Insulinoma carcinoid

　　Insulinoma carcinoid (Carcinoid) is a tumor originating from EC cells, which have the characteristics of APUD cells and are widely distributed in the gastrointestinal tract, pancreas, and lungs. When the size of the carcinoid is small and the diameter does not exceed 3.5 cm, it usually does not cause symptoms and signs; however, when the size of the carcinoid is large, due to the production of a large amount of 5-HT and other amines and polypeptide hormones, the liver cannot effectively metabolize and inactivate these secretory products of the carcinoid, so 5-HT, 5-HTP, bradykinin, and pancreatic polypeptide all enter the systemic circulation; in addition, when the carcinoid undergoes liver metastasis, the hormones secreted by the liver metastatic carcinoma can enter the systemic circulation directly without being metabolized by liver cells and act on target cells, thus causing the carcinoid syndrome.

　　In addition to the symptoms of pancreatic islet cell carcinoid and tumor, other endocrine hormone hyperfunction may also occur, such as insulin, glucagon, growth hormone, parathyroid hormone, adrenocorticotropic hormone, etc., which generally have corresponding characteristic manifestations for differentiation. In the late stage of carcinoid and tumor, emaciation, anemia, hypoproteinemia, and other cachexia manifestations may also occur.

　　This disease is often asymptomatic in the early stage, or without specific clinical symptoms; when patients have typical paroxysmal skin erythema and the reaction persists without cure, the possibility of this disease should be considered. When patients have skin erythema accompanied by tachycardia, blood pressure drop, asthma, dyspnea, abdominal pain, diarrhea, and other manifestations of carcinoid syndrome, it is more supportive of the diagnosis of this disease.

　　For patients suspected of having carcinoid syndrome, laboratory tests such as rough screening tests, 5-HIAA determination in urine, 5-HT determination in tumor tissue, and the use of B-ultrasound, CTMRCI, and ERCP, etc., for localization examination techniques, can provide diagnostic data for the formulation of surgical plans.

　　Pancreatic islet cell carcinoid can have typical carcinoid syndrome manifestations: paroxysmal facial flushing, hypotension, periorbital edema, and lacrimation, etc.

　　1, Paroxysmal flushing (Intermittent flushing):It mainly occurs in exposed areas such as the face, neck, and anterior chest, and can also spread throughout the body. The occurrence of skin erythema is often paroxysmal and sudden, presenting as bright red or dark red, lasting for several minutes to 1-2 days. However, the color change in black people or those with dark skin may not be obvious. If the course of the disease is long, fixed skin changes may appear in the frequently attacked areas, with multiple fine blood vessel dilatation, and the skin presenting as dark red. Factors that can affect the onset of skin erythema include alcohol consumption, pain, emotional fluctuations, and physical activity, which can induce skin erythema; epinephrine and norepinephrine can also promote the onset. The use of alpha-adrenergic blockers can stop the occurrence of skin erythema. During the onset of skin erythema, patients often have tachycardia, hypotension, periorbital edema, and symptoms of the gastrointestinal tract and lungs.

　　2, Cardiovascular system symptoms:When patients have skin erythema, they may be accompanied by tachycardia, blood pressure drop, and even shock; in the late stage, heart valve lesions or congestive right heart failure may occur.

　　3, Respiratory system symptoms:About 20-30% of patients may experience asthma and dyspnea simultaneously with paroxysmal skin erythema, similar to bronchial asthma. The mechanism is caused by bronchospasm induced by substances such as 5-HT.

　　4, Gastrointestinal symptoms:Patients may have varying degrees of abdominal pain, abdominal distension, diarrhea, and other symptoms. Abdominal pain is often related to the location of the primary tumor and/or metastatic cancer, as well as the compression and destruction of surrounding tissues when the tumor mass increases. Diarrhea is usually watery, and in severe cases, it can reach 10-20 times a day. It should be distinguished from WDHA syndrome.

　　5, Periorbital edema, conjunctival hemorrhage, lacrimation, often accompanied by skin erythema.

　　6. Other symptoms:Accompanied by insulinoma, other endocrine hormone hyperfunction may also occur, such as insulin, glucagon, growth hormone, parathyroid hormone, adrenocorticotropic hormone, etc., which generally have corresponding characteristic manifestations for differentiation. In the late stage of carcinoid, symptoms such as weight loss, anemia, hypoalbuminemia, and other cachexia may also occur.

　　Currently, there are no effective preventive measures for the disease, so early detection and early diagnosis are the key to the prevention and treatment of the disease. It is recommended to have a full-body examination once a year. If there are abnormalities found in B-ultrasound or CT, MRI, then consider the possibility of the disease. Once there is a suspicion of the disease, immediate surgical resection and pathological examination should be performed to clarify the nature of the tumor mass.

　　1. Screening test

　　Drop a drop of the patient's urine on a filter paper, then add azo P-nitroanilinediazo. If red appears, it indicates an increase in 5-hydroxyindoleacetic acid (5-HIAA) in the urine, supporting the diagnosis of the disease; if purple, it belongs to pheochromocytoma.

　　2. 5-HIAA determination in urine

　　Since 99% of 5-HT is converted into 5-HIAA in the body and excreted through urine, measuring the total amount of 5-HIAA in 24 hours of urine is helpful for the diagnosis of the disease. The normal total amount of 5-HIAA in 24 hours of urine is 10.5-42.0μmol, and the urine 5-HIAA of most patients is greater than 158μmol/24 hours. If it is greater than 263μmol/24 hours, it has diagnostic value.

　　3. 5-HT determination in tumor tissues

　　The content of 5-HT in carcinoid tissues is significantly increased, which is more sensitive than the 5-HIAA method measured in urine.

　　The use of ultrasound, CT, MRI, and ERCP and other examinations can help understand the location, size, and number of insulinoma, providing localization diagnostic data for the formulation of surgical plans.

　　1. What foods are good for the body after pancreatic cancer surgery

　　Diet should first choose nutrition-rich, easy to digest, low in刺激性, and low in fat. High-protein and high-carbohydrate foods such as dairy products, fish, liver, egg whites, refined flour products, lotus root powder, fruit juice, vegetable soup, and glutinous rice can be consumed. It is also recommended to eat foods that have a softening and dispersing effect, such as hawthorn, malt, Job's tears, leaven, adzuki bean, shepherd's purse, ophiopogon, costus, trichosanthes, angelica, astragalus, codonopsis, honeysuckle, kelp, seaweed, and nori. It is advisable to use tonics to nourish Qi and blood, strengthen the spleen, and harmonize the stomach, such as glutinous rice, adzuki bean, broad bean, yam, goji, dulse, fig, chestnut, milk, and water chestnut flour.

　　2. What foods should be avoided after pancreatic cancer surgery

　　It is necessary to avoid excessive drinking, overeating, alcoholism, and high-fat diets. It is recommended to eat less or limit foods that are difficult to digest, such as fatty meats, fish roe, brain, greasy, fried, and others. It is forbidden to eat spicy and刺激性 foods such as scallion, ginger, garlic, chili, and to avoid smoking and drinking.

　　Firstly, Surgical Treatment

　　Like other functional endocrine tumors, the early resection of the tumor is the preferred treatment method for this disease; the principles and methods of surgery are also the same. However, even if the disease has metastasized, if the primary carcinoid focus can be resected, the symptoms can be alleviated or even eliminated. For multicentric or metastatic carcinoids that are not suitable for radical resection, palliative resection of the pancreas or liver lobe can also have a certain therapeutic effect.

　　Secondly, Internal Medicine Treatment

　　1. Minimize or avoid the use of drugs that can promote the release of 5-HT

　　These include morphine, halothane, dextran, polymyxin, and others. It is also advisable to avoid or reduce alcohol consumption, emotional fluctuations, and strenuous exercise, which are factors that can easily induce attacks of carcinoid syndrome.

　　2. Application of histamine 1 and histamine 2 antagonists to inhibit carcinoid secretion of histamine and peptide hormones

　　(1) Methysergide: Used for the treatment of carcinoid syndrome attacks, administered intravenously in a single dose of 1 to 4mg; or 10 to 20mg added to 100 to 200ml of normal saline, infused intravenously over 1 to 2 hours, which can control symptoms such as skin erythema, asthma, and diarrhea.

　　(2) Cyproheptadine; taken orally at a dose of 4 to 8mg, three to four times a day, can alleviate symptoms and achieve the purpose of palliative treatment.

　　3. Tryptophan Hydroxylase Inhibitors

　　These drugs can inhibit the activity of tryptophan hydroxylase, thereby reducing the synthesis of 5-HT and alleviating the symptoms of the disease.

　　(1) Para-chlorophenylalanine (parachlophenylalanine): 1g each time, three to four times a day, taken orally. It can alleviate or reduce the severity of nausea, vomiting, diarrhea, and erythema of the skin. Its side effects can lead to dysfunction of the central nervous system or hypothermia, etc.

　　(2) Methylodopa (methylodpa): This drug can be used to treat pancreatic carcinoid tumors that secrete 5-hydroxytryptophan, taken orally at a dose of 0.25 to 0.5g, four times a day.

　　4. Somatostatin

　　It can broadly inhibit the release of endocrine hormones and is applied to patients with islet cell carcinomas, which can suppress the erythema caused by pentagastrin stimulation.

　　5. Chemotherapy:

　　Chemotherapy drugs such as 5-Fu, cyclophosphamide, and others can alleviate the symptoms of the disease, but the efficacy is poor.