Revised AJCC Classification of Extrahepatic Bile Duct Tumors.

Revised AJCC Classification of Extra-hepatic Bile Duct Tumors

Anatomy of the Bile Ducts

Definitions

hepatic hilum

proximal common duct(proximal hepatic duct)

cystic duct

ampulla of Vater

distal bile duct

perihilar bile ducts

7th AJCC classification

middle common duct

common bile duct

distal common duct

left hepatic ductright hepatic duct

AJCC Classification

Definitions

Including 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 edi-

tion (2002)

Separated into perihilar bile duct and

distal bile duct tumors in the 7th edition

(2010)

Extrahepatic Bile Duct Tumors

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 histo-logically

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 bilat-erally, common hepatic artery, or other adjacent structures, such as the colon, stomach, duodenum, or abdominal wall

Extrahepatic Bile Duct Tumor

6th AJCC Classification

Stage 0 Tis N0 M0

Stage IA T1 N0 M0

Stage IB T2 N0 M0

Stage IIA T3 N0 M0

Stage IIB T1-3 N1 M0

Stage III T4 Any N M0

Stage IV Any T Any N M1

Definitions of TNM


Primary tumor (T)




T1Tumor confined to the bile duct, with ex-tension 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; or the common he-patic artery; or the second-order biliary radicals bilaterally; or unilateral second-order biliary radicals with contralateral portal vein or hepatic artery involvement

Perihilar Bile Duct Tumor

Primary tumor (T)




T1Tumor confined to the bile duct histo-logically

T2Tumor invades beyond the wall of the bile duct

T3

Tumor invades the gallbladder, pan-creas, duodenum, or other adjacent organs without involvement of the celiac axis, or the superior mesenteric artery

T4Tumor involves the celiac axis, or the superior mesenteric artery

Distal Bile Duct Tumor

Definitions of TNM


Regional lymph nodes (N)

NXRegional lymph nodes cannot be as-sessed

N0 No regional lymph node metastasis

N1

Regional lymph node metastasis (in-cluding 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 nodes

Regional lymph nodes (N)

NX Regional lymph nodes cannot be as-sessed

N0 No regional lymph node metastasis

N1 Regional lymph node metastasis

N2Metastasis to periaortic, pericaval, superior mesenteric artery, and/or celiac artery lymph nodes

Distant metastasis (M)

M0 No distant metastasis

M1 Distant metastasis

Distant metastasis (M)

M0 No distant metastasis

M1 Distant metastasis



Anatomic Stage/Prognostic Groups


Stage 0 Tis N0 M0

Stage I T1 N0 M0

Stage II T2a-b N0 M0

Stage IIIA T3 N0 M0

Stage IIIB T1-3 N1 M0

Stage IVA T4 N0-1 M0

Stage IVB Any T N2Any N

M0M1

Stage 0 Tis N0 M0

Stage IA T1 N0 M0

Stage IB T2 N0 M0

Stage IIA T3 N0 M0

Stage IIB T1-3 N1 M0

Stage III T4 Any N M0

Stage IV Any T Any N M1



Perihilar Bile Duct Tumors

Summary

T1: confined to the bile ductT2: beyond the wall of the bile duct wall

T2b: invasion of adjacent hepatic parenchyma (T3 in the 6th edition)

T3: unilateral vascular invasion T4: bilateral biliary and/or vascular invasion Regional lymph node metastasis: reclassi-

fied as stage IIIB (stage IIB in the 6th edition)

T4: unresectable based on local invasion (IVA) or distant disease (IVB)

Distal Bile Duct Tumors

Summary

T1: confined to the bile ductT2: beyond the wall of the bile duct wall

T3: includes adjacent organs (invasion of adjacent organs such as the colon, stom-ach, duodenum or abdominal wall: classi-fied 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 involvement


Radiologic Staging

Stage I

• CT: wall thickening from left hepatic duct to distal common duct • Surgery: left major hepatobiliary resection, pathology: T1N0M0• Major surgery was performed due to extensive longitudinal in-

volvement

Stage II

• CT: wall thickening from both hepatic ducts to proximal com-mon duct, periductal invasion (+)

• Op: extended left hemihepatectomy, pathology: T2aN0M0


Radiologic Staging

Stage II

• CT: wall thickening and mass invading to adjacent hepatic parenchyma, from left hepatic duct to hepatic hilum

• Surgery: extended left hemihepatectomy, pathology: T2bN0M0• T3 in the 6th edition, T2b in the 7th edition


Radiologic Staging

Stage IIIA

• CT: polypoid mass from both hepatic ducts to hepatic hilum, inva-sion 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 invasion


Radiologic Staging

Stage IIIB

• CT: wall thickening from hepatic hilum to proximal common duct, lymph node (+)

• Surgery: segment resection and lymph node dissection, pathology: T2aN1Mo• Upstaged from stage IIB (T2N1M0) to IIIB (T2aN1M0) due to regional lymph

node metastasis


Radiologic Staging


Stage IA

• CT: polypoid mass from mid to distal, pericholedochal invasion (-)

• Surgery: PPPD, pathology: T1N0M0

• CT: wall thickening from mid to distal, pericholedochal invasion (+)


Stage IB

Radiologic Staging

Stage IIA


• CT: wall thickening involving distal common duct, pancreatic invasion (+)

• Surgery: PPPD and lymph node dissection, pathology: T3N0M0• Pancreatic invasion: T3 in 6th and 7th editions

Radiologic Staging

Stage IIA


• CT: wall thickening from distal common duct, pancreatic and duodenal inva-sion (+)

• Surgery: PPPD and lymph node dissection, pathology: T3N0M0 • Downstaged from stage IV (T4N0M0) to stage IIA (T3N0M0) due to duodenal

invasion

Radiologic Staging

Stage IIB


• CT: polypoid mass from mid to distal common duct, pancreatic inva-sion (+), regional lymph node (+)


Radiologic Staging

Stage IIB


• CT: wall thickening from proximal to distal common duct, duodenal and pan-creatic invasion (+), regional lymph node (+)

• Surgery: PPPD, pathology: T3N1M0• Downstaged from stage IV (T4N1M0) to stage IIB (T3N1M0) due to duodenal in-

vasion

Radiologic Staging

Stage IIB


• CT: wall thickening from middle to distal common duct, pancreatic inva-sion (+), regional lymph node (+)

• Surgery: PPPD and portal vein resection, pathology: T3N1M0• Portal vein invasion: T4 in the 6th edition, not defined T3 in the 7th edition

(maybe T3 as other adjacent organ)

Radiologic Staging

Limitations


False Negative Image Interpreta-tion

• Invasion to hepatic parenchyma: CT (-), pathology (+)

Limitations


False Positive Image Interpreta-tion

• Invasion to right hepatic artery: CT (+), pathology (-)

Limitations

Indefinite Staging System


• CT: Pancreatic invasion (+) • CT: Gallbladder invasion (+)

• T stage of pancreatic and gallbladder invasion: not clearly de-fined

Limitations


False Negative Image Interpreta-tion

• Pancreatic invasion: CT (-), pathology (+)

Limitations


False Positive Image Interpreta-tion

• Invasion beyond bile duct wall: CT (+), pathology (-)

Limitations


Indefinite Staging System

• Main portal vein invasion: CT (-), pathology (+) • Main portal invasion: T4 in the 6th edition, not clearly de-

fined in the 7th edition (maybe T3 as other adjacent organ)

New Staging

Perihilar Cholangiocarcinoma

Proposed Classification Sys-tem

DeOliveira MI, et al. Hepatology 2011;53:1363-1371

Bile ductCommon bile duct, hepatic duct confluence, right he-patic duct, left hepatic duct, right and left hepatic duct

Remnant liver volume

No information, percentage of total volume after resec-tion

Tumor size < 1 cm, 1-3 cm, > 3 cm Underlying liver disease

Fibrosis, NASH, PSC

Tumor formSclerosing, mass-forming, sclerosing and mass-form-ing, polypoid

Lymph nodesNo LN involvement, hilar and HA LN involvement, periaortic LN involvement

Involvement of portal vein

No portal involvement, main PV, PV bifurcation, right PV, left PV, right and left PVs

Metastasis No distant metastasis, dis-tant metastasis

Involvement of hepatic artery

No arterial involvement, proper HA, HA bifurcation, right HA, left HA, right and left HA

Revised AJCC Classification of Extrahepatic Bile Duct Tumors.

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