Question

A lady presented with recurrent attacks of giddiness and abdominal pain for three months. Endoscopy was normal. Her fasting blood glucose was 40 mg% and insulin levels were elevated. CT abdomen showed a well defined 8 mm enhancing lesion in the head of the pancreas, with no other abnormal findings. What should be the treatment plan for this patient?

• A. Whipple's operation
• B. Enucleation
• C. Enucleation with radiotherapy
• D. Administration of streptozotocin

Hint:

Small benign insulinoma wants the most tissue-sparing operation.

Answer 1

The Correct Option is B

Start from the biochemistry. Spells of giddiness and pain that go with a fasting glucose of 40 mg% and a high insulin level point straight to endogenous hyperinsulinism, and the small enhancing pancreatic nodule names the culprit as an insulinoma. The clinical story is essentially Whipple's triad.

The key facts that drive management are that insulinomas are typically tiny, single, and benign in about nine of ten cases. An 8 mm well-defined head lesion is the textbook benign insulinoma.

For such a lesion you want the least destructive curative operation, which is enucleation: shell out the tumour and keep the surrounding pancreas. A Whipple resection would needlessly sacrifice the duodenum and pancreatic head for a benign nodule. Radiotherapy adds nothing to a curable benign tumour. Streptozotocin is reserved for malignant, spread-out islet cell disease, which this patient does not have.

$\text{small + benign + localized insulinoma} \Rightarrow \text{enucleation}$
\[\boxed{\text{Enucleation}}\]