Hepatic Artery Embolization for Palliation of Symptomatic Hypoglycemia in Patients with Hepatic Insulinoma Metastases

Purpose To determine the safety and effectiveness of bland hepatic artery embolization (HAE) for palliation of symptomatic hypoglycemia in patients with hepatic insulinoma metastases refractory to medical management. Materials and Methods An IRB-approved retrospective review was undertaken of all patients with a tissue (n=18) or imaging (n=2) diagnosis of hepatic insulinoma metastases and symptomatic hyperinsulinemic hypoglycemia refractory to medical management who underwent bland hepatic artery embolization (HAE) at a single center between 1/1/1998 and 11/1/2020. Twenty patients (10 women, 10 men; mean age, 56 y; range, 18–84 y) were identified who individually underwent 1 (n = 7), 2 (n = 5), 3 (n = 5), 4 (n = 2), or 5 (n = 1) HAEs, for an overall total of 45 HAEs. Post-HAE hypoglycemia recurrence was defined as onset of adrenergic symptoms (e.g. sweating, weakness, tremor), neuroglycopenic symptoms (e.g. confusion, loss of consciousness), and/or documented serum glucose <50 mg/dL, in the absence of an alternative explanation. Median time to first hypoglycemia recurrence, hypoglycemia-free survival (HFS), and overall survival (OS) were calculated using Kaplan-Meier method. Results Prior to HAE, all patients experienced adrenergic or neuroglycopenic symptoms alleviated by glucose intake, and 60% (n = 12) of patients had documented serum glucose <50 mg/dL within 1 week of the first treatment. Median post-HAE follow-up was 9.4 months (mean, 26 m; range, 0.1–190 m). Post-procedural hypoglycemic symptom relief after the first HAE was reported in 100% (n = 20) of patients prior to discharge or at follow-up. Post-HAE hypoglycemia recurrence occurred in 60% (n = 12) of patients with a median time to first hypoglycemia recurrence of 2 months (mean, 14 m; range, 0.2–60 m). After the first HAE, median HFS was 14.5 months, and median OS was 16 months. One patient experienced labile post-procedure blood glucose levels requiring ICU admission for IV dextrose. Otherwise, no major procedure-related complications occurred. Conclusion Bland HAE is a safe, effective, and repeatable procedure for palliation of symptomatic hypoglycemia in patients with hepatic insulinoma metastases refractory to medical management.