Stages of biliary tract cancers

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Staging describes or classifies a cancer based on how much cancer there is in the body and where it is when first diagnosed. This is often called the extent of cancer. The healthcare team uses information from tests to find out the size of the tumour, which parts of the organ have cancer, whether the cancer has spread from where it first started and where the cancer has spread. Doctors use the stage to plan treatment and estimate the outcome (prognosis).

The most common staging system for biliary tract cancers is the AJCC TNM system. For biliary tract cancers, there are 5 stages – stage 0 followed by stages 1 to 4. Often the stages 1 to 4 are written as the Roman numerals I, II, III and IV. Generally, the higher the stage number, the larger the cancer is or the more the cancer has spread.

Sometimes, when describing the stage, doctors may use the words local, regional or distant. These are terms applied by the SEER system, which is used less often to stage biliary tract cancers.

Local means that the cancer is only in the gallbladder or bile duct and has not spread to other parts of the body.

Regional means close to the biliary tract or around it.

Distant means in a part of the body farther from the gallbladder or bile duct.

When cancer starts in gallbladder cells, it is called primary gallbladder cancer. When cancer starts in bile duct cells, it is called primary bile duct cancer. Gallbladder and bile duct cancers use the same staging system, but receive different stages based on features and specific information about each type of cancer. Details about the tumour (T), lymph nodes (N) and metastasis (M) classifications for each stage of each cancer type are described below. Talk to your doctor if you have questions about the stage you were given.

Find out more about staging cancer.

Gallbladder cancer

The following stages are used for adenocarcinoma of the gallbladder. Other rarer types of gallbladder cancer may be staged differently.

Stage 0 (carcinoma in situ)

There is cancer only in the inner lining of the gallbladder (epithelium). It has not grown into the wall of the gallbladder.

Stage 1

The tumour has grown into the layer of connective tissue (lamina propria) or the muscle layer surrounding it.

Stage 2

The tumour has grown into the connective tissue that surrounds the muscle layer (perimuscular layer), either on the side of the gallbladder beside the liver (stage 2A) or the peritoneum (stage 2B).

Stage 3

The tumour has grown through the gallbladder wall into the outer covering of the gallbladder (serosa) or 1 nearby organ, such as the liver (stage 3A).

OR

Cancer is found in 1 to 3 nearby lymph nodes and has not grown into any blood vessels or more than 1 nearby organ (stage 3B).

The cancer has not spread to other parts of the body.

Stage 4

The tumour has spread into the portal vein or hepatic artery (main blood vessels) or to 2 or more nearby organs, such as the liver. Cancer may be found in up to 3 nearby lymph nodes (stage 4A).

OR

The tumour is of any size and has spread to 4 or more nearby lymph nodes (stage 4B).

OR

The cancer has spread to other parts of the body (called distant metastasis), such as to the lungs, colon or bone (stage 4B). This is also called metastatic gallbladder cancer.

Intrahepatic bile duct cancer

The following stages are used for intrahepatic cholangiocarcinoma. Other rarer types of intrahepatic bile duct cancer may be staged differently.

Stage 0 (carcinoma in situ)

There is cancer only in the innermost layer (mucosa) of the bile duct. It has not grown into the walls of the bile duct.

Stage 1

There is only one tumour and it has not spread to nearby blood vessels. This stage is divided by whether the tumour is 5 cm or smaller (stage 1A) or is larger than 5 cm (stage 1B).

Stage 2

The tumour has spread into nearby blood vessels.

OR

There is more than one tumour.

Stage 3

The tumour has grown through the visceral peritoneum (stage 3A).

OR

The tumour has grown into 1 or more nearby organ other than the liver (stage 3B).

OR

The tumour is of any size and cancer is found in 1 or more nearby lymph nodes (stage 3B). The cancer has not spread to other parts of the body.

Stage 4

The cancer has spread to other parts of the body, such as to the lungs, liver or bone. This is also called metastatic intrahepatic bile duct cancer.

Perihilar bile duct cancer

The following stages are used for perihilar cholangiocarcinoma. Other rarer types of perihilar bile duct cancer may be staged differently.

Stage 0 (carcinoma in situ)

The cancer is only in the bile duct mucosa. It has not grown into the walls of the bile duct.

Stage 1

The tumour has grown into deeper layers of the bile duct walls, up to the muscle or fibrous tissue layer.

Stage 2

The tumour has grown out of the bile duct and spread into the surrounding fat.

OR

The tumour has spread into the liver.

Stage 3

The tumour has spread into the portal vein or hepatic artery on one side of the liver (stage 3A).

OR

The tumour has spread into the portal vein or hepatic artery on both sides of the liver (stage 3B).

OR

The tumour is of any size and cancer is found in 1 to 3 nearby lymph nodes (stage 3C). The cancer has not spread to other parts of the body.

Stage 4

The tumour is of any size and cancer is found in 4 or more nearby lymph nodes, but has not spread to other parts of the body (stage 4A).

OR

The cancer has spread to other parts of the body, such as to the lungs, liver or bone (stage 4B). This is also called metastatic perihilar bile duct cancer.

Distal extrahepatic bile duct cancer

The following stages are used for distal cholangiocarcinoma. Other rarer types of distal bile duct cancer may be staged differently.

Stage 0 (carcinoma in situ)

The cancer is only in the bile duct mucosa. It has not grown into the walls of the bile duct.

Stage 1

The tumour has grown 5 mm or less into the bile duct walls.

Stage 2

The tumour has grown up to 5 mm into the walls of the bile duct. Cancer is found in 1 to 3 nearby lymph nodes (stage 2A).

OR

The tumour has grown more than 5 mm, but no more than 12 mm into the walls of the bile duct (stage 2A). Cancer may also be found in up to 3 nearby lymph nodes (stage 2B).

OR

The cancer has spread more than 12 mm into the bile duct walls. Cancer may also be found in up to 3 nearby lymph nodes (stage 2B).

The cancer has not spread to other parts of the body.

Stage 3

The tumour is of any size and cancer is found in 4 or more nearby lymph nodes, but it has not spread to any blood vessels (stage 3A).

OR

The tumour has spread out of the bile duct walls into abdominal blood vessels such as the celiac axis, superior mesenteric artery or hepatic artery. It may have also spread into the nearby lymph nodes (stage 3B).

The cancer has not spread to other parts of the body.

Stage 4

The cancer has spread to other parts of the body, such as to the lungs, liver or bone. This is also called metastatic distal bile duct cancer.

Expert review and references

  • Jamil Asselah, MD
  • Aloia T, Pawlik TM, Taouli B, Rubbia-Brandt L, Vauthey JN. Intrahepatic bile ducts. Amin, MB (ed.). AJCC Cancer Staging Manual. 8th ed. Chicago, IL: American College of Surgeons; 2017: 23:314–321.
  • Krasinskas A, Pawlik TM, Mino-Kenudson M, Vauthey JN. Distal bile ducts. Amin, MB (ed.). AJCC Cancer Staging Manual. 8th ed. Chicago, IL: American College of Surgeons; 2017: 26:336–345.
  • Nagorney DM, Pawlik TM, Chin YS, Ebata T, Vauthey JN. Perihilar bile ducts. Amin, MB (ed.). AJCC Cancer Staging Manual. 8th ed. Chicago, IL: American College of Surgeons; 2017: 25:330–335.
  • Patel T, Mody K, Krishnan S. Cancer of the Biliary Tree. DeVita VT Jr, Lawrence TS, Rosenberg S. eds. DeVita Hellman and Rosenberg's Cancer: Principles and Practice of Oncology. 12th ed. Philadelphia, PA: Wolters Kluwer; 2023: Kindle version, [chapter 37], https://read.amazon.ca/?asin=B0BG3DPT4Q&language=en-CA.
  • Zhu AX, Pawlik TM, Kooby DA, Scheffer TE, Vauthey JN. Gallbladder. Amin, MB (ed.). AJCC Cancer Staging Manual. 8th ed. Chicago, IL: American College of Surgeons; 2017: 24:322–329.

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