SYNOPSIS An unusual islet-cell tumour found at necropsy in a patient who had died from a myocardial infarction is described. Of particular interest were the pedunculated nature and large size of the tumour. The clinical features of the case are considered. Four islet-cell tumours in the duodenum have previously been reported and it seems probable that such tumours arise in heterotopic pancreas.
CASE REPORTThe patient, a motor-coach driver of 56 years, was admitted to hospital as an emergency because of the sudden onset of severe chest pain. A diagnosis of myocardial infarction was made from the clinical features and this was confirmed by the electrocardiographic findings. He had previously been in good health apart from 'indigestion' which had been present and increasing in severity for six months. The haemoglobin on admission was 72% (10-7 g/100 ml.) and a blood film showed the features of iron deficiency.Treatment was commenced with anticoagulants. During the ensuing 72 hours he developed the symptoms and signs of heart failure which did not respond to the usual forms of treatment. He died on the fifth day after his admission.
POST-MORTEM EXAMINATION AND HISTOLOGYExamination of the heart revealed a recent extensive postero-septal myocardial infarct of the left ventricle. There was considerable atheroma of the coronary arteries.Within the lumen of the second part of the duodenum and arising from the medial wall was a mucosa-covered, pedunculated mass 3-5 x 2 x 1 cm. (Fig. 1). The mucosal pedicle which permitted limited movement of the mass within the duodenum was 1-5 cm. in length, 2 cm. in width, and 0-5 cm. thick (Fig. 2). The pedicle arose 7 cm. distal to the pylorus and 2 cm. proximal to the ampulla of Vater. The mucosal surface of the mass opposite the attachment of the pedicle showed central umbilication and several shallow ulcerated areas were present, the largest having a maximum diameter of 0 3 cm. The mass was firm and the cut surface had a finely trabeculated appearance with a yellowish white