Last Modified: 01/20/2012
Stage Information for Testicular Cancer
Note: This Stage Information section has been updated to include information from the 7th edition (2010) of the American Joint Committee on Cancer’s AJCC Cancer Staging Manual. The PDQ Adult Treatment Editorial Board, which is responsible for maintaining this summary, is currently reviewing the new staging categories to determine whether additional changes need to be made to other parts of the summary. Any necessary changes will be made as soon as possible.
Definitions of TNMThe 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| 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. |
| 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 | |
| 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 | |
| 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. |
| 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. | |
| bAFP = alpha-fetoprotein; hCG = human chorionic gonadotropin; LDH = lactase dehydrogenase; N indicates the upper limit of normal for the LDH assay. |
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
- 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.
- 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]