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How is testicular cancer staged?

The stage of a cancer describes how far it has spread. For testicular cancer, the stage is based on the results of the surgery to diagnose the cancer, blood tests for tumor markers, and imaging tests, all of which are described in the section “How is testicular cancer diagnosed?“

The stage of your cancer is very important for planning your treatment and estimating your prognosis (outlook).

If you have testicular cancer, ask your cancer care team to explain the stage in a way that you can understand. Knowing all you can about the stage of your cancer can help you take a more active role in making decisions about your treatment.

The TNM staging system

A staging system is a standard way for your cancer care team to sum up the extent of your cancer. Testicular cancer is staged using the TNM system created by the American Joint Committee on Cancer (AJCC). It’s based on 4 key pieces of information:

• T refers to how much the main (primary) tumor has spread to tissues next to the testicle.
• N describes how much the cancer has spread to regional (nearby) lymph nodes.
• M indicates whether the cancer has metastasized (spread to distant lymph nodes or other organs of the body).
• S indicates the serum (blood) levels of tumor markers that are made by some testicular cancers.

Letters or numbers appear after T, N, M, and S to provide more details about each piece of information. The numbers 0 through 4 indicate increasing severity. The letters “IS” after the T stand for in situ, which means the tumor is contained in one place and has not yet penetrated to a deeper layer of tissue. The letter X after T, N, M, or S means “cannot be assessed” because the information is not known.

Primary tumor (T)

TX: The primary tumor cannot be assessed

T0: There is no evidence of primary tumor

Tis: Carcinoma in situ (non-invasive cancer cells)

T1: The tumor has not spread beyond the testicle and epididymis (the tubes next to the testicles where sperm mature). The cancer has not reached nearby blood vessels or lymph vessels. The cancer might have grown through the inner layer surrounding the testicle (tunica albuginea), but it has not reached the outer layer covering the testicle (tunica vaginalis).

T2: Similar to T1 except that the cancer has spread to blood or lymph vessels near the tumor, or the tunica vaginalis

T3: The tumor is growing into the spermatic cord (which contains blood vessels, lymph vessels, nerves, and the vas deferens)

T4: The tumor is growing into the skin surrounding the testicles (scrotum)

Regional lymph nodes (N)

NX: Regional (nearby) lymph nodes cannot be assessed

N0: No spread to regional lymph nodes is seen on imaging tests

N1: The cancer has spread to at least one lymph node, but no lymph node is larger than 2 cm (about ¾ inch) across

N2: The cancer has spread to at least one lymph node that is larger than 2 cm but is not bigger than 5 cm (2 inches) across

N3: The cancer has spread to at least one lymph node that is larger than 5 cm across

If the lymph nodes were taken out during surgery, there is a slightly different classification:

pNX: Regional (nearby) lymph nodes cannot be assessed

pN0: Examination of regional lymph nodes removed with surgery reveals no cancer spread

pN1: Examination of regional lymph nodes removed with surgery reveals cancer spread in 1 to 5 lymph nodes, but no lymph node is larger than 2 cm (about ¾ inch) across

pN2: Examination of regional lymph nodes removed with surgery reveals cancer spread in at least one lymph node that is bigger than 2 cm but not larger than 5 cm across; OR spread to more than 5 lymph nodes that aren’t bigger than 5 cm; OR the cancer is growing out the side of a lymph node

pN3: Examination of regional lymph nodes removed with surgery reveals cancer spread in at least one lymph node that is bigger than 5 cm across

Distant metastasis (M)

M0: There is no distant metastasis (no spread to lymph nodes outside the area of the tumor or other organs, such as the lungs)

M1: Distant metastasis is present

M1a: The tumor has metastasized to distant lymph nodes or to the lung
M1b: The tumor has metastasized to other organs, such as the liver, brain, or bone

Serum tumor markers (S)

For staging, serum (blood) levels of tumor markers are measured after the testicle containing the cancer has been removed with surgery.

Note: Normal values vary among laboratories. Check with your doctor for your specific ranges.
LDH = lactate dehydrogenase (measured in Units per liter [U/liter])
HCG = human chorionic gonadotropin (measured in milli-International Units per milliliter [mIU/ml])
AFP = alpha-fetoprotein (measured in nanograms per milliliter [ng/ml])
< Means less than; > means more than.
*All the markers must be in the stated range to be considered S1
+Only one marker needs to be in the stated range to be considered S2 or S3

Stage grouping

Once the T, N, M, and S categories have been determined, they are combined in a process called stage grouping to assign an overall stage (using Roman numerals and letters).

Recurrent disease

Recurrent disease means that the cancer has come back (recurred) after treatment. Testicular cancer can recur in the testicle (if it was not removed during surgery), in regional lymph nodes, or in another part of the body.

Last Medical Review: 01/20/2015
Last Revised: 02/13/2015
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