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Endocrine Tumors of the Pancreas Dr. Methal Isam Al-Bayat General Surgery – KFHU Khobar – Saudi Arabia
Anatomy
Pancreatic Ducts
Blood Supply
Lymphatic Drainage
Nerve Supply
Physiology <ul><li>The pancreas is divided functionally into </li></ul><ul><ul><li>Exocrine Pancreas </li></ul></ul><ul><u...
Exocrine Pancreas <ul><li>secretes a clear, alkaline (pH 7-8.3) solution of 1-2 L/day, containing digestive enzymes </li><...
Endocrine Pancreas <ul><li>Nearly  one million islets of Langerhans in the normal adult pancreas </li></ul><ul><li>vary gr...
cont...
Hormone Functions
Endocrine Tumors  <ul><li>Pancreatic endocrine tumors are rare  </li></ul><ul><li>approximately 5 per 1,000,000 per year <...
cont... <ul><li>no environmental risk factors have been associated with the development of these tumors </li></ul><ul><li>...
Multiple Endocrine Neoplasia Type 1 <ul><li>characterized by </li></ul><ul><ul><li>parathyroid hyperplasia </li></ul></ul>...
cont... <ul><li>features of PET </li></ul><ul><ul><li>occur at an younger age </li></ul></ul><ul><ul><li>multifocal diseas...
Insulinomas <ul><li>60% of all PET </li></ul><ul><li>the average age at diagnosis 45 years </li></ul><ul><li>men and women...
cont... <ul><li>they are encapsulated, firm, yellow-brown nodules that are typically hypervascular </li></ul><ul><li>malig...
cont... <ul><li>Clinical presentation </li></ul><ul><ul><li>headache </li></ul></ul><ul><ul><li>lethargy </li></ul></ul><u...
cont... <ul><ul><li>weight gain </li></ul></ul><ul><li>Whipple's Triad </li></ul><ul><ul><li>low glucose level (<50 mg/dL)...
cont... <ul><li>Investigations </li></ul><ul><ul><li>Laboratory Studies </li></ul></ul><ul><ul><ul><li>low glucose levels ...
cont... <ul><li>management </li></ul><ul><ul><li>pre-operatively </li></ul></ul><ul><ul><ul><li>administration of diazoxid...
cont... <ul><ul><li>operative </li></ul></ul><ul><ul><ul><li>tumor enucleation </li></ul></ul></ul><ul><ul><ul><li>pancrea...
Gastrinoma <ul><li>2 nd  most common  </li></ul><ul><li>mean age of patients is 50 years </li></ul><ul><li>slight male pre...
cont... <ul><li>90% of gastrinomas are located within Passaro's triangle </li></ul>
cont... <ul><li>Clinical presentation </li></ul><ul><ul><li>severe form of peptic ulcer disease </li></ul></ul><ul><ul><ul...
cont... <ul><li>Investigations </li></ul><ul><ul><li>Laboratory findings </li></ul></ul><ul><ul><ul><li>fasting serum gast...
cont... <ul><ul><li>Localization </li></ul></ul><ul><ul><ul><li>CT (not for small tumors) ‏ </li></ul></ul></ul><ul><ul><u...
cont... <ul><li>Management </li></ul><ul><ul><li>indications for surgery </li></ul></ul><ul><ul><ul><li>curable resection ...
cont... <ul><li>Outcome </li></ul><ul><ul><li>5-yr survival 90% for patients without metastasis </li></ul></ul><ul><ul><li...
VIPoma <ul><li>VIPomas originate from neoplastic D2 cells </li></ul><ul><li>aka WDHA or Verner-Morrison syndrome </li></ul...
cont... <ul><li>Clinical presentation </li></ul><ul><ul><li>profuse, watery, iso-osmotic secretory diarrhea  </li></ul></u...
cont... <ul><ul><li>75% hypochlorhydia or achlorhydria </li></ul></ul><ul><ul><li>20% flushing </li></ul></ul><ul><li>W at...
cont... <ul><li>Investigations </li></ul><ul><ul><li>Laboratory findings </li></ul></ul><ul><ul><ul><li>serum levels of VI...
cont... <ul><li>Management </li></ul><ul><ul><li>pre-operative </li></ul></ul><ul><ul><ul><li>aggressive hydration </li></...
cont... <ul><li>Outcome </li></ul><ul><ul><li>only 1/3 are cured after resection </li></ul></ul>
Glucagonoma <ul><li>exceedingly rare tumors </li></ul><ul><li>2-3 times more common in women </li></ul><ul><li>averaging 5...
cont... <ul><li>Clinical presentation </li></ul><ul><ul><li>weight loss </li></ul></ul><ul><ul><li>hyperglycemia, with 76-...
cont... <ul><ul><li>migratory necrolytic dermatitis </li></ul></ul><ul><ul><ul><li>found in 2/3 of patients </li></ul></ul...
cont... <ul><li>Investigations </li></ul><ul><ul><li>Laboratory findings </li></ul></ul><ul><ul><ul><li>fasting glucagon l...
cont... <ul><ul><ul><li>IV infusion of amino acids to reverse symptoms and improve dermatitis </li></ul></ul></ul><ul><ul>...
Somatostatinoma <ul><li>Exceedingly rare tumors  </li></ul><ul><li>solitary, large tumors > 2 cm </li></ul><ul><li>patient...
cont... <ul><li>Clinical presentation </li></ul><ul><ul><li>steatorrhea  </li></ul></ul><ul><ul><li>cholelithiasis </li></...
cont... <ul><li>Dx of somatostatinomas is rarely made pre-operatively  </li></ul><ul><li>Management </li></ul><ul><ul><li>...
Nonfunctional Tumors & PPomas <ul><li>20% of PET are nonfunctional </li></ul><ul><li>PPomas are classified as nonfunctiona...
cont... <ul><li>Investigations </li></ul><ul><ul><li>localization with CT or MRI </li></ul></ul><ul><li>Management  </li><...
Other Pancreatic Endocrine Tumors <ul><li>Tumors which secrete </li></ul><ul><ul><li>gastrin-releasing factor </li></ul></...
References <ul><li>Schwartz's Principles of Surgery, by F. Charles Brunicardi, 8 th  edition </li></ul><ul><li>Maingot's A...
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Transcript of "Endocrine Tumors Of The Pancreas"

  1. 1. Endocrine Tumors of the Pancreas Dr. Methal Isam Al-Bayat General Surgery – KFHU Khobar – Saudi Arabia
  2. 2. Anatomy
  3. 3. Pancreatic Ducts
  4. 4. Blood Supply
  5. 5. Lymphatic Drainage
  6. 6. Nerve Supply
  7. 7. Physiology <ul><li>The pancreas is divided functionally into </li></ul><ul><ul><li>Exocrine Pancreas </li></ul></ul><ul><ul><ul><li>85% of pancreatic mass </li></ul></ul></ul><ul><ul><li>Endocrine Pancreas </li></ul></ul><ul><ul><ul><li>2% of pancreatic mass </li></ul></ul></ul>
  8. 8. Exocrine Pancreas <ul><li>secretes a clear, alkaline (pH 7-8.3) solution of 1-2 L/day, containing digestive enzymes </li></ul><ul><li>secretion is stimulated by </li></ul><ul><ul><li>secretin </li></ul></ul><ul><ul><li>CCK </li></ul></ul><ul><ul><li>parasympathetic vagal discharge </li></ul></ul>
  9. 9. Endocrine Pancreas <ul><li>Nearly one million islets of Langerhans in the normal adult pancreas </li></ul><ul><li>vary greatly in size </li></ul><ul><li>larger islets are located closer to the major arterioles </li></ul><ul><li>smaller islets are embedded more deeply in the pancreatic parenchyma </li></ul><ul><li>islet cells originate from neural crest cells, aka APUD cells </li></ul>
  10. 10. cont...
  11. 11. Hormone Functions
  12. 12. Endocrine Tumors <ul><li>Pancreatic endocrine tumors are rare </li></ul><ul><li>approximately 5 per 1,000,000 per year </li></ul><ul><li>about 20% are non-functional </li></ul><ul><li>functional tumors may be benign or malignant </li></ul><ul><li>the histologic characteristics do not predict their clinical behavior </li></ul><ul><li>for all types of endocrine tumors, malignancy is defined by the presence of metastases </li></ul>
  13. 13. cont... <ul><li>no environmental risk factors have been associated with the development of these tumors </li></ul><ul><li>some syndromes have been associated with pancreatic endocrine tumors </li></ul><ul><ul><li>MEN-1 </li></ul></ul><ul><ul><li>von Hippel-Lindau </li></ul></ul><ul><ul><li>Neurofibramatosis </li></ul></ul>
  14. 14. Multiple Endocrine Neoplasia Type 1 <ul><li>characterized by </li></ul><ul><ul><li>parathyroid hyperplasia </li></ul></ul><ul><ul><li>pituitary tumors </li></ul></ul><ul><ul><li>pancreatic endocrine tumors </li></ul></ul><ul><li>autosomal dominant </li></ul><ul><li>equal incidence in men & women </li></ul>
  15. 15. cont... <ul><li>features of PET </li></ul><ul><ul><li>occur at an younger age </li></ul></ul><ul><ul><li>multifocal disease </li></ul></ul><ul><ul><li>aggressive and malignant </li></ul></ul><ul><ul><li>found in uncommon sites </li></ul></ul><ul><ul><li>different incidence </li></ul></ul><ul><ul><ul><li>PPomas (>80%) ‏ </li></ul></ul></ul><ul><ul><ul><li>gastrinomas (54%) ‏ </li></ul></ul></ul><ul><ul><ul><li>insulinomas (21%) ‏ </li></ul></ul></ul><ul><ul><ul><li>glucagonomas (3%) ‏ </li></ul></ul></ul><ul><ul><ul><li>VIPomas (1%) ‏ </li></ul></ul></ul>
  16. 16. Insulinomas <ul><li>60% of all PET </li></ul><ul><li>the average age at diagnosis 45 years </li></ul><ul><li>men and women are equally affected </li></ul><ul><li>equally distributed in the head, body, and tail of the pancreas </li></ul><ul><li>rarely, they may be located in the duodenum, splenic hilum, or gastrocolic ligament </li></ul><ul><li>90% < 2 cm in size </li></ul>
  17. 17. cont... <ul><li>they are encapsulated, firm, yellow-brown nodules that are typically hypervascular </li></ul><ul><li>malignancy occurs in 10% of the cases </li></ul><ul><li>most are solitary lesions </li></ul><ul><li>multicentricity occurs in about 10% of cases and should raise the suspicion of MEN-1 </li></ul><ul><li>release large amounts of proinsulin (C-peptide and insulin) which cause hypoglycemia </li></ul>
  18. 18. cont... <ul><li>Clinical presentation </li></ul><ul><ul><li>headache </li></ul></ul><ul><ul><li>lethargy </li></ul></ul><ul><ul><li>dizziness </li></ul></ul><ul><ul><li>diplopia </li></ul></ul><ul><ul><li>amnesia </li></ul></ul><ul><ul><li>trembling </li></ul></ul><ul><ul><li>sweating </li></ul></ul><ul><ul><li>palpitations </li></ul></ul><ul><ul><li>nervousness </li></ul></ul><ul><ul><li>hunger </li></ul></ul>neuroglycopenic symptoms catecholamine release
  19. 19. cont... <ul><ul><li>weight gain </li></ul></ul><ul><li>Whipple's Triad </li></ul><ul><ul><li>low glucose level (<50 mg/dL) ‏ </li></ul></ul><ul><ul><li>symptoms of hypoglycemia </li></ul></ul><ul><ul><li>symptoms resolve with administration of glucose </li></ul></ul>
  20. 20. cont... <ul><li>Investigations </li></ul><ul><ul><li>Laboratory Studies </li></ul></ul><ul><ul><ul><li>low glucose levels (< 50 mg/dL) ‏ </li></ul></ul></ul><ul><ul><ul><li>insulin levels > 7 U/mL </li></ul></ul></ul><ul><ul><ul><li>insulin/glucose ratio > 0.3 </li></ul></ul></ul><ul><ul><ul><li>C-peptide to confirm endogenous source of insulin </li></ul></ul></ul><ul><ul><li>Localization </li></ul></ul><ul><ul><ul><li>CT and MRI for larger tumors </li></ul></ul></ul><ul><ul><ul><li>EUS can detect small tumors (<2 cm in size) ‏ </li></ul></ul></ul><ul><ul><ul><li>angiography showing a “blush” </li></ul></ul></ul>
  21. 21. cont... <ul><li>management </li></ul><ul><ul><li>pre-operatively </li></ul></ul><ul><ul><ul><li>administration of diazoxide to prevent hypoglycemic attacks </li></ul></ul></ul><ul><ul><ul><li>other agents as verapamil, glucocorticoids, and growth hormone </li></ul></ul></ul><ul><ul><li>peri-operatively </li></ul></ul><ul><ul><ul><li>glucose infusions </li></ul></ul></ul>
  22. 22. cont... <ul><ul><li>operative </li></ul></ul><ul><ul><ul><li>tumor enucleation </li></ul></ul></ul><ul><ul><ul><li>pancreaticoduodenectomy </li></ul></ul></ul><ul><ul><ul><li>tumor debulking </li></ul></ul></ul><ul><ul><li>post-operatively </li></ul></ul><ul><ul><ul><li>octreotide </li></ul></ul></ul><ul><ul><ul><li>systemic chemotherapy </li></ul></ul></ul><ul><li>Outcomes </li></ul><ul><ul><li>normal life expectancy for benign insulinoma </li></ul></ul><ul><ul><li>5 years for malignant insulinomas </li></ul></ul>
  23. 23. Gastrinoma <ul><li>2 nd most common </li></ul><ul><li>mean age of patients is 50 years </li></ul><ul><li>slight male predominance (60%) ‏ </li></ul><ul><li>gastrinomas produce ZES by overproduction of gastrin </li></ul><ul><li>over 60% are malignant </li></ul><ul><li>metastases may also involve the lungs or bone </li></ul>
  24. 24. cont... <ul><li>90% of gastrinomas are located within Passaro's triangle </li></ul>
  25. 25. cont... <ul><li>Clinical presentation </li></ul><ul><ul><li>severe form of peptic ulcer disease </li></ul></ul><ul><ul><ul><li>refractory to standard treatment </li></ul></ul></ul><ul><ul><ul><li>atypical location </li></ul></ul></ul><ul><ul><li>upper abdominal pain </li></ul></ul><ul><ul><li>GI bleeding </li></ul></ul><ul><ul><li>weight loss, nausea, vomiting </li></ul></ul><ul><ul><li>GERD </li></ul></ul><ul><ul><li>diarrhea relieved by NG suction </li></ul></ul>
  26. 26. cont... <ul><li>Investigations </li></ul><ul><ul><li>Laboratory findings </li></ul></ul><ul><ul><ul><li>fasting serum gastrin level 200-1000 pg/mL </li></ul></ul></ul><ul><ul><ul><ul><li>H2 blockers should be stopped 1 week prior to testing, and PPI 3 weeks </li></ul></ul></ul></ul><ul><ul><ul><li>basal acid output > 15 mEq/L </li></ul></ul></ul><ul><ul><li>Endoscopy </li></ul></ul><ul><ul><ul><li>multiple ulcers </li></ul></ul></ul><ul><ul><ul><li>large gastric rugal folds </li></ul></ul></ul><ul><ul><ul><li>mucosal edema </li></ul></ul></ul><ul><ul><ul><li>jejunal hypermotility </li></ul></ul></ul>
  27. 27. cont... <ul><ul><li>Localization </li></ul></ul><ul><ul><ul><li>CT (not for small tumors) ‏ </li></ul></ul></ul><ul><ul><ul><li>MRI (liver metastases) ‏ </li></ul></ul></ul><ul><ul><ul><li>SRS with radiolabeled octreotide </li></ul></ul></ul><ul><ul><ul><li>EUS </li></ul></ul></ul>
  28. 28. cont... <ul><li>Management </li></ul><ul><ul><li>indications for surgery </li></ul></ul><ul><ul><ul><li>curable resection appears possible </li></ul></ul></ul><ul><ul><ul><li>symptom control </li></ul></ul></ul><ul><ul><li>operative </li></ul></ul><ul><ul><ul><li>enucleation of small lesions </li></ul></ul></ul><ul><ul><ul><li>distal pancreatectomy </li></ul></ul></ul><ul><ul><ul><li>pancreaticoduodenectomy </li></ul></ul></ul><ul><ul><li>focus on symptomatic control for patients with metastatic disease </li></ul></ul>
  29. 29. cont... <ul><li>Outcome </li></ul><ul><ul><li>5-yr survival 90% for patients without metastasis </li></ul></ul><ul><ul><li>5-yr survival < 50% for patients with bulky metastasis </li></ul></ul>
  30. 30. VIPoma <ul><li>VIPomas originate from neoplastic D2 cells </li></ul><ul><li>aka WDHA or Verner-Morrison syndrome </li></ul><ul><li>exceedingly rare tumors </li></ul><ul><li>bimodal age distribution </li></ul><ul><ul><li>most patients are middle aged </li></ul></ul><ul><ul><li>10% < 10 years </li></ul></ul><ul><li>usually solitary located in body or tail </li></ul><ul><li>2/3 are malignant </li></ul>
  31. 31. cont... <ul><li>Clinical presentation </li></ul><ul><ul><li>profuse, watery, iso-osmotic secretory diarrhea </li></ul></ul><ul><ul><ul><li>may exceed 3 L/day </li></ul></ul></ul><ul><ul><ul><li>independent of food intake </li></ul></ul></ul><ul><ul><ul><li>doesn't resolve with NG suction </li></ul></ul></ul><ul><ul><ul><li>devoid of blood, fat, or inflammatory cells </li></ul></ul></ul><ul><ul><li>weight loss </li></ul></ul><ul><ul><li>crampy abdominal pain </li></ul></ul><ul><ul><li>dehydration </li></ul></ul><ul><ul><li>electrolyte abnormalities </li></ul></ul><ul><ul><li>metabolic acidosis </li></ul></ul>
  32. 32. cont... <ul><ul><li>75% hypochlorhydia or achlorhydria </li></ul></ul><ul><ul><li>20% flushing </li></ul></ul><ul><li>W atery </li></ul><ul><li>D iarrhea </li></ul><ul><li>H ypokalemia </li></ul><ul><li>A chlorhydria </li></ul>
  33. 33. cont... <ul><li>Investigations </li></ul><ul><ul><li>Laboratory findings </li></ul></ul><ul><ul><ul><li>serum levels of VIP > 150pg/mL after an overnight fast </li></ul></ul></ul><ul><ul><li>Localization </li></ul></ul><ul><ul><ul><li>CT or SRS </li></ul></ul></ul><ul><ul><ul><li>intraoperative U/S will localize most tumors if pre-operative studies are inconclusive </li></ul></ul></ul>
  34. 34. cont... <ul><li>Management </li></ul><ul><ul><li>pre-operative </li></ul></ul><ul><ul><ul><li>aggressive hydration </li></ul></ul></ul><ul><ul><ul><li>correction of electrolyte abnormalities and acid-base disturbances </li></ul></ul></ul><ul><ul><ul><li>octreotide to reduce diarrhea volume, if diarrhea persists glucocorticoid added </li></ul></ul></ul><ul><ul><li>operative </li></ul></ul><ul><ul><ul><li>partial pancreatic resection </li></ul></ul></ul><ul><ul><ul><li>simple enucleation is inadequate as VIPomas tend to be invasive </li></ul></ul></ul>
  35. 35. cont... <ul><li>Outcome </li></ul><ul><ul><li>only 1/3 are cured after resection </li></ul></ul>
  36. 36. Glucagonoma <ul><li>exceedingly rare tumors </li></ul><ul><li>2-3 times more common in women </li></ul><ul><li>averaging 5-10 cm </li></ul><ul><li>highly vascular </li></ul><ul><li>65-75% are found in the body or tail </li></ul><ul><li>malignancy occurs in 50-80% of patients </li></ul><ul><li>5-17% are associated with MEN 1 </li></ul>
  37. 37. cont... <ul><li>Clinical presentation </li></ul><ul><ul><li>weight loss </li></ul></ul><ul><ul><li>hyperglycemia, with 76-94% having diabetes </li></ul></ul><ul><ul><li>normochromic normocytic anemia </li></ul></ul><ul><ul><li>fat-soluble vitamin deficiency </li></ul></ul><ul><ul><li>hypoaminoacidemia </li></ul></ul><ul><ul><li>thromboembolism </li></ul></ul><ul><ul><li>diarrhea </li></ul></ul><ul><ul><li>vulvovaginitis </li></ul></ul>
  38. 38. cont... <ul><ul><li>migratory necrolytic dermatitis </li></ul></ul><ul><ul><ul><li>found in 2/3 of patients </li></ul></ul></ul><ul><ul><ul><li>due to severe amino acid deficiency </li></ul></ul></ul><ul><ul><ul><li>begins as erythematous patches that spread radially </li></ul></ul></ul><ul><ul><ul><li>bullae develop then slough with bacterial or fungal superinfection </li></ul></ul></ul><ul><ul><ul><li>healing begins in center, takes 2-3 weeks, leaving hyperpigmented skin </li></ul></ul></ul>
  39. 39. cont... <ul><li>Investigations </li></ul><ul><ul><li>Laboratory findings </li></ul></ul><ul><ul><ul><li>fasting glucagon level > 50 pmol/L </li></ul></ul></ul><ul><ul><li>Localization </li></ul></ul><ul><ul><ul><li>CT easily detects them </li></ul></ul></ul><ul><ul><ul><li>angiography is also successful because of vascularity </li></ul></ul></ul><ul><li>Management </li></ul><ul><ul><li>pre-operative </li></ul></ul><ul><ul><ul><li>supplemental enteral nutrition </li></ul></ul></ul><ul><ul><ul><li>high dose of octreotide to reverse catabolic state </li></ul></ul></ul>
  40. 40. cont... <ul><ul><ul><li>IV infusion of amino acids to reverse symptoms and improve dermatitis </li></ul></ul></ul><ul><ul><ul><li>prophylaxis against thromboembolism </li></ul></ul></ul><ul><ul><li>operative </li></ul></ul><ul><ul><ul><li>enucleation is rarely sufficient </li></ul></ul></ul><ul><ul><ul><li>distal pancreatectomy </li></ul></ul></ul><ul><ul><ul><li>pancreaticoduodenectomy and rarely total pancreatectomy may be required </li></ul></ul></ul><ul><li>Outcome </li></ul><ul><ul><li>5-yr survival 85% if no metastases present </li></ul></ul><ul><ul><li>5-yr survival 60% if metastases present </li></ul></ul>
  41. 41. Somatostatinoma <ul><li>Exceedingly rare tumors </li></ul><ul><li>solitary, large tumors > 2 cm </li></ul><ul><li>patients are usually in their 5 th or 6 th decade of life </li></ul><ul><li>most are in the head </li></ul><ul><li>majority are malignant </li></ul><ul><li>may be associated with neurofibromatosis </li></ul>
  42. 42. cont... <ul><li>Clinical presentation </li></ul><ul><ul><li>steatorrhea </li></ul></ul><ul><ul><li>cholelithiasis </li></ul></ul><ul><ul><li>diabetes </li></ul></ul><ul><ul><li>hypochlorhydria </li></ul></ul><ul><li>Investigations </li></ul><ul><ul><li>Laboratory </li></ul></ul><ul><ul><ul><li>elevated somatostatin levels </li></ul></ul></ul><ul><ul><li>Localization </li></ul></ul><ul><ul><ul><li>CT </li></ul></ul></ul>
  43. 43. cont... <ul><li>Dx of somatostatinomas is rarely made pre-operatively </li></ul><ul><li>Management </li></ul><ul><ul><li>pancreaticoduodenectomy </li></ul></ul><ul><li>Outcome </li></ul><ul><ul><li>cure rarely achieved </li></ul></ul>
  44. 44. Nonfunctional Tumors & PPomas <ul><li>20% of PET are nonfunctional </li></ul><ul><li>PPomas are classified as nonfunctional </li></ul><ul><li>2/3 are malignant </li></ul><ul><li>60-80% of malignant tumors have distant metastases at the time of Dx </li></ul><ul><li>typically larger (4-5 cm) ‏ </li></ul><ul><li>Clinical presentation </li></ul><ul><ul><li>abdominal pain </li></ul></ul><ul><ul><li>jaundice </li></ul></ul>
  45. 45. cont... <ul><li>Investigations </li></ul><ul><ul><li>localization with CT or MRI </li></ul></ul><ul><li>Management </li></ul><ul><ul><li>pancreaticoduodenectomy </li></ul></ul><ul><ul><li>distal pancreatectomy </li></ul></ul><ul><li>Outcome </li></ul><ul><ul><li>5-yr survival approximately 50% </li></ul></ul>
  46. 46. Other Pancreatic Endocrine Tumors <ul><li>Tumors which secrete </li></ul><ul><ul><li>gastrin-releasing factor </li></ul></ul><ul><ul><li>adrenocorticotropic hormone </li></ul></ul><ul><ul><li>neurotensin </li></ul></ul><ul><ul><li>calcitonin </li></ul></ul><ul><ul><li>enteroglucagon </li></ul></ul><ul><ul><li>CCK </li></ul></ul><ul><ul><li>gastric inhibitory peptide </li></ul></ul><ul><ul><li>leutenizing hormone </li></ul></ul>
  47. 47. References <ul><li>Schwartz's Principles of Surgery, by F. Charles Brunicardi, 8 th edition </li></ul><ul><li>Maingot's Abdominal Operations, by Michael J. Zinner and Stanely W. Ashley, 11 th edition </li></ul><ul><li>Current Surgical Therapy, by John L. Cameron, 8 th edition </li></ul><ul><li>126 Current Surgical Diagnosis and Treatment, 12 th edition </li></ul>
  48. 48. Thank You
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