Intra Abdominal Malignant Soft Tissue Tumour Producing Hypoglycemia
A 64 years old lady presented to us with complain of increasing abdominal girth and tight fitting garments day by day. On taking detail history we came to know that she was known diabetic taking insulin to combat hyperglycemia. Since last few months she had frequent episodes of hypoglycemia and ultimately forced to stop insulin. Even without treatment of diabetes and with proper diet, her blood sugar level frequently fell down to 30-40gm% and she had to take instant glucose to correct hypoglycemia.
For increasing abdominal girth her abdominal sonography was done which showed huge intra-abdominal tumour, exact site of origin not defined. Due to increasing size of tumor she had unbearable backache and couldn't sit for long duration. She did not have upper or lower GI symptoms, urinary symptoms or jaundice. She was referred by her physician at Dehradun to Dharamshila cancer hospital. We further investigated her with CECT abdomen and thorax and relevant blood investigations. Her serum insulin level was low in spite of hypoglycemia. The tumour was huge and involving colon, spleen, pancreas and stomach. Further decision was taken to remove the tumour. Seven k.g. tumour measuring around 50 cms in it's maximum length was removed successfully. En block resection of tumour with transverse colon, splenic flexure, decending colon, body and tail of pancreas, whole spleen, part of stomach near it's fundus and greater curvature and left perinephric fat was done successfully. End to end colo-colic anastomosis in single layer, closure of the pancreatic stump, and repair of stomach was performed. Patient recovered uneventfully and resumed to oral diet on 7th postoperative day. Postoperatively her blood sugar came in the diabetic range and managed with insulin in the usual dose. The final histopathology report is high grade sarcoma (Leiomyosarcoma). She require chemotherapy in the adjuvant setting.
Discussion:- Hypoglycemia due to tumour is usually attributed to islet cell tumor (Insulinoma) arising from the pancreas. Insulinomas are characterized by fasting hypoglycemia and neuroglycopenic symptoms. The episodic nature of the hypoglycemic attacks is due to the intermittent insulin secretion by the tumor. The majority of insulinomas are intrapancreatic, benign and solitary. It never attains such huge size to produce hypoglycemia. Huge size intra-abdominal tumor with features of hypoglycemia point towards Non islet cell tumor hypoglycemia (NICTH). Hypoglycemia due to NICTH in most of the reported case is due to Insulin like growth factor (IGF) secreted by the mesenchymal tumor. IGF lowers the blood sugar level which in turn gives negative feedback to lower the serum insulin level as occurred in this case. After removal of the tumor blood sugar rose to normal and the to diabetic level, which support the presence of IGF. The extent of surgery was massive in this case and there are chances of pancreatic fistula, postsplenectomy septicemia, anastomotic dehiscence, subphrenic abscess, pneumonia and deep vein thrombosis. This patient recovered uneventfully and resume her normal diet on 7th postoperative day and discharged. Due to high grade nature of sarcoma she will require chemotherapy in the adjuvant setting.
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