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Extrahepatic bile ducts

Tumors

TNM staging for Extrahepatic bile duct carcinoma


Reviewer: Hanni Gulwani, M.D. (see Reviewers page)
Revised: 15 February 2013, last major update September 2012
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

Staging of Perihilar Bile Duct tumors

General
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● Classification excludes sarcomas and carcinoid tumors
● Divided into perihilar (proximal) and distal bile duct tumors

Primary tumor (T) - perihilar bile duct tumors
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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; 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 involvement

Regional lymph nodes (N) - perihilar bile duct tumors
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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: Metastases to periaortic, pericaval, superior mesenteric artery or celiac artery lymph nodes

Distant metastasis (M) - perihilar bile duct tumors
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M0: No distant metastasis
M1: Distant metastasis

Stage grouping - perihilar bile duct tumors
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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 or any T any N M1


Staging of Distal Bile Duct tumors

General
=========================================================================

● Classification excludes sarcomas and carcinoid tumors
● Divided into perihilar (proximal) and distal bile duct tumors
● Bile duct wall is more precisely defined as occurring between the mucosa and the outermost boundary of dense fibromuscular tissue, without consideration of the presence or absence of blood vessels and nerve fibers (Am J Surg Pathol 2006;30:744)
● Primary tumor/vessel tumor/nodal tumor classification is better instead of current TNM classification for extrahepatic bile ductcarcinoma (Hum Pathol 2008;39:37)

Primary tumor (T) - distal bile duct tumors
=========================================================================

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 or other adjacent organs without involvement of the celiac axis or the superior mesenteric artery
T4: Tumor invades the celiac axis or the superior mesenteric artery

pT2 and pT3
● Extrahepatic biliary tree histology varies along its length, with little smooth muscle in wall of proximal ducts compared to distal bile duct, rendering assessment of depth of tumor invasion difficult
● Inflammatory changes in bile ducts and desmoplastic stromal response to tumor may also cause distortion
● To overcome these difficulties, recommended by some (but not widely adopted) to measure depth of tumor invasion from basal lamina of normal epithelium to the point of deepest tumor invasion
● The current pT3 stage of distal EBD carcinomas can be subdivided into superficial (pT3a) and deep pancreatic invasion (pT3b, Mod Pathol 2005;18:969)

Regional lymph nodes (N) - distal bile duct tumors
=========================================================================

NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Regional lymph node metastasis

● Proposed to classify as N1 (metastasis in 1-4 regional lymph nodes) or N2 (metastasis in 5+ regional lymph nodes, Am J Surg Pathol 2005;29:1177)

Distant metastasis (M) - distal bile duct tumors
=========================================================================

M0: No distant metastasis
M1: Distant metastasis

Stage grouping - distal bile duct tumors
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0: Tis N0 M0
IA: T1 N0 M0
IB: T2 N0 M0
IIA: T3 N0 M0
IIB: T1-3 N1 M0
III: T4 any N M0
IV: any T any N M1



Table - Stage groupings

Drawings
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Various images

Additional references
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Arch Pathol Lab Med 2010;134:e8, CAP protocol

End of Extrahepatic bile ducts > Tumors > TNM staging for Extrahepatic bile duct carcinoma


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