Liver metastases can be resected, or treated by bland embolization, radioembolization (SIRT), radiofrequency ablation (RFA), microwave and cryoablation, high-intensity focused ultrasound (HIFU), laser, brachytherapy and irreversible electroporation (IRE) depending on local availability. If hyperinsulinemia and hypoglycemia persist, diazoxide with a thiazide diuretic relieves hypoglycemia. In aggressive malignant (metastatic) cases, debulking of the panNENs, including locoregional lymph nodes can be considered. For single solitary tumors surgical excision or radiofrequency ablation are the treatments of choice. Glucagon-like peptide receptor 1 (GLP-1R) receptor positron emission tomography (PET) CT or MRI is a highly sensitive localization technique for indolent, localized (“benign”) insulinomas. Localization of the tumor and exclusion or confirmation of metastatic disease by computed tomography is still the preferred initial option followed by endoscopic ultrasonography (EUS) or MRI. The diagnosis of an insulinoma requires demonstration of inappropriately high insulin, proinsulin or C-peptide levels for the prevailing hypoglycemia in a 72h fast. Multiple synchronous or metachronous panNENs / insulinomas may occur in multiple endocrine neoplasia type 1 (MEN-1). Most are solitary and do not show signs of malignant spread. Insulinomas are rare pancreatic neuroendocrine neoplasms (panNENs - incidence of 1-3 cases per million per year).
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