Stage Information
TNM definitions
AJCC stage groupings
Note: Some citations in the text of this section are followed by a level of
evidence. The PDQ editorial boards use a formal ranking system to help the
reader judge the strength of evidence linked to the reported results of a
therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more
information.)
From a clinical and practical point of view, extrahepatic bile duct cancers can
be considered to be localized (resectable) or unresectable. This has obvious
prognostic importance.
Localized extrahepatic bile duct cancer
Patients with localized extrahepatic bile duct cancer have cancer that
can be completely removed by the surgeon. These patients represent a
very small minority of cases of bile duct cancer and usually are those with a
lesion of the distal common bile duct where 5-year survival rate of 25% may be
achieved. Extended resections of hepatic duct bifurcation tumors (Klatskin
tumors) to include adjacent liver, either by lobectomy or removal of portions
of segments 4 and 5 of the liver, may be performed. There has been no
randomized trial of adjuvant therapy for patients with localized disease.
Radiation therapy (external-beam radiation with or without
brachytherapy), however, has been reported to improve local control.[1,2][Level of evidence: 3iiiDiii]
Unresectable extrahepatic bile duct cancer
Patients with unresectable extrahepatic bile duct cancer have cancer that cannot be completely removed by the surgeon.
These patients represent the majority of patients with bile duct cancer. Often the
cancer invades directly into the portal vein, the adjacent liver or along the
common bile duct, and to adjacent lymph nodes. Spread to distant parts of the
body is uncommon but intra-abdominal metastases, particularly peritoneal
metastases, do occur. At this stage patient management is directed at
palliation.
The TNM staging system should be used when staging the disease of a patient
with extrahepatic bile duct cancer. Most cancers are staged following surgery
and pathologic examination of the resected specimen. Evaluation of the extent
of disease at laparotomy is most important for staging.
Staging depends on imaging, which often defines the limits of the tumor, and
surgical exploration with pathologic examination of the resected specimen. In
many cases, it may be difficult to completely resect the primary tumor.
The American Joint Committee on Cancer (AJCC) has designated staging by TNM
classification.[3] Stages defined by TNM classification apply to all primary
carcinomas arising in the extrahepatic bile duct or in the cystic duct and do
not apply to intrahepatic cholangiocarcinomas, sarcomas, or carcinoid
tumors.[3]
TNM definitions
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 liver, gallbladder, pancreas, and/or unilateral branches of the portal vein (right or left) or hepatic artery (right or left)
- T4: Tumor invades any of the following: main portal vein or its branches bilaterally, common hepatic artery, or other adjacent structures, such as the colon, stomach, duodenum, or abdominal wall
Regional lymph nodes (N)
- NX: Regional lymph nodes cannot be assessed
- N0: No regional lymph node metastasis
- N1: Regional lymph node metastasis
Distant metastasis (M)
- MX: Distant metastasis cannot be assessed
- M0: No distant metastasis
- M1: Distant metastasis
AJCC stage groupings
Stage 0
Stage IA
Stage IB
Stage IIA
Stage IIB
- T1, N1, M0
- T2, N1, M0
- T3, N1, M0
Stage III
Stage IV
References
-
Kopelson G, Galdabini J, Warshaw AL, et al.: Patterns of failure after curative surgery for extra-hepatic biliary tract carcinoma: implications for adjuvant therapy. Int J Radiat Oncol Biol Phys 7 (3): 413-7, 1981.
[PUBMED Abstract]
-
Minsky BD, Wesson MF, Armstrong JG, et al.: Combined modality therapy of extrahepatic biliary system cancer. Int J Radiat Oncol Biol Phys 18 (5): 1157-63, 1990.
[PUBMED Abstract]
-
Extrahepatic bile ducts. In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 145-150.
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