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Su incidencia es 1-4 casos por mill&#243;n de habitantes y a&#241;o<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a>&#46; La mayor&#237;a son espor&#225;dicos&#44; aunque un 6-8&#37; de ellos est&#225;n asociados a la neoplasia endocrina m&#250;ltiple tipo 1 &#40;NEM-1&#41;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4-6</span></a>&#46; El diagn&#243;stico viene determinado por la presencia de glucosa plasm&#225;tica &#60; 3 mmol&#47;l &#40;50<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; &#40;espont&#225;nea o inducida en el test de ayuno de 72 h&#44; que es la prueba m&#225;s sensible y espec&#237;fica&#41;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a>&#44; con valores de insulina plasm&#225;tica &#62; 18<span class="elsevierStyleHsp" style=""></span>pmol&#47;l &#40;&#62;3<span class="elsevierStyleHsp" style=""></span>&#956;U&#47;ml&#41;&#44; proinsulina &#62; 5<span class="elsevierStyleHsp" style=""></span>pmol&#47;l o p&#233;ptido <span class="elsevierStyleSmallCaps">C</span> &#62; 0&#44;2 nmol&#47;l&#46; Las determinaciones de niveles de sulfonilurea en orina y anticuerpos antiinsulina en plasma deben ser negativas&#46; La mayor&#237;a de los insulinomas son benignos y de peque&#241;o tama&#241;o&#44; catalog&#225;ndose como malignos cuando presentan met&#225;stasis o son irresecables&#46; La ex&#233;resis quir&#250;rgica es el tratamiento de elecci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4-7</span></a>&#46; En nuestro pa&#237;s&#44; los casos de insulinoma descritos son escasos y habitualmente de forma aislada&#46; El objetivo del estudio es realizar una revisi&#243;n retrospectiva de casos con diagn&#243;stico definitivo anatomopatol&#243;gico de insulinoma atendidos en un hospital de referencia entre los a&#241;os 2005 y 2016&#44; describiendo datos demogr&#225;ficos&#44; bioqu&#237;micos&#44; radiol&#243;gicos y evolutivos&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Se obtuvieron 14 casos &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#44; con una mediana de edad de 49&#44;5 a&#241;os&#46; Todos presentaron cl&#237;nica de hipoglucemia confirmada anal&#237;ticamente y con recuperaci&#243;n tras la ingesta de hidratos de carbono &#40;tr&#237;ada de Whipple&#41;&#46; Se detectaron 3<span class="elsevierStyleHsp" style=""></span>casos &#40;21&#44;4&#37;&#41; en contexto de NEM-1&#46; Se practic&#243; test de ayuno en 13 casos &#40;92&#37;&#41;&#44; resultando positivo en 12 &#40;92&#44;3&#37;&#41;&#46; La insulinemia media fue de 108&#44;9<span class="elsevierStyleHsp" style=""></span>pmol&#47;l y el p&#233;ptido C de 1&#44;01 nmol&#47;l&#46; El di&#225;metro medio del insulinoma por TC abdominal fue de 1&#44;9<span class="elsevierStyleHsp" style=""></span>cm&#44; siendo todos excepto 4<span class="elsevierStyleHsp" style=""></span>inferiores a 2<span class="elsevierStyleHsp" style=""></span>cm&#46; Dos presentaban met&#225;stasis al diagn&#243;stico&#44; pulmonares y hep&#225;ticas&#44; respectivamente&#46; Todos se trataron quir&#250;rgicamente&#44; salvo uno de los malignos que recibi&#243; tratamiento con diaz&#243;xido&#46; En la anatom&#237;a patol&#243;gica&#44; el 100&#37; de ellos marcaron para insulina en la inmunohistoqu&#237;mica&#46; Se obtuvo la determinaci&#243;n del ki67 de 11 casos &#40;91&#44;6&#37;&#41;&#44; siendo en 8 menor o igual al 2&#37;&#44; en uno igual al 3&#37; y en 2 igual al 5&#37;&#46; La evoluci&#243;n en los casos sin met&#225;stasis fue la curaci&#243;n tras la cirug&#237;a&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">La sospecha cl&#237;nica de hipoglucemia en el paciente sin diabetes no es f&#225;cil&#44; ya que los s&#237;ntomas pueden tener un predominio adren&#233;rgico&#44; pero pueden tambi&#233;n presentarse con sintomatolog&#237;a de neuroglucopenia<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#44; especialmente si los episodios de hipoglucemia son repetidos&#46; En nuestra serie el test de ayuno fue positivo en el 92&#44;3&#37; de los casos&#46; Hirshberg et al<span class="elsevierStyleItalic">&#46;</span> describieron que el 43&#37; de los pacientes con insulinoma tratados mediante un test de ayuno desarrollan hipoglucemia sintom&#225;tica en 12 h&#44; el 67&#37; en 24 h&#44; el 95&#37; en 48 h y el 100&#37; a las 72 h<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a>&#46; En este sentido&#44; fue excepcional el caso 13 por presentar hipoglucemias exclusivamente posprandiales y dando un resultado falso negativo en el test de ayuno&#44; circunstancia descrita solo en el 1&#37; de los insulinomas<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El porcentaje de casos en nuestra serie asociados a NEM-1 fue superior al descrito<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6-8</span></a>&#44; probablemente por ser nuestro centro de referencia para esta patolog&#237;a&#46; Adem&#225;s&#44; en el contexto de NEM-1&#44; los tumores son frecuentemente m&#250;ltiples<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#44; y de hecho en nuestro caso todos presentaban multifocalidad en la anatom&#237;a patol&#243;gica&#46; Dos casos fueron malignos &#40;14&#44;2&#37;&#41;&#44; porcentaje levemente superior al 10&#37; descrito en la literatura<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a>&#44; confirmando que es el tumor neuroendocrino pancre&#225;tico menos agresivo&#46; El tama&#241;o del tumor en nuestra serie es similar a las series publicadas&#44; donde el 90&#37; de ellos son menores a 2<span class="elsevierStyleHsp" style=""></span>cm<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6&#44;8</span></a>&#46; Destaca el caso 9&#44; que present&#243; un di&#225;metro de 11<span class="elsevierStyleHsp" style=""></span>cm asociado a met&#225;stasis pulmonares&#44; siendo irresecable y llevando al fallecimiento del paciente&#46; El otro caso&#44; con met&#225;stasis hep&#225;ticas&#44; fue intervenido mediante enucleaci&#243;n pancre&#225;tica y posterior trasplante hep&#225;tico&#44; con curaci&#243;n de la enfermedad en un seguimiento superior a 10 a&#241;os&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La t&#233;cnica de elecci&#243;n para la localizaci&#243;n preoperatoria del tumor es la TC abdominal o la resonancia magn&#233;tica&#44; obteni&#233;ndose en nuestra serie un 100&#37; de &#233;xito con la primera&#46; La ecograf&#237;a endosc&#243;pica tiene una sensibilidad descrita del 90&#37;&#59; el octreoscan detecta el 50&#37; de los casos&#44; por lo que no es una prueba fiable y la estimulaci&#243;n con inyecci&#243;n arterial selectiva de calcio presenta elevada sensibilidad&#44; pero rara vez se utiliza dado su car&#225;cter invasivo&#46; Intraoperatoriamente&#44; la ecograf&#237;a detecta los insulinomas con una sensibilidad del 98-100&#37;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#46; El tratamiento fue quir&#250;rgico en m&#225;s del 90&#37; de los casos de nuestra serie&#44; principalmente mediante la enucleaci&#243;n y la pancreatectom&#237;a corporocaudal&#44; con curaci&#243;n en todos los casos que no presentaron met&#225;stasis&#46; Esta evoluci&#243;n satisfactoria es an&#225;loga a la descrita en la literatura donde la curaci&#243;n supera el 95&#37; de los casos<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Las limitaciones de nuestro estudio son las propias de un estudio observacional de serie de casos retrospectivo&#46; No obstante&#44; nuestros datos cl&#237;nicos&#44; radiol&#243;gicos y anal&#237;ticos son concordantes con lo descrito en revisiones m&#225;s amplias&#44; entre las que destaca la de Mehrabi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> que reuni&#243; informaci&#243;n de un total de m&#225;s de 6&#46;000 casos&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En resumen&#44; el diagn&#243;stico de insulinoma se debe plantear en el estudio de hipoglucemias en el paciente no diab&#233;tico&#44; realiz&#225;ndose su evaluaci&#243;n mediante el test de ayuno&#44; que resulta concluyente en la gran mayor&#237;a de los pacientes&#44; aunque su negatividad no excluye el diagn&#243;stico&#46; La primera prueba de imagen para su localizaci&#243;n debe ser la TC abdominal&#46; Suelen ser tumores aislados&#44; peque&#241;os y benignos&#44; aunque se debe tener presente la posibilidad de casos at&#237;picos&#46; Disponemos de t&#233;cnicas quir&#250;rgicas que presentan excelentes resultados&#44; por lo que la correcta sospecha de la enfermedad es esencial&#46;</p></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AP&#58; anatom&#237;a patol&#243;gica&#59; DPC&#58; duodenopancreatectom&#237;a cef&#225;lica&#59; IQ&#58; tipo de intervenci&#243;n quir&#250;rgica&#59; M&#58; mujer&#59; NR&#58; no realizado&#59; PC&#58; pancreatectom&#237;a corporocaudal&#59; V&#58; var&#243;n&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Caso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Edad al diagn&#243;stico &#40;a&#241;os&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sexo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Di&#225;metro m&#225;ximo por TC &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Multic&#233;ntrico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AP&#46; Ki 67&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Test de ayuno&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IQ&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NEM-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PC&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enucleaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enucleaci&#243;n &#43; PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enucleaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enucleaci&#243;n &#43; PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M1 pulm&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enucleaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M1 hep&#225;ticas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enucleaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
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CORRESPONDENCIA
Hipoglucemia causada por insulinoma. Revisión de una serie de casos atendidos en un hospital terciario
Hypoglycemia caused by insulinoma. A review of a case series treated at a tertiary hospital
A. Simó-Servat
Autor para correspondencia
andreusimoservat@gmail.com

Autor para correspondencia.
, J. Puig de la Bellacasa Suils, M. Pérez Maraver
Servicio de Endocrinología y Nutrición, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">La principal causa de hipoglucemia en la poblaci&#243;n es el uso de antidiab&#233;ticos orales o insulina&#44; especialmente en personas de edad avanzada<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a>&#46; En los pacientes sin diabetes&#44; la hipoglucemia se clasifica en 2<span class="elsevierStyleHsp" style=""></span>grandes grupos&#44; con o sin hiperinsulinemia&#46; Si la insulinemia es apropiadamente baja&#44; las causas suelen ser enfermedades sist&#233;micas graves&#44; como la sepsis o la insuficiencia hep&#225;tica y renal graves<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a>&#46; Por el contrario&#44; si existe hiperinsulinemia&#44; el diagn&#243;stico diferencial incluye el insulinoma o la administraci&#243;n ex&#243;gena de insulina o sulfonilureas&#46; El insulinoma es el tumor neuroendocrino pancre&#225;tico funcionante m&#225;s frecuente y la causa principal de hipoglucemia de ayuno relacionada con secreci&#243;n de insulina end&#243;gena&#46; Su incidencia es 1-4 casos por mill&#243;n de habitantes y a&#241;o<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a>&#46; La mayor&#237;a son espor&#225;dicos&#44; aunque un 6-8&#37; de ellos est&#225;n asociados a la neoplasia endocrina m&#250;ltiple tipo 1 &#40;NEM-1&#41;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4-6</span></a>&#46; El diagn&#243;stico viene determinado por la presencia de glucosa plasm&#225;tica &#60; 3 mmol&#47;l &#40;50<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; &#40;espont&#225;nea o inducida en el test de ayuno de 72 h&#44; que es la prueba m&#225;s sensible y espec&#237;fica&#41;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a>&#44; con valores de insulina plasm&#225;tica &#62; 18<span class="elsevierStyleHsp" style=""></span>pmol&#47;l &#40;&#62;3<span class="elsevierStyleHsp" style=""></span>&#956;U&#47;ml&#41;&#44; proinsulina &#62; 5<span class="elsevierStyleHsp" style=""></span>pmol&#47;l o p&#233;ptido <span class="elsevierStyleSmallCaps">C</span> &#62; 0&#44;2 nmol&#47;l&#46; Las determinaciones de niveles de sulfonilurea en orina y anticuerpos antiinsulina en plasma deben ser negativas&#46; La mayor&#237;a de los insulinomas son benignos y de peque&#241;o tama&#241;o&#44; catalog&#225;ndose como malignos cuando presentan met&#225;stasis o son irresecables&#46; La ex&#233;resis quir&#250;rgica es el tratamiento de elecci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4-7</span></a>&#46; En nuestro pa&#237;s&#44; los casos de insulinoma descritos son escasos y habitualmente de forma aislada&#46; El objetivo del estudio es realizar una revisi&#243;n retrospectiva de casos con diagn&#243;stico definitivo anatomopatol&#243;gico de insulinoma atendidos en un hospital de referencia entre los a&#241;os 2005 y 2016&#44; describiendo datos demogr&#225;ficos&#44; bioqu&#237;micos&#44; radiol&#243;gicos y evolutivos&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Se obtuvieron 14 casos &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#44; con una mediana de edad de 49&#44;5 a&#241;os&#46; Todos presentaron cl&#237;nica de hipoglucemia confirmada anal&#237;ticamente y con recuperaci&#243;n tras la ingesta de hidratos de carbono &#40;tr&#237;ada de Whipple&#41;&#46; Se detectaron 3<span class="elsevierStyleHsp" style=""></span>casos &#40;21&#44;4&#37;&#41; en contexto de NEM-1&#46; Se practic&#243; test de ayuno en 13 casos &#40;92&#37;&#41;&#44; resultando positivo en 12 &#40;92&#44;3&#37;&#41;&#46; La insulinemia media fue de 108&#44;9<span class="elsevierStyleHsp" style=""></span>pmol&#47;l y el p&#233;ptido C de 1&#44;01 nmol&#47;l&#46; El di&#225;metro medio del insulinoma por TC abdominal fue de 1&#44;9<span class="elsevierStyleHsp" style=""></span>cm&#44; siendo todos excepto 4<span class="elsevierStyleHsp" style=""></span>inferiores a 2<span class="elsevierStyleHsp" style=""></span>cm&#46; Dos presentaban met&#225;stasis al diagn&#243;stico&#44; pulmonares y hep&#225;ticas&#44; respectivamente&#46; Todos se trataron quir&#250;rgicamente&#44; salvo uno de los malignos que recibi&#243; tratamiento con diaz&#243;xido&#46; En la anatom&#237;a patol&#243;gica&#44; el 100&#37; de ellos marcaron para insulina en la inmunohistoqu&#237;mica&#46; Se obtuvo la determinaci&#243;n del ki67 de 11 casos &#40;91&#44;6&#37;&#41;&#44; siendo en 8 menor o igual al 2&#37;&#44; en uno igual al 3&#37; y en 2 igual al 5&#37;&#46; La evoluci&#243;n en los casos sin met&#225;stasis fue la curaci&#243;n tras la cirug&#237;a&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">La sospecha cl&#237;nica de hipoglucemia en el paciente sin diabetes no es f&#225;cil&#44; ya que los s&#237;ntomas pueden tener un predominio adren&#233;rgico&#44; pero pueden tambi&#233;n presentarse con sintomatolog&#237;a de neuroglucopenia<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#44; especialmente si los episodios de hipoglucemia son repetidos&#46; En nuestra serie el test de ayuno fue positivo en el 92&#44;3&#37; de los casos&#46; Hirshberg et al<span class="elsevierStyleItalic">&#46;</span> describieron que el 43&#37; de los pacientes con insulinoma tratados mediante un test de ayuno desarrollan hipoglucemia sintom&#225;tica en 12 h&#44; el 67&#37; en 24 h&#44; el 95&#37; en 48 h y el 100&#37; a las 72 h<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a>&#46; En este sentido&#44; fue excepcional el caso 13 por presentar hipoglucemias exclusivamente posprandiales y dando un resultado falso negativo en el test de ayuno&#44; circunstancia descrita solo en el 1&#37; de los insulinomas<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El porcentaje de casos en nuestra serie asociados a NEM-1 fue superior al descrito<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6-8</span></a>&#44; probablemente por ser nuestro centro de referencia para esta patolog&#237;a&#46; Adem&#225;s&#44; en el contexto de NEM-1&#44; los tumores son frecuentemente m&#250;ltiples<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#44; y de hecho en nuestro caso todos presentaban multifocalidad en la anatom&#237;a patol&#243;gica&#46; Dos casos fueron malignos &#40;14&#44;2&#37;&#41;&#44; porcentaje levemente superior al 10&#37; descrito en la literatura<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a>&#44; confirmando que es el tumor neuroendocrino pancre&#225;tico menos agresivo&#46; El tama&#241;o del tumor en nuestra serie es similar a las series publicadas&#44; donde el 90&#37; de ellos son menores a 2<span class="elsevierStyleHsp" style=""></span>cm<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6&#44;8</span></a>&#46; Destaca el caso 9&#44; que present&#243; un di&#225;metro de 11<span class="elsevierStyleHsp" style=""></span>cm asociado a met&#225;stasis pulmonares&#44; siendo irresecable y llevando al fallecimiento del paciente&#46; El otro caso&#44; con met&#225;stasis hep&#225;ticas&#44; fue intervenido mediante enucleaci&#243;n pancre&#225;tica y posterior trasplante hep&#225;tico&#44; con curaci&#243;n de la enfermedad en un seguimiento superior a 10 a&#241;os&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La t&#233;cnica de elecci&#243;n para la localizaci&#243;n preoperatoria del tumor es la TC abdominal o la resonancia magn&#233;tica&#44; obteni&#233;ndose en nuestra serie un 100&#37; de &#233;xito con la primera&#46; La ecograf&#237;a endosc&#243;pica tiene una sensibilidad descrita del 90&#37;&#59; el octreoscan detecta el 50&#37; de los casos&#44; por lo que no es una prueba fiable y la estimulaci&#243;n con inyecci&#243;n arterial selectiva de calcio presenta elevada sensibilidad&#44; pero rara vez se utiliza dado su car&#225;cter invasivo&#46; Intraoperatoriamente&#44; la ecograf&#237;a detecta los insulinomas con una sensibilidad del 98-100&#37;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#46; El tratamiento fue quir&#250;rgico en m&#225;s del 90&#37; de los casos de nuestra serie&#44; principalmente mediante la enucleaci&#243;n y la pancreatectom&#237;a corporocaudal&#44; con curaci&#243;n en todos los casos que no presentaron met&#225;stasis&#46; Esta evoluci&#243;n satisfactoria es an&#225;loga a la descrita en la literatura donde la curaci&#243;n supera el 95&#37; de los casos<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Las limitaciones de nuestro estudio son las propias de un estudio observacional de serie de casos retrospectivo&#46; No obstante&#44; nuestros datos cl&#237;nicos&#44; radiol&#243;gicos y anal&#237;ticos son concordantes con lo descrito en revisiones m&#225;s amplias&#44; entre las que destaca la de Mehrabi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> que reuni&#243; informaci&#243;n de un total de m&#225;s de 6&#46;000 casos&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En resumen&#44; el diagn&#243;stico de insulinoma se debe plantear en el estudio de hipoglucemias en el paciente no diab&#233;tico&#44; realiz&#225;ndose su evaluaci&#243;n mediante el test de ayuno&#44; que resulta concluyente en la gran mayor&#237;a de los pacientes&#44; aunque su negatividad no excluye el diagn&#243;stico&#46; La primera prueba de imagen para su localizaci&#243;n debe ser la TC abdominal&#46; Suelen ser tumores aislados&#44; peque&#241;os y benignos&#44; aunque se debe tener presente la posibilidad de casos at&#237;picos&#46; Disponemos de t&#233;cnicas quir&#250;rgicas que presentan excelentes resultados&#44; por lo que la correcta sospecha de la enfermedad es esencial&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enucleaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enucleaci&#243;n &#43; PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enucleaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enucleaci&#243;n &#43; PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M1 pulm&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enucleaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M1 hep&#225;ticas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enucleaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DPC&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "referencia" => array:1 [
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                          "autores" => array:4 [
                            0 => "D&#46;S&#46; Budnitz"
                            1 => "M&#46;C&#46; Lovegrove"
                            2 => "N&#46; Shehab"
                            3 => "C&#46;L&#46; Richards"
                          ]
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                    0 => array:2 [
                      "doi" => "10.1056/NEJMsa1103053"
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                        "volumen" => "365"
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                      "autores" => array:1 [
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                    0 => array:2 [
                      "doi" => "10.1056/NEJM199504273321707"
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                        "volumen" => "332"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7700289"
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                  "contribucion" => array:1 [
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                      "titulo" => "Diagnosis and management of insulinoma"
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                          "autores" => array:6 [
                            0 => "T&#46; Okabayashi"
                            1 => "Y&#46; Shima"
                            2 => "T&#46; Sumiyoshi"
                            3 => "A&#46; Kozuki"
                            4 => "S&#46; Ito"
                            5 => "Y&#46; Ogawa"
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                    0 => array:2 [
                      "doi" => "10.3748/wjg.v19.i6.829"
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                        "tituloSerie" => "World J Gastroenterol"
                        "fecha" => "2014"
                        "volumen" => "19"
                        "paginaInicial" => "829"
                        "paginaFinal" => "837"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23430217"
                            "web" => "Medline"
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                  "contribucion" => array:1 [
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                      "titulo" => "Hyperinsulinaemic hypoglycaemia in children and adults"
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                          "autores" => array:5 [
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                            4 => "K&#46; Hussain"
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                    0 => array:2 [
                      "doi" => "10.1016/S2213-8587(16)30323-0"
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                        "tituloSerie" => "Lancet Diabetes Endocrinol&#46;"
                        "fecha" => "2017"
                        "volumen" => "5"
                        "paginaInicial" => "729"
                        "paginaFinal" => "742"
                        "link" => array:1 [
                          0 => array:2 [
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ISSN: 00142565
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