Workup/Staging Flashcards
What initial labs should be sent if suspecting CC or GB cancer?
Bilirubin, alk phos, aspartate aminotransferase (AST), and alanine transaminase (ALT) (can often be normal); γ-glutamyl transpeptidase, CEA, and CA 19-9 are particularly helpful in CC or GB cancer.
In what pts is CA 19-9 less reliable?
Pts without Lewis blood group antigen (10% of population) do not have CA 19-9. Hyperbilirubinemia can decrease specificity and accuracy of CA 19-9.
What initial imaging is used for suspected CC and GB cancer?
RUQ US, contrast CT (preferably multiphase), and MRCP are typically performed for suspected CC or GB cancer.
On contrast-enhanced CT, how can hepatocellular carcinoma (HCC) and IHCC be distinguished?
On contrast-enhanced CT of the liver, HCC usually enhances during the arterial phase, while IHCC may show delayed enhancement.
What is the imaging study of choice for EHCC?
MRCP is the imaging study of choice for EHCC, as it has improved the ability to define tumor extent and LN involvement.
What invasive imaging strategies are available?
ERCP and percutaneous transhepatic cholangiography (PTC) can help image obstruction, but MRCP/CT is preferred.
How is a pathologic Dx obtained for CC?
For resectable pts without obstruction, pathology can be obtained at Sg. For unresectable pts or pts with obstruction requiring stenting, duct brushings can be obtained at ERCP, or Bx can be done at time of PTC or EUS.
How is a pathologic Dx obtained for GB cancer?
Definitive resection is the diagnostic approach if GB cancer is suspected. Bile cytology (low yield) or percutaneous Bx can be performed in unresectable pts.
When is ERCP- or PTC-based stenting indicated prior to Sg?
If bilirubin is elevated (i.e., >10–15), ERCP- or PTC-guided stents are placed to decompress obstruction and allow liver recovery prior to Sg.
In addition to locoregional imaging, what staging imaging is recommended for GB cancer and CC?
In addition to locoregional imaging, staging for GB cancer and CC should include CT chest.
What staging procedure is recommended at the beginning of Sg for GB cancer or CC?
Staging laparoscopy is generally recommended at the beginning of Sg for GB cancer or CC to r/o peritoneal dissemination.
How should tumors arising from mid common bile duct (CBD) be staged?
These EHCCs are exceedingly rare, but they are staged as distal CCs.
What is the AJCC 8th edition (2017) T staging for IHCC (changes from 7th edition are in bold for all staging questions)?
Tis: carcinoma in situ
T1a: solitary tumor ≤5 cm without vascular invasion
T1b: solitary tumor >5 cm without vascular invasion
T2: solitary tumor with intrahepatic vascular invasion OR multiple tumors with or without vascular invasion
T3: tumor perforating visceral peritoneum
T4: tumor involving local extrahepatic structures by direct invasion
What is the AJCC 8th edition (2017) T staging for perihilar CC?
Tis: carcinoma in situ/high-grade dysplasia
T1: tumor confined to bile duct, with extension up to muscle layer or fibrous tissue
T2a: tumor invades beyond bile duct wall to surrounding fat
T2b: tumor invades hepatic parenchyma
T3: tumor invades unilat branches of portal vein (right or left) or hepatic artery (right or left)
T4: tumor invades any of the following: main portal vein or bilat branches, common hepatic artery, or unilat 2nd-order biliary radicals with contralat portal vein or hepatic artery involvement
What is the AJCC 8th edition (2017) T staging for distal bile duct CC?
Tis: carcinoma in situ/high-grade dysplasia
T1: tumor invades the bile duct wall to a depth <5 mm
T2: tumor invades the bile duct wall to a depth 5–12 mm
T3: tumor invades the bile duct wall to a depth >12 mm
T4: tumor invades celiac axis, SMA, and/or common hepatic artery
What is the AJCC 8th edition (2017) T staging for GB cancer?
The GB and cystic duct are included in this current classification:
Tis: carcinoma in situ
T1a: tumor invades lamina propria
T1b: tumor invades the muscular layer
T2a: tumor invades perimuscular connective tissue on the peritoneal side, without involvement of the serosa (visceral peritoneum)
T2b: tumor invades the perimuscular connective tissue on the hepatic side, with no extension into the liver
T3: tumor perforates serosa (visceral peritoneum) and/or directly invades liver and/or invades 1 adjacent organ/structure (stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts)
T4: tumor invades main portal vein, hepatic artery, or multiple extrahepatic organs/structures
What is the AJCC 8th edition (2017) N classification for IHCC?
N0: no regional LN
N1: regional LN mets present
What is the AJCC 8th edition (2017) N classification for perihilar CC, distal bile duct CC, and GB cancer?
Regional LNs differ by anatomic site of primary tumor as follows: perihilar: hilar, cystic duct, choledochal (i.e., CBD), portal vein, hepatic artery, post pancreaticoduodenal; distal bile duct: CBD, hepatic artery, post and ant pancreaticoduodenal, and right lat wall of SMA; GB: CBD, hepatic artery, portal vein, and cystic duct.
N0: no regional LN
N1: 1–3 regional LN mets present
N2: ≥4 regional LN mets present
What are the AJCC 8th edition (2017) groupings for IHCC?
Stage 0: TisN0
Stage IA: T1aN0M0
Stage IB: T1bN0M0
Stage II: T2N0M0
Stage IIIA: T3N0M0
Stage IIIB: T4N0M0 or Any T N1M0
Stage IV: Any T Any N M1
What are the AJCC 8th edition (2017) groupings for perihilar CC?
Stage 0: TisN0
Stage I: T1N0M0
Stage II: T2a–b N0M0
Stage IIIA: T3N0M0
Stage IIIB: T4N0M0
Stage IIIC: Any T N1M0
Stage IVA: Any T N2M0
Stage IVB: Any T Any N M1
What are the AJCC 8th edition (2017) groupings for distal bile duct CC?
Stage 0: TisN0
Stage I: T1N0M0
Stage IIA: T1N1M0 or T2N0M0
Stage IIB: T2N1M0 or T3N0–1M0
Stage IIIA: T1–3N2M0
Stage IIIB: T4 Any N M0
Stage IV: Any T Any N M1
What are the AJCC 8th edition (2017) groupings for GB cancer?
Stage 0: TisN0
Stage I: T1N0M0
Stage IIA: T2aN0M0
Stage IIB: T2bN0M0
Stage IIIA: T3N0M0
Stage IIIB: T1–3N1M0
Stage IVA: T4N0–1M0
Stage IVB: Any T N2M0 or Any T Any N M1
