Staging (Page 1 of 2)

Bruce,

The post that you found could have been in error. Another possibility, Stage IIB referred to an older, outdated staging system. Staging systems went through many updates.

You can find the current staging systems for ICC and ECC in the NCCN Guidelines. ICC system is on slide 27 (labelled ST-3). There is no Stage IIB.

Stage II is T2 N0 M0. Stage III is T3 N0 M0. There is nothing in between.

I been reviewing old messages to build a cc database based on the experience posted by foundation subscribers.  The stage IIB reference was from a 5/12/12 post by PCL1029, Subject; Re: Help! Post Recent Liver Resection - Benefits of Chemo??  It was,

"May 2009 diagnosis= intrahepatic CC stage IIB"

The following article listed this as an appropriate stage for Bile Duct Cancer, so I assumed it was correct.

http://www.uwhealth.org/healthfacts/B_E … 40204.html

Bruce Baird

Just realized something:

The current staging system (AJCC 7th edition) was published in 2010.

Prior to 7th edition, intrahepatic CC didn't have its own staging system. It was staged the same way as liver cancer (hepatocellular carcinoma = HCC).

2009 diagnosis of ICC must have used HCC staging.

But...

HCC doesn't have stage IIB either. It has stages I, II, IIIa, IIIb, IIIc, IVa and IVb.

Oh Oh! I went back and looked at PCL1029's comments about ICC which are,

"The staging (TNM) for ICC are Stage 0,I,II,III,IVA and stage IVB."

The foundation's discussion on staging, linked in previous post, shows,

The staging (TNM) for ICC are Stage I,II,IIIA,IIIB,IIIC and stage IV.

So now I'm really confused.

Bruce

Hi,
The stage (TNM) has both pTNM=pathologic( pT1N1MX in your case)  and cTNM= clinical classification.
And as you may understand that two classifications may be different upon surgical results returned and clinical presentation.
Currently AJCC staging Manual,7th edition(2010) is the one that American physicians used.

Personally ,I do not think the p-staging is as important as the c-staging classification. In this sense, your surgeon'comment after the resection was more important than the pTNM staging itself.
Anyway, based on the messages you wrote on this board; your wife might have ECCA ."" according to your description,spread to the liver and one hilar lymph node". And resection was performed with the right lobe completely removed along with some bile ducts and part of the left lobe and the affected lymph node. If this is correct, then your wife will have a better chance not to have recurrence than ICCA.But it will be still  in the 50% as compare to 75% for ICCA.
If you worry about the MX staging; ask the oncologist to order a PET scan and you will know the results.(but please remember PET is not 100% proof of the findings that some one has cancer ;it can be other problems as well)
I rotate my q3-4month scan between PET and Ct scan to get a better picture of my disease condition.
chemoradiation treatment after adjuvant chemotherapy is acceptable. I only had Gemzar after the first surgery and Xeloda after the 2nd resection. No radiation was provided.
The question you should seriously considerNOW is what should you do after the chemoradiation? Follow the doctors recommendations of Ct scan every 3-6month and then after a year or two, change to every year and hope the cancer will not return; or be more progressive in the anticipation of the return of the cancer and refine your thinking and research toward prevention or delay such outcome.
I am happy that you devote so much energy to take care of your wife and she is very lucky to have you at her side. You and Eli  are the few men that is details oriented and precise in your pursuit of information and knowledge and in so doing directly and indirectly contribute to this board substantially.
God bless.

Eli,
thanks, I will look at it now.
God bless.

Thanks Eli for the info that the foundation's link on staging is out of date.  I found that I could download all of the previous AJCC Cancer Staging Manuals from the AJCC website for free.  I downloaded the 6th version (2003-2009) and found that it matches the foundation's info on staging for ICC (pp131-138 of the manual.)  I also finally looked at the NCCN Guidelines for ICC (7th ed., 2010) which you mentioned and found the staging that Percy previously stated.  It's interesting that they dropped the MX classification (which the Ochsner pathologist used) so I assume, since they didn't find any distant metastasis, M0 must apply.  If that's the case, my wife's stage is Stage IVA.

At least that's what it looks like until after I digest Percy's comments.  Percy, I just learned today, after reading the 6th edition of the cancer staging manual that there is both clinical staging and  pathologic staging.  The surgeon never told us the clinical stage.  He did say that it was intrahepatic cholangiocarcinoma but because the cancerous lymph node, which was pressing against the common bile duct and causing it to bleed on the inside, I thing he said he was going to perform the surgery more like he would do extrahepatic cholangiocarcinoma surgery.  We had conflicting opinions on whether the lymph node had fused to the common bile duct.  I believe the surgeon thought it had and the doctor who inserted the stent thought they were separable. The surgeon intially said that he would have to remove all of the right lobe and some of the left lobe, a total of 72%, but after the surgery, he said he didn't have to remove as much as he initially thought.  A couple of weeks after the surgery we met in his office and he gave me a copy of the pathology report and he went throught it with us, emphasizing that it was the best he could have ever expected, specifically addressing the 1 positive node out of 7, and the 2 cm margins.  Later the oncologist went through the report with us and the one thing she was concerned with was the "poorly differentiated" histologic grade.

The pathologist report shows the following:

SPECIMEN:
1) Falciform ligament - fibrofatty and vascular tissue. Negative for malignancy
2) Hepatic Artery Lymph Node - One (1) benign lymph node
3) Biliary Stent: Gross Diagnosis only
4) Proximal Bile Duct Margin: Negative for Malignancy
5) Liver Segments 4B, 5, 7, and 8; Partial Hepatectory: See Synoptic Report:

Specimen: Liver
Procedure: partial hepatectomy, major hepatectomy
Tumor size: 6.4 cm
Tumor focality: Solitary
Histologic type: Cholangiocarcinoma
Histologic grade: Poorly differentiated G3 out of 4
Tumor growth pattern: Mass forming
Microscopic tumor extension: Confined to the hepatic parenchyma
Hepatic parenchymal margin: uninvolved, 2 cm from tumor
Bile duct margin uninvolved
No lymphovascular or perineural invasion identified
pT1 N1 MX
One (1) hilar lymph node positive for metastatic carcinoma out of 6
Additionally, hepatic artery lymph node is benign
Background liver is unremarkable

Immunostains performed with appropriate positive and negative controls. Tumor cells are positive for keratin 7 and negative for keratin  20, hepatocyte antigen, and estrogen receptor.  Findings are consistent with intrahepatic cholangiocarcinoma.  Tumor surrounds and invades a medium sized branch of the biliary tree.  There is marked acute inflammation and necrosis in the tumor.

I think I included both info from the surgeon and the pathology report in my previous messages on the discussion boards.

When I said "spread to the liver" I envisioned the cancer starting in a small bile duct contained within the liver and spreading from there to the liver which is in direct contact.

Thanks for the advice on the PET scan.  The surgeon said that their policy is a CT scan every 6 months.  Maybe this is a Medicare thing.  I'll ask the oncologist about the PET scan.

Right now my wife is scheduled to get GemCis for 4 months on a 21 day cycle, the amounts being the same as used in the Phase III study, and radiation with 5FU for 5 weeks, 5 days a week.  So, as you suggest, what I'm trying to do is research what we can do to extend the recurrence time.  I've read a lot of the published studies and I can't find the answer there, so I'm trying to research the members of this foundation to document their experience.  So, far I've got about 50 on the spreadsheet, but unfortunately, only 1 of the 50 comes close to my wife's condition.  I thought you might be a candidate because of the Stage IIB you reported.  The report I had said Stage IIB for bile duct cancer indicated the cancer had spread to nearby lymph nodes in addition to other factors.

Percy, thank you for your kind remarks about my contribution to the board.  Eli and I are both engineers, and I think it is in our nature to be detailed oriented.  I'm 76, retired when I was 57, and most of my career as an electrical engineer was supporting NASA on the Saturn/Apollo "moon" program, the Space Shuttle, and the International Space Station.  After the moon landing in 1969, people said, "If we can put men on the moon, then we should be able to _____ (fill in the blank)." Perhaps this should also apply to finding a cure for this horrible disease.

Bruce

Bruce...I agree in that we need to update the staging information on this site.  Eli has offered his help and we will start working on it within the next few days. 
Hugs,
Marion

Hi Bruce,

I'm not sure what's going on here. It's not just Figure 4 that looks odd. Look at the bottom chart in Figure 2. The last column (AJCC 7th ed) shows data splits for Stages I, II, III and IV. These stages are clearly at variance with NCCN Guidelines.

My best guess: AFC-IHCC-2009 Study Group wrote this paper before AJCC 7th Edition was finalized and published. Maybe they worked with a draft 7th edition which was subsequently modified? Just a guess.

I double-checked the stages in two other sources:

Source 1:

Summary of Changes. Understanding the Changes from the Sixth to the Seventh Edition of the AJCC Cancer Staging Manual

Quote from Page 10:

Source 2:

College of American Pathologists. Protocol for the Examination of Specimens From Patients With Carcinoma of the Intrahepatic Bile Ducts

Page 11 shows the same stage groupings as NCCN Guidelines.

Bruce, my husband was in his 70's and had Medicare. A couple of times he was turned down for PETs but after the ONC intervened and wrote them they always OK'd the PET. I am 72 and have another type of rare Cancer. In the beginning they never turned me down and now I have graduated to CT Scans instead, no problem.
Best of luck!

Percy, didn't you hear the latest rules? You don't go from a III to an IV. You go the other way from a III to a II. From my mouth to God's ears, I can hope right?

God Bless You too, Percy.