Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

The Eastern Cooperative Oncology Group (ECOG) performance status calculator is designed to evaluate a patient's functional ability and categorize it into a specific score from 0 to 5. This quantitative measure helps clinicians make informed decisions about treatment based on the patient's capacity for daily activities and self-care. Here's how it operates:

The user provides input by selecting the description that best matches the patient's current condition from a list of predefined options. These options encapsulate various levels of activity and ability:

- A patient who is "Fully active, able to carry on all pre-disease performance without restriction" is assigned a score of ECOG PS 0. This indicates that the patient is not limited in any capacity by their disease.
- If a patient is "Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, such as light housework, office work," they receive an ECOG PS 1. This means the patient can perform some self-care and work activities but faces restrictions with strenuous tasks.
- "Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours" corresponds to an ECOG PS 2. This reflects moderate impairment, where the patient is active for the majority of the day but not capable of work activities.
- A patient who is "Capable of only limited self-care, confined to bed or chair more than 50% of waking hours" gets an ECOG PS 3. This score denotes significant limitation, as the patient is mobile for less than 50% of the time and requires assistance for most activities.
- With "Completely disabled, cannot carry on any self-care, totally confined to bed or chair," the patient is categorized as ECOG PS 4, indicating severe impairment and complete dependency.
- Finally, if the patient is "Dead," they are assigned an ECOG PS 5.

These score assignments help standardize assessments, providing an objective measure of a patient's status which can be pivotal in guiding medical decisions and evaluating treatment options.

The Eastern Cooperative Oncology Group (ECOG) performance status, also known as the ECOG score, is a widely used tool in oncology to assess a patient's level of functioning in terms of their ability to care for themselves, daily activity, and physical ability (walking, working, etc.). It is applicable to patients with cancer of any type and at any stage.

The ECOG score ranges from 0 to 5, with 0 indicating fully active and able to carry on all pre-disease activities without restriction, and 5 indicating death. The score is used to determine a patient's prognosis, assess how a disease is progressing, and to determine appropriate treatment strategies. It is also often used in clinical trials to assess eligibility and to monitor patient progress.

There are no specific exclusion criteria for the use of the ECOG score, but it is important to note that it is a subjective measure and may not fully capture a patient's functional status. It is also less useful in patients with fluctuating or rapidly changing conditions.

Eastern Cooperative Oncology Group performance status (ECOG score)

The TNM classification for intrahepatic cholangiocarcinoma assigns a stage to a tumor based on three factors: tumor size and extent (T), regional lymph node involvement (N), and presence of distant metastasis (M). 

Inputs: 
- Tumor classification (T) can be one of the following: 
  Tx: Primary tumor cannot be assessed 
  T0: No evidence of primary tumor 
  Tis: Carcinoma in situ (intraductal tumor) 
  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 the visceral peritoneum 
  T4: Tumor involving local extrahepatic structures by direct invasion 

- Lymph Node classification (N): 
  Nx: Regional lymph nodes cannot be assessed 
  N0: No regional lymph node metastasis 
  N1: Regional lymph node metastasis present 

- Metastasis classification (M): 
  M0: No distant metastasis 
  M1: Distant metastasis present 

The computation determines the stage of intrahepatic cholangiocarcinoma based on a combination of the tumor, lymph node, and metastasis classifications:

- Stage 0 is assigned if the tumor is in situ (Tis), with no regional lymph node metastasis (N0), and no distant metastasis (M0).

- Stage IA is assigned when there is a solitary tumor ≤ 5 cm without vascular invasion (T1a), no regional lymph node metastasis (N0), and no distant metastasis (M0).

- Stage IB applies to a solitary tumor > 5 cm without vascular invasion (T1b), no regional lymph node metastasis (N0), and no distant metastasis (M0).

- Stage II is for a solitary tumor with intrahepatic vascular invasion or multiple tumors (T2), no lymph node involvement (N0), and no distant metastasis (M0).

- Stage IIIA involves a tumor perforating the visceral peritoneum (T3) with no lymph node involvement (N0) and no distant metastasis (M0).

- Stage IIIB applies in two scenarios: if the tumor involves local extrahepatic structures (T4), no lymph node metastasis (N0), and no distant metastasis (M0), or if there is any degree of tumor involvement (Tis, T1a, T1b, T2, T3, or T4), with lymph node involvement (N1), and no distant metastasis (M0).

- Stage IV is designated if there is any degree of tumor involvement (Tis, T1a, T1b, T2, T3, or T4), any lymph node status (Nx, N0, or N1), and presence of distant metastasis (M1).

- If the information is incomplete or does not fit the criteria, the output is "Stage cannot be fully assessed".

If none of the conditions for staging is met, the output encourages the user to ensure all inputs are provided.

This framework helps clinicians evaluate the progression of the disease, guiding treatment strategies and prognosis estimation for patients with intrahepatic cholangiocarcinoma.

The calculator in question is the TNM Classification for Intrahepatic Cholangiocarcinoma. TNM stands for Tumor, Node, Metastasis, and it is a globally recognized system used for classifying the extent of spread of cancer. This specific TNM classification is applicable to patients diagnosed with intrahepatic cholangiocarcinoma, a type of liver cancer that originates in the bile ducts within the liver.

The clinical utility of this calculator is to stage the cancer, which is crucial for determining the most appropriate treatment strategy and for predicting prognosis. The TNM classification takes into account the size and extent of the primary tumor (T), whether the cancer has spread to nearby lymph nodes (N), and whether it has metastasized, or spread, to other parts of the body (M).

There are no specific exclusion criteria for the use of the TNM classification for intrahepatic cholangiocarcinoma. However, it is important to note that this system is not applicable to other types of liver or bile duct cancers, and it should be used in conjunction with other diagnostic and clinical information for comprehensive patient management.

TNM classification for intrahepatic cholangiocarcinoma

The TNM classification for perihilar cholangiocarcinoma is a system that assesses the stage of cancer by examining three key parameters: the extent of the primary tumor (T), lymph node involvement (N), and the presence of distant metastasis (M). Here's how the classification works to determine cancer staging:

Tumor Classification:
- Tx: Primary tumor cannot be assessed
- T0: No evidence of primary tumor
- Tis: Carcinoma in situ/high-grade dysplasia
- T1: Tumor confined to bile duct with extension up to muscle layer or fibrous tissue
- T2a: Tumor invading beyond the wall of bile duct to surrounding adipose tissue
- T2b: Tumor invading adjacent hepatic parenchyma
- T3: Tumor invading unilateral branches of the portal vein or hepatic artery
- T4: Tumor invading major structures such as the main portal vein or common hepatic artery

Lymph Node Classification:
- Nx: Regional lymph nodes cannot be assessed
- N0: No regional lymph node metastasis
- N1: 1-3 positive lymph nodes 
- N2: 4 or more positive lymph nodes

Metastasis Classification:
- M0: No distant metastasis
- M1: Distant metastasis present

By taking these inputs, the classification assigns a cancer stage:

- Stage 0: Carcinoma in situ (Tis) without nodal (N0) or distant metastasis (M0).
- Stage I: Tumor is confined to early layers (T1) with no nodal (N0) or distant metastasis (M0).
- Stage II: Tumor invades deeper tissues (T2a or T2b) but no nodal (N0) or distant metastasis (M0).
- Stage IIIA: Unilateral vessel invasion (T3) without nodal involvement (N0) or distant metastasis (M0).
- Stage IIIB: Major vessel or biliary structure involvement (T4) with no nodal (N0) or distant metastasis (M0).
- Stage IIIC: Any tumor invasion (Tis to T4) with limited nodal positive presence (N1) and no distant metastasis (M0).
- Stage IVA: Any tumor presence (Tis to T4) with extensive nodal positive presence (N2) but no distant metastasis (M0).
- Stage IVB: Tumor demonstrates any level of invasion (Tis to T4) with confirmed distant metastasis (M1).

This detailed staging allows for a comprehensive understanding of the cancer's progression, guiding treatment decisions.

The calculator in question is the TNM Classification for Perihilar Cholangiocarcinoma. TNM stands for Tumor, Node, Metastasis, and it is a globally recognized system used for classifying the extent of spread of cancer. 

This specific TNM classification is applicable to patients diagnosed with perihilar cholangiocarcinoma, a type of cancer that occurs in the bile ducts near the liver. The TNM classification helps in staging the disease, which is crucial for determining the most appropriate treatment strategy and predicting patient prognosis.

The clinical utility of this calculator lies in its ability to provide a standardized method for assessing the severity of perihilar cholangiocarcinoma. It takes into account the size and extent of the primary tumor (T), whether the cancer has spread to nearby lymph nodes (N), and the presence of distant metastasis (M).

There are no specific exclusion criteria for the use of the TNM Classification for Perihilar Cholangiocarcinoma. However, it is not applicable to patients with other types of cancer or those who have not been definitively diagnosed with perihilar cholangiocarcinoma.

TNM classification for perihilar cholangiocarcinoma

The TNM classification calculator evaluates the stage of distal cholangiocarcinoma based on three specific criteria: tumor classification, lymph node classification, and metastasis classification, each with distinct options for assessment. 

The tumor classification describes the invasion depth or extent concerning the bile duct and surrounding areas:
- Tx: Primary tumor cannot be assessed.
- T0: No evidence of primary tumor.
- Tis: Carcinoma in situ/high-grade dysplasia.
- T1: Tumor invading bile duct wall with depth < 5 mm.
- T2: Tumor invading bile duct wall with depth 5-12 mm.
- T3: Tumor invading bile duct wall with depth > 12 mm.
- T4: Tumor invading critical arteries (celiac axis, superior mesenteric artery, and/or common hepatic artery).

The lymph node classification indicates regional lymph node involvement:
- Nx: Regional lymph nodes cannot be assessed.
- N0: No regional lymph node metastasis.
- N1: Metastasis in 1-3 regional lymph nodes.
- N2: Metastasis in 4 or more regional lymph nodes.

The metastasis classification checks for distant metastasis presence:
- M0: No distant metastasis.
- M1: Distant metastasis present.

The computation uses these classifications to determine the cancer stage, employing a set codified logic:

- Stage 0: Tis, N0, M0
- Stage I: T1, N0, M0
- Stage IIA: T2, N0, M0, or T1, N1, M0
- Stage IIB: T2, N1, M0, or T3, N0/N1, M0
- Stage IIIA: T1/T2/T3, N2, M0
- Stage IIIB: T4, any N, M0
- Stage IV: Any T (except T0), any N, M1

The calculator in question is the TNM Classification for Distal Cholangiocarcinoma. TNM stands for Tumor, Node, Metastasis, and it is a globally recognized system used for classifying the extent of spread of cancer. This specific TNM classification is applicable to patients diagnosed with distal cholangiocarcinoma, a type of cancer that occurs in the bile ducts.

The clinical utility of this calculator is to stage the cancer, which is crucial for determining the most appropriate treatment strategy and for predicting prognosis. The TNM classification takes into account the size and extent of the tumor (T), whether the cancer has spread to nearby lymph nodes (N), and whether it has metastasized, or spread to other parts of the body (M).

There are no specific exclusion criteria for the use of the TNM Classification for Distal Cholangiocarcinoma. However, it should be noted that this system is not applicable to other types of cancer or to cholangiocarcinoma that is not located in the distal part of the bile ducts. Furthermore, the accuracy of the TNM classification may be limited in cases where complete information about the tumor, nodes, and metastasis is not available.

TNM classification for distal cholangiocarcinoma

The Karnofsky Performance Scale (KPS) provides a practical method to evaluate a patient's functional ability and the extent of care required based on their health status. The scale ranges from 0% to 100%, where higher percentages signify better functional capacity and health.

This tool involves selecting a descriptive statement that best reflects a patient's current condition from a predefined list. Each statement is connected to a specific KPS percentage that indicates the patient’s ability to perform daily activities and their dependency levels. Here’s how the assessment works:

- When a patient is described as "Normal, no complaints, no evidence of disease," this is assessed as KPS 100%. At this level, the individual can engage in all regular activities, including work, without needing special care.

- If a patient can "carry on normal activity" but exhibits "minor signs or symptoms of disease," they are scored at KPS 90%, indicating the capability to maintain routine activities without requiring special care.

- A description of "Normal activity with effort, some signs or symptoms of disease" aligns with KPS 80%. This suggests the patient can still carry out normal activities but might require some extra effort.

- When the condition reflects "Cares for self, unable to carry on normal activity or to do active work," it corresponds to KPS 70%. The patient can handle most personal needs independently but may need occasional assistance.

- "Requires occasional assistance but is able to care for most personal needs" is rated as KPS 60%, implying increased dependency on assistance though the patient remains mostly self-sufficient.

- At KPS 50%, for conditions described as "Requires considerable assistance and frequent medical care," the patient can live at home but needs considerable help with personal care.

- As the need for care intensifies, with descriptions like "Disabled, requires special care and assistance," the KPS drops to 40%. This marks a significant deterioration in self-care ability.

- "Severely disabled, hospital admission is indicated, death not imminent" corresponds to KPS 30%, highlighting a need for hospitalization without immediate life-threatening conditions.

- For those "Very sick," necessitating hospital admission and "active supportive treatment," the KPS is 20%, indicating critical care requirements.

- At KPS 10%, "Moribund" denotes an inability to care for oneself, with urgent need for hospital-level care and a poor prognosis.

- Lastly, "Dead" is considered as KPS 0%.

This scale is instrumental in providing a quick overview of a patient's ability to function independently and their need for medical support, thereby facilitating better care planning and resource allocation.

The Karnofsky Performance Status Scale (KPSS) is a clinical calculator used primarily in patients with cancer. It is a simple, numerical scale that measures a patient's functional status, ability to perform daily activities, and overall quality of life. The KPSS ranges from 0 (indicating death) to 100 (indicating perfect health). 

The clinical utility of the KPSS is to assess a patient's prognosis, determine appropriate treatment strategies, and monitor changes in a patient's condition over time. It is particularly useful in oncology for determining eligibility for certain treatments, such as chemotherapy or surgery, and for predicting survival outcomes. 

There are no specific exclusion criteria for the use of the KPSS. However, it is less useful in patients with non-cancer illnesses or in those with cognitive impairment who may not be able to accurately self-report their functional status.

Karnofsky Performance Scale

The Modified Glasgow Prognostic Score (mGPS) is a key tool in predicting cancer outcomes, relying on the assessment of two biochemical markers: C-reactive protein (CRP) and albumin. This score helps to categorize the prognosis into three levels: good, intermediate, and poor.

To compute the mGPS:

- C-reactive protein is evaluated first. Two options are considered:  
  - If the CRP is less than or equal to 10 mg/L, it indicates lower systemic inflammation.
  - If the CRP is greater than 10 mg/L, it signifies higher inflammation levels.

- Albumin is the second marker, with two possibilities:  
  - An albumin level of less than 3.5 g/dL [35 g/L] suggests malnutrition or potential inflammatory conditions.
  - An albumin level equal to or greater than 3.5 g/dL [35 g/L] signifies a normal nutritional status and protein reserves.

The mGPS score is derived based on the following systematic interpretation:

- If CRP is <= 10 mg/L, regardless of the albumin level, the score is mGPS 0, corresponding to a good prognosis. This combination indicates a low level of inflammation, which is a favorable signal in cancer outcomes.
 
- If CRP is > 10 mg/L and albumin is >= 3.5 g/dL [35 g/L], the score is mGPS 1, associated with an intermediate prognosis. This combination suggests elevated inflammation yet with sufficient nutritional status, resulting in a moderate outlook.

- If CRP is > 10 mg/L and albumin is < 3.5 g/dL [35 g/L], the result is mGPS 2, indicating a poor prognosis. This reflects high inflammation levels coupled with low albumin, suggesting a more severe condition.

Here's a concise summary table for reference:

| C-reactive Protein | Albumin               | mGPS Score | Interpretation          |
|---------------------|-----------------------|-------------|-----------------------|
| <= 10 mg/L          | < 3.5 or >= 3.5 g/dL  | 0           | Good prognosis         |
| > 10 mg/L           | >= 3.5 g/dL           | 1           | Intermediate prognosis |
| > 10 mg/L           | < 3.5 g/dL            | 2           | Poor prognosis         |

This systematic approach enables healthcare providers to improve risk stratification in cancer patients, allowing for more tailored treatment planning.

The Modified Glasgow Prognostic Score (mGPS) is a clinical calculator used in the field of oncology to predict the prognosis of patients with cancer. It is applicable to a wide range of cancer types and stages, making it a versatile tool for clinicians. The mGPS is based on two simple, routinely measured inflammatory markers: C-reactive protein (CRP) and albumin levels. 

The clinical utility of the mGPS lies in its ability to stratify patients into different risk groups based on their inflammatory response to cancer. This can guide clinicians in making decisions about treatment strategies and follow-up plans. It can also provide valuable prognostic information to patients and their families.

There are no specific exclusion criteria for the use of the mGPS. However, it should be noted that the score may not be as accurate in patients with concurrent inflammatory or infectious conditions, as these can also affect CRP and albumin levels. Additionally, the mGPS may not be applicable to patients with rare types of cancer or those with very early or very advanced disease, as it has not been extensively validated in these groups.

Modified Glasgow Prognostic Score for cancer outcomes (mGPS)

Cholangiocarcinoma

Photodynamic therapy

Definitive systemic therapy

Definitive systemic therapy, first-line therapy

Biliary stenting

Imaging for staging

Imaging for staging, PET

Indications for screening

Indications for screening, PSC

Imaging for staging, EUS

Intra-arterial therapies

Surgical resection

Surgical resection (technical considerations)

General principles

Primary prevention

Exploratory laparoscopy

Liver transplantation

Liver transplantation, indications

Liver transplantation (technical considerations)

Molecular testing

Adjuvant chemotherapy

Preoperative care

Preoperative care (nutrition)

Right portal vein embolization

Preoperative care, antibiotic prophylaxis

Follow-up

Intraoperative care

Intraoperative care (anesthesia and analgesia)

Radiotherapy

Radiotherapy, indications

Preoperative care (counseling)

Surgical resection, indications

Definitive systemic therapy, second- and later-line therapy

Indications for screening (liver flukes)

Imaging for staging, CT/MRI

Local ablation

Prognosis

Postoperative care

Postoperative care (nutrition)

Preoperative care (corticosteroids)

Biopsy and histopathology

Diagnostic imaging

Postoperative care (antiemetics)

Intraoperative care (bleeding management)

Pregnant patients

Assessment of treatment response

Intraoperative care (fluid management)

Indications for screening (liver cirrhosis)

Patients with gastric outlet obstruction

Neoadjuvant chemotherapy

Radiotherapy (technical considerations)

Postoperative care (early mobilization)

Rehabilitation

Preoperative care (rehabilitation)

Preoperative care (biliary drainage)

Postoperative care (laxatives)

Classification

Preoperative care (preanesthetic medication)

Postoperative care (thromboprophylaxis)

Intraoperative care (temperature management)

The European Society of Medical Oncology (ESMO) has released an interim update on the management of advanced biliary tract cancer. For first-line therapy, cisplatin-gemcitabine-durvalumab and cisplatin-gemcitabine-pembrolizumab regimens are recommended (TOPAZ-1 and KEYNOTE-966 trials). For second- and later-line therapy, options include futibatinib or pemigatinib for FGFR2 fusions or rearrangements (FOENIX and FIGHT-202 trials), entrectinib, larotrectinib, or repotrectinib for NTRK fusions (phase 1/2 trials), selpercatinib for RET fusions (LIBRETTO-001 trial), trastuzumab deruxtecan for HER2 overexpression or amplification (MyPathway, KCSG-HB19-14, DESTINY-PanTumor02, and SGNTUC-019 trials; FDA-approved), and zanidatamab for previously treated HER2-positive disease (HERIZON-BTC-01 trial; FDA-approved).


Cholangiocarcinoma

Guidelines

Key sources