Editor(s): Jeffrey F. Molley, M.D., Gerard M. Doherty, M.D. Reviewers: Jon van Heerden, M.D, Robert Udelsman, M.D.

Approach to thyroid nodules

Gharib H. Changing concepts in the diagnosis and management of thyroid nodules. Endocrinology & Metabolism Clinics of North America 1997; 26(4):777-800.

Singer PA, Cooper DS, Daniels GH, Ladenson PW, Greenspan FS, Levy EG, Braverman L E, Clark OH, McDougall I R, Ain KV, Dorfman SG. Treatment guidelines for patients with thyroid nodules and well-differentiated thyroid cancer. American Thyroid Association, Archives of Internal Medicine 1996;156: 2165-72.

This paper provides clinical guidelines for evaluation and management of patients with thyroid nodules and thyroid cancer. The authors are an 11-member Standards of Care Committee of the American Thyroid Association, and include Orlo Clark, M.D. This is an excellent summary of current diagnosis and management of thyroid nodules and thyroid cancer.

Chen H, Nicol TL, Rosenthal DL, Udelsman R. The role of fine-needle aspiration in the evaluation of thyroid nodules. Problems in General Surgery 1997;14:1-13.

This is an excellent review of fine-needle aspiration cytology, the current diagnostic procedure of choice for thyroid nodules.

Tan GH, Gharib H. Thyroid incidentalomas: Management approaches to nonpalpable nodules discovered incidentally on thyroid imaging. Ann Intern Med 1997;126:226-31.

Differentiated thyroid carcinoma

Brink JS, van Heerden JA, McIver B, Salomao DR, Farley DR, Grant CS, Thompson GB, Zimmerman D, Hay ID. Papillary thyroid cancer with pulmonary metastases in children: Long-term prognosis. Surgery 2000; 128:887-887.

Cady B, Papillary carcinoma of the thyroid gland: treatment based on risk group definition. Surgical Oncology Clinics of North America 1998;7: 633-644.

This article describes the current controversy regarding the extent of treatment of papillary carcinoma of the thyroid, and outlines the author's approach to management based upon risk stratification.

Udelsman R, Lakatos E, and Ladenson P. Optimal surgery for papillary thyroid carcinoma. World Journal of Surgery 1996;20:88-93.

Discusses the controversies surrounding extent of surgery for differentiate thyroid cancer, and suggests trial design to address the issues with adequate statistical power.

Levin KE, Clark AH, Duh QY, Demeure M, Siperstein AE, and Clark OH. Reoperative thyroid surgery. Surgery 1992;111: 604-609.

This report describes the author's extensive experience with thyroid reoperations for benign and malignant conditions.

Moley JF, Lairmore TC, Doherty GM, Brunt LM, DeBenedetti MK. Preservation of the recurrent laryngeal nerves in thyroid and parathyroid reoperations. Surgery 1999;126: 673-677.

This report describes the authors' approach to exposure of the recurrent laryngeal nerves in thyroid and parathyroid reoperations. In this series of over 100 operations, no unintentional nerve transections were reported. The authors also discuss management in cases of nerve invasion by tumor.

Ladenson PW, Braverman LE, Mazzaferri EL, Brucker-Davis F, Cooper DS, Garber JR, Wondisford FE, Davies TF, DeGroot LJ, Daniels GH, Ross DS, Weintraub BD. Comparison of administration of recombinant human thyrotropin with withdrawal of thyroid hormone for radioactive iodine scanning in patients with thyroid carcinoma. New England Journal of Medicine 1997;337: 888-96.

This report describes the preparation of patients for radioiodine scanning following treatment of differentiated thyroid cancer. The report documents a series of patients prepared with recombinant thyrotropin, compared to patients prepared with a traditional course of thyroid hormone withdrawal.

Moley JF andls SA. Compartment-mediated dissection for papillary thyroid cancer. Langenbeck's Archives Surg 1999;384: 9-15.

This review discusses the rationale for node dissection in differentiated thyroid cancer, and critiques the trend in some European centers to perform routine neck dissections for these thyroid cancers.

Chen H, Udelsman R. Papillary thyroid carcinoma: Justification for total thyroidectomy and management of lymph node metastases. Surg Oncol Clinics N Amer 1998;7:645-63.

An excellent review of the most common thyroid malignancy.

Chen H, Zeiger MA, Clark DP, Westra WH, Udelsman R. Papillary carcinoma of the thyroid: Can operative management be based solely on fine-needle aspiration? J Am Coll Surg. 1997;184:605-10.

Chen H, Nicol TL, Zeiger MA, et al. Hurthle cell neoplasms of the thyroid: Are there factors predictive of malignancy? Annals of Surgery 1998;227:542-6.

This paper discussed an extensive institutional experience with Hurthle cell lesions of the thyroid.

Chen H, Nicol TL, Udelsman R. Follicular lesions of the thyroid. Does frozen section evaluation alter operative management? Annals of Surgery 1995;222:101-6.

This paper discusses the use of frozen section in the treatment of follicular lesions.

Sosa JA, Bowman HM, Tielsch JM, Rowe NR, Gordon TA, Udelsman R. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Annals of Surgery 1998;228:320-30.

This report presents data that supports the importance of surgeon experience on outcome with thyroidectomy.

Hundahl SA, Fleming ID, Frengen AM, Menchk HR. A National Cancer Database Report on 53,856 cases of thyroid carcinoma treated in the U.S., 1985-95. Cancer 1998;83:2638-48.

Medullary thyroid carcinoma (see also Multiple endocrine neoplasia type 2)

Grimm O, Dralle H. Reoperation in metastasizing medullary thyroid carcinoma: Is a tumor stage-oriented approach justified? Surgery 1997; 122(6):1124-30.

Moley JF, DeBenedetti M. Patterns of nodal metastases in palpable medullary thyroid carcinoma: Recommendations for extent of node dissection. Annals of Surgery 1999;229: 880-888.

This article describes the high frequency and location of nodal metastases in a series of over 70 patients with medullary thyroid carcinoma. Correlation with size and location of the primary tumor is given, and guidelines for extent of node dissection are provided.

Tung WS, Vesely TM and Moley JF. Laparoscopic detection of hepatic metastases in patients with residual or recurrent medullary thyroid cancer. Surgery 1995:118: 1024-1030.

This report documents the high incidence of liver metastases (25%) in patients with persistent elevation of calcitonin levels following surgery for medullary thyroid carcinoma. These metastases are often not seen on routine imaging studies, but are detectable by laparoscopy.

Van Heerden, JA; Grant, CS; Gharib, H; Hay, ID; Ilstrup, DM. Long-term course of patients with persistent hypercalcitoninemia after apparent curative primary surgery for medullary thyroid carcinoma. Annals of Surgery 1990;212: 395-401.

This report documents the excellent survival of patients treated for medullary thyroid carcinoma who have persistent elevation of calcitonin levels following primary surgical treatment.

Moley JF, Dilley WG, DeBenedetti MK. Improved results of cervical reoperation for medullary thyroid arcinoma. Annals of Surgery 1997;225: 734-743.

This paper describes experience with evaluation and treatment of a large number of patients with residual or persistent medullary thyroid carcinoma (elevated calcitonin levels) following primary surgical treatment. Laparoscopic inspection of the liver identified liver metastases in 25% of patients considered candidates for re-operation. Reoperation with nodal clearance resulted in normalization of calcitonin levels in 38% of patients.

Chen H, Robert JR, Ball DW, et al. Effective long-term palliation of symptomatic incurable metastatic medullary thyroid cancer by operative resection. Annals of Surgery 1998;227:887-95.

Gimm O, Ukat J, Dralle H. Determinative factors of biochemical cure after primary and reoperative surgery for sporadic medullary thyroid carcinoma. World J Surg 1998;22:562-8.

Multiple Endocrine Neoplasia type 2

Mulligan LM, Eng C, Healey CS, Clayton D, Kwok JB, Gardner E, Ponder MA, Frilling A, Jackson CE, Lehnert H et al. Specific mutations of the RET proto-oncogene are related to disease phenotype in MEN 2A and FMTC. Nature Genetics 1994;6:70-74.

Donis-Keller H, Dou S, Chi D, Carlson KM, Toshima K, Lairmore TC, Howe JR, Moley JF, Goodfellow P, Wells SA, Jr. Mutations in the RET proto-oncogene are associated with MEN 2A and FMTC. Human Molecular Genetics 1993;2:851-856.

These papers describes the association of mutations in the RET proto-oncogene with MEN 2A and FMTC. Mutations in this gene were also found to be responsible for MEN 2B.

Wells SA, Chi DD, Toshima K, Dehner LP, Coffin CM, Dowton SB, Ivanovich JL, DeBenedetti MK, Dilley WG, Moley JF, Norton JA, Donis-Keller H. Predictive DNA testing and prophylactic thyroidectomy in patients at risk for multiple endocrine neoplasia Type 2A. Annals of Surgery 1994;220: 237-250.

This report describes th application of "preventative" thyroidectomy to patients found to harbor mutations in the RET proto-oncogene. At-risk family members from MEN 2A kindreds underwent genetic testing, and patients found to have mutations were offered thyroidectomy. Pathologic examination revealed foci of medullary thyroid carcinoma in several MEN 2A gene carriers with normal stimulated calcitonin levels. This established genetic testing as a preferable screening method to yearly biochemical evaluation.

Eng, C. RET proto-oncogene in the development of human cancer [Review] J Clin Oncol 1999;17:380-393.

This is an excellent review of the molecular genetics of the MEN 2 syndromes by an expert in the field.

O'Riordain DS, O'Brien T, Crotty TB, Gharib H, Grant CS, van Heerden JA. Multiple endocrine neoplasia type 2B: more than an endocrine disorder. Surgery 1995;118:936-942.

A good overview of the clinical manifestations of MEN 2B, which is the rarest, but most dramatic and deadly of the MEN 2 syndromes.

Howe J R, Norton J A, Wells SA Jr. Prevalence of pheochromocytoma and hyperparathyroidism in multiple endocrine neoplasia type 2A: Results of long-term follow-up. Surgery, 1993;114:1070-7.

This paper describes the presentation and management of hyperparathyroidism and pheochromocytoma in patients with MEN 2A.

Adrenal - Incidentaloma

Abecassis M, McLoughlin MJ, Langer B, et al. Serendipitous adrenal masses: prevalence, significance and management. Am J Surg 1985;149:783-8.

Belldegrun A, Hussain S, Seltzer SE, et al. Incidentally discovered mass of the adrenal gland. Surg Gynecol Obstet 1986;163:203-208.

Barry MK, van Heerden JA, Farley DR, Grant CS, Thompson GB, Ilstrup DM. Can adrenal incidentalomas be safely observed? World J Surg 1998;22:599-604.

Francis IR, Smid A, Gross MD, et al. Adrenal masses in oncologic patients: functional and morphologic evaluation. Radiology 1988;166:353-356.

Herrera MF, Grant CS, van Heerden JA, et al. Incidentally discovered adrenal tumors: an institutional perspective. Surgery 1991;110:1014-1021.

These papers describe the differential diagnosis and radiologic characteristics of adrenal incidentalomas in several large series.

Mitchell DG, Crovello M, Matteucci T, Peterson RO, Miettinene MM. Benign adrenocortical masses: diagnosis with chemical shift MR imaging. Radiology 1992;185:345-51.

This paper describes the technique of chemical shift opposed phase imaging which can distinguish adrenal adenomas from other types of adrenal masses based upon fat content.

McLeod MK, Thompson NW, Gross MD, et al. Sub-clinical Cushing's Syndrome in patients with adrenal gland incidentalomas: pitfalls in diagnosis and management. Am Surg 1990;56:398-403.

Reincke M, Nieke J, Krestin GP, et al. PreClinical Cushing's syndrome in adrenal "incidentalomas,": comparison with adrenal Cushing's syndrome. J Clin Endocrinology and Metabolism 1992;75:826-832.

Rosen HN, Swartz SL. Subtle glucocorticoid excess in patients with adrenal incidentaloma. Am J Med 1992;92;213-216.

These papers describe the syndrome of "Pre-clinical Cushing's syndrome". This syndrome is important because if it is not recognized, a patient may develop adrenal insufficiency following removal of an incidentaloma which has been releasing low levels of cortisol, resulting in suppression of the contralateral gland.

Sosa JA, Udelsman R. Imaging of the adrenal gland. Surg Oncol Clinics N Amer 1999;8:109-27.

Pheochromocytoma (see also multiple endocrine neoplasia type 2 syndromes)

Pommier RF, Vetto JT, Billingsly K, Woltering EA, Brennan M F. Comparison of adrenal and extraadrenal pheochromocytomas. Surgery 1993;114:1160-1165; discussion 1165-6.

Freier DT, Thompson NW. Pheochromocytoma and pregnancy: the epitome of high risk. Surgery 1993;114:1148-1152.

Orchard T, Grant C S, van Heerden J A, Weaver A. Pheochromocytoma--continuing evolution of surgical therapy. Surgery 1993;114:1153-8; discussion 1158-1159.

Three excellent articles on pheochromocytoma from a superlative issue of Surgery containing reports from the 1993 American Association of Endocrine Surgery meeting. The December issue of Surgery is devoted to articles generated by the AAES meeting each year and is a must-read for all endocrine surgeons.

Lairmore TC, Ball DW, Baylin SB, Wells SA, Jr. Management of pheochromocytomas in patients with multiple endocrine neoplasia type 2 syndromes. Annals of Surgery 1993;217:595-603.

This report describes the approach to screening and selection of patients for adrenalectomy for pheochromocytomas in the MEN 2 syndromes. Because of the risk of Addisonian crisis associated with bilateral adrenalectomy, the authors recommend adrenalectomy of the affected side only when a unilateral pheochromocytoma is present with continued observation and biochemical screening of the other adrenal.

Krempf M, Lumbroso J, Mornex R, et al: Use of M-[131] Iiodobenzylguanidine in the treatment of malignant pheochromocytoma. J Clin Endocrinol Metab. 1991;72:455-61.

Describes their experience with 131-I MIBG in the treatment of malignant pheochromocytoma.

Adrenocortical carcinoma

Kendrick ML, Lloyd R, Erickson L, Farley DR, Grant CS, Thompson GB, Rowland C, Young WF Jr, van Heerden JA. Adrenocortical carcinoma: Surgical progress or status quo? Archives of Surgery 2001;136:543-9.

Luton J-P, Cerdas S, Billaud L, et al. Clinical features of adrenocortical carcinoma, prognostic factors, and the effect of mitotane therapy. N Engl J Med, 1990;322:1195-201.

Review of clinical features and treatment of adrenocortical carcinoma.

Pommier RF, Brennan MF. An eleven-year experience with adrenocortical carcinoma. Surgery 1992;112: 963-971.

Retrospective study of 73 patients with adrenocortical carcinoma treated at Memorial Sloan-Kettering Cancer Center. Recommend aggressive surgical resection of primary, residual, and recurrent disease.

Jensen JC, Pass HI, Sindelar WF, et al. Recurrent or metastatic disease in select patients with adrenocortical carcinoma: ggressive resection vs chemotherapy. Arch Surg, 1991;126:457-61.

Describes the N.C.I.experience with recurrent adrenocortical carcinoma.

Haak HR, Hermans J, van de Velde CJ, Lentjes EG, Goslings BM, Fleuren GJ, Krans HM. Optimal treatment of adrenocortical carcinoma with mitotane: results in a consecutive series of 96 patients. British J of Cancer 1994;69:947-951.

A large series of patients with adrenocortical carcinoma treated with mitotane. Following complete resection, mitotane did not improve survival. In other cases, modest efficacy was demonstrated only in patients in whom high serum levels were achieved.

Adrenalectomy

Gagner, M., Lacroix, A., Prinz, R. A., et al.: Early experience with laparoscopic approach for adrenalectomy. Surgery 1993;114:1120-1125.

Describes the trans-abdominal laparoscopic approach to adrenalectomy.

Brunt LM, Doherty GM, Norton JA, Soper NJ, Quasebarth MA, Moley JF. Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasms. J of the Am Coll of Surgeons 1996;183:1-10.

Compares laparoscopic adrenalectomy to open approaches with regard to time in hospital, cost, pain, return to work, and other parameters.

Doherty GM, Nieman LK, Cutler GB, et al. Time to recovery of the hypothalamic-pituitary-adrenal axis after curative resection of adrenal tumors in patients with Cushing's syndrome. Surgery 1990;108:1085-90.

Provides important information for follow-up of patients following unilateral adrenalectomy for cortisol producing adenomas and carcinomas.

Thompson GB, Grant CS, van Heerden JA, et al. Laparoscopic versus open posterior adrenalectomy: a case control study of 100 patients. Surgery 1997;122:1132-6.

Schell SR, Talamini MA, Udelsman R. Laparoscopic adrenalectomy for nonmalignant disease: improved safety, morbidity and cost-effectiveness. Surg Endosc 1999;13:30-34.

This report discussed an institutional experience with laparoscopic adrenalectomy compared with open adrenalectomy.

Hyperparathyroidism

"Surgical exploration for Hyperparathyroidism", IN: Udelsman R (Guest editor), Operative techniques in General Surgery, Volume 1, Number 1, September 1999, pp 1-102.

Silverberg SJ, Shane E, Jacobs TP, Siris E, Bilezikian JP. A 10-year prospective study of primary hyperparathyroidism with or without parathyroid surgery. N Engl J Medicine 1999;341:1249-55.

A prospective study of 121 patients with minimally or asymptomatic hyperparathyroidism, followed for ten years. Parathyroidectomy corrected calcium levels and improved bone mineral density, but only about one quarter of the un-operated patients developed progression of their disease within this period.

Chen H, Sokoll LJ, Udelsman R. Outpatient minimally invasive parathyroidectomy: a combination of sestamibi-SPECT localization, cervical block anesthesia, and intraoperative parathyroid hormone assay. Surgery 1999;126:1016-22.

A nicely detailed description of the use of pre-operative localization and intraoperative parathyroid hormone measurement as the intervention strategy for patients with primary hyperparathyroidism.

Norman J, Chheda H, Farrell C. Minimally invasive parathyroidectomy for primary hyperparathyroidism: decreasing operative time and potential complications while improving cosmetic results. Am Surg 1998;64:391-6.

Murphy C, Norman J. The 20% rule: A simple, instantaneous radioactivity measurement defines cure and allows elimination of frozen sections and hormone assays during parathyroidectomy. Surgery 1999;126:1023-9.

These two papers describe the technique for radio-guided parathyroidectomy, using sestamibi scanning on the day of operation and a hand-held gamma probe in the operating room

Udelsman R, Donovan PI, Sokoll LJ. 100 consecutive minimally invasive parathyroid explorations. Annals of Surgery 2000 (in press).

Westra WH, Pritchett DD, Udelsman R. Intraoperative confirmation of parathyroid tissue during parathyroid exploration: a retrospective evaluation of the frozen section. Am J Surg Pathol 1998;22:538-44.

Starr FL, DeCresce R, Prinz RA. Normalization of intraoperative parathyroid hormone does not predict normal postoperative parathyroid hormone levels. Surgery 2000;128:930-7.

This paper describes the author's experience with intraoperative parathyroid hormone monitoring and its correlation with postoperative calcium and parathyroid hormone levels. This paper indicates that there are occasional discrepancies between the intraoperative parathyroid levels and postoperative course.

Parathyroid carcinoma

Wynne AG, van Heerden JA, Carney JA, Fitzpatrick LA. Parathyroid carcinoma: Clinical and pathological features in 43 patients. Medicine 1992;71(4):197-205.

Bondeson L, Sandelin K, Grimelius L. Histopathological variables and DNA cytometry in parathyroid carcinoma. Am J Surg Pathol 1993;17:820-829.

A careful pathologic description of parathyroid carcinoma and histologic prognostic features, using pathologic material and outcome data from 95 patients.

Obara T, Okamoto T, Ito Y,Yamashita T, Kawano M, Nishi T, Tani M, Sato K, Demura H, Fujimoto Y. Surgical and medical management of patients with pulmonary metastases from parathyroid carcinoma. Surgery 1993;114:1040-1049.

Description of the courses of seven patients with pulmonary metastases from parathyroid cancer, and the roles of operative and bisphosphonate therapy in their management.

Sandelin K, Thompson NW, Bondeson L.Metastatic parathyroid carcinoma: dilemmas in management. Surgery 1991;110:978-988.

Detailed description of the courses of five patients with parathyroid carcinoma from a single surgeon experience, with emphasis on the role of operative resection in the ongoing management.

Carcinoid tumors

Soreide JA, van Heerden JA, Thompson GB, Schleck C, Ilstrup DM, Churchward M. Gastrointestinal carcinoid tumors: Long-term prognosis for surgically treated patients. World Journal of Surgery, 2000;24:1431-1436.

McDermott EW, Guduric B, Brennan MF. Prognostic variables in patients with gastrointestinal carcinoid tumors. Br J Surg 1994;81:1007-1009.

This study reviews the clinical courses of 188 patients with a median follow-up of 72 months. On univariate analysis variables of prognostic significance were gender, site of the primary tumor, depth of invasion, tumor size, presence of lymph node or liver metastases, mode of discovery and operative intent. On multivariate analysis the variables independently predictive of death from disease were gender (women have a better prognosis) and presence of metastases at the time of diagnosis.

Makridis C, Öberg K, Juhlin C, et al. Surgical treatment of mid-gut carcinoid tumors. World J Surg 1990;14:377-385.

This study details the courses of 51 patients with mid-gut carcinoid tumors who underwent operative exploration/resection. The operative approach appears to have substantial curative or palliative value.

Janson ET, Oberg K. Long-term management of the carcinoid syndrome: treatment with octreotide alone and in combination with alpha interferon. Acta Oncol 1993;32:225-229.

Study of 55 patients with metastatic carcinoid tumor managed with somatostatin analogue therapy, followed by interferon alpha therapy for those who failed. The somatostatin analogue was very effective at managing symptoms over the long-term in these patients with somewhat indolent tumors.

Multiple Endocrine Neoplasia type 1

Doherty GM, Olson JA, Frisella MM, Lairmore TC, Wells SA, Jr, Norton JA. Lethality of multiple endocrine neoplasia type 1. World J Surg 1998; 22:581-6.

Retrospective study defining the lethality of being an MEN-1 gene carrier. While the life span of carriers and unaffected family members are similar, there is a subset of patients who die early in the MEN-1 group, mainly of metastatic islet cell tumors.

Skogseid B, Eriksson B, Lundqvist G, Lörelius LE, Rastad J, Wide L, Akerstrom G, Öberg K. Multiple endocrine neoplasia type 1: a 10 years prospective screening study in four kindreds. J Clin Endocrinol Metab 1991; 73:281-287.

Study of 4 MEN-1 families prospectively evaluated for the development of the components of MEN-1. Family members with the gene developed biochemical abnormalities indicating hyperparathyroidism and islet cell tumor earlier than previously recognized and often developed the duodenopancreatic manifestations before the calcium abnormalities.

Chandrasekharappa SC, Guru SC, Manickam P et al. Positional cloning of the gene for multiple endocrine neoplasia type 1. Science 1997; 276:404-407.

The genetic abnormality responsible for MEN-1 was described by a group from the NIH in this paper.

Jensen RT. Management of the Zollinger-Ellison syndrome in patients with multiple endocrine neoplasia type 1. J Intern Med 1998;243:477-488.

Guidelines to the medical and surgical management of ZE syndrome in MEN-1 patients from the group with the most concentrated experience in this combination.

Insulinoma

Service FJ. Hypoglycemic disorders. N Engl J Med 1995; 332:1144-1152.

Overview of the evaluation and management of hypoglycemia from one of the medical endocrinology leaders of the field

Doherty GM, Doppman JL, Shawker TH, et al. Results of a prospective strategy to diagnose, localize, and resect insulinomas. Surgery 1991;110:989-997.

Careful cataloguing of the imaging and operative results in 25 patients with benign insulinoma. Demonstrates the primacy of intraoperative ultrasound in the localization of these tumors.

Gastrinoma

Norton JA. Fraker DL. Alexander HR. Venzon DJ. Doppman JL. Serrano J. Goebel SU. Peghini PL. Roy PK. Gibril F. Jensen RT. Surgery to cure the Zollinger-Ellison syndrome. N Engl J Med 1999;341:635-44.

Operative results of a single group with 151 gastrinoma patients over a 17 year period. The 10-year biochemical cure rate was 34%.

Termanini B, Gibril F, Reynolds JC, et al. Value of somatostatin receptor scintigraphy: a prospective study in gastrinoma of its effect on clinical management. Gastroenterology 1997;112:335-347.

Careful study of the utility of somatostatin receptor scintigraphy in the localization of gastrinoma, and the effect of the studies on patient management. After evaluating the test in 122 consecutive patients, the authors conclude that SRS should be the initial localization study in these patients.

Jensen RT. Pancreatic endocrine tumors: Recent Advances. Annals of Oncology 1999;10:S1701-6.

This paper is a summary of current clinical management of these tumors, by an expert in the field.