A 53-year-old woman presented to the Emergency Department on 2 occasions suffering from confusion and an altered level of consciousness. Hypoglycemia (2 mmol/L or less) was documented during these episodes. A 24-hour fast revealed symptomatic hypoglycemia (a blood glucose level of 2 mmol/L)and an elevated C-peptide level. At first, she was managed medically with frequent small meals and diazoxide. However, she continued to be symptomatic.
Two attempts to localize a suspected insulinoma by computed tomography and magnetic resonance imaging were unsuccessful. Finally, gadolinium-enhanced magnetic resonance imaging demonstrated a mass in the body of the pancreas measuring 1.5 cm in dimension (Fig. 1).
At laparotomy the pancreas was exposed; the mass (Fig. 2) was readily palpable. Although intraoperative sonography revealed that the mass was in close proximity to the splenic vein, the mass was enucleated without significant hemorrhage. Pathological examination supported the diagnosis of insulinoma. Electron microscopy showed abundant dense-core neurosecretory granules (Fig. 3) consistent with an islet cell tumour.
Footnotes
Section editors: David P. Girvan, MD, and Nis Schmidt, MD
Submissions to Surgical Images, soft-tissue section, should be sent to Dr. David P. Girvan, Victoria Hospital Corporation, PO Box 5375, Station B, London ON N6A 5A5 or to Dr. Nis Schmidt, Department of Surgery, St. Paul’s Hospital, 1081 Burrard St., Vancouver BC V6Z 1Y6.