Good Prognosis
Intermediate Prognosis
Poor Prognosis

Testicular cancer is broadly divided into seminoma and nonseminoma for treatment planning because seminomatous types of testicular cancer are more sensitive to radiation therapy. Nonseminomatous testicular tumors include yolk sac tumors.

An international germ cell tumor prognostic classification has been developed based on a retrospective analysis of 5,202 patients with metastatic nonseminomatous and 660 patients with metastatic seminomatous germ cell tumors.[1] All patients received treatment with cisplatin- or carboplatin-containing therapy as their first chemotherapy course. The prognostic classification, shown below, was agreed on in 1997 by all major clinical trial groups worldwide. It should be used for reporting clinical trial results of patients with germ cell tumors.

A meta-analysis of treatment outcomes for patients with advanced nonseminoma suggested that 5-year survival rates have improved for those patients with a poor prognosis during the period of 1989 to 2004.[2] In addition to improved therapy, the improvement seen in these survival rates could be due to publication bias, changes in patient selection in reported clinical trials, or more sensitive staging methods that could migrate less advanced stages to more advanced stage categories (i.e., stage migration).

Nonseminoma:

• Testis/retroperitoneal primary, and
• No nonpulmonary visceral metastases, and
• Good markers–all of:
  • Alpha-fetoprotein (AFP) less than 1,000 ng/mL, and
  • Human chorionic gonadotropin (hCG) less than 5,000 IU/mL (1,000 ng/mL), and
  • Lactate dehydrogenase (LDH) less than 1.5 × the upper limit of normal

  56%–61% of nonseminomas

  5-year progression-free survival (PFS) is 89%; 5-year survival is 92%–94%

Seminoma:

• Any primary site, and
• No nonpulmonary visceral metastases, and
• Normal AFP, any hCG, any LDH

  90% of seminomas

  5-year PFS is 82%; 5-year survival is 86%

Nonseminoma:

• Testis/retroperitoneal primary, and
• No nonpulmonary visceral metastases, and
• Intermediate markers–any of:
  • AFP 1,000 or more and 10,000 ng/mL or more, or
  • hCG 5,000 IU/L or more and 50,000 IU/L or more, or
  • LDH 1.5 or more × N* and 10 × N*

  13%–28% of nonseminomas

  5-year PFS is 75%; 5-year survival is 80%–83%

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

Seminoma:

• Any primary site, and
• Nonpulmonary visceral metastases, and
• Normal AFP, any hCG, any LDH

  10% of seminomas

  5-year PFS is 67%; 5-year survival is 72%

Nonseminoma:

• Mediastinal primary, or
• Nonpulmonary visceral metastases, or
• For markers–any of:
  • AFP more than 10,000 ng/mL, or
  • hCG more than 50,000 IU/mL (10,000 ng/mL), or
  • LDH more than 10 × the upper limit of normal

  16%–26% of nonseminomas

  5-year PFS is 41%; 5-year survival is 71%

Seminoma:

• No patients are classified as poor prognosis.

References

1. International Germ Cell Consensus Classification: a prognostic factor-based staging system for metastatic germ cell cancers. International Germ Cell Cancer Collaborative Group. J Clin Oncol 15 (2): 594-603, 1997.  [PUBMED Abstract]
   
   
2. van Dijk MR, Steyerberg EW, Habbema JD: Survival of non-seminomatous germ cell cancer patients according to the IGCC classification: An update based on meta-analysis. Eur J Cancer 42 (7): 820-6, 2006.  [PUBMED Abstract]
   
   

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