# Hypoalbuminemia as a prognostic marker for survival in biliary tract cancer: associations with tumor type, treatment and sex

## TL;DR

Low albumin levels predict poor survival in biliary tract cancer patients, with differences seen across cancer types and genders.

## Contribution

This study identifies hypoalbuminemia as a standalone prognostic marker in biliary tract cancer, stratified by tumor type, treatment, and sex.

## Key findings

- Hypoalbuminemia was a negative prognostic factor for survival in resectable and unresectable BTC.
- Low albumin levels were more common in perihilar and gallbladder cancers compared to intrahepatic cancers.
- Hypoalbuminemia predicted worse outcomes in intrahepatic and gallbladder cancers but not in perihilar cancers.

## Abstract

Albumin in combination with other inflammatory markers has shown prognostic value in malignancy, including biliary tract cancer (BTC). This study aimed to evaluate the prognostic value of hypoalbuminemia alone in patients with BTC, with stratified analyses according to tumor type, treatment and sex.

A retrospective regional referral center cohort study was conducted, including consecutive patients with a measurement of preoperative albumin and intended resection of suspected BTC: intrahepatic cholangiocarcinoma (iCCA), perihilar cholangiocarcinoma (pCCA) or gallbladder cancer (GBC) between 2009 and 2017. The primary outcome was overall survival (OS), analyzed by Kaplan-Meier estimate and Cox regression.

Out of 221 patients, 191 underwent resection, while 30 patients were diagnosed with unresectable BTC (14%). In the resection group, 147 patients had confirmed BTC, while 44 (20%) were postoperatively diagnosed with a benign lesion. Hypoalbuminemia (< 35 g/L) was more frequent in pCCA (75%) and GBC (59%), compared to iCCA (34%, p < 0.001). The preoperative albumin level was positively associated with resectability (p = 0.025). In patients with resection, hypoalbuminemia was associated with a tumor positive resection margin (p < 0.001). Hypoalbuminemia was a negative prognostic factor in resectable (p < 0.001) and unresectable BTC (p < 0.001), and in both women (p = 0.002) and men (p = 0.004). Hypoalbuminemia was negatively associated with OS in iCCA (p < 0.001) and GBC (p = 0.022), but not in pCCA (p = 0.210).

Preoperative albumin was prognostic for survival in patients with iCCA and GBC, in both women and men and regardless of tumor resectability. Patients with pCCA more often had low albumin, and hypoalbuminemia alone was not prognostic in this subgroup.

The online version contains supplementary material available at 10.1007/s00432-025-06408-2.