Staging

Staging is a way of describing where a cancer has spread. Doctors use diagnostic tests, including CT scans and blood tests, to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and helps predict a patient's prognosis. There are different stage descriptions for different types of cancer. There are also two different types of staging for most cancers: clinical staging and pathological staging. In clinical staging, the stage is based on a physical examination of the patient or x-rays, CT scans, and other imaging tests. In pathological staging, the stage is based on evaluating tissue under a microscope after it has been removed during surgery. Both clinical and pathological staging are used to stage testicular cancer.

One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. For testicular cancer, the TNM staging system also includes information on how highly elevated the three serum (S) tumor markers, AFP, hCG, and LDH, are (see Diagnosis). The results are combined to determine the stage of cancer for each person. There are three stages of testicular cancer: stages I, II, and III (one, two, and three). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors, plus serum tumor markers, to determine the stage of testicular cancer:

• How much has the primary tumor grown and where is it located? (Tumor, T)
  
  
• Has the tumor spread to the lymph nodes? (Node, N)
  
  
• Has the cancer metastasized to other parts of the body? (Metastasis, M)
  
  
• Are serum tumor markers elevated and, if so, how high are they? (Serum, S)

Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. For most testicular cancers, the T stage can only be determined when tissue removed during surgery is examined under a microscope. This means that the T stage is only determined after the testicle is removed. Specific tumor stage information is below.

TX: The primary tumor cannot be evaluated. If a man has not had a radical inguinal orchiectomy (surgical removal of the testicle[s]), the term "TX" is used.

T0: There is no evidence of a primary tumor in the testicles.

Tis: In this stage, there is intratubular germ cell neoplasia (a precancerous condition in which there are germ cells that appear cancerous but are not yet behaving the way cancer cells do), also called carcinoma in situ (CIS). CIS becomes cancer when the cells spread to areas of the testicle(s) where they do not normally belong.

T1: The primary tumor is only in the testicle (with or without involvement of the epididymis), and it has not invaded blood vessels or lymph vessels in the testicles. The tumor may have invaded the tunica albuginea (the inner membrane layer surrounding the testicle) but not the tunica vaginalis (the outer membrane layer surrounding the testicle).

T2: The tumor is in the testicle (with or without involvement of the epididymis) and has invaded blood vessels or lymphatic vessels, and/or the tumor has grown through the tunica albuginea and into the tunica vaginalis.

T3: The tumor has invaded the spermatic cord.

T4: The tumor has invaded the scrotum.

Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. The lymph nodes that receive lymphatic fluid directly from the testicles are called regional lymph nodes. The regional lymph nodes for testicular cancer are the nodes in the retroperitoneum. Lymph nodes in other parts of the body are called distant lymph nodes.

If the cancer appears to have spread to lymph nodes based on a CT scan or other imaging test, then the stage is a clinical stage. If the cancer is shown to have spread to the lymph nodes by removing lymph nodes and looking at them under a microscope, then the stage is a pathological stage. To determine the pathological stage for testicular cancer, the lymph nodes are removed using a procedure called a lymph node dissection (surgical removal of lymph nodes) or, less commonly, a tissue sample from a biopsy of a lymph node.

Pathological staging is more reliable because a patient can have enlarged lymph nodes on an imaging test, but the lymph nodes may be noncancerous when viewed under the microscope. In such a situation, the cancer would be clinical stage II but pathological stage I. A lowercase p before the N indicates the pathological stage. Most often the “N” is estimated by using CT scans before the tissue is examined under a microscope.

NX: The regional lymph nodes (lymph nodes near the testicles) cannot be evaluated.

N0: There is no spread to regional lymph nodes.

N1: There are enlarged lymph nodes in the retroperitoneum but none are larger than 2 centimeters (cm).

pN1: There is metastatic cancer in five or fewer lymph nodes, and none of the involved lymph nodes measures longer than 2 cm in its greatest dimension.

N2:There are enlarged lymph nodes (or a lymph node mass) in the retroperitoneum that are larger than 2 cm but none that are larger than 5 cm.

pN2: There is metastasis to at least one lymph node with a lymph node mass that is larger than 2 cm but smaller than 5 cm. Or, there is metastasis to more than five lymph nodes but none are larger than 5 cm.

N3: There are enlarged lymph nodes or a lymph node mass larger than 5 cm in the retroperitoneum.

pN3: There is metastasis to at least one lymph node, and at least one lymph node mass is larger than 5 cm.

Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body. When testicular cancer spreads beyond the regional lymph nodes, the most common sites are the lymph nodes of the chest and pelvis and the lungs. More advanced stages may have spread to the liver and bones. Testicular cancer rarely spreads to the brain.

MX: Distant metastasis cannot be evaluated.

M0: The disease has not metastasized to distant lymph nodes or other organs.

M1: There is distant metastasis.

M1a: There is cancer in distant lymph nodes and/or the lungs.

M1b: The cancer has spread to organs other than or in addition to the lung. (For example, a cancer that has spread to the liver or the bones is stage M1b.)

Serum tumor markers (S). The amount of certain tumor markers in a man’s blood also helps to stage testicular cancer (see Diagnosis). The substances are produced either by the tumor itself or by the body in response to the cancer or certain noncancerous conditions.

SX: Tumor marker levels are not available or not performed.

S0: Tumor marker levels are normal.

S1: Tumor marker levels are above normal (LDH less than 1.5 times the upper limit of the normal range; and hCG [mIu/mL] less than 5,000, and AFP [ng/mL] less than 1,000).

S2: Tumor marker levels are substantially above normal (LDH 1.5 to 10 times the upper limit of the normal range, or hCG [mIu/mL]) 5,000 to 50,000 or AFP [ng/mL] 1,000 to 10,000).

S3: Tumor marker levels are very highly elevated (LDH more than 10 times the upper limit of the normal range, or hCG [mIu/mL] more than 50,000 or AFP [ng/mL] more than 10,000).

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications and the S level information.

Stage 0: Refers to carcinoma in situ, also called intratubular germ cell neoplasia (pTis).

Stage I: Cancer is at any T level, and serum marker tests have not been performed or are unavailable, and there is no evidence of spread to either lymph nodes or other organs (any T, N0, M0, SX).

Stage IA: Cancer is only in the testicle and has not spread to lymph nodes or distant sites. Serum markers are normal (pT1, N0, M0, S0).

Stage IB: Cancer is outside the testicle or has invaded blood or lymphatic vessels within the testicles and has not spread to lymph nodes or distant sites. Serum markers are normal (pT2, pT3, or pT4, N0, M0, S0).

Stage IS: Cancer is of any T stage and has not spread to lymph nodes or distant sites. Serum markers remain persistently above normal levels after the cancerous testicle has been removed (ant T, N0, M0, S1, S2, or S3).

Stage II: The cancer has spread to any regional lymph nodes but not to lymph nodes in other parts of the body or distant organs. Serum markers are unavailable.

Stage IIA: Cancer has spread to retroperitoneal lymph nodes, either clinical or pathological stage N1, but none is larger than 2 cm and, if a lymph node dissection has been performed, no more than five lymph nodes contain cancer. In addition, serum markers are at normal levels or slightly elevated (S0 or S1) and there is no evidence of cancer having spread anywhere other than the retroperitoneum.

Stage IIB: Cancer has spread to lymph nodes in the retroperitoneum, at least one of which is greater than 2 cm and none of which are greater than 5 cm (N2); or, if a lymph node dissection has been performed, cancer has spread to more than five nodes, none more than 5 cm. Serum markers are at normal levels or slightly elevated (S0 or S1) and there is no evidence of cancer having spread anywhere other than the retroperitoneum.

Stage IIC: Cancer has spread to at least one lymph node that is larger than 5 cm (N3). Serum markers are at normal levels or slightly elevated (S0 or S1) and there is no evidence of cancer having spread anywhere other than the retroperitoneum.

Stage IIIA: Cancer has spread to distant lymph nodes or the lungs (M1a). Serum markers are at normal levels or slightly elevated (S0 or S1).

Stage IIIB: Cancer has spread to any lymph nodes (N1, N2, or N3) and/or the lungs but not to any other organs, and serum markers are at substantially elevated levels (S2).

Stage IIIC: Either or both of the following:
(1) Serum marker levels are highly elevated (S3), and the cancer has spread to at least one lymph node or organ (N1, N2, or N3 or M1a or M1b).

(2) The cancer has spread to an organ other than the lungs (M1b).

Recurrent: Recurrent cancer is cancer that comes back after treatment.

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, www.cancerstaging.net.

Advanced testicular cancer: risk group classification

If the disease has spread to lymph nodes or other organs, the following system is used to classify germ cell tumors into good-risk, intermediate-risk, or poor-risk groups. This is based on the ability to successfully treat patients with this disease. Patients with poor-risk disease still have about a 50% chance of successful treatment.

Source: Journal of Clinical Oncology.