Page 3 - Guideline

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Management of testicular germ cell cancer

Table 2a. Staging of testis tumours: UICC/American Joint Stage grouping
Committee on Cancer Stage Tumour Node Metastasis Serum factor
TNM staging Unit Value Stage 0 pTis N0 M0 S0
Primary pTX Primary tumour cannot be assessed. Stage I pT1-4 N0 M0 SX
tumour* (If no radical orchidectomy has been
performed, Tx is used) Stage IA pT1 N0 M0 S0
pT0 No evidence of primary tumour Stage 1B pT2 N0 M0 S0
(e.g., histologic scar in testis)
pT3 N0 M0 S0
pTis Intratubular germ cell neoplasia
(carcinoma in situ) pT4 N0 M0 S0
pT1 Tumour limited to the testis and
epididymis without vascular/ Stage IS Any T N0 M0 S1-3
lymphatic invasion. Tumour may Stage II Any T N1-3 M0 SX
invade into the tunica albuginea
but not the tunica vaginalis. Stage IIA Any T N1 M0 S0
pT2 Tumour limited to the testis and Any T N1 M0 S1
epididymis with vascular/lymphatic
invasion, or tumour extending Stage IIB Any T N2 M0 S0
through the tunica albuginea with
involvement of the tunica vaginalis Any T N2 M0 S1
pT3 Tumour invades the spermatic Stage IIC Any T N3 M0 S0
cord with or without
vascular/lymphatic invasion Any T N3 M0 S1
pT4 Tumour invades the scrotum with or
without vascular/lymphatic invasion Stage III Any T Any N M1 SX
Regional NX Regional lymph nodes cannot be Stage IIIA Any T Any N M1a S0
lymph nodes assessed
Any T Any N M1a S1
(N) clinical
N0 No regional lymph node Stage IIIB Any T N1-3 M0 S2
metastasis
Any T Any N M1a S2
N1 Metastasis with a lymph node mass
2 cm or less in greatest dimension; Stage IIIC Any T N1-3 M0 S3
or multiple lymph nodes, none more
than 2 cm in greatest dimension Any T Any N M1a S3
N2 Metastasis with a lymph node mass, Any T Any N M1B Any S
more than 2 cm but not more than 5 *The extent of primary tumour is classified after radical orchidectomy. LDH = lactate dehy-
cm in greatest dimension; or drogenase; HCG = human chorionic gonadotrophin; AFP = alpha-fetoprotein. Adapted from
multiple lymph nodes, any one mass Sobin LH, Wittekind C (eds). UICC TNM classification of malignant tumours. 6th ed. New
greater than 2 cm but not more than York: John Wiley & Sons, 2002.
5 cm in greatest dimension
N3 Metastasis with a lymph node
mass more than 5 cm in greatest sufficient discrimination to be clinically useful. Even patients
dimension
in the high-risk group have a greater than 65% chance of
M1 Distant metastasis being relapse-free on surveillance.
M1a Non-regional nodal or pulmonary At relapse, most patients can be successfully treated with
metastasis retroperitoneal radiotherapy alone. One concern regarding
M1b Non-pulmonary visceral metastasis the routine use of surveillance was the potential for the
Serum SX Marker studies not available or not increased use of chemotherapy. However, data from PMH
tumour performed indicates that the 10-year actuarial risk of requiring
markers (S) chemotherapy at any time in the management of patients
S0 Marker study levels within normal was 4.6% in patients managed by surveillance and 3.9%
limits
in those managed by adjuvant radiotherapy; this data sug-
S1 LDH <1.5 × Normal and HCG (mIu/mL) gest that there is no significant increase of the use of
< 5000 and AFP (ug/mL) < 1000 19
chemotherapy in patients followed on surveillance.
S2 LDH 1.5 – 10 × Normal or HCG An optimal follow-up strategy for patients on surveil-
(mIu/mL) 5000 – 50 000 or AFP
(ug/mL) 1000 – 10 000 lance has not yet been determined. The National Cancer
Research Institute in the United Kingdom has opened a
S3 LDH >10 × Normal or HCG (mIu/mL)
> 50 000 or AFP (ug/mL) > 10 000 randomized trial (TRISST) to address this issue. Patients
with stage I seminoma will be randomized to either CT or

CUAJ • April 2010 • Volume 4, Issue 2 E21