TNM Classification for Biliary Tract Cancers

The tumor-node-metastasis (TNM) staging classifications for biliary tract cancers are provided below, including those for biliary tract cancer, intrahepatic bile duct tumors, perihilar bile duct tumors, and distal bile duct tumors.^{[1, 2]}

Gallbladder cancer staging

Table. Gallbladder cancer staging (Open Table in a new window)

Primary tumor (T)
TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
Tis	Carcinoma in situ
T1	Tumor invades lamina propria or muscular layer
T1a	Tumor invades lamina propria
T1b	Tumor invades muscular layer
T2	Tumor invades perimuscular connective tissue; without involvement of serosa (visceral peritoneum) or liver extension
T2a	Tumor invades into perimuscular connective tissue on peritoneal side, without serosal involvement
T2b	Tumor invades into perimuscular connective tissue on hepatic side, without extension into liver
T3	Tumor perforates the serosa (visceral peritoneum) and/or directly invades the liver and/or one other adjacent organ or structure, such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts
T4	Tumor invades main portal vein, or hepatic artery, or invades two or more extrahepatic organs or structures
Regional lymph nodes (N)
NX	Regional lymph nodes cannot be assessed
N0	No regional lymph node metastasis
N1	Metastasis to one to three regional lymph nodes
N2	Metastases to four or more regional lymph nodes
Distant metastasis (M)
M0	No distant metastasis
M1	Distant metastasis

Table. Histologic grading (Open Table in a new window)

Histologic grading
GX	Grade cannot be assessed
G1	Well differentiated
G2	Moderately differentiated
G3	Poorly differentiated

Table. Anatomic stage/prognostic groups (Open Table in a new window)

Stage	T	N	M
0	Tis	N0	M0
I	T1	N0	M0
IIA	T2a	N0	M0
IIB	T2b	N0	M0
IIIA	T3	N0	M0
IIIB	T1-3	N1	M0
IVA	T4	N0-1	M0
IVB	Any T	N2	M0
IVB	Any T	Any N	M1

Intrahepatic bile duct tumor staging

Table. Intrahepatic bile duct tumor staging (Open Table in a new window)

Primary tumor (T)
TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
Tis	Carcinoma in situ (intraductal tumor)
T1	Solitary tumor without vascular invasion
T1a	Solitary tumor ≤ 5 cm in size, without vascular invasion
T1b	Solitary tumor > 5 cm in size, without vascular invasion
T2	Solitary tumor with intrahepatic vascular invasion or multiple tumors, with or without vascular invasion
T3	Tumor perforating the visceral peritoneum
T4	Tumor involving local extrahepatic structures by direct invasion
Regional lymph nodes (N)
NX	Regional lymph nodes cannot be assessed
N0	No regional lymph node metastasis
N1	Regional lymph node metastasis present
Distant metastasis (M)
M0	No distant metastasis
M1	Distant metastasis present

Table. Histologic grading (Open Table in a new window)

Histologic grading
GX	Grade cannot be determined
G1	Well differentiated
G2	Moderately differentiated
G3	Poorly differentiated

Table. Anatomic stage/prognostic groups (Open Table in a new window)

Stage	T	N	M
0	Tis	N0	M0
IA	T1a	N0	M0
IB	T1b	N0	M0
II	T2	N0	M0
IIIA	T3	N0	M0
IIIB	T4	N0	M0
IIIB	Any T	N1	M0
IV	Any T	Any N	M1

Perihilar bile duct tumor staging

Table. Perihilar bile duct tumor staging (Open Table in a new window)

Primary tumor (T)
TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
Tis	Carcinoma in situ/ high grade dysplagia
T1	Tumor confined to the bile duct, with extension up to the muscle layer or fibrous tissue
T2	Tumor invades beyond the wall of the bile duct to surrounding adipose tissue, or tumor invades adjacent hepatic parenchyma
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 second-order biliary radicals bilaterally; or second-order biliary radicals unilaterally, with contralateral portal vein or hepatic artery involvement
Regional lymph nodes (N)
NX	Regional lymph nodes cannot be assessed
N0	No regional lymph node metastasis
N1	One to three positive lymph nodes involving the hilar, cystic duct, common bile duct, hepatic artery, posterior pancreatoduodenal, and portal vein lymph nodes
N2	Four or more positive lymph nodes from the sites described for N1
Distant metastasis (M)
M0	No distant metastasis
M1	Distant metastasis

Table. Histologic grading (Open Table in a new window)

Histologic grading
GX	Grade cannot be assessed
G1	Well differentiated
G2	Moderately differentiated
G3	Poorly differentiated

Table. Anatomic stage/prognosis groups (Open Table in a new window)

Stage	T	N	M
0	Tis	N0	M0
I	T1	N0	M0
II	T2a-b	N0	M0
IIIA	T3	N0	M0
IIIB	T4	N0	M0
IIIC	Any T	N1	M0
IVA	Any T	N2	M0
IVB	Any T	Any N	M1

Distal bile duct tumor staging

Table. Distal bile duct tumor staging (Open Table in a new window)

Primary tumor (T)
TX	Primary tumor cannot be assessed
Tis	Carcinoma in situ/high-grade dysplagia
T1	Tumor invades the bile duct wall with a depth < 5 mm
T2	Tumor invades the bile duct wall with depth of 5-12 mm
T3	Tumor invades the bile duct wall with a depth > 12 mm
T4	Tumor involves the celiac axis, superior mesenteric artery, and/or common hepatic artery
Regional lymph nodes (N)
NX	Regional nodes cannot be assessed
N0	No regional lymph node metastasis
N1	Metastasis in 1-3 regional lymph nodes
N2	Metastasis in 4 or more regional lymph nodes
Distant metastasis (M)
M0	No distant metastasis
M1	Distant metastasis

Table. Histologic grading (Open Table in a new window)

Histologic grading
GX	Grade cannot be assessed
G1	Well differentiated
G2	Moderately differentiated
G3	Poorly differentiated

IIB

Table. Anatomic stage/prognosis groups (Open Table in a new window)

Stage	T	N	M
0	Tis	N0	M0
I	T1	N0	M0
IIA	T1	N1	M0
IIA	T2	N0	M0
IIB	T2	N1	M0
IIB	T3	N0-1	M0
IIIA	T1-3	N2	M0
IIIB	T4	Any N	M0
IV	Any T	Any N	M1

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Author

Kirby Rebecca Walker, MD Fellow in Complex General Surgical Oncology, Roger Williams Medical Center

Kirby Rebecca Walker, MD is a member of the following medical societies: American College of Surgeons, Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Christopher D Braden, DO Hematologist/Oncologist, Chancellor Center for Oncology at Deaconess Hospital; Medical Director, Deaconess Hospital Outpatient Infusion Centers; Chairman, Deaconess Hospital Cancer Committee

Christopher D Braden, DO is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology

Disclosure: Nothing to disclose.

Chief Editor

N Joseph Espat, MD, MS, FACS Harold J Wanebo Professor of Surgery, Assistant Dean of Clinical Affairs, Boston University School of Medicine; Chairman, Department of Surgery, Director, Adele R Decof Cancer Center, Roger Williams Medical Center

N Joseph Espat, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Clinical Oncology, Americas Hepato-Pancreato-Biliary Association, Association for Academic Surgery, Central Surgical Association, Chicago Medical Society, International Hepato-Pancreato-Biliary Association, Pancreas Club, Sigma Xi, The Scientific Research Honor Society, Society for Leukocyte Biology, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, Society of University Surgeons, Southeastern Surgical Congress, Southern Medical Association, Surgical Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

Tomislav Dragovich, MD, PhD Chief, Section of Hematology and Oncology, Banner MD Anderson Cancer Center

Tomislav Dragovich, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Society of Clinical Oncology, SWOG

Disclosure: Nothing to disclose.

Jeffrey B VanDeusen, MD, PhD Assistant Clinical Professor of Internal Medicine, Medical Director, James Cancer Network, Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center

Disclosure: Nothing to disclose.