Stage Information for Testicular Cancer
Table 5. Site-Specific Prognostic Factorsa
|Serum Tumor Markers (S) Required for Staging|
|a Reprinted with permission from AJCC: Testis. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 469-78.|
|b AFP = alpha-fetoprotein; hCG = human chorionic gonadotropin; LDH = lactase dehydrogenase; N indicates the upper limit of normal for the LDH assay.|
|SX||Marker studies not available or not performed.|
|S0||Marker study levels within normal limits.|
|S1||LDH <1.5 × Nband hCG (mIu/ml) <5,000and AFP (ng/ml) <1,000.|
|S2||LDH 1.5–10 × Nor hCG (mIu/ml) 5,000–50,000or AFP (ng/ml) 1,000–10,000.|
|S3||LDH >10 × Nor hCG (mIu/ml) >50,000or AFP (ng/ml) >10,000.|
In addition to the clinical stage definitions, surgical stage may be designated based on the results of surgical removal and microscopic examination of tissue.
Stage I testicular cancer is limited to the testis. Invasion of the scrotal wall by tumor or interruption of the scrotal wall by previous surgery does not change the stage but does increase the risk of spread to the inguinal lymph nodes, and this must be considered in treatment and follow-up. Invasion of the epididymis tunica albuginea and/or the rete testis does not change the stage. Invasion of the tunica vaginalis or lymphovascular invasion signifies a T2 tumor, while invasion of the spermatic cord signifies a T3 tumor, and invasion of the scrotum signifies a T4. Increases in T stage are associated with increased risk of occult metastatic disease and recurrence. Men with stage I disease who have persistently elevated serum tumor markers after orchiectomy are staged as IS, but stage IS nonseminomas are treated as stage III. Elevated serum tumor markers in stage I or II seminoma are of unclear significance except that a persistently elevated or rising hCG usually indicates metastatic disease.
Stage II testicular cancer involves the testis and the retroperitoneal or peri-aortic lymph nodes usually in the region of the kidney. Retroperitoneal involvement should be further characterized by the number of nodes involved and the size of involved nodes. The risk of recurrence is increased if more than five nodes are involved or if the size of one or more involved nodes is more than 2 cm. Bulky stage II disease (stage IIC) describes patients with extensive retroperitoneal nodes (>5 cm), which portends a less favorable prognosis.