title: Downstaging chemotherapy and alteration in the classic computed tomography/magnetic resonance imaging signs of vascular involvement in patients with pancreaticobiliary malignant tumors: influence on patient selection for surgery.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Retrospective cohort study; prospective database.
  
  
  METHODS
  University pancreatic disease center.
  
  
  METHODS
  Patients with unresectable pancreaticobiliary cancer who underwent curative intent surgery after completing DCTx.
  
  
  METHODS
  Use of CT/MRI scan, pancreatic resection, and palliative bypass.
  
  
  METHODS
  Resectability after DCTx and disease-specific survival.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of General Surgery, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA 90095-6904, USA. tdonahue@mednet.ucla.edu
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Donahue
authors.forename: William H
authors.initials: WH
authors.lastname: Isacoff
authors.forename: O Joe
authors.initials: OJ
authors.lastname: Hines
authors.forename: James S
authors.initials: JS
authors.lastname: Tomlinson
authors.forename: James J
authors.initials: JJ
authors.lastname: Farrell
authors.forename: Yasser M
authors.initials: YM
authors.lastname: Bhat
authors.forename: Edward
authors.initials: E
authors.lastname: Garon
authors.forename: Barbara
authors.initials: B
authors.lastname: Clerkin
authors.forename: Howard A
authors.initials: HA
authors.lastname: Reber
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D001661:Biliary Tract Neoplasms / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D002140:California / Q000453:epidemiology; D017024:Chemotherapy, Adjuvant; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D010166:Palliative Care / Q000379:methods; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D018579:Patient Selection; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014057:Tomography, X-Ray Computed / Q000379:methods*; D019043:Vascular Neoplasms / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy
chemical_list: D000970:Antineoplastic Agents