|
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 invades the
spermatic cord (which contains blood vessels, lymph vessels, nerves,
and the vas deferens)
T4: The tumor invades 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)
MX: Distant metastasis
cannot be assessed
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)
| |
LDH (U/liter) |
HCG (mIU/ml) |
AFP (ng/ml) |
| SX |
Marker studies
not available or not performed. |
| S0 |
Normal |
Normal |
Normal |
| S1* |
<1.5 x Normal |
<5,000 |
<1,000 |
| S2+ |
1.5 - 10 x Normal |
5,000 - 50,000 |
1,000 - 10,000 |
| S3+ |
>10 x Normal |
>50,000 |
>10,000 |
Note: Normal values vary between laboratories. Check with your doctor
for your specific ranges.
LDH = lactate dehydrogenase (measured in Units per liter [U/liter])
HCG = human chorionic gonadotropin (measured in milli-International
Units per milliliter [mIU/ml])
AFP = alpha-fetoprotein (measured in nanograms per milliliter [ng/ml])
< Means less than; > means more than.
*All the markers must be in the stated range to be considered S1
+Only one marker needs to be in the stated range to be considered S2 or
S3
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.
| Stage |
T |
N |
M |
S |
| Stage 0 |
Tis (in situ) |
N0 |
M0 |
S0 |
| Stage I |
T1-T4 |
N0 |
M0 |
SX |
| Stage IA |
T1 |
N0 |
M0 |
S0 |
| Stage IB |
T2-T4 |
N0 |
M0 |
S0 |
| Stage IS |
Any T |
N0 |
M0 |
S1-S3 |
| Stage II |
Any T |
N1-N3 |
M0 |
SX |
| Stage IIA |
Any T |
N1 |
M0 |
S0-S1 |
| Stage IIB |
Any T |
N2 |
M0 |
S0-S1 |
| Stage IIC |
Any T |
N3 |
M0 |
S0-S1 |
| Stage III |
Any T |
Any N |
M1 |
SX |
| Stage IIIA |
Any T |
Any N |
M1a |
S0-S1 |
| Stage IIIB |
Any T |
N1-N3 |
M0 |
S2 |
| |
Any T |
Any N |
M1a |
S2 |
| Stage IIIC |
Any T |
N1-N3 |
M0 |
S3 |
| |
Any T |
Any N |
M1a |
S3 |
| |
Any T |
Any N |
M1b |
Any S |
Another application of the TNM system used for more advanced
disease takes into account the tumor markers and classifies the cancer
as good, intermediate, or poor outlook. Some doctors give more
aggressive chemotherapy regimens to patients who are in a higher-risk
category.
| Risk
Status |
Non-seminoma
|
Stages |
Seminoma
|
Stages |
Good prognosis
(outlook)
|
No non-lung spread* All
good markers:
AFP < 1,000
HCG < 5,000
LDH < 1.5 x normal |
IS (S1)
IIA (S1)
IIB (S1)
IIC (S1)
IIIA |
No non-lung spread*
AFP normal
HCG and
LDH can be any level |
IIC
IIIA
IIIB
IIIC |
| Intermediate prognosis |
No non-lung spread*
Any intermediate markers:
AFP 1,000 -10,000
HCG 5,000 - 50,000
LDH 1.5 – 10 x normal
|
IS (S2)
IIC (S2)
IIIB |
Non-lung spread*
AFP normal
HCG and LDH can be any level |
IIIC with non-
lung spread* |
| Poor prognosis |
Non-lung spread*
Mediastinal primary +
Any high markers:
AFP >10,000
HCG > 50,000
LDH > 10 x normal
|
IS (S3)
IIC (S3)
All IIIC |
None (seminoma is never
classified as poor outlook) |
|
*Spread to non-lung
sites such as the brain or liver generally indicates a poorerprognosis
(outlook).
AFP = alpha-fetoprotein; HCG = human chorionic gonadotropin; LDH =
lactate dehydrogenase
< Means less than; > means greater than.
+Tumor found in the mediastinum, not the testicle, as the primary site.
The 5-year survival rate for patients with these more advanced
stages and with a good prognosis is 91%, for an intermediate prognosis
it is 79%, and for a poor prognosis it is 48%. These survival rates are
taken from a study of patients treated more than 10 years ago. Survival
is likely to be better today.
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.
Last Medical Review: 08/03/2009
Last Revised: 08/03/2009
|
