figure 30.6. Duodenal malignant GIST in a 56-year-old male patient presenting with a palpable abdominal mass. (A) Coronal volume-rendered image reveals a large mass (arrow) with peripheral enhancement and central necrosis, arising from the second portion of the duodenum. Interactive volume rendering helps in confirming the duodenal origin of the mass, which should not be mistaken for pancreatic neoplasm. (B) Coronal maximum intensity projection image better reveals the superior mesen-teric artery (arrow) and its branches draped around the mass. No vascular encasement was seen; this was confirmed at pathology. (C) Sagittal reconstruction demonstrates the craniocaudal and anteroposterior extent of the mass (arrow) and the relation to the surrounding organs, including the liver (L), gallbladder (G), and right kidney (X). These findings are important for surgical planning.
with metastases to the liver, peritoneum, or omentum. Ascites may occur but is uncommon. Patients with neurofi-bromatosis (type I) may have multiple small intestinal GISTs18,19 (Figure 30.7).
Differential diagnosis for small intestinal GISTs includes adenocarcinoma, which is the most common primary malignancy of the proximal small bowel. However, adenocarci-noma typically manifests as an annular lesion in the proximal small bowel, which is not a feature of GISTs. Lymphoma may be indistinguishable from GISTs, especially when it produces large masses that may cavitate, ulcerate, and extend into the mesentery. However, the presence of lymphadenopathy favors the diagnosis of lymphoma. Tumors of the duodenum and proximal small bowel may cause a significant mass effect on the pancreas or simulate a pancreatic primary50,51 (Figure 30.8). Judicious application of image postprocessing may help in avoiding this pitfall.
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Among the evils which a vitiated appetite has fastened upon mankind, those that arise from the use of Tobacco hold a prominent place, and call loudly for reform. We pity the poor Chinese, who stupifies body and mind with opium, and the wretched Hindoo, who is under a similar slavery to his favorite plant, the Betel but we present the humiliating spectacle of an enlightened and christian nation, wasting annually more than twenty-five millions of dollars, and destroying the health and the lives of thousands, by a practice not at all less degrading than that of the Chinese or Hindoo.