Seminoma staging

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sujit Routray, M.D. [2]

Staging

The staging for testicular seminoma is performed according to the TNM system with staging groupings. It can be remembered in its abbreviated form as:

• Stage I: confined to testis, epididymis, spermatic cord, scrotum
• Stage II: lymph nodes involved but no distant metastases, and serum tumor markers are not very high
• Stage III: distant metastases or moderately high serum tumor markers

The American Joint Committee on Cancer (AJCC) includes serum tumor marker levels in the stages for germ cell tumors, including seminoma. S describes the levels of serum tumour markers in the blood after orchiectomy. The serum tumor markers measured are alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and lactate dehydrogenase (LDH).

S	Serum tumor marker levels
SX	Tumor marker levels are not available or have not been measured.
S0	Tumor marker levels are normal.
S1	All tumor marker levels are above normal. AFP is less than 1,000 ng/mL. HCG is less than 5,000 mIU/mL. LDH is less than 1.5 times the upper limit of the normal range.
S2	At least one tumor marker level is high. AFP is between 1,000 and 10,000 ng/mL. HCG is between 5,000 and 50,000 mIU/mL. LDH is 1.5–10 times the upper limit of the normal range.
S3	At least one tumor marker level is very high. AFP is higher than 10,000 ng/mL. HCG is higher than 50,000 mIU/mL. LDH is more than 10 times the upper limit of the normal range.

TNM Classification for Seminoma

TNM stands for tumor, nodes, and metastasis. TNM staging describes:

• size and extent of the primary tumor
• number and location of any regional lymph nodes (abdominal retroperitoneal nodes) infiltrated by tumor cells
• whether the cancer metastasized to distant part of the body

TNM Classification	Definition
Primary Tumor (T)
TX	Primary tumor cannot be assessed (orchiectomy not performed)
T0	No evidence of primary tumor
Tis	Intratubular germ cell neoplasia (carcinoma in situ)
T1	Tumor limited to testis and epididymis May invade tunica albuginea May NOT invade tunica vaginalis No vascular or lymphatic invasion
T2	Tumor limited to testis and epididymis Involvement of tunica vaginalis Vascular or lymphatic invasion
T3	Invasion of the spermatic cord
T4	Invasion of the scrotum
Regional Lymph Nodes (N)
NX	Regional lymph nodes cannot be assessed
N0	No evidence of nodal involvement
N1	One or more lymph nodes involved, but all <2 cm in greatest dimension
N2	One or more lymph nodes involved 2-5 cm in greatest dimension
N3	One or more lymph nodes involved >5 cm in greatest dimension
Distant Metastasis (M)
MX	Presence of metastases cannot be assessed
M0	No evidence of metastases
M1	Distant metastases present M1a: non-regional lymph node OR pulmonary metastases M1b: distant metastases not fulfilling M1a

Stage Grouping for Testicular Seminoma

Stage grouping, is based on the TNM system and serum tumor marker levels (S). Each stage is given a number from 0 to 3, usually as a Roman numeral (0, I, II or III). Generally, the higher the number, the more the cancer has progressed.

Stage 0

The following describes all stage 0 testicular cancers.

Stage	TNM and S	Explanation
Stage 0	Tis	Intratubular germ cell neoplasia, unclassified (IGCNU), is present.
	N0	There is no regional lymph node metastasis.
	M0	There is no distant metastasis.
	S0	Serum tumor marker levels are normal.

Stage I

Stage I testicular cancer can be one of the following.

Stage	TNM and S	Explanation
Stage IA	T1	Tumor is only in the testicle and epididymis. It hasn’t grown into lymph or blood vessels. The tumor may have grown into the tunica albuginea.
	N0	There is no regional lymph node metastasis.
	M0	There is no distant metastasis.
	S0	Serum tumor marker levels are normal.
Stage IB	T2, T3, T4	Tumor is in the testicle and epididymis. It has grown into lymph or blood vessels or the tumor is in the tunica vaginalis.The tumor may have spread to the spermatic cord or scrotum, and may have grown into lymph or blood vessels.
	N0	There is no regional lymph node metastasis.
	M0	There is no distant metastasis.
	S0	Serum tumor marker levels are normal.
Stage IS	any T	Tumor is in the testicle and epididymis. It may have grown into lymph or blood vessels or the tumor has grown into the tunica albuginea or both [[tunica albuginea] and tunica vaginalis. The tumor may have spread to the spermatic cord or scrotum, and may have grown into lymph or blood vessels.
	N0	There is no regional lymph node metastasis.
	M0	There is no distant metastasis.
	S1, S2, S3	One or more serum tumor markers are higher than normal.

Stage II

Stage II testicular cancer can be one of the following.

Stage	TNM and S	Explanation
Stage IIA	any T	Tumor is in the testicle and epididymis. It may have grown into lymph or blood vessels. Or the tumor has grown into the tunica albuginea or both [[tunica albuginea] and tunica vaginalis. The tumor may have spread to the spermatic cord or scrotum, and may have grown into lymph or blood vessels.
	N1	There is regional lymph node metastasis. There are cancer cells in 1–5 lymph nodes near the testicle. None of the lymph nodes are larger than 2 cm in diameter.
	M0	There is no distant metastasis.
	S0, S1	Serum tumor marker levels are normal or slightly high.
Stage IIB	any T	Tumor is in the testicle and epididymis. It may have grown into lymph or blood vessels. Or the tumor has grown into the tunica albuginea or both [[tunica albuginea] and tunica vaginalis. The tumor may have spread to the spermatic cord or scrotum, and may have grown into lymph or blood vessels.
	N2	There is regional lymph node metastasis. Cancer cells are in one lymph node that is 2–5 cm in diameter or in more than 5 lymph nodes but none of the lymph nodes are larger than 5 cm in diameter. The cancer may have spread outside of the lymph nodes to surrounding tissues (extranodal tumor extension).
	M0	There is no distant metastasis.
	S0, S1	Serum tumor marker levels are normal or slightly high.
Stage IIC	any T	Tumor is in the testicle and epididymis. It may have grown into lymph or blood vessels. Or the tumor has grown into the tunica albuginea or both [[tunica albuginea] and tunica vaginalis. The tumor may have spread to the spermatic cord or scrotum, and may have grown into lymph or blood vessels.
	N3	There is regional lymph node metastasis. There are cancer cells in at least one lymph node. The lymph nodes with cancer are larger than 5 cm in diameter.
	M0	There is no distant metastasis.
	S0, S1	Serum tumor marker levels are normal or slightly high.

Stage III

Stage III testicular cancer can be one of the following.

Stage	TNM and S	Explanation
Stage IIIA	any T	Tumor is in the testicle and epididymis. It may have grown into lymph or blood vessels. Or the tumor has grown into the tunica albuginea or both [[tunica albuginea] and tunica vaginalis. The tumor may have spread to the spermatic cord or scrotum, and may have grown into lymph or blood vessels.
	any N	There may or may not be regional lymph node metastasis. The tumor may have extranodal tumor extension.
	M1a	There is distant metastasis, i.e. the cancer has spread to lymph nodes farther from the testicle or to the lungs.
	S0, S1	Serum tumor marker levels are normal or slightly high.

Stage	TNM and S	Explanation
Stage IIIB	any T	Tumor is in the testicle and epididymis. It may have grown into lymph or blood vessels. Or the tumor has grown into the tunica albuginea or both [[tunica albuginea] and tunica vaginalis. The tumor may have spread to the spermatic cord or scrotum, and may have grown into lymph or blood vessels.
	N1, N2, or N3	There is regional lymph node metastasis. The tumor may have extranodal tumor extension.
	M0	There is no distant metastasis.
	S2	Serum tumor marker levels are high.
Stage IIIB	any T	Tumor is in the testicle and epididymis. It may have grown into lymph or blood vessels. Or the tumor has grown into the tunica albuginea or both [[tunica albuginea] and tunica vaginalis. The tumor may have spread to the spermatic cord or scrotum, and may have grown into lymph or blood vessels.
	any N	There may or may not be regional lymph node metastasis. The tumor may have extranodal tumor extension.
	M1a	There is distant metastasis, i.e. the cancer has spread to lymph nodes farther from the testicle or to the lungs.
	S2	Serum tumor marker levels are high.

Stage	TNM and S	Explanation
Stage IIIB	any T	Tumor is in the testicle and epididymis. It may have grown into lymph or blood vessels. Or the tumor has grown into the tunica albuginea or both [[tunica albuginea] and tunica vaginalis. The tumor may have spread to the spermatic cord or scrotum, and may have grown into lymph or blood vessels.
	N1, N2, or N3	There is regional lymph node metastasis. The tumor may have extranodal tumor extension.
	M0	There is no distant metastasis.
	S2	Serum tumor marker levels are high.
Stage IIIB	any T	Tumor is in the testicle and epididymis. It may have grown into lymph or blood vessels. Or the tumor has grown into the tunica albuginea or both [[tunica albuginea] and tunica vaginalis. The tumor may have spread to the spermatic cord or scrotum, and may have grown into lymph or blood vessels.
	any N	There may or may not be regional lymph node metastasis. The tumor may have extranodal tumor extension.
	M1a	There is distant metastasis, i.e. the cancer has spread to lymph nodes farther from the testicle or to the lungs.
	S2	Serum tumor marker levels are high.
Stage IIIB	any T	Tumor is in the testicle and epididymis. It may have grown into lymph or blood vessels. Or the tumor has grown into the tunica albuginea or both [[tunica albuginea] and tunica vaginalis. The tumor may have spread to the spermatic cord or scrotum, and may have grown into lymph or blood vessels.
	any N	There may or may not be regional lymph node metastasis. The tumor may have extranodal tumor extension.
	M1a	There is distant metastasis, i.e. the cancer has spread to lymph nodes farther from the testicle or to the lungs.
	S2	Serum tumor marker levels are high.