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Media Gallery

Bismuth classification for perihilar cholangiocarcinoma. Shaded areas represent tumor location.
Tight stricture of a common hepatic duct in a patient presenting with jaundice. Cytologic studies confirmed cholangiocarcinoma.
Three-dimensional treatment planning uses CT scan slices to reconstruct the patient as a volume. Shown here is the display for planning external-beam radiotherapy to the cholangiocarcinoma (green structure). A biliary catheter (red tube) runs through the tumor volume and was used to deliver brachytherapy, which was given in addition to external-beam radiotherapy. Such technology has assisted greatly in the delivery of high doses to the tumor, while sparing vital normal structures, such as the kidney and spinal cord.

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Table 1. TNM staging for intrahepatic bile duct tumors

T - Primary tumor
TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
Tis	Carcinoma in situ (intraductal tumor)
T1	Solitary tumor without vascular invasion, ≤5 cm or > 5 cm
	T1a		Solitary tumor ≤5 cm without vascular invasion
	T1b	Solitary tumor > 5 cm 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
N – Regional lymph nodes
NX	Regional lymph nodes cannot be assessed
N0	No regional lymph node metastasis
N1	Regional lymph node metastasis present
M – Distant metastasis
M0	No distant metastasis
M1	Distant metastasis present

Table 2. TNM staging for perihilar bile duct tumors.

T - Primary tumor
TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
Tis	Carcinoma in situ – high-grade dysplasia
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 unilateral second-order biliary radicals bilaterally with contralateral portal vein or hepatic artery involvement
N – Regional lymph nodes
NX	Regional lymph nodes cannot be assessed
N0	No regional lymph node metastasis
N1	One to three positive lymph nodes typically 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
M – Distant metastasis
M0	No distant metastasis
M1	Distant metastasis

Table 3. TNM staging for distal bile duct tumors.

T - Primary tumor
TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
Tis	Carcinoma in situ – high-grade dysplasia
T1	Tumor invades the bile duct wall with a depth less than 5 m
T2	Tumor invades the bile duct wall with a depth of 5–12 m
T3	Tumor invades the bile duct wall with a depth greater than 12 mm
T4	Tumor involves the celiac axis, superior mesenteric artery, and/or common hepatic artery
N – Regional lymph nodes
NX	Regional lymph nodes cannot be assessed
N0	No regional lymph node metastasis
N1	Metastasis in 1-3 regional lymph nodes
N2	Metastasis in ≥4 regional lymph nodes
M – Distant metastasis
M0	No distant metastasis
M1	Distant metastasis

Table. 1

Intrahepatic bile duct tumor
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
	Any T	N1	M0
IV	Any T	Any N	M1

Table. 2

Perihilar bile duct tumor
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	T4	N2	M0
IVB	Any T	Any N	M1

Table. 3

Distal bile duct tumor
Stage	T	N	M
0	Tis	N0	M0
I	T1	N0	M0
IIA	T1	N1	M0
	T2	N0	M0
IIB	T2	N1	M0
	T3	N0	M0
	T3	N1	M0
IIIA	T1-3	N2	M0
IIIB	T4	N0-2	M0
IV	Any T	Any N	M1

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