cm posterior and inferior to the neck of the pancreas.

6. Management for a Pancreatic Insulinoma Laparotomy for removal of Pancreatic Insulinoma: Frozen section of the neck of pancreas mass showed it was a benign lymph node Palpation of the pancreas intra-operatively and intra- operative US showed a 5mm nodule at the junction of the body and tail of the pancreas. Frozen section showed a pancreatic endocrine tumour. Additional two nodules in the body of the pancreas - found to be normal pancreatic tissue

7. Surprising Staining Histology of nodule: pancreatic islet cell adenoma unencapsulated with an irregular margin, thought to be completely excised. On staining: opositive for glucagon onegative for insulin, somatostatin and VIP Normal islets in the pancreatic biopsy tissue did stain positive for insulin

8. Post-operative course Twelve hours post-operatively patient became hypoglycemic Formal testing 10 days later was consistent with persistent hypoglycemia and hyperinsulinemia.

9. Summary 14 yo male with hypoglycemia and hyperinsulinemia Pancreatic nodule identified on imaging, only found to be a benign LN Pancreatic nodule at the junction of the body and tail found to stain positive for glucagon Ongoing hypoglycemia and hyperinsulinemia post-operatively - Symptoms were controlled by avoiding fasting of longer than 8 hours - BGL monitoring detected further hypoglycemia to a minimum of 2.2mmol/L, however mostly asymptomatic

10. Progress Imaging Two months post-surgery Indium-111 Octreotide scan positive for abnormal focal uptake in the right upper abdomen CT localised the lesion within the pancreas

12. 2005 Transhepatic Portal Venous Sampling with calcium stimulation Hotspot of high insulin secretion at the head of the pancreas Suggested a lesion secreting insulin in the head of the pancreas

13. Second Surgery Nine months after first surgery Re-exploration of the pancreas Four pancreatic adenomas found Relatively large insulinoma in the head of the pancreas, new since 2004 Two other small adenomas both found to be glucagonomas Another smaller nodule on manual examination – was found to be a small insulinoma (appeared to be infiltrative and extended to the margins of the excision)

14. Post-operative Course Second surgery was complicated by a pseudocyst of the pancreas which became infected and required percutaneous drainage No further hypoglycemia Normal fasting BGLs However, persistently elevated Insulin level

15. Progress Imaging In 2006 (eighteen months after second surgery) Indium-111 Octreotide scan showed a hotspot in the right upper abdomen in the region of the pancreas. Reported as unchanged from Oct 2004. Thought to be possible recurrence but patient was clinically well and not keen for further exploratory surgery, so he continued to be managed conservatively.

16. Transition to Adult care Recurrence of hypoglycemic symptoms in 2010 after five years of no symptoms 20 years old, with symptoms after fasting for 12hours and after exercise Fasting BGLs 2 -3 mmol/L and occasionally <2 mmol/L. Not all episodes were symptomatic No abdominal pain No medications

17. Social History Studying Commerce at university Non-smoker, nil etoh Family history - Renal calculi in grandmother - Parents and five siblings all well

18. Examination Weight 113 kg, height 188cm, BMI 32.0 (at age 14: weight 96 kg, considered obese for his age in childhood) No rashes Abdominal examination – central adiposity, no masses

19. Overnight Fast Nadir capillary BGL 2.3mmol/L at 02:30 (17 hours fasting) Minimal hypoglycemic symptoms experienced 17 hours (02:30AM) Reference Range BGL2.6 Insulin130-16 mIU/L C-peptide0.830.3-0.6 nmol/L Proinsulin87.00-13.3 pmol/L

20. Hyperinsulinism No mass lesions identified on Contrast CT Scan PET – Gallium-68 Octreotide Scan Two Octreotide avid abnormalities within the pancreas at the junction of the body/tail in the pancreatic head

23. Enrolled in a Pasireotide Trial for recurrent neuroendocrine tumour Pasireotide LAR 60mg IMI q4wkly - 6 injections Sept 2010 to Feb 2011 No major hypoglycemic episodes Normal physical examination No adverse effects September 2010

24. Fasting Insulin Level

25. Fasting Glucose Level

26. Fasting Glucagon Levels

27. Pasireotide Treatment No further recurrent hypoglycemic episodes during or after treatment completed in February 2011.

28. Meanwhile Corrected Ca level elevated at 2.64 mmol/L with normal PTH 3.8 pmol/L. Prolactin level elevated 1863 mIU/L Testosterone level 8.1 nmol/L (NR 10-30), with FSH 4 IU/L, LH 4 IU/L (both low) Screen for carcinoid syndrome was negative

29. Pituitary MRI Pituitary MRI showed 7mm pituitary adenoma

30. Gene Testing Positive mutation of the MEN 1 gene on DNA sequencing study cDNA: 249-253 del GTCT Causing a frameshift mutation in exon 2 of Chromosome 11q13

31. Summary Index case of MEN-1 with Multiple recurrent pancreatic neuroendocrine tumours Hyperprolactinemia Pituitary microadenoma Evidence of pituitary insufficiency Recurrence of hypoglycemic symptoms

32. July 2012 Progress Octreotide PET scan More numerous areas of uptake in the pancreas than in 2010. Two dominant areas of increased uptake in the pancreas - most intense in proximal tail of pancreas and another area of increased uptake in the pancreatic head Smaller foci of mildly increased uptake: three in the distal tail, two in the head and one in the body No discrete mass seen on low-dose non-contrast CT. No other sites of disease

33. Current status No symptoms of hypoglycemia even with periods of prolonged fasting 2012 Fasting BGL3.0 Fasting Insulin290 – 16 mIU/L C-peptide1.490.3 – 0.6 nmol/L Gastrin606 – 55 pmol/L Chromogranin3.9< 6.0 nmol/L

34. 2012 Prolactin3077 <325 FSH3 <9 LH2 <9 Morning Testosterone6.1 8-26 Morning ACTH5.6 0-12 Morning Cortisol342 138-580 TSH2.55 0.2 – 3.5 T415 10-22 GH1.2 0-15 mIU/L IGF-150.6 18.7-46.2 nmol/L

35. Hyperprolactinemia and size of microadenoma did not change with treatment

36. Plan Pancreatic insulinomas MRI to further identify pancreatic lesions ? Endoscopic US to biopsy pancreatic lesions ? Further medical therapy ? Further surgery Pituitary microadenoma Progress Pituitary MRI yearly Treatment for hyperprolactinemia which may improve Testosterone level Possible Hyperparathyroidism Monitor Calcium level Family screening Await MEN 1 testing of parents before testing siblings

37. Discussion Points Case of coexistent insulinomas with glucagonomas Outline MEN1 Treatment options for recurrent NETs in MEN1 Pasireotide treatment

38. MEN 1 Multiple endocrine neoplasia type 1 Defined clinically as the presence of two of three tumour types: Parathyroid Entero-pancreatic endocrine Pituitary Rare autosomal dominant disorder with a prevalence of around 2 per 100,000 1000 MEN1 gene mutations have been detected that inactivate or disrupt menin function, resulting in loss of tumour suppression. Brandi et al. Guidelines for diagnosis and therapy of MEN type 1 and type 2. J Clin Endocrinol Metab. 2001;86(12):5658.

39. 2 Marx S. et al. Multiple Endocrine Neoplasia Type 1: Clinical and Genetic Topics. Annals of Internal Medicine. 129(6):484- 494, 1998. Age at onset of endocrine tumor expression in MEN1

40. MEN 1 The peak age at onset of expression of endocrine tumours in patients with MEN1 is about 20 years earlier than the age at onset of sporadic tumors in patients with insulinoma, gastrinoma and hyperparathyroidism. However, the age at onset of prolactinoma is the same in MEN1-associated and sporadic tumours.

41. Insulinoma in MEN1 Among MEN1 patients, 10% will develop an insulinoma by the age of 40 years. The disease in these cases is often multifocal. Recurrence of insulinomas after surgery occur at a rate of 21 per cent at ten years, compared to 5% at ten years in non-MEN associated insulinomas. Malignant insulinomas occurred in MEN1-associated insulinomas at a rate of 6% in one study cohort. Malignant insulinomas not associated with MEN1 are otherwise thought to be rare. For patients with benign disease, the long-term survival is normal. Survival is significantly worse for patients with malignant insulinoma (survival of 29% versus 88% at 10 years postoperatively) Mathur, et al. Insulinoma. Surg Clin North Am 2009;89:1105–1121. Brandi, et al. Guidelines for diagnosis and therapy of MEN type 1 and type 2. J Clin Endocrinol Metab 2001;86:5658–5671. Batcher E, et al. Pancreatic Neuroendocrine Tumors. Endocrine Research, 36(1): 35–43, 2011

42. Glucagonoma Glucagonoma syndrome is rare in MEN1 However, one third of MEN1 pancreatico-duodenal neuroendocrine tumours immunostain for glucagon Glucagon can be released by other types of islet cell tumours.

43. Treatment of recurrent Insulinoma There is no compelling evidence to suggest that surgical removal of small tumours that are not producing a hormonal syndrome, improves overall outcome. Though surgical resection remains the treatment of choice for multiple insulinomas, the extent of pancreatectomy, which can prevent hypoglycemia recurrence and avoid diabetes or exocrine failure, is still not definite. Local resection will fail in MEN-I insulinomas as they are usually multiple Surgery can be associated with increased morbidity and iatrogenic diabetes.

44. Medical options to prevent symptomatic hypoglycemia include: Diazoxide Octreotide Lanreotide

45. Pasireotide Pasireotide (SOM-230) is a somatostatin analogue with affinity to four of the five human SST receptor subtypes, with IC50 values for hSST5 > hSST2 > hSST3 > hSST1for SSTR 1-3 and SSTR 5. It is being developed for the potential treatment of acromegaly, Cushing's disease and neuroendocrine tumours, with Phase III clinical trials in progress. Pasireotide has the potential to be more effective than octreotide and lanreotide which are preferential for SSTR 2. Pasireotide exhibits a longer half-life than octreotide or lanreotide. In phase II clinical trials, pasireotide inhibited GH secretion from GH- secreting pituitary tumours, controlled symptoms associated with metastatic carcinoid tumors, and inhibited adrenocorticotropic hormone secretion in Cushing's disease. However, a major advantage for pasireotide compared with octreotide was not demonstrated. Side effects have included mild to moderate gastrointestinal events (diarrhea, abdominal discomfort, nausea and vomiting).

46. Insulinoma and glucagonoma in the same patient Is this divine intervention? If there is a God, He/She is an Endocrinologist