A 68 year old Ecuadorian man was investigated for
polyuria,
polydipsia and
weight loss of 3 kg during the previous two months.
Insulin dependent diabetes mellitus was diagnosed 10 year before admission and treated with appropriate diet and
insulin (35 U/d). 18 months before was diagnosed in El Ecuador of "multiple liver nodes non-suggestive of
malignancy". Physical examination showed a large multinodular petrous
hepatomegaly. There was no evidence of skin lesions. Results of laboratory studies included a basal plasma
glucose level that ranged between 275-367 mg/dl (N=60-100), glycosylated haemoglobin of 8.9% (N<5) and a
serum albumin of 2.8 gr./dl (N=3.4-4.8). At admission non-other laboratory alterations were detected. Computed tomography showed a mass on the head of the pancreas with loco-regional lymph nodes and liver
metastases.
Tumor markers were normal. Fine-needle aspiration cytology of the liver masses revealed the presence of liver
metastases of a non-differentiated malignant
tumor. A 111In-DTPAOC scintigraphy revealed the presence of
somatostatin receptors in the liver
metastases, also detecting the presence of multiple bone
metastases in the axial and appendicular skeleton. Plasma
glucagon level was 678 pg/ml (N<250). A diagnosis of metastatic
glucagonoma was established and
therapy with
streptozocin,
5-FU,
insulin and synthetic
somatostatin analogs was initiated. Three months after the
therapy initiation the patient was symptom free. Some weeks after the patient suffered from left hip
pain, and a control 111In-DTPA scintigraphy showed progression of his bone
metastases. In conclusion,
glucagonoma must be suspected in all diabetic patients with metastatic liver, even in absence of necrotic migratory
erythema. In these circumstances, plasmatic
glucagon level and
somatostatin receptors scintigraphy will be a useful tool for establishing the final diagnosis.