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.
Posts tagged ‘Tissue’
Mohs Surgery
Mohs surgery, also known as Mohs micrographic surgery, is a precise surgical technique for removing several types of skin cancers. During Mohs surgery, layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains. When performed by an experienced surgeon, Mohs surgery offers maximum removal of cancer with minimum damage to surrounding healthy tissue. Mohs surgery is usually done on an outpatient basis using a local anesthetic. Mohs surgery is often cited as having the highest cure rate for the most common type of skin cancer, basal cell carcinoma. It’s also highly effective for recurrent basal cell carcinoma and offers the highest cure rate for these cancers, as well.
Why it’s done
Mohs surgery is used to treat the most common skin cancers, basal cell carcinoma and squamous cell carcinoma, as well as some kinds of melanoma and other more unusual skin cancers. Mohs surgery is especially useful for skin cancers that:
• Have a high risk of recurrence or that have recurred after previous treatment
• Are located in areas where you want to preserve as much healthy tissue as possible, such as the eyes, ears, nose, mouth, hairline, hands, feet and genitals
• Have borders that are hard to define
• Are large or aggressive
What you can expect
Mohs surgery is done on an outpatient basis, usually at your surgeon’s office. The tissue that has been removed it is then sent to a laboratory for immediate examination of tissue. The procedure lasts about an hour. But since it can be difficult to tell how extensive a skin tumor’s “roots” are just by looking at its surface, doctors often advise reserving additional time for the procedure. You likely won’t have to change into a surgical gown unless the location of the tumor requires it. To prepare you for surgery, your surgeon or a nurse cleanses the area to be operated on, outlines it with a special pen and injects the area with a local anesthetic. The injection may pinch or sting a bit at first, but numbness usually sets in quickly. If you’re especially anxious, oral sedatives may be available.
During the procedure
Once the anesthetic has taken effect, your surgeon uses a scalpel to remove the visible portion of the cancer along with a thin, underlying layer of tissue that’s slightly larger than the visible tumor. A temporary bandage is placed on your incision. This takes only a few minutes. This tissue is then sent to the laboratory, where it’s prepared for examination under a microscope. This portion of the procedure typically takes the longest amount of time. If cancer remains, your surgeon notes its location on the Mohs map and uses the map as a guide to remove an additional layer of tissue from your skin, taking care to remove tissue that contains cancer while leaving as much healthy tissue as possible intact. The steps outlined above are repeated until the last tissue sample removed is cancer-free. Local anesthetic can be re-administered as necessary.
After the procedure
After all of the cancer has been removed, you and your surgeon can decide on how to repair the wound. Depending on the extent of the operation, this might include:
• Letting the wound heal on its own
• Using stitches to close the wound
• Using a skin graft from another part of the body, such as behind the ear, to cover the wound
• Shifting skin from an adjacent area (skin flap) to cover the wound
Results
One of the advantages of Mohs surgery is that you know your results right away. Your surgeon or referring doctor will want to monitor your recovery to make sure your wound is healing properly. After that, regular follow-up visits are important to catch any recurrence of cancer or new skin cancers as early as possible.
