Pancreatic & Biliary Tract Cancer Staging

Criteria for TNM Clinical Staging
Site Criteria
Pancreas Imaging procedures, including scanning, CT, ultrasound, laparoscopy, cytology; laparotomy, surgical exploration.
Gallbladder Staging depends on assessment of invasion through wall; clinical staging is not applicable.
Liver Physical examination and imaging procedures.
Extrahepatic bile ducts and ampulla of Vater Same as pathologic staging.

Criteria for TNM Pathologic Staging
Site Criteria
Pancreas Complete/subtotal resection of pancreas and regional lymph nodes.
Gallbladder Surgical exploration, examination of resected specimen, histologic confirmation of liver involvement, depth of invasion into/through wall, invasion into liver, other adjacent organs that are involved, assessment of regional nodes.
Liver No criteria exist for pathologic staging of liver cancer.
Extrahepatic bile ducts and ampulla of Vater Imaging, surgical exploration with examination of resected specimen and lymph nodes.

TNM staging for liver, gallbladder, extrahepatic bile duct cancer applies only to carcinomas. TNM staging for pancreatic cancer applies only to carcinomas; islet cell tumors are excluded from the staging system.

Brief Summaries of 6th Edition Categories

Liver & Intrahepatic Bile Ducts
AJCC Definition
T1 Solitary tumor without vascular invasion.
T2 Solitary tumor with vascular invasion; or multiple tumors none more than 5 cm.
T3 Multiple tumors more than 5 cm or tumor involving a major branch of the portal or hepatic vein(s).
T4 Tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of visceral peritoneum.
N1 Regional lymph node metastases.

Gallbladder
AJCC Definition
T1 Tumor invades lamina propria or muscle layer.
T1a Tumor invades lamina propria.
T1b Tumor invades muscle layer.
T2 Tumor invades perimuscular connective tissue; (no extension beyond serosa or into liver).
T3 Tumor perforates serosa and/or invades the liver and/or one other adjacent organ or structure.
T4 Tumor invades main portal vein or hepatic artery or invades multiple extrahepatic organs or structures.
N1 Regional lymph node metastasis.

Extrahepatic Bile Ducts
AJCC Definition
T1 Tumor confined to bile duct histologically.
T2 Tumor invades beyond wall of bile duct.
T3 Tumor invades liver, gallbladder, pancreas, and/or unilateral branches of portal vein or hepatic artery.
T4 Tumor invades main portal vein or branches bilaterally, common hepatic artery, or other structures.
N1 Regional lymph node metastasis.

Ampulla of Vater
AJCC Definition
T1 Limited to Ampulla or sphincter of Oddi.
T2 Invades duodenal wall.
T3 Invades pancreas
T4 Invades peripancreatic soft tissues or other adjacent organs or structures
N1 Regional lymph node metastases.

Pancreas
AJCC Definition
T1 Limited to pancreas =< 2 cm.
T2 Limited to pancreas > 2 cm.
T3 Beyond pancreas but without celiac axis or superior mesenteric artery involvement.
T4 Involves celiac axis or superior mesenteric artery (unresectable primary).
N1 Regional lymph node metastases.

Collaborative Stage Elements

For more details on Collaborative Stage, see the Intro to Collaborative Staging module.