Donahue Timothy R, Isacoff William H, Hines O Joe, Tomlinson James S, Farrell James J, Bhat Yasser M, Garon Edward, Clerkin Barbara, Reber Howard A
Division of General Surgery, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA 90095-6904, USA.
Arch Surg. 2011 Jul;146(7):836-43. doi: 10.1001/archsurg.2011.152.
To determine whether computed tomography (CT)/magnetic resonance imaging (MRI) signs of vascular involvement are accurate after downstaging chemotherapy (DCTx) and to highlight factors associated with survival in patients who have undergone resection.
Retrospective cohort study; prospective database.
University pancreatic disease center.
Patients with unresectable pancreaticobiliary cancer who underwent curative intent surgery after completing DCTx.
Use of CT/MRI scan, pancreatic resection, and palliative bypass.
Resectability after DCTx and disease-specific survival.
We operated on 41 patients (1992-2009) with locally advanced periampullary malignant tumors after a median of 8.5 months of DCTx. Before DCTx, most patients (38 [93%]) were unresectable because of evidence of vascular contact on CT/MRI scan or operative exploration. Criteria for exploration after DCTx were CT/MRI evidence of tumor shrinkage and/or change in signs of vascular involvement, cancer antigen 19-9 decrease, and good functional status. None had progressive disease. At operation, we resected tumors in 34 of 41 patients (83%), and 6 had persistent vascular involvement. Surprisingly, CT/MRI scan was only 71% sensitive and 58% specific to detect vascular involvement after DCTx. "Involvement" on imaging was often from tumor fibrosis rather than viable cancer. Radiographic decrease in tumor size also did not predict resectability (P = .10). Patients with tumors that were resected had a median 87% decrease in cancer antigen 19-9 (P = .04) during DCTx. The median follow-up (all survivors) was 31 months, and disease-specific survival was 52 months for patients with resected tumors.
In patients with initially unresectable periampullary malignant tumors, original CT/MRI signs of vascular involvement may persist after successful DCTx. Patients should be chosen for surgery on the basis of lack of disease progression, good functional status, and decrease in cancer antigen 19-9.
确定在进行降期化疗（DCTx）后，计算机断层扫描（CT）/磁共振成像（MRI）显示的血管受累迹象是否准确，并强调与接受手术切除患者的生存相关的因素。
回顾性队列研究；前瞻性数据库。
大学胰腺疾病中心。
不可切除的胰胆管癌患者，在完成DCTx后接受了根治性手术。
使用CT/MRI扫描、胰腺切除术和姑息性旁路手术。
DCTx后的可切除性和疾病特异性生存率。
我们对41例患者（1992 - 2009年）进行了手术，这些患者患有局部晚期壶腹周围恶性肿瘤，DCTx的中位时间为8.5个月。在DCTx之前，大多数患者（38例[93%]）因CT/MRI扫描或手术探查显示血管受累而不可切除。DCTx后进行探查的标准是CT/MRI显示肿瘤缩小和/或血管受累迹象改变、癌抗原19 - 9降低以及良好的功能状态。无一例患者有疾病进展。手术时，我们在41例患者中的34例（83%）切除了肿瘤，6例仍有持续性血管受累。令人惊讶的是，DCTx后CT/MRI扫描检测血管受累时的敏感性仅为71%，特异性为58%。影像学上的“受累”往往是由于肿瘤纤维化而非存活癌。肿瘤大小的影像学减小也不能预测可切除性（P = 0.10）。接受肿瘤切除的患者在DCTx期间癌抗原19 - 9的中位数下降了87%（P = 0.04）。中位随访时间（所有幸存者）为31个月，接受肿瘤切除患者的疾病特异性生存率为52个月。
对于最初不可切除的壶腹周围恶性肿瘤患者，成功的DCTx后，最初的CT/MRI血管受累迹象可能持续存在。应根据无疾病进展、良好的功能状态和癌抗原19 - 9降低来选择患者进行手术。
