A 77-year-old woman with a history of distal pancreatectomy for insulinoma 3 years previously presented with recurrent symptoms of hypoglycemia. The results of 72-hr fasting test were marginal. Abdominal echography showed multiple spherical-shaped, high-echoic lesions in the liver without any findings in the pancreas (Picture 1). An enhanced CT scan revealed non-enhanced multiple heterogeneous low density areas in the liver (Picture 2). T1 weighted MRI showed multiple heterogeneous high intensity lesions (Picture 3). A chemical shift image corresponding to Picture 3 indicated focal hepatic steatosis (Picture 4). Although the target liver biopsy showed large fatty droplets to be deposited in hepatocytes, no tumor cells were found in the specimen. A significant increase in the serum immunoreactive insulin (IRI) level on the celiac and proper hepatic arterial stimulation in arterial stimulation venous sampling (ASVS) were observed, and therefore a diagnosis of liver metastasis of malignant insulinoma was made.
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Picture 2.
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Picture 4.
Though typical insulinoma occurs as a hypervascular tumor, focal fatty liver around the small metastatic foci occasionally demonstrate characteristic image findings (1,2).
The authors state that they have no Conflict of Interest (COI).
References
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