Gallbladder cancer presenting with jaundice: Uniformly fatal or still potentially curable?

Abstract

336 Background: The prognosis of patients with gallbladder cancer (GBC) who present with jaundice has historically been considered dismal, however recent Eastern literature has demonstrated that surgical resection can be associated with long-term survival. The objective of this study was to utilize a contemporary, Western, multi-institutional dataset to examine the prognostic significance of preoperative jaundice on short- and long-term outcomes after GBC resection. Methods: Patients with GBC managed surgically from 2000 to 2015 in 10 academic institutions participating in the U.S. Extrahepatic Biliary Malignancy Consortium were stratified based on the presence of preoperative jaundice (bilirubin > 3 mg/ml or requiring preoperative biliary drainage). Postoperative morbidity, mortality, and overall survival were compared. Results: Of 449 patients with GBC evaluated for resection, 301 (67%) eventually underwent curative-intent resection. Resectability for cure was much lower in patients with preoperative jaundice (48% vs. 79%, p < 0.001). Of 273 patients who underwent curative-intent resection and had available preoperative bilirubin levels, 53 (19%) had preoperative jaundice and were noted to have tumors of T3/4 stage (63% vs 42%, P = 0.008), with lymph node metastasis (63% vs. 41%; p = 0.014), lymphovascular invasion (68% vs 39%; p = 0.003), and R1 margins (37 vs. 9%; p < 0.001). Patients with jaundice more commonly required CBD (55% vs 32%, P = 0.004), major liver (25% vs. 7%; p < 0.001) and portal vein resection (8% vs. 0.5%; p = 0.006), as well as intraoperative blood transfusion (29 % vs. 11%; p = 0.002). Overall morbidity (57% vs. 38%; p = 0.031) and in-hospital mortality (7.5% vs. 1.4%; p = 0.029) rates were higher in patients with jaundice. Overall survival after curative-intent resection was worse in patients with jaundice (median 12 vs 33 months; p < 0.001). Conclusions: Half of GBC patients presenting with jaundice are not resectable for cure and when they are, their 5-year survival is 12%. These patients should not be excluded from multidisciplinary treatment strategies that include surgery, however expectations should be clearly set and selection should be cautious.