Testicular cancer (staging)

The staging for testicular tumours is performed according to the TNM system with staging groupings. It can be remembered in its abbreviated form as: 

• stage I: confined to testis, epididymis, spermatic cord, scrotum
• stage II: lymph nodes involved but no distant metastases and serum tumour markers are not very high
• stage III: distant metastases or moderately high serum tumour markers

TNM staging

T: Tumour

Primary tumour staging is from histological assessment following orchiectomy ^1-2 :

• Tx: primary tumour cannot be assessed (orchidectomy not performed)
• T0: no evidence of primary tumour
• Tis: intratubular germ cell neoplasia (carcinoma in situ)
• T1:
  • tumour limited to testis and epididymis
  • may invade tunica albuginea
  • may NOT invade tunica vaginalis
  • no vascular or lymphatic invasion
• T2:
  • tumour limited to testis and epididymis
  • involvement of tunica vaginalis
  • vascular or lymphatic invasion
• T3: invasion of spermatic cord
• T4: invasion of scrotum

N: Nodes

Abdominal retroperitoneal nodes are considered regional lymph nodes. A CT short axis measurement threshold threshold of 7-8 mm has 70% sensitivity and specificity for malignant involvement or retroperitoneal nodes⁴. The largest dimension of a lymph node is used to differentiate between N1-N3.

• Nx: nodes cannot be assessed
• N0: no evidence of nodal involvement
• N1: one or more lymph nodes involved but all <2 cm in greatest dimension
• N2: one or more lymph nodes involved 2 2-5 cm in greatest dimension
• N3: one or more lymph nodes involved>5 cm in greatest dimension

M: Metastases

• Mx: presence of metastases cannot be assessed
• M0: no evidence of metastases
• M1: distant metastases present
  • M1a: non-regional lymph node OR pulmonary metastases
  • M1b: distant metastases not fulfilling M1a

S: serum tumour markers

Most men with nonseminomatous germ cell tumour have elevated serum B hCG and AFP. For men with seminomas, B hCG is elevated only in a minority and AFP level are almost always normal ⁵.

• Sx: no serum tumour markers available
• S0: within normal limits
• S1:
  • alpha fetoprotein: <1000 ng/ml
  • beta hCG: <5000 IU/L
  • LDH: <1.5x upper limit of normal
• S2:
  • alpha fetoprotein: 1,000-10,000 ng/ml
  • beta hCG: 5,000-50,000 IU/L
  • LDH: 1.5-10x upper limit of normal
• S3:
  • alpha fetoprotein: >10,000 ng/ml
  • beta hCG: >50,000 IU/L
  • LDH: >10x upper limit of normal

Serologic markers are often used to monitor treatment and/or detect recurrence.

Stage groupings

• stage I: T1–4, N0, M0, SX
• stage II: any pT/Tx, N1–3, M0, SX
  • IIa: any pT/Tx, N1, M0, S0 OR any pT/Tx, N1, M0, S1
  • IIb: any pT/Tx, N2, M0, S0 OR any pT/Tx, N2, M0, S1
  • IIc: any pT/Tx, N3, M0, S0 OR any pT/Tx, N3, M0, S1
• stage III: any pT/Tx, any N, M1, SX
  • IIIa: any pT/Tx, any N, M1a, S0 OR any pT/Tx, any N, M1a, S1
  • IIIb: any pT/Tx, N1–3, M0, S2 OR any pT/Tx, any N, M1a, S2
  • IIIc: any pT/Tx, N1–3, M0, S3 OR any pT/Tx, any N, M1a, S3
  • OR any pT/Tx, any N, M1b, any S