# Radiation Oncology/Bile duct/Staging

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## 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 parenchyma
* 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 involvement
Regional 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 nodes
Distant Metastases:
* M0 - no
* M1 - yes
Stage Grouping:
* I - T1 N0
* II - T2a-b N0
* IIIA - T3 N0
* IIIB - T1-3 N1
* IVA - T4 N0-1
* IVB - N2 or M1
Distal 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 artery
Regional Lymph Nodes:
* N0 - no
* N1 - regional lymph node metastasis
Distant Metastases:
* M0 - no
* M1 - yes
Stage Grouping:
* IA - T1 N0
* IB - T2 N0
* IIA - T3 N0
* IIB - T1-3 N1
* III - T4
* IV - M1
Prognostic 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 - yes
Distant Metastases:
* M0 - no
* M1 - yes
Stage Grouping:
* IA - T1 N0
* IB - T2 N0
* IIA - T3 N0
* IIB - N1
* III - T4
* IV - M1
AJCC 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 nodes
Stage 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 invasion
Regional 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, pericaval
* N0 - no
* N1 - yes
Distant Metastases:
* M0 - none
* M1 - yes
Stage Grouping:
* I - T1 N0
* II - T2 N0
* III - T3 N0
* IVA - T4 N0, Any N1
* IVB - M1