Testicular cancer

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

TNMS staging system

The TNMS classification system is commonly used to stage testicular cancer and describes the extent of disease based on the following factors:[6][7]

Size and extent of the primary tumour (T), with the American Joint Committee on Cancer (AJCC) staging system further subdividing T1 by size (T1a tumour <3 cm; T1b tumour ≥3 cm)
Regional lymph node involvement (N)
Presence or absence of distant metastases (M)
Post-orchiectomy nadir serum tumour marker levels (S): lactate dehydrogenase (LDH), human chorionic gonadotropin (hCG), and alpha-fetoprotein (AFP). A worse prognosis is noted with high tumour marker levels.[6][7]

Staging[6][7]

Stage IA: tumour confined to testis (includes rete testis invasion in the AJCC staging system) with normal post-orchiectomy serum tumour markers.

Stage IB: locally invasive tumour with spread beyond tunica albuginea and involvement of tunica vaginalis; or invasion of spermatic cord or scrotum; with or without vascular/lymphatic invasion; and without nodal or metastatic disease. Serum tumour markers are normal.

Stage IS: any size and extent of the primary tumour (or size and extent cannot be assessed), without nodal or metastatic disease, with at least one elevated serum tumour marker.

Stage II: spread to regional (retroperitoneal) nodes, with or without slightly elevated serum tumour markers (LDH <1.5 times upper limit of normal [ULN], hCG <5000 IU/L, and AFP <1000 microgram/L [ng/mL]).

Stage III: spread beyond retroperitoneal nodes, visceral metastatic disease, or regional node-only involvement with high tumour marker levels (LDH ≥1.5 times ULN, hCG ≥5000 IU/L, and AFP ≥1000 microgram/L [ng/mL]).

Notably, there is no prognostic stage IV disease in testicular cancer.

International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic factors classification for advanced germ cell tumours

Non-seminoma

The original IGCCCG classification, as published in 1997, retains its relevance as a reference for treatment decisions in daily practice and is outlined below.[61] The 2021 IGCCCG Update model for metastatic non-seminomatous germ cell tumours includes age and lung metastases as additional adverse prognostic factors and uses a single cutoff of LDH at 2.5 times ULN.[62] Every decade-of-life increase translates into a 25% increase in the risk of progression. The presence of lung metastases translates into a 62% increase in the risk of progression compared with patients without lung metastases.[62] This newer risk model for prognostic information can be accessed online. IGCCCG update Opens in new window

Good prognosis:

Testis or retroperitoneal primary and
No non-pulmonary visceral metastases (such as liver, bone, or brain) and
Post-orchiectomy markers, all of:
- AFP <1000 microgram/L (ng/mL)
- hCG <5000 IU/L
- LDH <1.5 times ULN

Intermediate prognosis:

Testis or retroperitoneal primary and
No non-pulmonary visceral metastases and
Post-orchiectomy markers, any of:
- AFP 1000-10,000 ng/mL
- hCG 5000 IU/L to 50,000 IU/L
- LDH 1.5-10 times ULN

Poor prognosis:

Mediastinal primary or
Non-pulmonary visceral metastases or
Post-orchiectomy markers, any of:
- AFP >10,000 ng/mL
- hCG >50,000 IU/L
- LDH >10 times ULN

Seminoma

The original 1997 IGCCCG classification identified two prognostic groups for seminomas: good and intermediate only (detailed below).[61] The 2021 IGCCCG Update model for metastatic seminomatous germ cell tumours added LDH above 2.5 times ULN prior to chemotherapy as an additional adverse prognostic factor within the good prognosis group.[63]