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Testicular Cancer Treatment (PDQ®)

Stage Information for Testicular Cancer

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
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.
pTX Primary tumor cannot be assessed.
pT0 No evidence of primary tumor (e.g., histologic scar in testis).
pTis Intratubular germ cell neoplasia (carcinoma in situ).
pT1 Tumor limited to the testis and epididymis without vascular/lymphatic invasion; tumor may invade into the tunica albuginea but not the tunica vaginalis.
pT2 Tumor limited to the testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis.
pT3 Tumor invades the spermatic cord with or without vascular/lymphatic invasion.
pT4 Tumor invades the scrotum with or without vascular/lymphatic invasion.
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
NX Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastasis.
N1 Metastasis with a lymph node mass ≤2 cm in greatest dimension; or multiple lymph nodes, none >2 cm in greatest dimension.
N2 Metastasis 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.
N3 Metastasis with a lymph node mass >5 cm in greatest dimension.
Pathologic (pN)
pNX Regional lymph nodes cannot be assessed.
pN0 No regional lymph node metastasis.
pN1 Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension.
pN2 Metastasis 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.
pN3 Metastasis 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.
M0 No distant metastasis.
M1 Distant metastasis.
M1a Nonregional nodal or pulmonary metastasis.
M1b Distant 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.
0 pTis N0 M0 S0
I pT1–4 N0 M0 SX
IA pT1 N0 M0 S0
IB pT2 N0 M0 S0
pT3 N0 M0 S0
pT4 N0 M0 S0
IS Any pT/Tx N0 M0 S1–3
II Any pT/Tx N1–3 M0 SX
IIA Any pT/Tx N1 M0 S0
Any pT/Tx N1 M0 S1
IIB Any pT/Tx N2 M0 S0
Any pT/Tx N2 M0 S1
IIC Any pT/Tx N3 M0 S0
Any pT/Tx N3 M0 S1
III Any pT/Tx Any N M1 SX
IIIA Any pT/Tx Any N M1a S0
Any pT/Tx Any N M1a S1
IIIB Any pT/Tx N1–3 M0 S2
Any pT/Tx Any N M1a S2
IIIC Any pT/Tx N1–3 M0 S3
Any pT/Tx Any N M1a S3
Any pT/Tx Any N M1b Any S
Table 5. Site-Specific Prognostic Factorsa
Serum Tumor Markers (S) Required for Staging
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.
SX Marker studies not available or not performed.
S0 Marker study levels within normal limits.
S1 LDH <1.5 × Nband hCG (mIu/ml) <5,000 and AFP (ng/ml) <1,000.
S2 LDH 1.5–10 × N or hCG (mIu/ml) 5,000–50,000 or AFP (ng/ml) 1,000–10,000.
S3 LDH >10 × N or hCG (mIu/ml) >50,000 or AFP (ng/ml) >10,000.

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 0

Stage 0 testicular cancer is testicular intraepithelial neoplasia (TIN), which is also referred to as intratubular germ cell neoplasia (ITGCN). TIN is analogous to carcinoma in situ. In most cases, TIN is diagnosed as a result of an orchiectomy that was performed to remove an invasive germ cell tumor (pT1–T4); generally, TIN has already been removed from the body at the time of diagnosis and requires no treatment. A more challenging situation arises if a biopsy is performed of the contralateral testis and TIN is discovered. Because of the low incidence and low mortality rates associated with contralateral germ cell tumors, such biopsies are performed rarely in the United States; therefore, TIN is almost never diagnosed in testicles that do not also have an invasive tumor. Consequently, a treatment decision about TIN in stage 0 testicular cancer is rarely faced in the United States. Treatment options for ITGCN include radiation therapy, surveillance, and orchiectomy.

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]
  • Updated: February 25, 2015