LAUSR

A 49-year-old woman with hypoglycemic coma with the diagnosis of insulinoma was admitted to our department. Contrast-enhanced computed tomography (CT) with pancreas perfusion imaging showed a small nodular mass with higher blood flow in the body of the pancreas, considered to be the insulinoma (Fig. 1, panel P). However, two concomitant liver lesions were found in segment S7 (Fig. 1, panel S7) and S8 (Fig. 1, panel S8). This homogeneous lesion was hypodense on native CT scan, hyperdense during the arterial phase, and isodense on later images. CT findings therefore were suggestive of insulinoma with suspicious liver metastases. Then, magnetic resonance imaging (MRI) clearly located the insulinoma in the pancreatic body as a high signal intensity nodular mass on T2-weighted images, a solid mass, 1.1 cm × 1.2 cm in size (Fig. 1, panel P). The liver lesions showed low signal intensity on T1-weighted and high signal intensity on T2-weighted sequences with a central area of hyperintensity that were enhanced on contrasted T2-weighted MRI that confirm the diagnosis of insulinoma with liver metastases (Fig. 1, panels S7 and S8). Surgical pathology reported a pancreatic primary neuroendocrine origin (G1, Fig. 2, panel P), the lesion in the segment S7 was hepatic adenoma (Fig. 2, panel S7), and the lesion in the segment S8 was neuroendocrine origin in the hepatic adenoma (G1, Fig. 2, panel S8). This is the first reported case of metastasis from a primary insulinoma to a hepatic adenoma. Liver is the most common site of metastasis of insulinomas. CT and MRI can provide information that may assist surgery decisions like the extent of primary tumor, potential metastatic nodal involvement, or identification of liver metastasis. So sometimes it is difficult to differentiate the hepatic adenoma from the hepatic metastasis lesion in CT or MRI. The diagnosis of metastatic insulinoma within hepatic adenoma can only be definitively made through pathology.