Revised AJCC Classification of
Extrahepatic Bile Duct Tumors
Definitions
Anatomy of the Bile Ducts
right hepatic duct
left hepatic duct
hepatic hilum
perihilar bile ducts
proximal common duct
(proximal hepatic duct)
cystic duct
middle common duct
common bile duct
distal bile duct
distal common duct
ampulla of
Vater
7th AJCC classification
Definitions
AJCC Classification
Extrahepatic Bile Duct Tumors
 Including bile duct tumors arising from the
hepatic hilum of the right and left hepatic
ducts to the distal common duct above the
ampulla of Vater in the 6th edition (2002)
 Separated into perihilar bile duct and distal
bile duct tumors in the 7th edition (2010)
6th AJCC Classification
Extrahepatic Bile Duct Tumor
Primary tumor (T)
Stage 0
Tis
N0
M0
Stage IA
T1
N0
M0
Stage IB
T2
N0
M0
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
Stage IIA
T3
N0
M0
T3
Tumor invades the liver, gallbladder,
pancreas, and/or unilateral branches of the
portal vein (right or left) or hepatic artery
(right or left)
Stage IIB
T1-3
N1
M0
Stage III
T4
Any N
M0
T4
Tumor invades any of the following: main
portal vein or its branches bilaterally,
common hepatic artery, or other adjacent
structures, such as the colon, stomach,
duodenum, or abdominal wall
Stage IV
Any T
Any N
M1
7th AJCC Classification
Definitions of TNM
Perihilar Bile Duct
Tumor
Primary tumor (T)
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
Distal Bile Duct
Tumor
Primary tumor (T)
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 involves the celiac axis, or the
superior mesenteric artery
7th AJCC Classification
Definitions of TNM
Perihilar Bile Duct
Tumor
Regional lymph nodes (N)
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
Metastasis to periaortic, pericaval,
superior mesenteric artery, and/or
celiac artery lymph nodes
Distant metastasis (M)
Distal Bile Duct
Tumor
Regional lymph nodes (N)
NX
Regional lymph nodes cannot be
assessed
N0
No regional lymph node metastasis
N1
Regional lymph node metastasis
N2
Metastasis to periaortic, pericaval,
superior mesenteric artery, and/or
celiac artery lymph nodes
Distant metastasis (M)
M0
No distant metastasis
M0
No distant metastasis
M1
Distant metastasis
M1
Distant metastasis
7th AJCC Classification
Anatomic Stage/Prognostic Groups
Perihilar Bile Duct
Tumor
Distal Bile Duct
Tumor
Stage 0
Tis
N0
M0
Stage 0
Tis
N0
M0
Stage I
T1
N0
M0
Stage IA
T1
N0
M0
Stage II
T2a-b
N0
M0
Stage IB
T2
N0
M0
Stage IIIA
T3
N0
M0
Stage IIA
T3
N0
M0
Stage IIIB
T1-3
N1
M0
Stage IIB
T1-3
N1
M0
Stage IVA
T4
N0-1
M0
Stage III
T4
Any N
M0
Stage IVB
Any T
N2
Any N
M0
M1
Stage IV
Any T
Any N
M1
Summary
Perihilar Bile Duct Tumors
 T1: confined to the bile duct
T2: beyond the wall of the bile duct wall
 T2b: invasion of adjacent hepatic parenchyma
(T3 in the 6th edition)
 T3: unilateral vascular invasion
 T4: bilateral biliary and/or vascular invasion
 Regional lymph node metastasis: reclassified as
stage IIIB (stage IIB in the 6th edition)
 T4: unresectable based on local invasion (IVA) or
distant disease (IVB)
Summary
Distal Bile Duct Tumors
 T1: confined to the bile duct
T2: beyond the wall of the bile duct wall
 T3: includes adjacent organs (invasion of
adjacent organs such as the colon, stomach,
duodenum or abdominal wall: classified as T4
in the 6th edition)
 Invasion of the portal vein and hepatic artery:
excluded in classification (T3 or T4 in the 6th
edition)
 No criteria on the longitudinal involvement
Radiologic Staging
Perihilar Bile Duct Tumors
Stage I
• CT: wall thickening from left hepatic duct to distal common duct
• Surgery: left major hepatobiliary resection, pathology: T1N0M0
• Major surgery was performed due to extensive longitudinal involvement
Radiologic Staging
Perihilar Bile Duct Tumors
Stage II
• CT: wall thickening from both hepatic ducts to proximal common
duct, periductal invasion (+)
• Op: extended left hemihepatectomy, pathology: T2aN0M0
Radiologic Staging
Perihilar Bile Duct Tumors
Stage II
• CT: wall thickening and mass invading to adjacent hepatic parenchyma,
from left hepatic duct to hepatic hilum
• Surgery: extended left hemihepatectomy, pathology: T2bN0M0
• T3 in the 6th edition, T2b in the 7th edition
Radiologic Staging
Perihilar Bile Duct Tumors
Stage IIIA
• CT: polypoid mass from both hepatic ducts to hepatic hilum, invasion
to right hepatic artery
• Surgery: segmental resection due to old age, pathology: T3N0M0
• Upstaged from stage IIA (T3N0M0) to stage IIIA (T3N0M0) in case of
unilateral vascular invasion
Radiologic Staging
Perihilar Bile Duct Tumors
Stage IIIB
• CT: wall thickening from hepatic hilum to proximal common duct, lymph node (+)
• Surgery: segment resection and lymph node dissection, pathology: T2aN1Mo
• Upstaged from stage IIB (T2N1M0) to IIIB (T2aN1M0) due to regional lymph node
metastasis
Radiologic Staging
Distal Bile Duct Tumors
Stage IA
• CT: polypoid mass from mid to
distal, pericholedochal invasion (-)
• Surgery: PPPD, pathology: T1N0M0
Stage IB
• CT: wall thickening from mid to
distal, pericholedochal invasion (+)
• Surgery: PPPD, pathology: T2N0M0
Radiologic Staging
Distal Bile Duct Tumors
Stage IIA
• CT: wall thickening involving distal common duct, pancreatic invasion (+)
• Surgery: PPPD and lymph node dissection, pathology: T3N0M0
• Pancreatic invasion: T3 in 6th and 7th editions
Radiologic Staging
Distal Bile Duct Tumors
Stage IIA
• CT: wall thickening from distal common duct, pancreatic and duodenal invasion (+)
• Surgery: PPPD and lymph node dissection, pathology: T3N0M0
• Downstaged from stage IV (T4N0M0) to stage IIA (T3N0M0) due to duodenal invasion
Radiologic Staging
Distal Bile Duct Tumors
Stage IIB
• CT: polypoid mass from mid to distal common duct, pancreatic invasion (+),
regional lymph node (+)
• Surgery: PPPD, pathology: T3N1M0
Radiologic Staging
Distal Bile Duct Tumors
Stage IIB
• CT: wall thickening from proximal to distal common duct, duodenal and pancreatic
invasion (+), regional lymph node (+)
• Surgery: PPPD, pathology: T3N1M0
• Downstaged from stage IV (T4N1M0) to stage IIB (T3N1M0) due to duodenal invasion
Radiologic Staging
Distal Bile Duct Tumors
Stage IIB
• CT: wall thickening from middle to distal common duct, pancreatic invasion (+),
regional lymph node (+)
• Surgery: PPPD and portal vein resection, pathology: T3N1M0
• Portal vein invasion: T4 in the 6th edition, not defined T3 in the 7th edition
(maybe T3 as other adjacent organ)
Limitations
Perihilar Bile Duct Tumors
False Negative Image Interpretation
• Invasion to hepatic parenchyma: CT (-), pathology (+)
Limitations
Perihilar Bile Duct Tumors
False Positive Image Interpretation
• Invasion to right hepatic artery: CT (+), pathology (-)
Limitations
Perihilar Bile Duct Tumors
Indefinite Staging System
• CT: Pancreatic invasion (+)
• CT: Gallbladder invasion (+)
• T stage of pancreatic and gallbladder invasion: not clearly defined
Limitations
Distal Bile Duct Tumors
False Negative Image Interpretation
• Pancreatic invasion: CT (-), pathology (+)
Limitations
Distal Bile Duct Tumors
False Positive Image Interpretation
• Invasion beyond bile duct wall: CT (+), pathology (-)
Limitations
Distal Bile Duct Tumors
Indefinite Staging System
• Main portal vein invasion: CT (-), pathology (+)
• Main portal invasion: T4 in the 6th edition, not clearly defined in
the 7th edition (maybe T3 as other adjacent organ)
New Staging
Perihilar Cholangiocarcinoma
Proposed Classification System
Bile duct
Common bile duct, hepatic
duct confluence, right hepatic
duct, left hepatic duct, right
and left hepatic duct
Remnant liver
volume
No information, percentage of
total volume after resection
Tumor size
< 1 cm, 1-3 cm, > 3 cm
Underlying
liver disease
Fibrosis, NASH, PSC
Tumor form
Sclerosing, mass-forming,
sclerosing and mass-forming,
polypoid
Lymph nodes
No LN involvement, hilar and
HA LN involvement, periaortic
LN involvement
Involvement of
portal vein
No portal involvement, main
PV, PV bifurcation, right PV,
left PV, right and left PVs
Metastasis
No distant metastasis, distant
metastasis
Involvement of
hepatic artery
No arterial involvement, proper
HA, HA bifurcation, right HA,
left HA, right and left HA
DeOliveira MI, et al. Hepatology 2011;53:1363-1371