INS and Hyperinsulinemia: In PDA cases, hyperinsulinemia or exogenous insulin use is related to the elevated PDA incidence and increased tumor volume (Stolzenberg-Solomon et al., 2005; Zyromski et al., 2009; White et al., 2010; Wolpin et al., 2013; Boursi et al., 2017; Carreras-Torres et al., 2017).