Revised AJCC Classification of Extrahepatic Bile Duct Tumors

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Revised AJCC Classification of Extrahepatic Bile Duct Tumors

Anatomy of the Bile DuctsDefinitionshepatic hilumproximal common duct(proximal hepatic duct)cystic ductampulla of Vaterdistal bile ductperihilar bile ducts7th AJCC classificationmiddle common ductcommon bile ductdistal common ductleft hepatic ductright hepatic ductAJCC Classification DefinitionsIncluding bile duct tumors arising from the hepatic hilum of the right and left hepatic ducts to the distal common duct above the ampulla of Vater in the 6th edition (2002) Separated into perihilar bile duct and distal bile duct tumors in the 7th edition (2010)Extrahepatic Bile Duct TumorsPrimary tumor (T)TXPrimary tumor cannot be assessedT0No evidence of primary tumorTisCarcinoma in situT1Tumor confined to the bile duct histologicallyT2Tumor invades beyond the wall of the bile ductT3Tumor invades the liver, gallbladder, pancreas, and/or unilateral branches of the portal vein (right or left) or hepatic artery (right or left)T4Tumor 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 wallExtrahepatic Bile Duct Tumor6th AJCC ClassificationStage 0TisN0M0Stage IAT1N0M0Stage IBT2N0M0Stage IIAT3N0M0Stage IIBT1-3N1M0Stage IIIT4Any NM0Stage IVAny TAny NM1Definitions of TNM7th AJCC ClassificationPrimary tumor (T)TXPrimary tumor cannot be assessedT0No evidence of primary tumorTisCarcinoma in situT1Tumor confined to the bile duct, with extension up to the muscle layer or fibrous tissueT2aTumor invades beyond the wall of the bile duct to surrounding adipose tissueT2bTumor invades adjacent hepatic parenchymaT3Tumor invades unilateral branches of the portal vein or hepatic arteryT4Tumor invades main portal vein or its branches bilaterally; or the common hepatic artery; or the second-order biliary radicals bilaterally; or unilateral second-order biliary radicals with contralateral portal vein or hepatic artery involvementPerihilar Bile Duct TumorPrimary tumor (T)TXPrimary tumor cannot be assessedT0No evidence of primary tumorTisCarcinoma in situT1Tumor confined to the bile duct histologicallyT2Tumor invades beyond the wall of the bile ductT3Tumor invades the gallbladder, pancreas, duodenum, or other adjacent organs without involvement of the celiac axis, or the superior mesenteric arteryT4Tumor involves the celiac axis, or the superior mesenteric arteryDistal Bile Duct TumorDefinitions of TNM7th AJCC ClassificationRegional lymph nodes (N)NXRegional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Regional lymph node metastasis (including nodes along the cystic duct, common bile duct, hepatic artery, and portal vein)N2Metastasis to periaortic, pericaval, superior mesenteric artery, and/or celiac artery lymph nodesRegional lymph nodes (N)NXRegional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Regional lymph node metastasisN2Metastasis to periaortic, pericaval, superior mesenteric artery, and/or celiac artery lymph nodesDistant metastasis (M)M0No distant metastasisM1Distant metastasisDistant metastasis (M)M0No distant metastasisM1Distant metastasisPerihilar Bile Duct TumorDistal Bile Duct TumorAnatomic Stage/Prognostic Groups7th AJCC ClassificationStage 0TisN0M0Stage IT1N0M0Stage IIT2a-bN0M0Stage IIIAT3N0M0Stage IIIBT1-3N1M0Stage IVAT4N0-1M0Stage IVBAny TN2Any NM0M1Stage 0TisN0M0Stage IAT1N0M0Stage IBT2N0M0Stage IIAT3N0M0Stage IIBT1-3N1M0Stage IIIT4Any NM0Stage IVAny TAny NM1Perihilar Bile Duct TumorDistal Bile Duct TumorPerihilar Bile Duct TumorsSummaryT1: confined to the bile ductT2: beyond the wall of the bile duct wallT2b: invasion of adjacent hepatic parenchyma (T3 in the 6th edition)T3: unilateral vascular invasionT4: bilateral biliary and/or vascular invasionRegional lymph node metastasis: reclassified as stage IIIB (stage IIB in the 6th edition) T4: unresectable based on local invasion (IVA) or distant disease (IVB) Distal Bile Duct TumorsSummaryT1: confined to the bile ductT2: beyond the wall of the bile duct wallT3: includes adjacent organs (invasion of adjacent organs such as the colon, stomach, duodenum or abdominal wall: classified as T4 in the 6th edition)Invasion of the portal vein and hepatic artery: excluded in classification (T3 or T4 in the 6th edition)No criteria on the longitudinal involvementPerihilar Bile Duct TumorsRadiologic StagingStage ICT: wall thickening from left hepatic duct to distal common duct Surgery: left major hepatobiliary resection, pathology: T1N0M0Major surgery was performed due to extensive longitudinal involvement

Stage IICT: wall thickening from both hepatic ducts to proximal common duct, periductal invasion (+) Op: extended left hemihepatectomy, pathology: T2aN0M0Perihilar Bile Duct TumorsRadiologic Staging

Stage IICT: wall thickening and mass invading to adjacent hepatic parenchyma, from left hepatic duct to hepatic hilum Surgery: extended left hemihepatectomy, pathology: T2bN0M0T3 in the 6th edition, T2b in the 7th editionPerihilar Bile Duct TumorsRadiologic Staging

Stage IIIACT: polypoid mass from both hepatic ducts to hepatic hilum, invasion to right hepatic artery Surgery: segmental resection due to old age, pathology: T3N0M0 Upstaged from stage IIA (T3N0M0) to stage IIIA (T3N0M0) in case of unilateral vascular invasionPerihilar Bile Duct TumorsRadiologic Staging

Stage IIIBCT: wall thickening from hepatic hilum to proximal common duct, lymph node (+) Surgery: segment resection and lymph node dissection, pathology: T2aN1MoUpstaged from stage IIB (T2N1M0) to IIIB (T2aN1M0) due to regional lymph node metastasisPerihilar Bile Duct TumorsRadiologic Staging

Distal Bile Duct TumorsStage IACT: polypoid mass from mid to distal, pericholedochal invasion (-)Surgery: PPPD, pathology: T1N0M0 CT: wall thickening from mid to distal, pericholedochal invasion (+)Surgery: PPPD, pathology: T2N0M0 Stage IBRadiologic Staging

Stage IIADistal Bile Duct TumorsCT: wall thickening involving distal common duct, pancreatic invasion (+) Surgery: PPPD and lymph node dissection, pathology: T3N0M0Pancreatic invasion: T3 in 6th and 7th editionsRadiologic Staging

Stage IIADistal Bile Duct TumorsCT: wall thickening from distal common duct, pancreatic and duodenal invasion (+)Surgery: PPPD and lymph node dissection, pathology: T3N0M0 Downstaged from stage IV (T4N0M0) to stage IIA (T3N0M0) due to duodenal invasionRadiologic Staging

Stage IIBDistal Bile Duct TumorsCT: polypoid mass from mid to distal common duct, pancreatic invasion (+), regional lymph node (+) Surgery: PPPD, pathology: T3N1M0Radiologic Staging

Stage IIBDistal Bile Duct TumorsCT: wall thickening from proximal to distal common duct, duodenal and pancreatic invasion (+), regional lymph node (+) Surgery: PPPD, pathology: T3N1M0Downstaged from stage IV (T4N1M0) to stage IIB (T3N1M0) due to duodenal invasionRadiologic Staging

Stage IIBDistal Bile Duct TumorsCT: wall thickening from middle to distal common duct, pancreatic invasion (+), regional lymph node (+)Surgery: PPPD and portal vein resection, pathology: T3N1M0Portal vein invasion: T4 in the 6th edition, not defined T3 in the 7th edition (maybe T3 as other adjacent organ)Radiologic Staging

LimitationsPerihilar Bile Duct TumorsFalse Negative Image InterpretationInvasion to hepatic parenchyma: CT (-), pathology (+)

LimitationsPerihilar Bile Duct TumorsFalse Positive Image InterpretationInvasion to right hepatic artery: CT (+), pathology (-)

LimitationsIndefinite Staging SystemPerihilar Bile Duct TumorsCT: Pancreatic invasion (+) CT: Gallbladder invasion (+) T stage of pancreatic and gallbladder invasion: not clearly defined

LimitationsDistal Bile Duct TumorsFalse Negative Image InterpretationPancreatic invasion: CT (-), pathology (+)

LimitationsDistal Bile Duct TumorsFalse Positive Image InterpretationInvasion beyond bile duct wall: CT (+), pathology (-)

LimitationsDistal Bile Duct TumorsIndefinite Staging SystemMain portal vein invasion: CT (-), pathology (+) Main portal invasion: T4 in the 6th edition, not clearly defined in the 7th edition (maybe T3 as other adjacent organ)

New StagingPerihilar CholangiocarcinomaProposed Classification SystemDeOliveira MI, et al. Hepatology 2011;53:1363-1371Bile ductCommon bile duct, hepatic duct confluence, right hepatic duct, left hepatic duct, right and left hepatic duct Remnant liver volumeNo information, percentage of total volume after resectionTumor size< 1 cm, 1-3 cm, > 3 cm Underlying liver diseaseFibrosis, NASH, PSCTumor formSclerosing, mass-forming, sclerosing and mass-forming, polypoidLymph nodesNo LN involvement, hilar and HA LN involvement, periaortic LN involvementInvolvement of portal veinNo portal involvement, main PV, PV bifurcation, right PV, left PV, right and left PVs MetastasisNo distant metastasis, distant metastasisInvolvement of hepatic arteryNo arterial involvement, proper HA, HA bifurcation, right HA, left HA, right and left HA