Beruflich Dokumente
Kultur Dokumente
Division of HematoOncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan, R.O.C.
DOI: 10.3892/ol.2015.3915
Abstract. Non-islet cell tumor hypoglycemia (NICTH) is an patient who presented with refractory NICTH. The patient
uncommon but serious complication of malignancy. Patients provided written informed consent.
with NICTH may appear unwell due to the underlying tumor,
particularly when the mechanism of hypoglycemia is extensive Case report
tumor burden in the liver. Hepatocellular carcinoma (HCC) is
reported to be the second most common cause of NICTH. The A 54yearold male presented at Chang Gung Memorial
therapeutic strategies used in treating NICTH involve reduc- Hospital, Keelung, Taiwan in April 2012 due to a 2month
tion of the tumor mass or tumor load, and palliative treatment history of constant pain in the upper right abdomen and a weight
of symptoms if curative attempts fail. In the present study we loss of 9kg in the previous 2months. A clinical survey revealed
report the successful control of hypoglycemia using systemic chronic hepatitisB and multiple hepatic masses infiltrating both
chemotherapy in an advanced HCC patient who presented hepatic lobes. Ultrasonographyguided biopsy of the liver mass
with refractory NICTH. revealed tumor cells consistent with moderately differentiated
HCC. A computed tomography (CT) scan revealed no evidence
Introduction of extrahepatic spread of the tumor. Due to extensive tumor infil-
tration the hepatoma was considered to be inoperable and liver
Patients with advanced hepatocellular carcinoma (HCC) occa- transplantation was not indicated at that time. The patient was
sionally develop a paraneoplastic syndrome that manifests as then treated twice with selective hepatic artery chemoemboliza-
hypoglycemia, erythrocytosis, hypercalcemia or severe watery tion with doxorubicin. The patient refused further anticancer
diarrhea, and is generally associated with a poor prognosis(1). treatment and was lost to followup thereafter.
Hypoglycemia, which normally occurs in advanced HCC, At the end of January 2013, the patient was readmitted to
is understood to develop due to the tumor's high metabolic our hospital due to recurrent episodes of drowsiness, dizziness,
requirements. Hypoglycemia is typically mild; however, more confusion and sweating, which were particularly notable in the
severe reductions in blood sugar may occur, resulting in leth- early morning and partially relieved after eating. A CT scan of the
argy and confusion. Less than 5% of tumors secrete insulinlike liver revealed massive liver enlargement and multilocular infil-
growth factorII (IGFII), which results in stimulation of the tration by hepatoma (Fig.1). The patient was on no medications
insulin receptors and increased glucose utilization and could and had no underlying diabetes mellitus. Blood glucose was low
cause severe symptomatic hypoglycemia(2,3). Hypoglycemia (1.9mmol/l) but administration of glucose reversed the symp-
may be caused by several tumors, including islet and nonislet toms, demonstrating that they were caused by hypoglycemia.
tumors. Nonislet cell tumor hypoglycemia (NICTH) is Laboratory tests revealed elevated transaminase levels with
an uncommon but serious complication of malignancy(4). AST 189U/l (normal, <35U/l), ALT 34U/l (normal, <35U/l),
Systemic chemotherapy was previously demonstrated to lead and hyperbilirubinemia with total bilirubin 1.9mg/dl (normal,
to an unfavorable outcome for hypoglycemia in patients with <1.5mg/dl). However, frequent hypoglycemia episodes devel-
HCC(3). We report herein the successful control of hypo- oped following admission. Further laboratory tests performed
glycemia with systemic chemotherapy in an advanced HCC during the hypoglycemic episodes revealed suppressed insulin
(<1U/ml) and Cpeptide (0.15ng/ml) levels, indicating that
the hypoglycemia was not caused by endogenously or exog-
enously raised insulin levels. IGFI levels (43.42ng/ml; normal,
Correspondence to: Dr PeiHung Chang, Division of 81225ng/ml) were also suppressed. The IGFII and big IGFII
HematoOncology, Department of Internal Medicine, Chang Gung levels could not be measured at our institution. The patient
Memorial Hospital, No. 200, Lane 208, Jijin 1st Road, Keelung8862, experienced further recurrent hypoglycemia (four episodes
Taiwan, R.O.C. of glucose levels lower than 3mmol/l in 3days) despite his
Email: ph555chang@cgmh.org.tw monitored diet and a continuous intravenous infusion of 10%
glucose water solution. Glucocorticoid treatment was started,
Key words: hepatoma, non-islet tumor hypoglycemia, chemotherapy but did not reduce the frequency or severity of hypoglycemic
episodes. Glucagon caused a transient glycemic reaction with
HUANG and CHANG: HEPATOMA WITH SEVERE NON-ISLET CELL TUMOR HYPOGLYCEMIA 899
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