Staging of a cancer provides a way to describe a tumor and whether and how far it has spread. The higher the stage number, the more widespread is the cancer. These stages are used to determine the type of treatment for testicular cancer.
TNM System
Once a biopsy has been performed, a tool called the TNM (tumor, node, metastasis) system can be used to determine the stage of cancer. This system is not a staging system in itself; rather, it is used to define the characteristics of the cancer so that its stage can then be determined.
Each type of cancer has its own TNM system. Most TNM systems use three sets of criteria, but the TNM system for testicular cancer uses four criteria:
T - Characteristics of the tumor itself
N - Whether and how far the cancer has spread to the lymph nodes (The lymph system helps drain fluid and waste from the body; lymph nodes are like tiny way stations that filter out impurities and help fight infection.)
M - Metastasis, or spread, of the cancer to other areas of the body (beyond the lymph nodes)
S - Serum tumor markers, or the levels of ?-hCG, AFP, and LDH that have been determined from the bloodwork
For testicular cancer, the “T” in the TNM cancer describes the location and extent of the tumor.
TX - The primary, or original, tumor cannot be assessed because of incomplete information.
T0 - There is no evidence of cancer in the removed testicle.
Tis - Carcinoma in situ, or “in its original place”; the cancer has not spread beyond the original site of the tumor.
T1 - The tumor is limited to the testis and epididymis and has not invaded lymph or blood vessels. The tumor may extend into the tunica albuginea (the inner layer surrounding the testicle), but not the tunica vaginalis (the outer layer covering the testicle).
T2 - The tumor is limited to the testicle and epididymis (the narrow tubules where sperm cells are stored) and except has invaded lymph or blood vessels, or the tumor extends through to the tunica vaginalis (the outer layer covering of the testicle).
T3 - The tumor invades the spermatic cord (a cordlike structure consisting of blood and lymphatic vessels, nerves, and the vas deferens), with or without invasion into lymph or blood vessels.
T4 - The tumor invades the scrotum with or without invasion into lymph or blood vessels.
The “N” in the TNM staging system indicates whether and how the regional lymph nodes have been affected by the cancer:
NX - The regional or nearby lymph nodes cannot be assessed because of incomplete information.
N0 - The cancer has not spread (metastized) to the regional lymph nodes.
N1 - The tumor has spread to a single lymph node and is 2 cm (about ¾ inch) or less in greatest dimension; or it has spread to multiple lymph nodes, none of which is more than 2 cm in greatest dimension.
N2 - The tumor has spread to a single lymph node and is more than 2 cm but no more than 5 cm (about 2 inches) in greatest dimension; or it has spread to multiple lymph nodes, none of which is more than 5 cm in greatest dimension.
N3 - The tumor has spread to one or more lymph nodes and is 5 cm or more in greatest dimension.
If lymph nodes were removed during surgery the following, somewhat different classification, is used:
pNX - Regional or nearby lymph nodes cannot be assessed because of incomplete information.
pNO - The cancer has not spread to nearby lymph nodes.
pNI - The cancer has spread to 1 to 5 lymph nodes, but no lymph node is larger than 2 cm (about ¾ inch) in its largest dimension.
pN2 - Metastasis is present in at least one lymph node and this metastasis larger than 2 cm but not larger than 5 cm (one inch). Or, there is metastasis to more than 5 lymph nodes that are no larger than 5 cm across. Or, the cancer has grown out of the side of the lymph node.
pN3 - The cancer that has spread to at least one lymph node that is larger than 5 cm (one inch).
The “M” in the TNM system refers to distant metastases—whether, and how far, the cancer has spread outside the original site:
MX - Distant metastases cannot be evaluated because of incomplete information.
M0 - There is no evidence that the cancer has spread beyond the original site.
M1 - The cancer has spread beyond the original site:
M1a - The tumor has spread to distant lymph nodes or to the lung(s).
M1b - The tumor has spread to other organs, such as the liver, brain, or bone.
Serum Tumor Marker Category
For testicular cancer, the “S” category is also added, indicating the results of serum tumor marker tests.
| Designation |
LDH (units/liter) |
hCG (milliunits/milliliter) |
AFP (nanograms/milliliter) |
| SX |
Marker studies not available or not performed |
Marker studies not available or not performed |
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 |
Cancer Stages
Combining information from the T, N, and M classifications and the “S” (serum marker) information, doctors assign a stage to the cancer to estimate the number of testicular cancer cells there are in the body. The stages of testicular cancer include the following:
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Stage I - the cancer is limited to the testicle and spermatic cord
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Stage II - the cancer involves the testis and has spread to the lymph nodes in the lower abdomen
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Stage III - the cancer is more advanced and has spread to lymph nodes outside of the lower abdomen to the lungs or to another organ