Radiation Oncology/Bile duct/Staging

Extrahepatic bile ducts

Current staging

AJCC 7th Edition (2009)
For the 7th Edition staging, there are now separate staging classifications for perihilar (proximal) and distal bile duct tumors

Perihilar Bile Ducts
Primary Tumor:

• Tis - carcinoma in situ
• T1 - confined to the bile duct, with extension up to the muscle layer or fibrous tissue
• T2
  • T2a - invades beyond the wall of the bile duct to surrounding adipose tissue
  • T2b - invades adjacent hepatic parenchyma
• T3 - invades unilateral branches of the portal vein or hepatic artery
• T4 - invades main portal vein or its braches bilaterally; common hepatic artery; second-order biliary radicals bilaterally; or unilateral second-order biliary radicals with contralateral portal vein or hepatic artery involvement

Regional Lymph Nodes:

• N0 - no
• N1 - regional lymph node metastasis (along the cystic duct, common bile duct, hepatic artery, and portal vein)
• N2 - metastasis to periaortic, pericaval, superior mesenteric artery, and/or celiac artery lymph nodes

Distant Metastases:

• M0 - no
• M1 - yes

Stage Grouping:

• I - T1 N0
• II - T2a-b N0
• IIIA - T3 N0
• IIIB - T1-3 N1
• IVA - T4 N0-1
• IVB - N2 or M1

Distal Bile Duct
Primary Tumor:

• Tis - carcinoma in situ
• T1 - confined to the bile duct
• T2 - invades beyond the wall of the bile duct
• T3 - invades the gallbladder, pancreas, duodenum, or other adjacent organs without involvement of the celiac axis or the superior mesenteric artery
• T4 - involves the celiac axis or the superior mesenteric artery

Regional Lymph Nodes:

• N0 - no
• N1 - regional lymph node metastasis

Distant Metastases:

• M0 - no
• M1 - yes

Stage Grouping:

• IA - T1 N0
• IB - T2 N0
• IIA - T3 N0
• IIB - T1-3 N1
• III - T4
• IV - M1

Prognostic factors : serum CEA, CA19.9

Changes from 6th Edition:

• Now separate staging classifications for perihilar and distal extrahepatic bile duct tumors

Previous editions

AJCC 6th Edition (2002)
For the 6th edition - all extrahepatic bile duct tumors (perihilar or distal) are included in one classification

Primary Tumor:

• Tis - carcinoma in situ
• T1 - confined to the bile duct
• T2 - invades beyond the wall of the bile duct
• T3 - invades liver, gallbladder, pancreas, and/or unilateral branches of the portal vein or hepatic artery
• T4 - invades main portal vein or its braches bilaterally, common hepatic artery, or other adjacent structures such as the colon, stomach, duodenum, or abdominal wall (unresectable)

Regional Lymph Nodes:

• N0 - no
• N1 - yes

Distant Metastases:

• M0 - no
• M1 - yes

Stage Grouping:

• IA - T1 N0
• IB - T2 N0
• IIA - T3 N0
• IIB - N1
• III - T4
• IV - M1

AJCC 5th edition (1997)
Primary Tumor:

• T1

  T1a - invades subepithelial connective tissue

  T1b - invades fibromuscular layer

• T2 - invades perifibromuscular connective tissue
• T3 - invades adjacent structures (liver, pancreas, duodenum, gallbladder, colon, stomach)

Regional Lymph Nodes:

• N1 - metastasis in cystic duct, pericholedochal and/or hilar lymph nodes (i.e in the hepatoduodenal ligament)
• N2 - metastasis in peripancreatic (head only), periduodenal, periportal, celiac, and/or superior mesenteric and/or posterior pancreatic duodenal lymph nodes

Stage grouping:

• I - T1 N0
• II - T2 N0
• III - T1-2 N1-2
• IVA - T3 Any N
• IVB - M1

Intrahepatic bile ducts

AJCC 7th Edition (2009)
Note: New staging category beginning with the 7th edition. In prior editions, staging for intrahepatic bile ducts was grouped in with Liver staging.

Primary tumor:

• Tis - carcinoma in situ (intraductal tumor)
• T1 - solitary tumor without vascular invasion
• T2
  • T2a - solitary tumor with vascular invasion
  • T2b - multiple tumors, with or without vascular invasion
• T3 - tumor penetrating the visceral peritoneum or involving the local extrahepatic structures by direct invasion
• T4 - tumor with periductal invasion

Regional Lymph Nodes:

Regional nodes:

Right liver (segments 5-8) - hilar (common bile duct, hepatic artery, portal vein, and cystic duct), periduodenal, peripancreatic, inferior phrenic

Left liver (segments 2-4) - hilar, gastrohepatic, inferior phrenic

Distant nodes (M1) - celiac, periaortic, pericaval

• N0 - no
• N1 - yes

Distant Metastases:

• M0 - none
• M1 - yes

Stage Grouping:

• I - T1 N0
• II - T2 N0
• III - T3 N0
• IVA - T4 N0, Any N1
• IVB - M1