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Testicular Cancer Treatment (PDQ®)

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Stage Information for Testicular Cancer

Definitions of TNM



Definitions of TNM

The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification to define testicular cancer.[1]

Table 1. Primary Tumor (T)a,b,c
pTXPrimary tumor cannot be assessed.
pT0No evidence of primary tumor (e.g., histologic scar in testis).
pTisIntratubular germ cell neoplasia (carcinoma in situ).
pT1Tumor limited to the testis and epididymis without vascular/lymphatic invasion; tumor may invade into the tunica albuginea but not the tunica vaginalis.
pT2Tumor limited to the testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis.
pT3Tumor invades the spermatic cord with or without vascular/lymphatic invasion.
pT4Tumor invades the scrotum with or without vascular/lymphatic invasion.

aReprinted with permission from AJCC: Testis. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 469-78.
bThe extent of primary tumor is usually classified after radical orchiectomy, and for this reason, a pathologic stage is assigned.
cExcept for pTis and pT4, extent of primary tumor is classified by radical orchiectomy. TX may be used for other categories in the absence of radical orchiectomy.

Table 2. Regional Lymph Nodes (N)a
aReprinted with permission from AJCC: Testis. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 469-78.
Clinical
NXRegional lymph nodes cannot be assessed.
N0No regional lymph node metastasis.
N1Metastasis with a lymph node mass ≤2 cm in greatest dimension; or multiple lymph nodes, none >2 cm in greatest dimension.
N2Metastasis with a lymph node mass >2 cm but not >5 cm in greatest dimension; or multiple lymph nodes, any one mass >2 cm but not >5 cm in greatest dimension.
N3Metastasis with a lymph node mass >5 cm in greatest dimension.
Pathologic (pN)
pNXRegional lymph nodes cannot be assessed.
pN0No regional lymph node metastasis.
pN1Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension.
pN2Metastasis with a lymph node mass >2 cm but not >5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor.
pN3Metastasis with a lymph node mass >5 cm in greatest dimension.

Table 3. Distant Metastasis (M)a
aReprinted with permission from AJCC: Testis. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 469-78.
M0No distant metastasis.
M1Distant metastasis.
M1aNonregional nodal or pulmonary metastasis.
M1bDistant metastasis other than to nonregional lymph nodes and lung.

Table 4. Anatomic Stage/Prognostic Groupsa
Group  T N M S (Serum Tumor Markers) 
aReprinted with permission from AJCC: Testis. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 469-78.
0pTisN0M0S0
IpT1–4N0M0SX
IApT1N0M0S0
IBpT2N0M0S0
pT3N0M0S0
pT4N0M0S0
ISAny pT/TxN0M0S1–3
IIAny pT/TxN1–3M0SX
IIAAny pT/TxN1M0S0
Any pT/TxN1M0S1
IIBAny pT/TxN2M0S0
Any pT/TxN2M0S1
IICAny pT/TxN3M0S0
Any pT/TxN3M0S1
IIIAny pT/TxAny NM1SX
IIIAAny pT/TxAny NM1aS0
Any pT/TxAny NM1aS1
IIIBAny pT/TxN1–3M0S2
Any pT/TxAny NM1aS2
IIICAny pT/TxN1–3M0S3
Any pT/TxAny NM1aS3
Any pT/TxAny NM1bAny S

Table 5. Site-Specific Prognostic Factorsa
Serum Tumor Markers (S) Required for Staging 
SXMarker studies not available or not performed.
S0Marker study levels within normal limits.
S1LDH <1.5 × Nband hCG (mIu/ml) <5,000 and AFP (ng/ml) <1,000.
S2LDH 1.5–10 × N or hCG (mIu/ml) 5,000–50,000 or AFP (ng/ml) 1,000–10,000.
S3LDH >10 × N or hCG (mIu/ml) >50,000 or AFP (ng/ml) >10,000.

AFP = alpha-fetoprotein; hCG = human chorionic gonadotropin; LDH = lactase dehydrogenase; N indicates the upper limit of normal for the LDH assay.
aReprinted with permission from AJCC: Testis. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 469-78.

In addition to the clinical stage definitions, surgical stage may be designated based on the results of surgical removal and microscopic examination of tissue.

Stage I

Stage I testicular cancer is limited to the testis. Invasion of the scrotal wall by tumor or interruption of the scrotal wall by previous surgery does not change the stage but does increase the risk of spread to the inguinal lymph nodes, and this must be considered in treatment and follow-up. Invasion of the epididymis tunica albuginea and/or the rete testis does not change the stage. Invasion of the tunica vaginalis or lymphovascular invasion signifies a T2 tumor, while invasion of the spermatic cord signifies a T3 tumor, and invasion of the scrotum signifies a T4. Increases in T stage are associated with increased risk of occult metastatic disease and recurrence. Men with stage I disease who have persistently elevated serum tumor markers after orchiectomy are staged as IS, but stage IS nonseminomas are treated as stage III. Elevated serum tumor markers in stage I or II seminoma are of unclear significance except that a persistently elevated or rising hCG usually indicates metastatic disease.

Stage II

Stage II testicular cancer involves the testis and the retroperitoneal or peri-aortic lymph nodes usually in the region of the kidney. Retroperitoneal involvement should be further characterized by the number of nodes involved and the size of involved nodes. The risk of recurrence is increased if more than five nodes are involved or if the size of one or more involved nodes is more than 2 cm. Bulky stage II disease (stage IIC) describes patients with extensive retroperitoneal nodes (>5 cm), which portends a less favorable prognosis.

Stage III

Stage III implies spread beyond the retroperitoneal nodes based on physical examination, imaging studies, and/or blood tests (i.e., patients with retroperitoneal adenopathy and highly elevated serum tumor markers are stage III). Stage III can be further stratified based on the location of metastasis and the degree of elevation of serum tumor markers. In the favorable group (IIIA), metastases are limited to lymph nodes and lung, and serum tumor markers are no more than mildly elevated. Stage IIIB patients have moderately elevated tumor markers, while stage IIIC patients have highly elevated markers and/or metastases to liver, bone, brain or some organ other than the lungs. These subclassifications of stage III correspond to the International Germ Cell Consensus Classification system for disseminated germ cell tumors.[2]

References
  1. Testis. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 469-78. 

  2. International Germ Cell Consensus Classification: a prognostic factor-based staging system for metastatic germ cell cancers. International Germ Cell Cancer Collaborative Group. J Clin Oncol 15 (2): 594-603, 1997.  [PUBMED Abstract]