How is testicular cancer staged?

Staging is the process of finding out how far the cancer has spread. In addition to tests used to diagnose testicular cancer, imaging tests and blood tests are also used to determine the stage.

The stage of your cancer is very important for planning your treatment and estimating your prognosis (outlook). If you have testicular cancer, ask your cancer care team to explain staging in a way that you can understand. Knowing all you can about staging lets you take a more active role in making decisions about your treatment.

The TNM staging system

A staging system is a standardized way for your cancer care team to summarize and describe the extent of your cancer. Testicular cancer is staged using the TNM system created by the American Joint Committee on Cancer (AJCC).

The staging system of testicular cancer contains 4 key pieces of information:

• T refers to how much the primary tumor has spread to tissues next to the testicle.
• N describes how much the cancer has spread to regional (nearby) lymph nodes.
• M indicates whether the cancer has metastasized (spread to distant lymph nodes or other organs of the body).
• S indicates the serum levels of certain proteins (tumor markers) that are produced by some testicular cancers.

Additional letters or numbers appear after T, N, M, and S to provide more details about each piece of information. The numbers 0 through 4 indicate increasing severity. The letters "is" after the T stand for in situ, which means the tumor is contained in one place and has not yet penetrated to a deeper layer of tissue. The letter X after T, N, M, or S means "cannot be assessed" because the information is not known.

Primary tumor (T)

TX: The primary tumor cannot be assessed

T0: There is no evidence of primary tumor

Tis: Carcinoma in situ (noninvasive cancer cells)

T1: The tumor has not spread beyond the testicle and the narrow tubules next to the testicles where sperm undergo final maturation (epididymis). Cancer cells are not found inside blood vessels or lymph vessels next to the tumor. The cancer may have grown through the inner layer surrounding the testicle (tunica albuginea) but not the outer layer covering the testicle (tunica vaginalis).

T2: Similar to T1 except that the cancer has spread to blood or lymph vessels near the tumor, or the tunica vaginalis

T3: The tumor is growing into the spermatic cord (which contains blood vessels, lymph vessels, nerves, and the vas deferens)

T4: The tumor is growing into the skin surrounding the testicles (scrotum)

Regional lymph nodes (N)

NX: Regional (nearby) lymph nodes cannot be assessed

N0: No spread to regional lymph nodes is seen on x-rays

N1: There is spread to at least one lymph node, but no lymph node is larger than 2 cm (about 3/4 inch) in any dimension

N2: There is spread to at least one lymph node that is larger than 2 cm but is not bigger than 5 cm (2 inches) in any dimension

N3: There is spread at least one lymph node that is larger than 5 cm in any dimension

If the lymph nodes were taken out during surgery, there is a slightly different classification:

pNX: Regional (nearby) lymph nodes cannot be assessed

pN0: There is no spread to regional lymph nodes

pN1: There is spread to 1 to 5 lymph nodes, with no lymph node larger than 2 cm (about 3/4 inch) across in greatest dimension

pN2: There is spread to at least one lymph node that is bigger than 2 cm but not larger than 5 cm; OR spread to more than 5 lymph nodes that aren't bigger than 5 cm; OR the cancer is growing out the side of the lymph node

pN3: There is spread to at least one lymph node that is bigger than 5 cm

Distant metastasis (M)

M0: There is no distant metastasis (no spread to lymph nodes outside the area of the tumor or other organs, such as the lungs)

M1: Distant metastasis is present

• M1a: The tumor has metastasized to distant lymph nodes or to the lung
• M1b: The tumor has metastasized to other organs, such as the liver, brain, or bone

Serum tumor markers (S)

Stage grouping

Using the TNM staging system, the descriptions of the tumor, lymph nodes, metastasis, and serum markers are combined in a process called stage grouping to assign a stage using Roman numerals.

* For stage IS, tumor markers are measured after the testicle has been removed with surgery (for all other stages, the values obtained before surgery are used).

International Germ Cell Cancer Consensus Group Classification

Another application of the TNM system used for more advanced disease takes into account the tumor markers (measured after surgery) and where the cancer has spread. It classifies the cancer as good, intermediate, or poor prognosis (outlook). Some doctors give more aggressive chemotherapy regimens to patients who are in a higher-risk category.

Recurrent disease

Recurrent disease means that the cancer has come back (recurred) after treatment. Testicular cancer may recur in the testicle (if it was not removed during surgery) or in another part of the body.