Chemoembolization with Epirubicin in the Treatment of Malignant Insulinoma

Insulinoma liver metastases are rare because only a minority of insulinomas (10%) is malignant. We report a case of a 54 year-old patient diagnosed with malignant insulinoma with synchronous liver metastases, treated first by systemic chemotherapy by Streptozotocin and 5-Fluorouracil without clinical control of symptoms (hypoglycemia), then by pancreatic resection and seven chemoembolization with Epirubicin of liver metastases. After the first chemoembolization with Epirubicin the patient presented a total control of hypoglycemia and an objective response on liver metastases. Because of difficulties of catheterization of the hepatic artery after seven chemoembolizations, the patient was treated by somatostatin analogs, by Sunitinib (in the SUTENT study) for 1 year and then by Everolimus (in the RADIANT-3 study) for 1 year. In front of the progression of liver metastases and recurrence of hypoglycemia, a new chemoembolization with streptozotocin was performed without clinical, biological or radiological response. A second chemoembolization with Epirubicin was performed with a major biological response on tumor markers, reduction of 30% of liver metastases and a total control of symptoms.