|Ahead of print publication
Prognostic and predictive factors in cancer patients with obstructive jaundice treated by percutaneous transhepatic biliary drainage: A single-center experience
Hayriye Sahinli1, Ahmet Özet2
1 Department of Medical Oncology, Ankara Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
2 Department of Medical Oncology, Faculty of Medicine, Gazi University, Ankara, Turkey
|Date of Submission||24-Jul-2019|
|Date of Acceptance||19-Dec-2019|
|Date of Web Publication||22-Jul-2020|
Ankara Dışkapı Yıldırım Beyazıt Training and Research Hospital, Medical Oncology Clinic, Ömer Halis Demir Street, Altındaǧ, Ankara
Source of Support: None, Conflict of Interest: None
Background: Short-term survival rates are reported in the patients undergoing percutaneous transhepatic biliary drainage (PTBD). The purpose of this study was to determine the factors predicting survival following percutaneous biliary drainage.
Materials and Methods: The data of 90 patients undergoing PTBD due to malignant biliary obstruction were analyzed retrospectively between January 2009 and November 2014.
Results: The median age of the patients were 64 years. Fifty-one (57%) of the patients were male. Median survival following PTBD was 44 days. Survival rates at 1 month, 3 months, and 6 months following PTBD were 58%, 33%, and 8.9%, respectively. Multivariate Cox's regression analysis showed that platelet (PLT) count is significantly associated with predictors of survival; the other factors affecting survival were receiving chemotherapy following PTBD, liver metastasis, and serum albumin levels.
Conclusion: Lower serum PLT level following PTBD is associated with the short-term survival. Survival of patients who are not able to receive chemotherapy after PTBD, having a low level of serum albumin, and patients with liver metastasis were shorter.
Keywords: Biliary, drain, malignant, survival
|How to cite this URL:|
Sahinli H, Özet A. Prognostic and predictive factors in cancer patients with obstructive jaundice treated by percutaneous transhepatic biliary drainage: A single-center experience. J Can Res Ther [Epub ahead of print] [cited 2020 Oct 26]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=290468
| > Introduction|| |
Obstruction in bile ducts may develop due to benign or malign causes. Periampullary carcinoma, cholangiocarcinoma, carcinoma of the gallbladder, metastatic lymph nodules located in hepatic hilus, and hepatoduodenal ligament are the common causes of bile duct obstruction due to malign reasons. The development of jaundice in malignant diseases indicates a poor prognosis., Short-time survival is reported in the patients undergoing percutaneous transhepatic biliary drainage (PTBD) due to malignant bile duct obstruction.,,
Percutaneous biliary drainage and stents placed into the bile ducts have an important place in the palliative treatment of jaundice due to malignant causes. PTBD has become a salvage method in inoperable patients who are unsuitable for endoscopic procedures due to deterioration of health condition and anatomical inaccessibility and enables local treatments, surgery, and chemotherapy following drainage., Survival advantage was provided in few previous studies conducted with patients receiving chemotherapy following PTBD. However, in a study conducted by Robson et al., it was concluded that PTBD did not increase the life quality independent from technical success.
In some studies, the factors predicting survival following PTBD were investigated, and differences among these factors were determined. The factors predicting short- and long-term survival are uncertain. When the factors which predict survival are well determined, the patients who will not benefit from PTBD will be predetermined and unnecessary invasive procedures will be avoided. The purpose of this study is to determine the factors predicting survival in patients undergoing PTBD.
| > Materials and Methods|| |
Ninety patients histopathologically diagnosed with malignant disease and undergoing PTBD due to malignant bile duct obstruction at Gazi University Medical Faculty between January 2009 and November 2014 were included in the study. Informed consent of the patients was obtained. The study was carried out in compliance with the principles of the Helsinki declaration. Patients' characteristics were obtained retrospectively from the patients' records. Gender, age, diagnosis, liver metastasis, prior chemotherapy before PTBD, outcomes after PTBD, levels of alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), albumin, creatinine (Cr), hemoglobin (Hb), platelet (PLT), and leukocyte counts of patients were evaluated retrospectively. Successful PTBD is defined as achieving a serum total bilirubin concentration of <1, 5 mg/dl after PTBD.
The data were analyzed using the IBM SPSS Statistics for Windows, version 20.0 (Armonk, NY: IBM Corp.). Descriptive statistics were shown as mean ± standard deviation or median (minimum or maximum) for continuous variables and case number and percentages for categorical variables. Survival curves were analyzed by the Kaplan–Meier method, and the statistical significance of survival was evaluated by the log-rank test. Individual univariate analysis was completed on all extracted variables, and significant variables were included in the multivariate analysis model. The Cox proportional-hazards model was used for the regression analysis to determine which variables retained significance. P values were considered statistically significant at values of < 0.05.
| > Results|| |
Median patients' age was 64 years. Fifty-one (57%) of the patients were male. Primary cancers that caused biliary obstruction were 43.3% pancreas cancer, 20% stomach cancer, 10% colorectal cancer, 6.7% cholangiocarcinoma, 5.6% gall bladder carcinoma, 5.6% lung cancer, 3.3% ovarian cancer, 2.2% renal carcinoma, 1.1% hepatocellular carcinoma, 1.1% breast cancer, and 1. 1% had cancer of unknown primary origin. Nine patients (10%) had liver metastasis prior PTBD. Laboratory parameters of the patients are shown in the [Table 1].
Median survival was 44 days following PTBD (1–454 days). Survival rates of the patients at the 1st, 3rd, and 6th months after PTBD were 58%, 33%, and 8.9%, respectively [Figure 1]. Nearly 11.6% of the patients undergo unsuccessful PTBD had multiple liver metastasis. Median survival of the patients having multiple liver metastasis was 10 days following PTBD [Figure 2]. Fifty-one patients (56%) received chemotherapy before PTBD. Sixteen of these patients (17%) received at least second-line chemotherapy. Twenty-two patients (24.2%) received chemotherapy following PTBD. The survival of the patients receiving chemotherapy following PTBD was significantly longer (P = 0.00). The median survival of the patients receiving chemotherapy following PTBD was found as 159 days, whereas median survival of the patients not receiving chemotherapy was 30 days [Figure 3]. Twenty-three patients (23.3%) received successful PTBD, and the remaining 69 (67.6%) patients received unsuccessful PTBD. One hundred and ninety days for patients who had undergone successful PTBD and 30 days in the remaining patients who had undergone unsuccessful percutaneous transhepatic. Twenty-two percent of the patients (n = 26) were over 70 years old. No statistically significant difference was found in overall survival when patients were categorized as over and under 70 years old (P = 0.163). There were no statistically significant differences between the histological types of tumors (P = 0.056).
|Figure 1: Survival ratios at 1 month, 3 months, and 6 months 58%, 33%, and 8.9%, respectively|
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|Figure 3: Survival of patients receiving chemotherapy following percutaneous transhepatic biliary drainage|
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Univariate Cox regression analysis revealed no relationship between survival and leukocyte count, Hb level, serum Cr level, GGT, and ALT levels [Table 2]. Multivariate Cox regression analysis revealed that serum albumin level, PLT count, presence of liver metastasis, and receiving chemotherapy following PTBD were significantly associated with the survival [Table 3].
|Table 2: Univariate cox regression analysis for predictive factors associated with survival following percutaneous transhepatic biliary drainage|
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|Table 3: Multivariate Cox regression analysis of the factors independently associated with survival following percutaneous transhepatic biliary drainage|
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| > Discussion|| |
Bile duct obstruction confronts us as a common complication in gastrointestinal, liver, and bile duct malignancies. Malignant bile duct obstruction often develops by the external pressure of lymph node metastasis or spread of cancer directly to the bile ducts. It may occur usually secondary to tumor pressure at the beginning of the treatment or further stages. Majority of the patients with malignant obstructive jaundice are inoperable or in advanced stage at the time of the diagnosis.
Malign obstructive jaundice in majority of the patients is incurable and has a poor prognosis. PTBD may be considered in these patients as a palliative treatment method.
Previous studies have shown that obstructive jaundice with poor prognostic factors could not receive survival benefit from PTBD, even though they achieved an improvement in their liver dysfunction. A few studies were performed to investigate the factors predicting short-term survival in patients with malignant bile duct obstruction.,, The purpose of this study was to identify the predictive factors of short-term survival following PTBD in patients with malignant bile duct obstruction. We can be avoided such an invasive procedure if we can identify patients who will not increase wellbeing or survival.
In our study, survival rates of the patients undergoing PTBD at the 1st, 3rd, and 6th months were 53%, 33%, and 8.9%, respectively. Median survival following PTBD was 44 days (1–454 days). Median survival has reported the range of 79–104 days in some previous studies. Median survival time in our study is lower compared to these studies.,, In some studies, the effects of presence multiple liver metastasis, age of patients, type of tumor histology, receiving chemotherapy following drainage, receiving multiple chemotherapy before drainage on survival were investigated. In Kasuga et al.'s study, it was determined that the presence of multiple liver metastasis and receiving multiple chemotherapy were independent poor risk factors. In our study, the presence of multiple liver metastasis was found as a poor prognostic factor as well; however, no relationship was found between receiving multiple chemotherapy before PTBD and survival.
In a study performed by Tuqan et al., the median survival was found as 46 days and they attributed this lower median survival to the small number of patients receiving chemotherapy following PTBD. In our study, median survival was similar as compared to this study. In our study, 24.2% of the patients received chemotherapy following PTBD. Median survival of the patients receiving and not receiving chemotherapy following PTBD was 150 days and 30 days, respectively. Survival of the patients receiving chemotherapy following PTBD was significantly longer (P = 0.00) [Figure 3]. The small number of patients receiving chemotherapy following PTBD, the presence of liver metastasis in 10% of the patients, and lower success rate after PTBD were considered as the causes of low median survival. In a study conducted by Kasuga et al., the median survival of the patients receiving chemotherapy following PTBD was found 273 days, median survival of the patients not receiving chemotherapy following successful PTBD was found 65 days, and following unsuccessful PTBD the median survival was 34 days. In Crosara Teixeira et al.'s study, the median survival was found as 2.9 months and half of the patients received chemotherapy following PTBD. In Zhang et al.'s study, overall survival of the patients receiving chemotherapy following PTBD was found 285 days and for those not receiving chemotherapy was 150 days.
In our study, success rate after PTBD was found 23.3% (n = 21). Median survival following successful PTBD was 190 days, and median survival following unsuccessful PTBD was 30 days. Lower success rate of PTBD was considered as a reason of shorter median survival following PTBD. In a study by Zhang et al., a decrease of more than 20% in bilirubin levels within 7 days was accepted as a successful procedure. In this study of Zhang et al., the success rate was 76.5%. In our study, decreasing of total bilirubin level to normal level following PTBD was considered as a successful procedure. This is considered as the most important reason for the low success rate in our study. In addition, the presence of liver metastasis in 11.6% of patients was considered as one of the reasons. Overall survival of the patients with multiple liver metastasis was 10 days [Figure 2]. The success rate following PTBD was ranged between 75% and 98% in previous clinical studies. The presence of liver metastasis was reported to decrease the rate of clinical success in a study performed by Tuqan et al. The reason of lower success rate in this study compared to the other studies was interpreted as less laboratory response due to poor liver reserve resulting from liver metastasis.
In our study, there was no statistically significant difference between the patient groups receiving and not receiving chemotherapy before PTBD (P = 0, 8). Receiving multiple chemotherapy before PTBD was determined as a poor prognostic factor in a study performed by Kasuga et al.; however, in our study, it is found that it has no effect on survival.
In some studies, it was shown that serum albumin level before treatment had a strong prognostic effect in cancer patients. Serum albumin level was determined as one of the factors predicting survival in patients undergoing PTBD in previous studies. Being a strong and inexpensive indicator is the most important advantage of serum albumin level. In our study, serum albumin level before PTBD was determined as one of the most important independent factors predicting short-term survival as well.
In the study conducted by Tuqan et al., PLT count was not identified among the factors predicting survival; however, it was determined as one of the factors which independently predict survival following PTBD in our study. This is the first study in which PLT count is identified as an independent factor predicting survival following PTBD.
In a study performed by Castoldi et al. with 86 cancer cases, it was found that serum levels of indirect bilirubin, serum cholinesterase, leukocyte, blood urea nitrogen, histotype of metastasis, and large volume cancer were the factors predicting short-term survival. In another study, receiving chemotherapy following intervention was found to be associated with better survival. In the study conducted by Kasuga et al., poor performance situation, presence of multiple liver metastasis, presence of ascites, receiving multiple chemotherapy before intervention, undifferentiated tumor type, and high level of serum carcinoembryonic antigen-19.9 were identified as independent and poor predictive factor. In our study, the presence of multiple liver metastasis, albumin level, PLT count, receiving chemotherapy following PTBD were found as predictive factors for the survival. Receiving multiple chemotherapy, type of tumor histology, serum Cr level, leukocyte count, and ALT and GGT levels were not found as survival predicting factors.
The limitations of our study are its retrospective nature and small sample size. Prospective multicenter studies are needed.
| > Conclusion|| |
Consequently, PTBD is an invasive procedure. İf we can predict patients who will benefit from PTBD we can avoid unnecessary invasive procedures.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]