Gallbladder Cancer Presenting with Jaundice: Uniformly Fatal or Still Potentially Curable?

Abstract

Background Jaundice as a presenting symptom of gallbladder cancer has traditionally been considered to be a sign of advanced disease, inoperability, and poor outcome. However, recent studies have demonstrated that a small subset of these patients can undergo resection with curative intent. Methods Patients with gallbladder cancer managed surgically from 2000–2014 in 10 US academic institutions were stratified based on the presence of jaundice at presentation (defined as bilirubin ≥ 4 mg/ml or requiring preoperative biliary drainage). Perioperative morbidity, mortality, and overall survival were compared between jaundiced and non-jaundiced patients. Results Of 400 gallbladder cancer patients with available preoperative data, 108 (27%) presented with jaundice while 292 (73%) did not. The fraction of patients who eventually underwent curative-intent resection was much lower in the presence of jaundice (n=33, 30%) than not (n=218, 75%, P<0.001). Jaundiced patients experienced higher perioperative morbidity (69% vs. 38%, P=0.002), including a much higher need for reoperation (12% vs. 1%, P=0.003). However, 90-day mortality (6.5% vs. 3.6%, P=0.35) was not significantly higher. Overall survival after resection was worse in jaundiced patients (median 14 vs. 32 months, P<0.001). Further subgroup analysis within the jaundiced patients revealed a more favorable survival after resection in the presence of low CA19-9 < 50 (median 40 vs. 12 months, P=0.003) and in the absence of lymphovascular invasion (40 vs. 14 months; P=0.014). Conclusion Jaundice is a powerful preoperative clinical sign of inoperability and poor outcome among gallbladder cancer patients. However, some of these patients may still achieve long-term survival after resection, especially when preoperative CA19-9 levels are low and no lymphovascular invasion is noted pathologically.

Outcomes of surgical resection of gallbladder cancer in patients presenting with jaundice: A systematic review and meta‐analysis

“…Among the 168 studies that met the initial search criteria, eight studies [9][10][11][12][13][14][15][16] were selected for the meta-analysis. Figure 1…”

“…Seven studies [9][10][11][12][13][14]16 consisting of 1960 participants reported overall survival. Overall survival was significantly worse among patients who presented with jaundice, compared with patients who did not (HR: 2.21, 95% CI, 1.64-2.97; P < 0.001).…”

“…Two studies 9,12 reported multivariable analyses of factors associated with patient survival in which jaundice was included.…”

“…All of the eight studies 9,[11][12][13][14]16,17 were included in the resectability analysis. Patients with jaundice were consistently noted to have the more advanced disease than non-jaundiced patients (pooled ORs 5.87; 95% CI, 2.41-14.33; P < 0.001).…”

“…Postoperative morbidity data were available from five studies. [9][10][11][12]14 Results of the meta-analyses of the secondary outcomes are reported in…”