Persistent hypoglycemia in the setting of metastatic malignant insulinoma to the liver treated with chemoembolization and bland embolization

We are describing a patient with malignant insulinoma and unusual clinical and pathological features. The patient presented late in the course of the disease with history of abdominal pain and was found to have large tumor of the pancreas and metastasis to the liver. Also, he presented with acute diarrhea which is not a feature of Insulinoma. During the hospital stay the patient had sever hypoglycemia with very inappropriately high to the low blood glucose levels of Insulin, C- peptide and Proinsulin. On biopsy of the tumor it was found to be neuroendocrine tumor, but staining’s for Insulin were negative. The patient was treated with surgical resection of the distal pancreas when the insulinoma was located, splenectomy, cholecystectomy and appendectomy. Also, chemoembolization and embolization of the metastatic tumors of the liver were done and patient’s hypoglycemia was treated with Diazoxide and short course of Steroids and Octreotide.
We underscore the need of combined clinical, laboratory, radiological and pathological approach while diagnosing malignant Insulinoma.