TNM Definitions
AJCC Stage Groupings

The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification.[1]

Primary tumor (T)

The extent of primary tumor is classified after radical orchiectomy, and for this reason a pathologic stage is assigned.

• pTX: Primary tumor cannot be assessed*
• pT0: No evidence of primary tumor (e.g., histologic scar in testis)
• pTis: Intratubular germ cell neoplasia (carcinoma)
• pT1: Tumor limited to the testis and epididymis without lymphatic/vascular invasion; tumor may invade into the tunica albuginea but not the tunica vaginalis
• pT2: Tumor limited to the testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis
• pT3: Tumor invades the spermatic cord with or without vascular/lymphatic invasion
• pT4: Tumor invades the scrotum with or without vascular/lymphatic invasion

* [Note: Except for pTis and pT4, the extent of primary tumor is classified by radical orchiectomy. TX may be used for other categories in the absence of radical orchiectomy.]

Regional lymph nodes (N)

• NX: Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1: Metastasis with a single lymph node mass 2 cm or less in greatest dimension; or multiple lymph nodes, 2 cm or less in greatest dimension
• N2: Metastasis with a single lymph node mass larger than 2 cm but no more than 5 cm in greatest dimension; or multiple lymph nodes, no more than 5 cm in greatest dimension
• N3: Metastasis with a lymph node mass 5 cm or more in greatest dimension

Distant metastasis (M)

• MX: Presence of distant metastasis cannot be assessed
• M0: No distant metastasis
• M1: Distant metastasis
  • M1a: Nonregional nodal or pulmonary metastasis
  • M1b: Distant metastasis other than to nonregional lymph nodes and lungs

Serum tumor markers (S)

• SX: Marker studies not available or not performed
• S0: Marker study levels within normal limits
• S1: Lactate dehydrogenase (LDH) less than 1.5 × N*, and
  • Human chorionic gonadotropin (hCG) less than 5,000 (mIU/mL), and
  • Alpha-fetoprotein (AFP) less than 1,000 (ng/mL)
• S2: LDH 1.5–10 × N* or
  • hCG 5,000–50,000 (mIU/mL), or
  • AFP 1,000–10,000 (ng/mL)
• S3: LDH more than 10 × N*, or
  • hCG more than 50,000 (mIU/mL), or
  • AFP more than 10,000 (ng/mL)

* [Note: N indicates the upper limit of normal for the LDH assay.]

Stage 0

• pTis, N0, M0, S0

Stage I

• pT1–4, N0, M0, SX

Stage IA

• pT1, N0, M0, S0

Stage IB

• pT2, N0, M0, S0
• pT3, N0, M0, S0
• pT4, N0, M0, S0

Stage IS

• Any pT/Tx, N0, M0, S1–3

Stage II

• Any pT/Tx, N1–3, M0, SX

Stage IIA

• Any pT/Tx, N1, M0, S0
• Any pT/Tx, N1, M0, S1

Stage IIB

• Any pT/Tx, N2, M0, S0
• Any pT/Tx, N2, M0, S1

Stage IIC

• Any pT/Tx, N3, M0, S0
• Any pT/Tx, N3, M0, S1

Stage III

• Any pT/Tx, any N, M1, SX

Stage IIIA

• Any pT/Tx, any N, M1a, S0
• Any pT/Tx, any N, M1a, S1

Stage IIIB

• Any pT/Tx, N1–3, M0, S2
• Any pT/Tx, any N, M1a, S2

Stage IIIC

• Any pT/Tx, N1–3, M0, S3
• Any pT/Tx, any N, M1a, S3
• Any pT/Tx, any N, M1b, any S

In addition to the clinical stage definitions, surgical stage may be designated based on the results of surgical removal and microscopic examination of tissue.

Stage I

Stage I testicular cancer is limited to the testis. Invasion of the scrotal wall by tumor or interruption of the scrotal wall by previous surgery does not change the stage but does increase the risk of spread to the inguinal lymph nodes, and this must be considered in treatment and follow-up. Invasion of the epididymis tunica albuginea and/or the spermatic cord also does not change the stage but does increase the risk of retroperitoneal nodal involvement and the risk of recurrence. This stage corresponds to AJCC stage I and stage II.

Stage II

Stage II testicular cancer involves the testis and the retroperitoneal or para-aortic lymph nodes usually in the region of the kidney. Retroperitoneal involvement should be further characterized by the number of nodes involved and the size of involved nodes. The risk of recurrence is increased if more than five nodes are involved, if the size of one or more involved nodes is more than 2 cm, or if there is extranodal fat involvement. Bulky stage II disease describes patients with extensive retroperitoneal nodes (>5 cm) who require primary chemotherapy and who have a less favorable prognosis. This stage corresponds to AJCC stage III and stage IV (no distant metastasis).

Stage III

Stage III implies spread beyond the retroperitoneal nodes based on physical examination, x-rays, and/or blood tests. Stage III is subdivided into nonbulky stage III versus bulky stage III. In nonbulky stage III, metastases are limited to lymph nodes and lung with no mass more than 2 cm in diameter. Bulky stage III includes extensive retroperitoneal nodal involvement, plus lung nodules or spread to other organs such as the liver or brain. This stage corresponds to AJCC stage IV (distant metastasis).

References

1. Testis. In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 317-322. 
   
   

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