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]

Overview

According to the TNM classification and stage groupings, there are 3 stages of seminoma based on the size and extent of the primary tumor, number and location of any regional lymph nodes (abdominal retroperitoneal) infiltrated by tumor cells, distant metastasis, and serum tumor marker levels.

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
• Testicular cancer may be classified into several subtypes based on the TNM system and the American Joint Committee on Cancer (AJCC).

The American Joint Committee on Cancer (AJCC) includes serum tumor marker levels in the stages for germ cell tumors. Doctors use S to describe the levels of serum tumor markers in the blood after surgery to remove the testicle. The serum tumor markers measured are alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and lactate dehydrogenase (LDH).

Stage	TNM/S	Description
Stage 0	pTisb	Germ cell neoplasia in situ
	N0	cNO No regional lymph node metastasis
	N0	pNO No regional lymph node metastasis
	M0	No distant metastasis
	SO	SO Marker study levels within normal limits
Stage I	pT1	Tumor limited to testis (including rete testis invasion) without lymphovascular invasion.
	pT1ab	Tumor <3 cm in size
	pT1bb	Tumor ≥3 cm in size
	pT2	Tumor limited to testis (including rete testis invasion) with lymphovascular invasion OR tumor invading hilar soft tissue or epididymis or penetrating visceral mesothelial layer covering the external surface of tunica albuginea with or without lymphovascular invasion.
	pT3	Tumor directly invades spermatic cord soft tissue with or without lymphovascular invasion.
	pT4	Tumor invades scrotum with or without lymphovascular invasion.
	cNO	No regional lymph node metastasis.
	pNO	No regional lymph node metastasis.
	MO	No distant metastasis.
	SX	Marker studies not available or not performed.
Stage IA	pT1	Tumor limited to testis (including rete testis invasion) without lymphovascular invasion.
	pT1aa	Tumor <3 cm in size
	pT1bb	Tumor ≥3 cm in size
	cNO	No regional lymph node metastasis.
	pNO	No regional lymph node metastasis.
	MO	No distant metastasis.
	S0	Marker study levels within normal limits.
Stage IB	pT2	Tumor limited to testis (including rete testis invasion) with lymphovascular invasion OR tumor invading hilar soft tissue or epididymis or penetrating visceral mesothelial layer covering the external surface of tunica albuginea with or without lymphovascular invasion.
	cN0	No regional lymph node metastasis
	pN0	No regional lymph node metastasis
	M0	No distant metastasis
	S0	Marker study levels within normal limits.
	pT3	Tumor directly invades spermatic cord soft tissue with or without lymphovascular invasion.
	cN0	No regional lymph node metastasis
	pN0	No regional lymph node metastasis
	M0	No distant metastasis
	S0	Marker study levels within normal limits.
	pT4	Tumor invades scrotum with or without lymphovascular invasion.
	cN0	No regional lymph node metastasis
	pN0	No regional lymph node metastasis
	M0	No distant metastasis
	S0	Marker study levels within normal limits.
Stage IS	pTX	Primary tumor cannot be assessed.
	pT0	No evidence of primary tumor.
	pTis	Germ cell neoplasia in situ.
	pT1	Tumor limited to testis (including rete testis invasion) without lymphovascular invasion.
	pT1ab	Tumor 3 cm in size.
	pT1bb	Tumor ≥3 cm in size.
	pT2	Tumor limited to testis (including rete testis invasion) with lymphovascular invasion OR tumor invading hilar soft tissue or epididymis or penetrating visceral mesothelial layer covering the external surface of tunica albuginea with or without lymphovascular invasion.
	pT3	Tumor directly invades spermatic cord soft tissue with or without lymphovascular invasion.
	pT4	Tumor invades scrotum with or without lymphovascular invasion.
	cN0	No regional lymph node metastasis.
	pN0	No regional lymph node metastasis.
	M0	No distant metastasis
	S1	LDH < 1.5 × Nc and hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000.
	S2	LDH 1.5–10 × Nc or hCG (mIU/mL) 5,000–50,000 or AFP (ng/mL) 1,000–10,000.
	S3	LDH > 10 × Nc or hCG (mIU/mL) >50,000 or AFP (ng/mL) >10,000.
Stage II	Any pT/TX	Primary tumor cannot be assessed/Marker studies not available or not performed.
	cN1	Metastases with a lymph node mass ≤2 cm in greatest dimension OR multiple lymph nodes, none >2 cm in greatest dimension.
	cN2	Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension.
	cN3	Metastasis with a lymph node mass >5 cm in greatest dimension.
	pN1	Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension.
	pN2	Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor.
	pN3	Metastasis with a lymph node mass >5 cm in greatest dimension.
	M0	No distant metastases.
	SX	Marker studies not available or not performed.
Stage IIA	Any pT/TX	Primary tumor cannot be assessed/Marker studies not available or not performed.
	cN1	Metastases with a lymph node mass ≤2 cm in greatest dimension OR multiple lymph nodes, none >2 cm in greatest dimension.
	pN1	Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension.
	M0	No distant metastasis
	S1	LDH < 1.5 × Nb and hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000.
Stage IIB	Any pT/TX	See above description.
	cN2	Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension.
	pN2	Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor.
	M0	No distant metastases.
	S0	Marker study levels within normal limits.
	pT/TX	See above description
	cN2	Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension.
	pN2	Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor.
	M0	No distant metastases.
	S1	LDH < 1.5 × Nb and hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000.
Stage IIC	Any pT/TX	See above description.
	cN3	Metastasis with a lymph node mass >5 cm in greatest dimension.
	pN3	Metastasis with a lymph node mass >5 cm in greatest dimension.
	M0	No distant metastases.
	S0	Marker study levels within normal limits.
	Any pT/TX	See above description.
	cN3	Metastasis with a lymph node mass >5 cm in greatest dimension.
	pN3	Metastasis with a lymph node mass >5 cm in greatest dimension.
	M0	No distant metastasis
	S1	LDH < 1.5 × Nb and hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000.
Stage III	Any pT/TX	See above description.
	cNX	Regional lymph nodes cannot be assessed.
	cN0	No regional lymph node metastasis.
	cN1	Metastases with a lymph node mass ≤2 cm in greatest dimension OR multiple lymph nodes, none >2 cm in greatest dimension.
	cN2	Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension.
	cN3	Metastasis with a lymph node mass >5 cm in greatest dimension.
	pNX	Regional lymph nodes cannot be assessed.
	pN0	No regional lymph node metastasis.
	pN1	Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension.
	pN2	Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor.
	pN3	Metastasis with a lymph node mass >5 cm in greatest dimension.
	M1	Distant metastases.
	M1a	Nonretroperitoneal nodal or pulmonary metastases.
	M1b	Nonpulmonary visceral metastases.
	SX	Marker studies not available or not performed.
Stage IIIA	Any pT/TX	See above description.
	Any N	See descriptions in this table, Stage III.
	M1a	Nonretroperitoneal nodal or pulmonary metastases.
	S0	Marker study levels within normal limits.
	Any pT/TX	See above description.
	Any N	See descriptions in this table, Stage III.
	M1a	Nonretroperitoneal nodal or pulmonary metastases.
	S1	LDH < 1.5 × Nb and hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000.
Stage IIIB	Any pT/TX	See above descriptions
	cN1	Metastases with a lymph node mass ≤2 cm in greatest dimension OR multiple lymph nodes, none >2 cm in greatest dimension.
	cN2	Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension.
	cN3	Metastasis with a lymph node mass >5 cm in greatest dimension.
	pN1	Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension.
	pN2	Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor.
	pN3	Metastasis with a lymph node mass >5 cm in greatest dimension.
	M0	No distant metastases.
	S2	LDH 1.5–10 × Nb or hCG (mIU/mL) 5,000–50,000 or AFP (ng/mL) 1,000–10,000.
	Any pT/TX	See above descriptions
	Any N	See descriptions in this table, Stage III.
	M1a	Nonretroperitoneal nodal or pulmonary metastases.
	S2	LDH 1.5–10 × Nb or hCG (mIU/mL) 5,000–50,000 or AFP (ng/mL) 1,000–10,000.
Stage IIIC	Any pT/TX	See above descriptions.
	cN1	Metastases with a lymph node mass ≤2 cm in greatest dimension OR multiple lymph nodes, none >2 cm in greatest dimension.
	cN2	Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension.
	cN3	Metastasis with a lymph node mass >5 cm in greatest dimension.
	pN1	Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension.
	pN2	Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor.
	pN3	Metastasis with a lymph node mass >5 cm in greatest dimension.
	M0	No distant metastases.
	S3	LDH > 10 × Nb or hCG (mIU/mL) >50,000 or AFP (ng/mL) >10,000.
	Any pT/TX	See above descriptions.
	Any N	See descriptions in this table, Stage III.
	M1a	Nonretroperitoneal nodal or pulmonary metastases.
	S3	LDH > 10 × Nb or hCG (mIU/mL) >50,000 or AFP (ng/mL) >10,000.
	Any pT/TX	See above descriptions.
	Any N	See descriptions in this table, Stage III.
	M1b	Nonpulmonary visceral metastases.
	SX	Marker studies not available or not performed.
	S0	Marker study levels within normal limits.
	S1	LDH < 1.5 × Nb and hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000.
	S2	DH 1.5–10 × Nb or hCG (mIU/mL) 5,000–50,000 or AFP (ng/mL) 1,000–10,000.
	S3	LDH > 10 × Nb or hCG (mIU/mL) >50,000 or AFP (ng/mL) >10,000.