Insulinoma medical therapy: Difference between revisions
Jump to navigation
Jump to search
(Mahshid) |
|||
| (30 intermediate revisions by 3 users not shown) | |||
| Line 1: | Line 1: | ||
__NOTOC__ | __NOTOC__ | ||
{{CMG}} {{AE}}{{ADS}} | |||
{{CMG}} {{AE}}{{ADS | |||
{{Insulinoma}} | {{Insulinoma}} | ||
==Overview== | ==Overview== | ||
Medical therapy is reserved for those who are unable to undergo the primary surgical therapy. Drugs commonly used for benign insulinoma are [[diazoxide]], [[octreotide]]/lanreotide, [[phenytoin]], [[verapamil]] and [[everolimus]]. For malignant insulinoma, these drugs are used with the [[chemotherapy]] drugs [[streptozocin]], 5 [[fluorouracil]], [[doxorubicin]], [[bevacizumab]] and [[capecitabine]] in different combinations. For [[metastasis]] mainly going to [[liver]] regimens include [[hepatic artery]] [[embolization]], [[Radiation therapy|radiation]], chemo-embolization, [[ethanol]] ablation, [[radiofrequency ablation]], and [[cryoablation]]. | |||
[ | |||
==Medical Therapy== | ==Medical Therapy== | ||
*The primary treatment is surgical excision. Medical therapy is reserved for: | *The primary treatment is surgical excision. Medical therapy is reserved for: | ||
**Those who | **Those who are unable to undergo [[surgery]]: | ||
***High-risk patients | ***High-risk patients | ||
***Unresectable metastatic disease | ***Unresectable [[metastatic]] disease | ||
**Those who refuse to undergo surgery | **Those who refuse to undergo [[surgery]]: | ||
* The medical therapy is mainly used to reduce/prevent symptoms of [[hypoglycemia]] | * The medical therapy is mainly used to reduce/prevent symptoms of [[hypoglycemia]]. | ||
*Pharmacologic medical therapies for insulinoma include | *Pharmacologic medical therapies for insulinoma include [[diazoxide]], [[octreotide]]/[[lanreotide]], [[phenytoin]], [[verapamil]], and [[everolimus]]. | ||
==='''Benign Insulinoma'''=== | ==='''Benign Insulinoma'''=== | ||
===1. '''Adult'''=== | ===1. '''Adult'''=== | ||
*'''Parenteral''' | *'''1.1 Parenteral''' | ||
** Preferred regimen : Octreotide | ** Preferred regimen (1): [[Octreotide]] 30 mg IM (depot) every 4 weeks until [[tumor]] progression or death. | ||
*'''Oral''' | ** Preferred regimen (2): [[Octreotide]] 100-500 μg SQ q 8-12h（can be increased to maximum 1500 μg daily）for 1 year. | ||
**Preferred regimen : Diazoxide 3-8 mg/kg 200-300 mg PO q8h for 14-21 days (1200 mg max to be divided in 3 doses and max is 400 mg/dose)<ref name="pmid3019020">{{cite journal |vauthors=Goode PN, Farndon JR, Anderson J, Johnston ID, Morte JA |title=Diazoxide in the management of patients with insulinoma |journal=World J Surg |volume=10 |issue=4 |pages=586–92 |year=1986 |pmid=3019020 |doi= |url=}}</ref><ref name="pmid9497974">{{cite journal |vauthors=Gill GV, Rauf O, MacFarlane IA |title=Diazoxide treatment for insulinoma: a national UK survey |journal=Postgrad Med J |volume=73 |issue=864 |pages=640–1 |year=1997 |pmid=9497974 |pmc=2431498 |doi= |url=}}</ref> | ** Preferred regimen (3): [[Lanreotide]] 120 mg SQ every 4 weeks until [[tumor]] progression. | ||
** Alternative regimen: Phenytoin 300-600 mg PO q daily<ref name="MathurGorden2009">{{cite journal|last1=Mathur|first1=Aarti|last2=Gorden|first2=Philip|last3=Libutti|first3=Steven K.|title=Insulinoma|journal=Surgical Clinics of North America|volume=89|issue=5|year=2009|pages=1105–1121|issn=00396109|doi=10.1016/j.suc.2009.06.009}}</ref> | *'''1.2 Oral''' | ||
**Preferred regimen : [[Diazoxide]] 3-8 mg/kg OR 200-300 mg PO q8h for 14-21 days (1200 mg max to be divided in 3 doses and max is 400 mg/dose).<ref name="pmid3019020">{{cite journal |vauthors=Goode PN, Farndon JR, Anderson J, Johnston ID, Morte JA |title=Diazoxide in the management of patients with insulinoma |journal=World J Surg |volume=10 |issue=4 |pages=586–92 |year=1986 |pmid=3019020 |doi= |url=}}</ref><ref name="pmid9497974">{{cite journal |vauthors=Gill GV, Rauf O, MacFarlane IA |title=Diazoxide treatment for insulinoma: a national UK survey |journal=Postgrad Med J |volume=73 |issue=864 |pages=640–1 |year=1997 |pmid=9497974 |pmc=2431498 |doi= |url=}}</ref> | |||
** Alternative regimen (1): [[Phenytoin]] 300-600 mg PO q daily. <ref name="MathurGorden2009">{{cite journal|last1=Mathur|first1=Aarti|last2=Gorden|first2=Philip|last3=Libutti|first3=Steven K.|title=Insulinoma|journal=Surgical Clinics of North America|volume=89|issue=5|year=2009|pages=1105–1121|issn=00396109|doi=10.1016/j.suc.2009.06.009}}</ref> | |||
**Alternative regimen (2): [[Everolimus]] 10 mg PO q daily until disease progression. | |||
**[[Verapamil]] and [[Propranolol]] to control symptoms are used either as alone or in combination. | |||
**[[Glucocorticoids]] and g[[Glucagon|lucagon]] have been used in combination with diazoxide. | |||
===2. '''Pediatric'''=== | |||
* '''2.1 [[Neonates]] and [[Infants]]:''' | |||
**'''2.1.1 Oral''' | |||
***Preferred regimen: [[Diazoxide]] | |||
****Initial dose: 10 mg/kg/day divided into 3 equal doses q 8 hours. | |||
****Maintenance dosing range: 8 to 15 mg/kg/day divided into 2 or 3 equal doses every 8 to 12 hours. | |||
* '''2.2 [[Children]] and [[Adolescent|adolescents]]''' | |||
** Follow the adult regimen | |||
==='''[[Malignant]] ([[metastatic]]) Insulinoma'''=== | |||
'''1. [[Chemotherapy]]'''<br>It is used in the different combination of the following drugs: | |||
* [[Streptozocin]] 500 mg/m<sup>2</sup>/day IV for 5 consecutive days every 6 weeks | |||
* [[Doxorubicin]] 40-75 mg/m<sup>2</sup> IV every 21 to 28 days | |||
* 5 [[Fluorouracil]]([[5-FU]]) | |||
* Temozolamide 200 mg/m<sup>2</sup> PO QHS days 10 to 14 of a 28-day treatment cycle (in combination with [[capecitabine]]) | |||
* [[Bevacizumab]] | |||
* [[Capecitabine]] | |||
'''2. Liver-directed therapy''' (for [[metastasis]]) | |||
*2.1 [[Radiation therapy|Radiation]] | |||
**2.1.1 Selective internal radiation therapy | |||
**2.1.2 Peptide receptor radionuclide therapy (PRRT): [[cytotoxic]] doses of [[radiation]] are given locally to the site of [[tumor]] (sometimes also called Radio-embolization) | |||
*2.2 [[Hepatic artery]] [[embolization]], chemo-embolization, and [[infusion]]. Infusion consists of: | |||
**2.2.1 [[Hepatic artery]] [[infusion]] (HIA): HIA is the administration of [[Chemotherapeutic agent|chemotherapeutic]] agents (high doses of [[streptozocin]] and [[5-FU]]) into the [[hepatic artery]]. Response rates are 0 to 100%. | |||
**2.2.2 Isolated hepatic perfusion (IHP): HIP gave rise to minimally invasive, percutaneous hepatic perfusion.<ref name="MathurGorden2009">{{cite journal|last1=Mathur|first1=Aarti|last2=Gorden|first2=Philip|last3=Libutti|first3=Steven K.|title=Insulinoma|journal=Surgical Clinics of North America|volume=89|issue=5|year=2009|pages=1105–1121|issn=00396109|doi=10.1016/j.suc.2009.06.009}}</ref> | |||
*2.3 Percutaneous [[ethanol]] injection/ [[Ethanol]] ablation | |||
*2.4 [[Radiofrequency ablation]] ([[RFA]]) | |||
*2.5 [[Cryoablation]] | |||
==References== | ==References== | ||
| Line 84: | Line 64: | ||
{{WikiDoc Help Menu}} | {{WikiDoc Help Menu}} | ||
{{WikiDoc Sources}} | {{WikiDoc Sources}} | ||
[[Category:Medicine]] | |||
[[Category:Endocrinology]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Oncology]] | |||
[[Category:Medicine]] | |||
[[Category:Gastroenterology]] | |||
[[Category:Surgery]] | |||
Latest revision as of 02:07, 27 November 2017
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]
|
Insulinoma Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Insulinoma medical therapy On the Web |
|
American Roentgen Ray Society Images of Insulinoma medical therapy |
|
Risk calculators and risk factors for Insulinoma medical therapy |
Overview
Medical therapy is reserved for those who are unable to undergo the primary surgical therapy. Drugs commonly used for benign insulinoma are diazoxide, octreotide/lanreotide, phenytoin, verapamil and everolimus. For malignant insulinoma, these drugs are used with the chemotherapy drugs streptozocin, 5 fluorouracil, doxorubicin, bevacizumab and capecitabine in different combinations. For metastasis mainly going to liver regimens include hepatic artery embolization, radiation, chemo-embolization, ethanol ablation, radiofrequency ablation, and cryoablation.
Medical Therapy
- The primary treatment is surgical excision. Medical therapy is reserved for:
- Those who are unable to undergo surgery:
- High-risk patients
- Unresectable metastatic disease
- Those who refuse to undergo surgery:
- Those who are unable to undergo surgery:
- The medical therapy is mainly used to reduce/prevent symptoms of hypoglycemia.
- Pharmacologic medical therapies for insulinoma include diazoxide, octreotide/lanreotide, phenytoin, verapamil, and everolimus.
Benign Insulinoma
1. Adult
- 1.1 Parenteral
- Preferred regimen (1): Octreotide 30 mg IM (depot) every 4 weeks until tumor progression or death.
- Preferred regimen (2): Octreotide 100-500 μg SQ q 8-12h（can be increased to maximum 1500 μg daily）for 1 year.
- Preferred regimen (3): Lanreotide 120 mg SQ every 4 weeks until tumor progression.
- 1.2 Oral
- Preferred regimen : Diazoxide 3-8 mg/kg OR 200-300 mg PO q8h for 14-21 days (1200 mg max to be divided in 3 doses and max is 400 mg/dose).[1][2]
- Alternative regimen (1): Phenytoin 300-600 mg PO q daily. [3]
- Alternative regimen (2): Everolimus 10 mg PO q daily until disease progression.
- Verapamil and Propranolol to control symptoms are used either as alone or in combination.
- Glucocorticoids and glucagon have been used in combination with diazoxide.
2. Pediatric
- 2.1 Neonates and Infants:
- 2.1.1 Oral
- Preferred regimen: Diazoxide
- Initial dose: 10 mg/kg/day divided into 3 equal doses q 8 hours.
- Maintenance dosing range: 8 to 15 mg/kg/day divided into 2 or 3 equal doses every 8 to 12 hours.
- Preferred regimen: Diazoxide
- 2.1.1 Oral
- 2.2 Children and adolescents
- Follow the adult regimen
Malignant (metastatic) Insulinoma
1. Chemotherapy
It is used in the different combination of the following drugs:
- Streptozocin 500 mg/m2/day IV for 5 consecutive days every 6 weeks
- Doxorubicin 40-75 mg/m2 IV every 21 to 28 days
- 5 Fluorouracil(5-FU)
- Temozolamide 200 mg/m2 PO QHS days 10 to 14 of a 28-day treatment cycle (in combination with capecitabine)
- Bevacizumab
- Capecitabine
2. Liver-directed therapy (for metastasis)
- 2.1 Radiation
- 2.2 Hepatic artery embolization, chemo-embolization, and infusion. Infusion consists of:
- 2.2.1 Hepatic artery infusion (HIA): HIA is the administration of chemotherapeutic agents (high doses of streptozocin and 5-FU) into the hepatic artery. Response rates are 0 to 100%.
- 2.2.2 Isolated hepatic perfusion (IHP): HIP gave rise to minimally invasive, percutaneous hepatic perfusion.[3]
- 2.3 Percutaneous ethanol injection/ Ethanol ablation
- 2.4 Radiofrequency ablation (RFA)
- 2.5 Cryoablation
References
- ↑ Goode PN, Farndon JR, Anderson J, Johnston ID, Morte JA (1986). "Diazoxide in the management of patients with insulinoma". World J Surg. 10 (4): 586–92. PMID 3019020.
- ↑ Gill GV, Rauf O, MacFarlane IA (1997). "Diazoxide treatment for insulinoma: a national UK survey". Postgrad Med J. 73 (864): 640–1. PMC 2431498. PMID 9497974.
- ↑ 3.0 3.1 Mathur, Aarti; Gorden, Philip; Libutti, Steven K. (2009). "Insulinoma". Surgical Clinics of North America. 89 (5): 1105–1121. doi:10.1016/j.suc.2009.06.009. ISSN 0039-6109.