Criteria
TNMS staging system
The TNMS classification system is commonly used to stage testicular cancer and describes the extent of disease based on the following factors:[6][7]
Size and extent of the primary tumor (T), with the American Joint Committee on Cancer (AJCC) staging system further subdividing T1 by size (T1a tumor <3 cm; T1b tumor ≥3 cm)
Regional lymph node involvement (N)
Presence or absence of distant metastases (M)
Postorchiectomy nadir serum tumor marker levels (S): lactate dehydrogenase (LDH), human chorionic gonadotropin (hCG), and alpha-fetoprotein (AFP). A worse prognosis is noted with high tumor marker levels.[6][7]
Stage IA: tumor confined to testis (includes rete testis invasion in the AJCC staging system) with normal postorchiectomy serum tumor markers.
Stage IB: locally invasive tumor with spread beyond tunica albuginea and involvement of tunica vaginalis; or invasion of spermatic cord or scrotum; with or without vascular/lymphatic invasion; and without nodal or metastatic disease. Serum tumor markers are normal.
Stage IS: any size and extent of the primary tumor (or size and extent cannot be assessed), without nodal or metastatic disease, with at least one elevated serum tumor marker.
Stage II: spread to regional (retroperitoneal) nodes, with or without slightly elevated serum tumor markers (LDH <1.5 times upper limit of normal [ULN], hCG <5000 IU/L, and AFP <1000 ng/mL).
Stage III: spread beyond retroperitoneal nodes, visceral metastatic disease, or regional node-only involvement with high tumor marker levels (LDH ≥1.5 times ULN, hCG ≥5000 IU/L, and AFP ≥1000 ng/mL).
Notably, there is no prognostic stage IV disease in testicular cancer.
International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic factors classification for advanced germ cell tumors
Nonseminoma
The original IGCCCG classification, as published in 1997, retains its relevance as a reference for treatment decisions in daily practice and is outlined below.[60] The 2021 IGCCCG Update model for metastatic nonseminomatous germ cell tumors includes age and lung metastases as additional adverse prognostic factors and uses a single cutoff of LDH at 2.5 times ULN.[61] Every decade-of-life increase translates into a 25% increase in the risk of progression. The presence of lung metastases translates into a 62% increase in the risk of progression compared with patients without lung metastases.[61] This newer risk model for prognostic information can be accessed online. IGCCCG update Opens in new window
Good prognosis:
Testis or retroperitoneal primary and
No nonpulmonary visceral metastases (such as liver, bone, or brain) and
Postorchiectomy markers, all of:
AFP <1000 ng/mL
hCG <5000 IU/L
LDH <1.5 times ULN
Intermediate prognosis:
Testis or retroperitoneal primary and
No nonpulmonary visceral metastases and
Postorchiectomy markers, any of:
AFP 1000-10,000 ng/mL
hCG 5000 IU/L to 50,000 IU/L
LDH 1.5-10 times ULN
Poor prognosis:
Mediastinal primary or
Nonpulmonary visceral metastases or
Postorchiectomy markers, any of:
AFP >10,000 ng/mL
hCG >50,000 IU/L
LDH >10 times ULN
Seminoma
The original 1997 IGCCCG classification identified two prognostic groups for seminomas: good and intermediate only (detailed below).[60] The 2021 IGCCCG Update model for metastatic seminomatous germ cell tumors added LDH above 2.5 times ULN prior to chemotherapy as an additional adverse prognostic factor within the good prognosis group.[62]
Good prognosis:
Any primary site and
No nonpulmonary visceral metastases and
Normal AFP, any hCG, and any LDH
Intermediate prognosis:
Nonpulmonary visceral metastases
Poor prognosis:
No patients classified as poor prognosis
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