Diagnostic challenge and surgical management of multiple pancreatic neuroendocrine tumors - A case report

Insulinoma is the most common functional solitary, benign pancreatic neuroendocrine tumor. In this paper, we share our experience of triple pancreatic insulinomas, with an idea to highlight the fact that despite the high frequency of solitary insulinoma, there is the possibility of multiple lesions and point out the need for a systematic and detailed radiographic and clinical examination. A 33-year-old woman was admitted to our clinic due to chronic fatigue, sweating, sporadic episodes of palpitations, unsteady hands, and blurred images, which resolve spontaneously after a few minutes. A comprehensive radiological examination revealed two lesions in the pancreatic tail, highly indicative of neuroendocrine tumor - insulinoma, so we elected for surgical treatment. Intraoperative exploration by manual palpation and ultrasonography revealed two more lesions. In the case of sporadically distributed lesions in the pancreas and if it is not possible to accurately differentiate those that represent the insulinoma for sure, the surgical procedure should be delayed. Additionally, tests such as selective arterial calcium stimulation testing should be carried out, and then, with more information in hands, make a re-plan of the potential surgical treatment which should be made.