A rare synchrony of adenocarcinoma of the ampulla with an ileal gastrointestinal stromal tumor: A case report

Table 1 Liver function tests

Liver function tests	On admission	On discharge
ALT	299	196
AST	122	75
ALP	848	754
Total Bilirubin	5.9	2.6
Direct Bilirubin	4.2	2.0
Albumin	3.0	2.6

AST: Aspartate aminotransferase, ALT: Alanine aminotransferase, ALP: Alkaline phosphatase. AST/ALT/ALP = U/Liter.

Table 2 Tumor markers

Tumor marker	Result	Normal range
CEA	0.99	0.01-4.00
CA-19	454	0.00-37

CEA: Carcinoembryonic antigen, ng/mL; CA-19: Carbohydrate antigen-19, U/mL.

Table 3 Endoscopic

Endoscopic			Surgical
Curative	Palliative	Surveillance	Trans-duodenal ampullectomy	Radical or Whipple’s resection
Endoscopic snare polypectomy or piecemeal polypectomy	Invasive ampullary adenocarcinoma	FAPS	Benign ampullary adenomas that are difficult to operate on endoscopically[7]. The advantage of this is less morbidity and mortality and alternative access to ampullary tumor resection[7]	Ampullary adenocarcinoma. Radical resection if tumor burden in the duct is high

FAPS: Familial adenomatous polyposis syndrome.

Table 4 Management of Localized gastrointestinal stromal tumors

Imatinib-sensitive mutation					Imatinib-insensitive mutation
Uncomplicated (No major complications expected with surgery)		Complicated (Major complications expected with surgery)			See Table 5
Surgery (Resection of tumor with negative margins)		Preoperative imatinib for 6 mo
Low/Intermediaterisk	High risk	Tumor negative or microscopically positive margins feasible		Tumor negative or microscopically positive margins not feasible
Follow-up	Adjuvant treatment with imatinib for 36 mo	Low/Intermediaterisk	High risk	Manage as advanced GIST or metastatic GIST
		Follow-up	Adjuvant imatinib for 36 mo

GIST: Gastrointestinal stromal tumors.

Table 5 Management of advanced or metastatic gastrointestinal stromal tumors

Imatinib-sensitive mutations			Imatinib-insensitive mutations
KIT mutations (except exon-9 variety)	Exon-9 KIT mutations		PDGFRA842 V2V mutation	BRAF mutation	NTRK translocation	SDHB	All other mutations
Imatinib 400 mg daily	Imatinib 800 mg daily		Avapritinib	BRAF inhibitor	NTRK inhibitorentrectiniblarotrectinib	Customized management	Sunitinib
Imatinib responsive	Imatinib unresponsive
Surgery of the residual disease and continue imatinib for life	Excision and ablation of progressing lesion	Add and continue sunitinib if responsive