From:
Bruce Williams, DVM
Date: 2001-04-21 08:22:00 UTC
Subject: Re: Follow up Mackenzie's insulinoma surgery
--- In Ferret-Health-list@y..., macdoodle99@y... wrote:
> > Once again, I'm going o be a cynic about the pathologic
diagnosis.
> > You say that the pancreatic lesion was not an islet cell
neoplasm,
> > but hyperplasia, and that MacKenzie has no evidence of
> > hyperglycemia.
WHOOPS - my mistake - late night posting strikes again. I mean
hypoglycemia, not hyperglycemia. Animals with insulinom have LOW
blood sugar (it may become high after surgery).
> >
> > Your description of the widespread tumors does indicate a
> malignancy,
> > which may be an adenocarcinoma of some other origin.
> >
> > This may seem like a small issue, but when we try to get
prognostic
> > information on various neoplasms, such as the extremely rare
> > metastatic islet cell tumor, we need to be extremely sure that
the
> > diagnosis is valid.
> next day. I don't know whether you consider that hyperglycemic or
> not, but this was a ferret who had a blood sugar of 46 on diagnosis
> and was started on pediapred with a subsequent blood sugar of 47.
> One week later, after empirically boosting the pediapred to 1.5 cc
> three times a day, her blood sugar was 49, at which point she went
to
> surgery for refractory hypoglcemia.
OK - I must have missed this in the original message. I stand
corrected.
> Regarding the ulcers: This time she presented with anorexia and
> teeth grinding. She had gastric ulcers 5 years prior at age 2 with
> all the classic sign: anorexia, lip smacking, teeth grinding, and
> black tarry stools. She couldn't even drink water without it
causing
> teeth grinding. She lost half her body weight. She required SQ
> fluids for a while. She was treated with a 6 week course of amox
and
> flagyl and with carafate for about a year (because shortly after
> stopping the carafate the teeth grinding would return, although
> within about a week of starting treatment with the 3 meds all
> symptoms disappeared.) So when she presented this time, we
> empirically started carafate (didn't think we would need to treat
for
> the helicobacter again.) After two weeks, no effect. That's when
we
> pursued other diagnoses and came up with insulinoma. But
throughout
> this whole thing, she has been on the carafate, actually at higher
> doses than she was treated with when she did have ulcers. She also
> did get a full course of amoxicillin for a possible oral ulcer.
>
> As for the hyperplasia in the pancreatic mass: I think my vet
thinks
> he did not find the primary tumor. I believe that the primary
> tumor's size does not always indicate probability of metastasis but
> it does seem a bit odd that the mets would be so much bigger than
the
> primary. Also, we did no imaging prior to the surgery, so my vet
> operated based on what he could see and feel.
> Regarding comment on prognosis: Her symptoms have never responded
to
> treatment. Given her refractory hypoglycemia before surgery, and
the
> rapidity with which this thing has progressed over 4 weeks when she
> was normal two months ago, I really feel this seems to be
consistent
> with a metastatic islet cell carcinoma.
Well, I think that if there is a primary tumor which was not
identified, she wuld still be hyperglycemic. There is at this point
a way that the diagnosis can be proven - simply to look for the
presence of insulinoma in the tumor cells in the liver and abdomen
(you already have that tissue available.) However, due to the rarity
of this tumor in ferets, and the fact that this one does not fit the
expected pattern, I am still hesitant to call it without definitive
proof.
I think her symptoms reflect
> abdominal pain due to the tumors (but I don't know because I seem
to
> get a wide variety of opinions on her teeth grinding and what it
> means in this case).
This is a pretty good theory.
I feel her elevated blood sugars now are due to
> decreased tumor burden after debulking them in surgery with a
> resultant decrease in insulin production. And I expect that this
> tumor will grow back very quickly and that we will shortly be
seeing
> low blood sugars again.
I am simply surprised that with the primary not found, that the
hypoglycemia has abated.
I read your post in response to another
> person whose ferret was diagnosed with metastatic islet cell
> carcinoma. You imply a tumor that grows and spreads rapidly. I
> think Mackenzie's case is very consistent with that.
Islet cell tumors in dogs and cats grow and spread rapidly. This has
not been the case in ferrets - they are so uncommon, and none have
truly been published (there are a couple of anecdotal reports out
there, but with no details.)
>
> However, if it would benefit you and anyone else on this list, I
can
> probably get you the pathology slides or the actual report.
That would be great - actually the paraffin blocks for the case are
vetter - at that point, I could run the insulin test on the tumors
for you (at no charge) and make the diagnosis definitively.
With kindest regards,
Bruce H. Williams, DVM, DACVP
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