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Journal of Clinical Endocrinology & Metabolism, doi:10.1210/jc.2005-1713
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The Journal of Clinical Endocrinology & Metabolism Vol. 91, No. 3 933-940
Copyright © 2006 by The Endocrine Society

Congenital Hyperinsulinism: Pancreatic [18F]Fluoro-L-Dihydroxyphenylalanine (DOPA) Positron Emission Tomography and Immunohistochemistry Study of DOPA Decarboxylase and Insulin Secretion

Pascale de Lonlay, Aurore Simon-Carre, Maria-João Ribeiro, Nathalie Boddaert, Irina Giurgea, Kathleen Laborde, Christine Bellanné-Chantelot, Virginie Verkarre, Michel Polak, Jacques Rahier, André Syrota, David Seidenwurm, Claire Nihoul-Fékété, Jean-Jacques Robert, Francis Brunelle and Francis Jaubert

Departments of Pediatrics (P.d.L., I.G., M.P., J.-J.R.), Biology (A.S.-C., K.L.), Radiology (N.B., F.B.), Pathology (V.V., F.J.), and Pediatric Surgery (C.N.-F.), Hôpital Necker Enfants Malades, Université Paris-Descartes, Faculté de Médecine, 75743 Paris, France; ERM 0205 Institut National de la Santé et de la Recherche Médicale-Commissariat à l’Energie Atonomique (M.-J.R., A.S.), Service Hospitalier Frédéric Joliot, DSV, DRM, 91401 Orsay, France; Department of Biology (C.B.-C.), Hôpital Saint-Antoine, 75571 Paris, France; Department of Pathology (J.R.), University of Louvain, Faculty of Medicine, B-1200 Brussels, Belgium; and Radiological Associates of Sacramento (D.S.), Sutter Medical Center, Sacramento, California 95816

Address all correspondence and requests for reprints to: Dr. Pascale de Lonlay, Département de Pédiatrie, Hôpital Necker–Enfants Malades, Université Paris-Descartes, Faculté de Médecine, 149 rue de Sèvres, 75743 Paris cedex 15, France. E-mail: pascale.delonlay{at}nck.aphp.fr.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Discussion
 References
 
Context: Congenital hyperinsulinism (HI) is characterized by hypoglycemia related to inappropriate insulin secretion. Focal and diffuse forms of hyperinsulinism share a similar clinical presentation, but their treatment is dramatically different. Preoperative differential diagnosis was based on pancreatic venous sampling, a technically demanding technique.

Objective: Positron emission tomography (PET) after injection of [18F]fluoro-L-DOPA (L-dihydroxyphenylalanine) has been evaluated for the preoperative differentiation between focal and diffuse HI, by imaging uptake of radiotracer and the conversion of [18F]fluoro-L-DOPA into dopamine by DOPA decarboxylase. We propose to validate this test by immunohistochemical approach.

Patients and Methods: Pancreatic surgical specimens of four focal and three diffuse HI were studied, using anti-DOPA decarboxylase and proinsulin antibodies. The effect of an inhibitor of DOPA decarboxylase (carbidopa) on insulin secretion was evaluated in vivo and in cultured INS-1 cells.

Results: Immunohistochemical detection of DOPA decarboxylase showed diffuse staining of Langerhans islets in the whole pancreas in all diffuse cases, in contrast with dense focal staining in all focal cases. Staining of Langerhans islets outside the focal lesion was diffusely but weakly positive. We correlated the localization of DOPA decarboxylase and proinsulin in normal pancreas and in both diffuse and focal HI tissues. The diffuse PET uptake found before treatment in one child with diffuse HI disappeared completely after carbidopa administration, suggesting in vivo that pancreatic cells can take up amine precursors and contain DOPA decarboxylase. The insulin secretion measured in the supernatant was the same whether INS-1 cells were treated by dopamine or Lodosyn or untreated.

Conclusion: We validate PET with as a consistent test to differentiate diffuse and focal HI.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Discussion
 References
 
CONGENITAL HYPERINSULINISM (HI, Online Mendelian Inheritance in Man 256450) is characterized by profound hypoglycemia caused by inappropriate insulin secretion (1, 2, 3, 4). Focal and diffuse forms of hyperinsulinism share a similar clinical presentation (5) but result from different molecular mechanisms (6, 7, 8). Discriminating between the two histopathological forms is clinically crucial because the diffuse form is often treated by near total pancreatectomy, which carries a high risk of iatrogenic diabetes (9), whereas hypoglycemia can be completely cured in patients with focal HI by limited resection of the hypersecreting lesion (5).

Until recently a preoperative differential diagnosis was based on pancreatic venous sampling (PVS), an invasive and technically demanding technique that requires maintenance of controlled hypoglycemia during the entire procedure (10). Because only a few centers have acquired expertise in PVS, an easier and less invasive method was needed for preoperative diagnosis of the histological subtypes. Attempts were made to discriminate them with the iv stimulation of insulin secretion by calcium and tolbutamide but with little success (11, 12).

Positron emission tomography (PET) after injection of [18F]fluoro-L-DOPA has been evaluated in the preoperative differentiation between focal or diffuse insulin hypersecretion (13, 14). [18F]Fluoro-L-DOPA has been extensively used for brain examination in patients with Parkinson’s disease as well as for pheochromocytoma and gastrointestinal carcinoid tumor detection (15, 16). Its use in hyperinsulinism was initially considered promising because pancreatic islet cells possess neuroendocrine characteristics (17, 18). L-Dihydroxyphenylalanine (L-DOPA) is present in neuroendocrine cells and is converted into dopamine, a precursor of catecholamines, by the aromatic amino acid decarboxylase or DOPA decarboxylase enzyme pathway. Because several studies have confirmed that ß-cells take up L-DOPA and that DOPA decarboxylase is active in the pancreatic islet cells (19, 20, 21), [18F]fluoro-L-DOPA PET could be an effective diagnostic test for HI. The first results obtained suggested that PET could differentiate focal from diffuse insulin hypersecretion. PET with [18F]fluoro-L-DOPA has now become an important differential diagnostic tool in infantile hyperinsulinemic hypoglycemia.

The aim of this work was to further validate PET with [18F]fluoro-L-DOPA as a reliable test for differentiation of diffuse and focal HI lesions. We compared the dopamine pancreatic localization of known HI patients as determined by PET with pathological studies from the same patients using immunohistochemical and anti-DOPA decarboxylase antibodies. We also correlated the localization of DOPA decarboxylase with insulin secretion in normal human pancreas and both diffuse and focal HI lesions. Finally, the effects of an inhibitor of DOPA decarboxylase on insulin secretion was evaluated in vivo and in cultured INS-1 cells.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Discussion
 References
 
Patient studies

Seven patients were studied, three suffering the diffuse form and four the focal form of HI (Table 1Go). In all cases, the diagnosis of HI was based on persistent hypoglycemia, which responded to iv glucagon, and each patient depended on high rates of glucose infusion to maintain near normal blood glucose levels. Blood insulin levels were elevated at the time of hypoglycemia. All patients underwent presurgical PET and some of them had PVS, but pancreatic specimens were obtained from these seven infants at the time of surgery and the diagnosis of diffuse and focal forms of HI was definitively established by histopathology.


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  		TABLE 1. Clinical characteristics of the patients, and findings at PET scan, pancreatic catheterization, surgery, and histology

 
PET studies were performed as previously described (13) using an ECAT EXACT HR+ scanner (CPS, Knoxville, TN) that collects 63 simultaneous 2.4-mm-thick slices with an intrinsic in-plane resolution of 4.3 mm. The patients were positioned supine in the tomograph using three-dimensional (3D) laser alignment, and the acquisitions were performed in a 3D mode. We hypothesized that diffuse accumulation of [18F]fluoro-L-DOPA would be observed in the whole pancreas in patients with diffuse HI, whereas localized accumulation of [18F]fluoro-dopamine should be found in the affected part of the pancreas in those patients with focal adenomatous hyperplasia. Magnetic resonance imaging of the abdomen was performed using a 1.5-T imager (Signa, GE, London, UK) (before or after PET study) on the same day, to allow 3D reconstruction of magnetic resonance images, to improve the PET localization of focal lesions.

The surgical technique used was guided by the results of the preoperative investigations. In those patients with a preoperative diagnosis of the diffuse form, total pancreatectomy was performed after the diffuse abnormality was confirmed by frozen section histological examination of multiple random pancreatic biopsies. When the preoperative diagnosis was the focal form, the area of the suspected pancreatic abnormality, based on results of imaging studies, was biopsied and removed. When frozen section confirmed that the histological abnormality was confined to the focal lesion, partial pancreatectomy was performed in the relevant location. The patients who underwent limited pancreatectomy for the focal form of HI showed normal postoperative blood glucose levels, and they remained normoglycemic over the years. The condition of the patients with the diffuse form was variable, probably dependent on the amount of residual pancreas after surgery. One of them still presented hypoglycemic episodes, which, however, were less frequent and less severe so that he could be managed medically. The others were relieved from hypoglycemia, but one of them subsequently developed diabetes mellitus, immediately after surgery.

One child with the diffuse form of HI, suspected at PVS and confirmed by histological examination, was treated with an inhibitor of DOPA decarboxylase [the L-{alpha}-hydrazino-{alpha}-methyl-ß-(3,4-dihydroxyphenyl) propionic acid or carbidopa] before having a subtotal pancreatectomy because hypoglycemia resisted to all medical treatments. PET images were obtained before and after 2 wk of carbidopa administration, to demonstrate in vivo that pancreatic cells could take up amine precursors and convert [18F]fluoro-L-DOPA into [18F]fluoro-dopamine. Insulin secretion and amino acid decarboxylase protein were studied immunohistochemically in surgical specimens from the pancreas of this patient and compared with the pancreatic specimen from another diffuse HI patient without carbidopa treatment.

Pancreatic immunohistochemistry

Pancreatic samples of HI patients were compared with surgical or necropsy pancreatic samples obtained from normal subjects at 33 wk gestation and at 1 month and 2, 8, 12, and 17 yr of age (one normal subject for each age; these samples corresponded to the body of each pancreas). Pancreatic tissue was fixed in formalin and embedded in paraffin; serial sections cut at 3 µm were studied by immunohistochemistry after a water bath antigen retrieval step. The primary antibodies used were: antiinsulin (1:150 mouse monoclonal, 2D11H5, Novocastra, Newcastle upon Tyne, UK), antiproinsulin (1:400 mouse monoclonal, 1G4, Novocastra), anti-DOPA decarboxylase [1:100 rabbit polyclonal, (pH 9.4); Chemicon International, Hampshire, UK], anti-Chromogranin A (1:200 mouse monoclonal antibody, DAK-A3; Dako, Glostrup, Denmark), antisynaptophysin (1:50 rabbit polyclonal, Dako), followed by the Dako kit of peroxydase labeling protocol. Chromogranin A and synaptophysin were studied as components of intracellular granules.

In vitro study on rat INS-1 cells

Normal rat pancreas was compared with rat INS-1 cells, derived from a rat insulinoma secreting insulin on a permanent basis (22), using antiinsulin K36aC10 sigma (1:2000 monoclonal), antiproinsulin (1:400 mouse monoclonal, 1G4; Novocastra), anti-DOPA decarboxylase [1:100 rabbit polyclonal (pH 9.4); Chemicon International], anti-Chromogranin A (1:200 mouse monoclonal antibody, DAK-A3; Dako), and antisynaptophysin (1:50 rabbit polyclonal; Dako), followed by the Dako kit of peroxydase labeling protocol, as previously described. Cells were cultured in 6-well plates in RPMI 1640 supplemented with 10% heat-inactivated fetal calf serum, 2 mM L-glutamine, 100 U/ml penicillin, 100 µg/ml streptomycin, 1 mM sodium pyruvate, 10 mM HEPES, and 50 µM 2-mercaptoethanol. The INS-1 cell line was exposed to 10 µM dopamine or 10 µM Lodosyn (anti DOPA decarboxylase agent), and further insulin secretion was measured by RIA of the culture fluid using insulin antibody at 30 min and 3, 7, 24, and 48 h after the beginning of treatment. Samples of the cells were trypsinized and cytocentrifugation pellets of the cell suspension were also studied immunohistochemically.

The study was performed in conformance with the human research policy and informed consent for all studies was obtained from the parents of each of our patients. In addition, tissue specimens were managed in compliance with the human tissue research policies.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Discussion
 References
 
Localization of dopamine by PET and immunohistochemistry

The localization of dopamine in the four patients with the focal form and the three patients with the diffuse form, as determined by PET using the conversion of [18F]fluoro-L-DOPA into dopamine, was confirmed by immunohistochemical detection of DOPA decarboxylase in all pancreas surgical specimens (Fig. 1Go). Indeed, immunohistochemical detection of DOPA decarboxylase showed diffuse staining of Langerhans islets in the whole pancreas in all three diffuse cases, compared with dense focal staining in all focal cases, whereas staining of Langerhans islets outside the lesion were diffusely but weakly positive.


Figure 1
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  		FIG. 1. Immunohistochemistry of focal (left) and diffuse (right) forms of HI. Note the enlarged nuclei in the islets. In the focal form, DOPA decarboxylase was strongly positive in the surrounding exocrine cells and mass of ß-cells (lower portion of the field). Proinsulin was more strongly positive than insulin. In the diffuse form, DOPA decarboxylase distribution and intensity of staining did not differ from normal pancreas, and insulin was more positive than proinsulin, as in control islets (x100).

 
Colocalization of insulin, proinsulin, and DOPA decarboxylase in control human pancreas and human focal and diffuse pancreatic ß-cell hyperplasia

In normal pancreas, DOPA decarboxylase level was low in ß-cell protoplasm at 33 wk and remained at the same level at later ages, with no difference from 2 to 17 yr (Fig. 2Go). In focal HI, DOPA decarboxylase was strongly and diffusely positive in the protoplasm of all the aggregated ß-cells (Fig. 1AGo), whereas the level of DOPA decarboxylase did not differ from normal in ß-cells of diffuse HI (Fig. 1BGo).


Figure 2
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  		FIG. 2. Immunohistochemistry of normal pancreas at 33 wk gestation and from 1- and 8-yr-old children. DOPA decarboxylase level was high in exocrine pancreas but low in pancreatic islets. Insulin level was higher than proinsulin in pancreatic ß-cells (x100).

 
Insulin and proinsulin were secreted by ß-cells at 33 wk gestation, insulin at a higher level than proinsulin, and the same pattern was observed until the age of 17 yr (Fig. 2Go). In focal HI, proinsulin secretion was strongly enhanced and stained more intensely than insulin in the protoplasm of the same ß-cells as DOPA decarboxylase in studies on serial sections (Fig. 1AGo). By contrast, staining for proinsulin was reduced, with a high level of insulin, in intralobular islets of diffuse HI, contrasting with a reversed pattern in the extralobular islets (Fig. 1BGo).

In normal pancreas, chromogranin and synaptophysin were strongly positive at all stages in the protoplasma of endocrine cells. In focal hyperinsulinism, an increased positivity for synaptophysin was present, whereas chromogranin positivity was decreased. In diffuse forms of hyperinsulinism, chromogranin and synaptophysin showed a concomitant global decrease.

Study of one patient treated preoperatively with the DOPA decarboxylase competitive agonist

An inhibitor of DOPA decarboxylase, carbidopa, was administered to one hypoglycemic patient. The dosage was initially 25 mg/d in four divided doses. Plasma glucose levels were lower than 2.5 mmol/liter before treatment, and they became higher than 4 mmol/liter during the first 2 d of treatment (Table 2Go). However, because hypoglycemia relapsed after these 2 d, dosage was increased to 75 mg/d. Because the treatment was ineffective on plasma glucose at this higher dosage (Table 2Go), surgery was indicated.


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  		TABLE 2. Plasma glucose levels before and after carbidopa treatment of a patient with diffuse HI

 
Figure 3Go shows PET images before and after treatment with an inhibitor of DOPA decarboxylase. The diffuse uptake found before treatment (Fig. 3AGo) disappeared completely after carbidopa treatment (Fig. 3BGo), suggesting that in vivo pancreatic cells can take up amine precursors in the diffuse form of HI and that the pancreas of these patients contains DOPA decarboxylase responsible for the conversion of [18F]fluoro-L-DOPA into dopamine.


Figure 3
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  		FIG. 3. PET images in a patient with diffuse HI. A, The uptake of the radiotracer is large and diffuse over the pancreatic area (coronal, saggital, and axial projections). Physiological distribution of the radiotracer with high accumulation in the kidneys and urinary bladder and a lower accumulation in the liver can also be seen. B, After carbidopa treatment of the patient, there was no uptake of [18F]fluoro-L-DOPA by the pancreas.

 
Regarding immunohistochemistry, the case treated preoperatively with the DOPA decarboxylase competitive agonist did not show any difference in DOPA decarboxylase protein detection in comparison with pancreas of other diffuse HI patients, except for a lower intensity in protoplasm of extralobular islets. However, the comparison between pancreatic specimens from two brothers who had surgery for diffuse HI (one was operated under standard conditions, and the other had DOPA decarboxylase inhibitor preoperatively for 3 wk) showed that DOPA decarboxylase was diffuse in protoplasm when no treatment was given, whereas it was reduced and concentrated in the Golgi area after treatment (data not shown). Insulin staining did not differ, whereas proinsulin was mainly protoplasmic in the brother with no treatment and in the Golgi after carbidopa. ß-Cell secretory granules were more dense after carbidopa treatment.

Insulin secretion in rat INS-1 cells: effect of dopamine or anti-DOPA decarboxylase agent (Fig. 4Go)

In normal rat pancreas proinsulin exhibited a dotted Golgi perinuclear pattern, whereas insulin was abundant in protoplasm and diffuse. DOPA decarboxylase was positive in protoplasm at low intensity. By contrast, INS-1 cells at rest showed a diffuse protoplasmic proinsulin and insulin positivity with peripheral enhancement, whereas DOPA decarboxylase was protoplasmically diffuse and of moderate intensity. The INS-1 cell profile of proinsulin, insulin, and DOPA decarboxylase was similar to that observed in HI focal forms.


Figure 4
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  		FIG. 4. Insulin concentration in the supernatant of INS-1 cell line, exposed to 10 µM dopamine or 10 µM Lodosyn (anti-DOPA decarboxylase agent). The insulin secretion did not differ between INS-1 cells, untreated or treated with dopamine or Lodosyn. AADC, Amino acid decarboxylase.

 
Insulin secretion was measured in the culture fluid of INS-1 cells without treatment and after exposure to 10 µM dopamine or 10 µM Lodosyn (carbidopa) at 30 min and 3, 7, 24, and 48 h. The insulin secretion measured in the supernatant was the same whatever INS-1 cells were treated by dopamine or Lodosyn or untreated (Fig. 4Go). Comparative immunohistochemistry of nontreated Ins-1 cell suspension used as controls was compared with cell suspensions after treatment by dopamine and Lodosyn. The results showed no difference for insulin between treated and control cells. There was also no difference for DOPA decarboxylase and proinsulin stainings (data not shown).


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
References
 
The present study not only confirms but also extends the understanding of the previously reported results that PET is a reliable test to differentiate diffuse and focal HI lesions (13). In previous studies, fewer patients were studied, and the reference investigations were PVS and conventional histopathology, rather than immunohistochemistry of the resected specimens. The dopamine focalization provided by PET in HI pancreas after [18F]fluoro-L-DOPA uptake correlated with the immunohistochemical positivity for DOPA decarboxylase, proinsulin and insulin in the pathological foci. PET with [18F]fluoro-L-DOPA has thus become an important clinical technique for studying these patients and can be used as an alternative or a complementary method to PVS, which was up to now the only reliable method for differential diagnosis between focal and diffuse HI forms.

The staining pattern differs between the focal and diffuse forms of HI, being localized to small clusters of cells and more intense in the focal forms. DOPA decarboxylase concentration was considerably higher in the focal form than in diffuse HI and precisely correlated with proinsulin and insulin staining. This is due to pathological recruitment of ß-cells in the focal form (23), whereas the normal pancreatic structure is maintained in the diffuse form.

The principle underlying the PET examination is that when [18F]fluoro-L-DOPA is injected, it is taken up by the cells as an amino acid (19, 20). The decarboxylation of [18F]fluoro-L-DOPA into dopamine, and its accumulation inside the cells, demands the presence of DOPA decarboxylase. If this enzyme is blocked, [18F]fluoro-L-DOPA may partly diffuse back from the cells to the extracellular space, thus lowering the trapping mechanism, and no uptake by the pancreatic cell may be visualized. The disappearance of dopamine focalization at PET after the administration of carbidopa, a competitive inhibitor of DOPA decarboxylase, suggests that this putative mechanism indeed accounts for the imaging findings.

Even if there was a colocalization between DOPA decarboxylase and insulin staining, this does not prove a relationship between dopamine levels in pathologic ß-cells and insulin secretion rates (24). There is little literature suggesting that hyperglyemia can be caused by L-DOPA (25) and that systemic treatment with sympatholytic dopamine agonists participates in the regulation of ß-cell insulin secretion (21, 26). There are two possible mechanisms by which pancreatic insulin secretion may be influenced by the action of dopamine, one central occurring along the hypothalamic pituitary axis and the other at the level of the pancreatic secretory cell itself. The peripheral mechanism could be more relevant to the role of PET.

The central mechanism is supported by the fact that dopamine is a precursor of norepinephrine and epinephrine and plays a role as a transmitter for the central and the peripheral nervous system. The sympathetic nervous system, with norepinephrine and epinephrine, is known to inhibit insulin secretion, whereas acetylcholine released by parasympathetic neurons has the opposite effect (27). This is regulated by glucose-sensing neurons in hypothalamic and other hindbrain regions (26, 28, 29).

The local mechanism is supported by the neuroendocrine nature of pancreatic islet cells (17, 18, 30). Because neuroendocrine cells store amines in neurosecretory granules (17, 18, 30, 31, 32, 33, 34, 35), catecholamines also play a role in the ß-cell exocytic machinery (21). Chromogranins A and C store insulin inside dense part of the secretory granules and play a role in insulin exocytosis by binding calcium and releasing small peptides (36, 37). A colocalization of insulin in the dense core part of the granule and dopamine in the surrounding clear area was demonstrated by electron microscopy immunohistochemistry and autoradiography (21).

If the genetic and biochemical mechanisms that link dopamine uptake and insulin secretion are incompletely understood, several recent lines of inquiry converge on potential links. In pancreatic ß-cells, coupling of ATP-sensitive K+ channels have been shown to regulate insulin release using H2O2 as a potential regulator (38). In a guinea pig striatum model, dopamine release was modulated by a closely linked pathway involving an H2O2 intermediary (39). Thus, a direct mechanism linking the secretion of insulin and dopamine uptake seems likely. Another line of evidence is genetic. Dopamine uptake after secretion is due to a solute carrier gene sharing some characteristics with the SLC22A, which is implicated in Beckwith Wiedeman syndrome (40). This gene shares a locus at chromosome 11p15 with the SUR1 gene implicated in HI (41). The structure of these genes is similar, perhaps suggesting that they serve similar functions (42). For these reasons, it is tempting to speculate that the proteins encoded by these genes play a direct role in linking the uptake and decarboxylation of dopamine with the pathologic secretion of insulin in HI. Direct interactions of dopamine with inwardly rectifying K+ have been demonstrated in medial prefrontal cortex pyramid neurons of rats (43) as well as in striatum of rats (44) and midbrain neurons of mice (45). More interestingly, the insulin secretory granule is the major site of ATP-sensitive K+ channels of the endocrine pancreas (46). Thus, possible candidates for the genes that encode the proteins linking dopamine with pathological insulation secretion, in secretory granules, are the SUR1 and Kir6.2 genes that have been demonstrated to be abnormal in neonatal HI. In the focal form, the genetic abnormality has been shown to have two components, a paternally inherited mutation in the SUR1 or Kir6.2 gene and, only in the abnormal pancreatic islet cells, a loss of the maternal 11p15 chromosome including the SUR1 gene as well as the Kir6.2.

Improved understanding of the links between dopaminergic pathways and insulin secretion might lead to novel therapeutic approaches for hyperinsulinism resistant to usual medical treatments. However, the study of Lodosyn and dopamine on INS-1 cells showed no effects on insulin secretion. If this negative result is somewhat disappointing, as well as the in vivo results of treatment with carbidopa albeit in a single patient, INS-1 cells appear to be a potentially useful model on immunohistochemical basis for the in vitro study of dopaminergic regulation of insulin secretion because they showed immunohistochemical profiles comparable with those of focal HI in humans. However, they differ from focal HI cells by their tumoral nature and did not show any response to carbidopa.

In conclusion, we demonstrate here by immunohistopathological studies that PET with [18F]fluoro-L-DOPA seems to be a reliable method for differentiation of diffuse and focal HI lesions. Thus, PET with [18F]fluoro-L-DOPA can replace PVS, which is very useful for differentiation of diffuse and focal lesions but technically laborious. Additionally, we report that the abnormal uptake of [18F]fluoro-L-DOPA is blocked in the pancreas of a patient with HI with an inhibitor of DOPA decarboxylase.


   Footnotes
 
This work was supported by the GIS-Institut des Maladies Rares.

First Published Online January 10, 2006

Abbreviations: HI, Hyperinsulinism; L-DOPA, L-dihydroxyphenylalanine; PET, positron emission tomography; PVS, pancreatic venous sampling; 3D, three-dimensional.

Received August 1, 2005.

Accepted December 20, 2005.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 References
 

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