Topic: Staging

The foundation's discussion on Cholangiocarcinoma discusses the TNM system of staging where the staging description is different for intrahepatic and extrahepatic cholangiocarcinoma.  On some of the discussion boards, it appears the same staging system is used for both intrahepatic and extrahepatic cholangiocarcinoma.  For example I found a staging of intrahepatic cholagioncarcinoma of Stage IIB for a cancer diagnosed in May 2009 and this description is not included in the TNM system for ICC. Perhaps the foundation's discussion on staging should include this other staging system also.

Bruce Baird

Please be advised that any advice or information in my posts is my personal opinion only and is not intended nor implied to be a substitute for professional medical advice.  ALWAYS seek the advice of your physician or other qualified health care provider.

2 (edited by eli Sat, 01 Dec 2012 22:19:37)

Re: Staging

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 Another possibility, Stage IIB referred to an older, outdated staging system.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.

Re: Staging

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

The staging(TNM) for  perihilar CCA are stage0,I,II,IIIA,IIIB,IVA, and IVB.

The stageing(TNM) for distal CCA are stage0,IA,IB,IIA,IIB,III, and IV.

from uptodate.com 9/14/2012 literature review and Eli is right that they can change frequently ,and there are new staging system proposed by the ASIA medical group and the Barcelona  system  of Spain.
I never ask  oncologist what stage I was . My surgeon told me the stage which was different than before my second resection.
God bless.

Please know that my personal opinion is not intended nor implied to be a substitute for professional medical advice. If  provided, information are for educational purposes.Consult doctor is a MUST for changing of treatment plans.

Re: Staging

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

Please be advised that any advice or information in my posts is my personal opinion only and is not intended nor implied to be a substitute for professional medical advice.  ALWAYS seek the advice of your physician or other qualified health care provider.

Re: Staging

Hi Bruce,

The article that you linked talks about stages of bile duct cancer in general. It doesn't make the distinction between intrahepatic, perihilar and extrahepatic CC. This is not quite accurate.

Each sub-type of CC has its own staging system. You can find the staging systems in the NCCN Guidelines. Stage IIB is a valid stage for ECC, but not for ICC.

Hope this helps,
Eli

6 (edited by eli Sun, 02 Dec 2012 19:24:46)

Re: Staging

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.

Re: Staging

Thanks Eli. 

The main point of my original post was that the foundation's discussion  of staging, which is at http://www.cholangiocarcinoma.org/staging.htm , should be revised to include the earlier staging system (AJCC 6th edition) since posts (2006 through 2009)on the discussion boards include staging comments which were made while that system was in effect.  I think this is still good, regardless of the Stage IIB comments.

Another thing, my wife's pathology report states the findings are consistent with intrahepatic cholangiocarcinoma and shows pT1N1MX but did not provide a stage.  I understand the T1 (single 6.4 cm mass forming tumor totally contained in liver and not involving blood vessels) and N1 (spread to a hilar node), but MX means the tumor cannot be accessed.  Does that mean they don't know if the tumor has metasized to another part of the body?  Does it mean the liver is not counted as another part of the body for ICC?  I can understand how they can determine M1, but can they really determine M0 without a full body scan or something like that?

In any case it appears my wife's stage is either Stage IIIC or Stage IV.

Bruce

Please be advised that any advice or information in my posts is my personal opinion only and is not intended nor implied to be a substitute for professional medical advice.  ALWAYS seek the advice of your physician or other qualified health care provider.

Re: Staging

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

Please be advised that any advice or information in my posts is my personal opinion only and is not intended nor implied to be a substitute for professional medical advice.  ALWAYS seek the advice of your physician or other qualified health care provider.

Re: Staging

Bruce, the foundation page on staging is out of date. It's doesn't match AJCC 7th edition.

10 (edited by PCL1029 Mon, 03 Dec 2012 11:07:56)

Re: Staging

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.

Please know that my personal opinion is not intended nor implied to be a substitute for professional medical advice. If  provided, information are for educational purposes.Consult doctor is a MUST for changing of treatment plans.

Re: Staging

Percy, thanks for your comments.

This recent paper contains a very detailed, technical discussion of various staging systems:

Clinical diagnosis and staging of cholangiocarcinoma
http://www.ncbi.nlm.nih.gov/pmc/article … 1/#S6title

Re: Staging

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

Please know that my personal opinion is not intended nor implied to be a substitute for professional medical advice. If  provided, information are for educational purposes.Consult doctor is a MUST for changing of treatment plans.

Re: Staging

Thanks for the link and thoughts. I posted on the topic "what's my label?" To try to figure out what stage my sister is. They didn't tell her. Perhaps it's not a true staging without "opening her up" to clinically see things.

Willow

14 (edited by 2000miler Tue, 04 Dec 2012 07:13:57)

Re: Staging

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

Please be advised that any advice or information in my posts is my personal opinion only and is not intended nor implied to be a substitute for professional medical advice.  ALWAYS seek the advice of your physician or other qualified health care provider.

Re: Staging

Hi,
Honestly ,without Eli and you Bruce,among others,the medical information on this board will not be as vast and accurate as today right now; thanks all for your contribution on the research side. I frequently ask Eli to help me in looking into hard to find information,esp. computer related topics; I talk to Gavin via email  for his undying devotion and overall knowledge ,understanding and interest to the members of this board. All of you,with others like Lainy, Karen,Barbara,among others,are indispensable . As you all know,I am a patient and I am a realistic person.  and therefore my contribution to this board is limited to what I can do now rather than,like all of you, unlimited in the future.
Bruce, one thing I want to say about your wife but did not in the previous message.(because,I do not know how well you will response?) is about the ""poorly differentiated" cells comment on then pathology slides.
The grading for my 1st. resection is "moderately differentiated" and I have 1.2cm clear margin, I have ICCA and was on Gemzar for 14 months,8 months more than it suppose to be;after the adjuvant chemotherapy, 6 months later it came back on a different site FAR away from the original operated site.. so what I am trying to say is be vigilant and keep on researching, the chance of recurrence is no joke.
God bless.

Please know that my personal opinion is not intended nor implied to be a substitute for professional medical advice. If  provided, information are for educational purposes.Consult doctor is a MUST for changing of treatment plans.

Re: Staging

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

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

17 (edited by 2000miler Wed, 05 Dec 2012 17:33:59)

Re: Staging

Eli - The AJCC 7th edition shows the stage for N1 to be either IVA with no distant metastases or IVB with distant metastases.  However, the paper "AJCC 7th Edition of TNM Staging Accurately Discriminates Outcomes of Patients with Resectable Intrahepatic Cholangiocarcinoma" by the AFC-IHCC-2009 Study Group, Figure 4, shows lymph node metastases as Stage III.  Do you know why?

http://onlinelibrary.wiley.com/doi/10.1 … 25712/full

Please be advised that any advice or information in my posts is my personal opinion only and is not intended nor implied to be a substitute for professional medical advice.  ALWAYS seek the advice of your physician or other qualified health care provider.

18 (edited by eli Wed, 05 Dec 2012 21:46:42)

Re: Staging

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:

Stage IV includes all patients with metastasis, whether nodal or distant, separated into IVA and B to permit identification of each subgroup.
• Stage IVA now includes node-positive disease (N1).
• Stage IVB now includes distant metastasis (M1).

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.

Re: Staging

Thanks Eli.  I'll try to find an email address for one of the authors and write him about it.

Percy, I checked with the medical oncologist this morning and she told me that the clinical TNM status was T1N1M0.  She said the patholist always uses MX because she does not know (I guess from the specimen) what the M status is.

Also, I asked the oncologist about alternating PET scans with CT scans.  She said that PET scans are not approved for CC or gallbladder cancers, although they are approved for colon cancers.  This is probably a Medicare thing.

Bruce

Please be advised that any advice or information in my posts is my personal opinion only and is not intended nor implied to be a substitute for professional medical advice.  ALWAYS seek the advice of your physician or other qualified health care provider.

Re: Staging

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!

Teddy ~In our hearts forever~ATTITUDE is EVERYTHING
Any suggestion I offer is intended as friendly advice based solely on my own experience. Please consult your doctor for professional guidance.

Re: Staging

Hi, Bruce,
just  do like Lainy and try to talk s/he into the PET if you think it will make a difference. . T1N1M0 is much better than T1N1M something.
In my case ,when the CCA recured and after the  2nd resection; they (both the oncologist and the liver surgeon) told me I am in stage III due to the recurrence.As recent as this month ,even I am clean,my oncologist still gives me the stage III rating. Is that means next time  when the CCA recur again and get fixed,I will be in stage IV? I will ask him next time for the answer.
God bless.

Please know that my personal opinion is not intended nor implied to be a substitute for professional medical advice. If  provided, information are for educational purposes.Consult doctor is a MUST for changing of treatment plans.

Re: Staging

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?

Teddy ~In our hearts forever~ATTITUDE is EVERYTHING
Any suggestion I offer is intended as friendly advice based solely on my own experience. Please consult your doctor for professional guidance.

Re: Staging

Hi, Lainy,
That will be music to my ears.
Thanks Lainy, sometimes when I know too much about this disease,and compound for the fact that I was  part of the caregiver team for my sister-in-law and saw the outcome from the beginning to the end of this disease that I have; I get depressed at times; but I know I have already had a good run for 44 months and that has been a gift from God already and I could not ask for more than that. I will report to all of you about the FDA meeting late tomorrow or early the next morning.
God bless.

Please know that my personal opinion is not intended nor implied to be a substitute for professional medical advice. If  provided, information are for educational purposes.Consult doctor is a MUST for changing of treatment plans.

Re: Staging

God Bless You too, Percy.

Willow

Re: Staging

Hi, Willow,

Same to your sister too.

God bless.

Please know that my personal opinion is not intended nor implied to be a substitute for professional medical advice. If  provided, information are for educational purposes.Consult doctor is a MUST for changing of treatment plans.