[<< wikibooks] 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 parencyma
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 involvementRegional 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 nodesDistant Metastases:

M0 - no
M1 - yesStage Grouping:

I - T1 N0
II - T2a-b N0
IIIA - T3 N0
IIIB - T1-3 N1
IVA - T4 N0-1
IVB - N2 or M1Distal 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 arteryRegional Lymph Nodes:

N0 - no
N1 - regional lymph node metastasisDistant Metastases:

M0 - no
M1 - yesStage Grouping:

IA - T1 N0
IB - T2 N0
IIA - T3 N0
IIB - T1-3 N1
III - T4
IV - M1Prognostic 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 - yesDistant Metastases:

M0 - no
M1 - yesStage Grouping:

IA - T1 N0
IB - T2 N0
IIA - T3 N0
IIB - N1
III - T4
IV - M1AJCC 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 nodesStage 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 invasionRegional 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, pericavalN0 - no
N1 - yesDistant Metastases:

M0 - none
M1 - yesStage Grouping:

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