Testicular cancer (staging)

Last revised by Dr Daniel J Bell on 08 Nov 2018

The staging for testicular tumors 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 tumor markers are not very high
  • stage III: distant metastases or moderately high serum tumor markers

TNM staging

T: tumor

Primary tumor staging is from histological assessment following orchiectomy 1,2 :

  • Tx: primary tumor cannot be assessed (orchiectomy not performed)
  • T0: no evidence of primary tumor
  • Tis: intratubular germ cell neoplasia (carcinoma in situ)
  • T1:
    • tumor limited to testis and epididymis
    • may invade tunica albuginea
    • may not invade tunica vaginalis
    • no vascular or lymphatic invasion
  • T2:
    • tumor 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 of 7-8 mm has 70% sensitivity and specificity for malignant involvement or retroperitoneal nodes 4. 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 2-5 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 tumor markers

Most men with nonseminomatous germ cell tumor have elevated serum beta hCG and alpha fetoprotein (AFP). For men with seminomas, beta hCG is elevated only in a minority and AFP levels are almost always normal 5.

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

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