Biliary Tract Cancer Staging
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The tumor-node-metastasis (TNM) staging classifications for biliary tract cancers are provided below, including those for biliary tract cancer, intrahepatic bile duct tumors, perihilar bile duct tumors, and distal bile duct tumors. [1, 2]
Table. Gallbladder cancer staging (Open Table in a new window)
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
T1
Tumor invades lamina propria or muscular layer
T1a
Tumor invades lamina propria
T1b
Tumor invades muscular layer
T2
Tumor invades perimuscular connective tissue; no extension beyond serosa or into liver
T3
Tumor perforates the serosa (visceral peritoneum) and/or directly invades the liver and/or one other adjacent organ or structure, such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts
T4
Tumor invades main portal vein or hepatic artery or invades 2 or more extrahepatic organs or structures
Regional lymph nodes (N)
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Metastases to nodes along the cystic duct, common bile duct, hepatic artery, and/or portal vein
N2
Metastases to periaortic, pericaval, superior mesenteric artery, and/or celiac artery lymph nodes
Distant metastasis (M)
M0
No distant metastasis
M1
Distant metastasis
Table. Histologic grading (Open Table in a new window)
Histologic grading
GX
Grade cannot be assessed
G1
Well differentiated
G2
Moderately differentiated
G3
Poorly differentiated
G4
Undifferentiated
Table. Anatomic stage/prognostic groups (Open Table in a new window)
Stage
T
N
M
0
Tis
N0
M0
I
T1
N0
M0
II
T2
N0
M0
IIIA
T3
N0
M0
IIIB
T1-3
N1
M0
IVA
T4
N0-1
M0
IVB
Any T
N2
M0
Any T
Any N
M1
Table. Intrahepatic bile duct tumor staging (Open Table in a new window)
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ (intraductal tumor)
T1
Solitary tumor without vascular invasion
T2a
Solitary tumor with vascular invasion
T2b
Multiple tumors, with or without vascular invasion
T3
Tumor perforating the visceral peritoneum or involving the local extrahepatic structures by direct invasion
T4
Tumor with periductal invasion (the pathologic definition of periductal invasion is the finding of a longitudinal growth pattern along the intrahepatic bile ducts on both gross and microscopic examination)
Regional lymph nodes (N)
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Regional lymph node metastasis present
Distant metastasis (M)
M0
No distant metastasis
M1
Distant metastasis present
Table. Histologic grading (Open Table in a new window)
Histologic grading
G1
Well differentiated
G2
Moderately differentiated
G3
Poorly differentiated
G4
Undifferentiated
Table. Anatomic stage/prognostic groups (Open Table in a new window)
Stage
T
N
M
0
Tis
N0
M0
I
T1
N0
M0
II
T2
N0
M0
III
T3
N0
M0
IVA
T4
N0
M0
Any T
N1
M0
IVB
Any T
Any N
M1
Table. Perihilar bile duct tumor staging (Open Table in a new window)
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
T1
Tumor confined to the bile duct, with extension up to the muscle layer or fibrous tissue
T2a
Tumor invades beyond the wall of the bile duct to surrounding adipose tissue
T2b
Tumor invades adjacent hepatic parenchyma
T3
Tumor invades unilateral branches of the portal vein or hepatic artery
T4
Tumor invades main portal vein or its branches bilaterally; the common hepatic artery; the second-order biliary radicals bilaterally; or the second-order biliary radicals unilaterally, with contralateral portal vein or hepatic artery involvement
Regional lymph nodes (N)
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Regional lymph node metastasis (including nodes 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 metastasis (M)
M0
No distant metastasis
M1
Distant metastasis
Table. Histologic grading (Open Table in a new window)
Histologic grading
GX
Grade cannot be assessed
G1
Well differentiated
G2
Moderately differentiated
G3
Poorly differentiated
G4
Undifferentiated
Table. Anatomic stage/prognosis groups (Open Table in a new window)
Stage
T
N
M
0
Tis
N0
M0
I
T1
N0
M0
II
T2a-b
N0
M0
IIIA
T3
N0
M0
IIIB
T1-3
N1
M0
IVA
T4
N0-1
M0
IVB
Any T
N2
M0
Any T
Any N
M1
Table. Distal bile duct tumor staging (Open Table in a new window)
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
T1
Tumor confined to the bile duct histologically
T2
Tumor invades beyond the wall of the bile duct
T3
Tumor invades the gallbladder, pancreas, duodenum, other adjacent organs without involvement of the celiac axis, or the superior mesenteric artery
T4
Tumor involves the celiac axis or the superior mesenteric artery
Regional lymph nodes (N)
N0
No regional lymph node metastasis
N1
Regional lymph node metastasis
Distant metastasis (M)
M0
No distant metastasis
M1
Distant metastasis
Table. Histologic grading (Open Table in a new window)
Histologic grading
GX
Grade cannot be assessed
G1
Well differentiated
G2
Moderately differentiated
G3
Poorly differentiated
G4
Undifferentiated
Table. Anatomic stage/prognosis groups (Open Table in a new window)
Stage
T
N
M
0
Tis
N0
M0
IA
T1
N0
M0
IB
T2
N0
M0
IIA
T3
N0
M0
IIB
T1
N1
M0
T2
N1
M0
T3
N1
M0
III
T4
Any N
M0
IV
Any T
Any N
M1
NCCN Clinical Practice Guidelines in Oncology: Hepatobiliary Cancers. National Comprehensive Cancer Network. Available at http://bit.ly/leKxOv. Version 3.2018 — August 29, 2018; Accessed: August 30, 2018.
American Joint Committee on Cancer. Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, et al, eds. AJCC Cancer Staging Manual. 8th edition. New York, NY: Springer; 2017.
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
T1
Tumor invades lamina propria or muscular layer
T1a
Tumor invades lamina propria
T1b
Tumor invades muscular layer
T2
Tumor invades perimuscular connective tissue; no extension beyond serosa or into liver
T3
Tumor perforates the serosa (visceral peritoneum) and/or directly invades the liver and/or one other adjacent organ or structure, such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts
T4
Tumor invades main portal vein or hepatic artery or invades 2 or more extrahepatic organs or structures
Regional lymph nodes (N)
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Metastases to nodes along the cystic duct, common bile duct, hepatic artery, and/or portal vein
N2
Metastases to periaortic, pericaval, superior mesenteric artery, and/or celiac artery lymph nodes
Distant metastasis (M)
M0
No distant metastasis
M1
Distant metastasis
Histologic grading
GX
Grade cannot be assessed
G1
Well differentiated
G2
Moderately differentiated
G3
Poorly differentiated
G4
Undifferentiated
Stage
T
N
M
0
Tis
N0
M0
I
T1
N0
M0
II
T2
N0
M0
IIIA
T3
N0
M0
IIIB
T1-3
N1
M0
IVA
T4
N0-1
M0
IVB
Any T
N2
M0
Any T
Any N
M1
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ (intraductal tumor)
T1
Solitary tumor without vascular invasion
T2a
Solitary tumor with vascular invasion
T2b
Multiple tumors, with or without vascular invasion
T3
Tumor perforating the visceral peritoneum or involving the local extrahepatic structures by direct invasion
T4
Tumor with periductal invasion (the pathologic definition of periductal invasion is the finding of a longitudinal growth pattern along the intrahepatic bile ducts on both gross and microscopic examination)
Regional lymph nodes (N)
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Regional lymph node metastasis present
Distant metastasis (M)
M0
No distant metastasis
M1
Distant metastasis present
Histologic grading
G1
Well differentiated
G2
Moderately differentiated
G3
Poorly differentiated
G4
Undifferentiated
Stage
T
N
M
0
Tis
N0
M0
I
T1
N0
M0
II
T2
N0
M0
III
T3
N0
M0
IVA
T4
N0
M0
Any T
N1
M0
IVB
Any T
Any N
M1
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
T1
Tumor confined to the bile duct, with extension up to the muscle layer or fibrous tissue
T2a
Tumor invades beyond the wall of the bile duct to surrounding adipose tissue
T2b
Tumor invades adjacent hepatic parenchyma
T3
Tumor invades unilateral branches of the portal vein or hepatic artery
T4
Tumor invades main portal vein or its branches bilaterally; the common hepatic artery; the second-order biliary radicals bilaterally; or the second-order biliary radicals unilaterally, with contralateral portal vein or hepatic artery involvement
Regional lymph nodes (N)
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Regional lymph node metastasis (including nodes 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 metastasis (M)
M0
No distant metastasis
M1
Distant metastasis
Histologic grading
GX
Grade cannot be assessed
G1
Well differentiated
G2
Moderately differentiated
G3
Poorly differentiated
G4
Undifferentiated
Stage
T
N
M
0
Tis
N0
M0
I
T1
N0
M0
II
T2a-b
N0
M0
IIIA
T3
N0
M0
IIIB
T1-3
N1
M0
IVA
T4
N0-1
M0
IVB
Any T
N2
M0
Any T
Any N
M1
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
T1
Tumor confined to the bile duct histologically
T2
Tumor invades beyond the wall of the bile duct
T3
Tumor invades the gallbladder, pancreas, duodenum, other adjacent organs without involvement of the celiac axis, or the superior mesenteric artery
T4
Tumor involves the celiac axis or the superior mesenteric artery
Regional lymph nodes (N)
N0
No regional lymph node metastasis
N1
Regional lymph node metastasis
Distant metastasis (M)
M0
No distant metastasis
M1
Distant metastasis
Histologic grading
GX
Grade cannot be assessed
G1
Well differentiated
G2
Moderately differentiated
G3
Poorly differentiated
G4
Undifferentiated
Stage
T
N
M
0
Tis
N0
M0
IA
T1
N0
M0
IB
T2
N0
M0
IIA
T3
N0
M0
IIB
T1
N1
M0
T2
N1
M0
T3
N1
M0
III
T4
Any N
M0
IV
Any T
Any N
M1
Jeffrey B VanDeusen, MD, PhD Fellow, Department of Hematology/Oncology, Duke University School of Medicine
Disclosure: Nothing to disclose.
Tomislav Dragovich, MD, PhD Chief, Section of Hematology and Oncology, Banner MD Anderson Cancer Center
Tomislav Dragovich, MD, PhD is a member of the following medical societies: American Association for Cancer Research, SWOG, American Society of Clinical Oncology
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Christopher D Braden, DO Hematologist/Oncologist, Chancellor Center for Oncology at Deaconess Hospital; Medical Director, Deaconess Hospital Outpatient Infusion Centers; Chairman, Deaconess Hospital Cancer Committee
Christopher D Braden, DO is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology
Disclosure: Nothing to disclose.
N Joseph Espat, MD, MS, FACS Harold J Wanebo Professor of Surgery, Assistant Dean of Clinical Affairs, Boston University School of Medicine; Chairman, Department of Surgery, Director, Adele R Decof Cancer Center, Roger Williams Medical Center
N Joseph Espat, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Clinical Oncology, Americas Hepato-Pancreato-Biliary Association, Association for Academic Surgery, Central Surgical Association, Chicago Medical Society, International Hepato-Pancreato-Biliary Association, Pancreas Club, Sigma Xi, Society for Leukocyte Biology, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, Society of University Surgeons, Southeastern Surgical Congress, Southern Medical Association, Surgical Infection Society
Disclosure: Nothing to disclose.
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