Download Testicular Cancer Info: Staging

Testicular Cancer Info: Staging
What is Staging?
Once testicular cancer has been diagnosed, the doctor will perform more tests to determine
whether the cancer has spread from the testicle to other parts of the body. Classifying a
person's cancer by the degree to which it has spread is called staging. Staging is used to
determine the available treatment options. Keep in mind that staging is only as accurate as
the information available, and the stage of a person's cancer can change as more information
or more accurate information is gathered. If the doctor comes out of the operating room and
tells you he thinks he got it all, don't be so quick to trust him. It takes urologists, pathologists
and radiologists to ultimately determine the stage of the cancer.
There are two type of staging: Clinical and Pathological. Clinical staging uses radiological and
physical clues to estimate the stage. Pathological staging uses stronger evidence like tissue
samples and blood tests to determine the stage. For example, assume you have gone
through the orchiectomy and based on all the test results, your doctor says that you have
Clinical Stage I Nonseminoma. At this point you choose to have an RPLND. If they find no
cancer during the RPLND, they will change you to Pathological Stage I. If they do find cancer,
then you will become Pathological Stage II. As you can see, the Pathological Stage is more
accurate since it used actual tissue samples to determine the presence or absence of cancer.
Tests & Procedures
It is one thing for the doctor to do a physical exam and conclude that you probably have
cancer. It is another thing to determine the stage. Usually the stage cannot be estimated until
after surgery, blood tests and xrays have been done. Here is a list of tests that may be used
to determine the stage:
Surgery: Without surgery, in this case an orchiectomy, it is often difficult to conclude that
there is cancer there at all, so surgery is usually the first step.
Blood tests: Some testicular cancers secrete something called tumor markers, high levels of
certain proteins that can be detected through blood tests. These markers of testicular cancer
include alpha-fetoprotein (AFP), beta human chorionic gonadotropin (ß-HCG) and lactate
dehydrogenase (LDH). If a guy's AFP or HCG level are above normal AND there is something
wrong with his testicle, then you can usually assume that he has testicular cancer. If the
tumor markers do not fall back to normal after an orchiectomy, then you can usually assume
that the cancer has spread, even if no other tests show where it has gone. For more
information on tumor markers, click here.
Computed Tomography (CT) scanning: This machine uses a rotating X-ray beam to create
a series of pictures of the body from many different angles. A computer processes the
information and produces a detailed cross-sectional image of selected parts of the body.
Sometimes, a dye is injected into a vein to highlight details on the scan. A CT scan is
especially valuable for identifying the spread of tumors to lymph nodes. If the tumor markers
are high enough, a CT scan may also be done of the brain. Keep in mind, however, that it is
hard to see into areas like the abdomen, and just because a CT scan says everything is
normal does not mean that the cancer has not spread at all.
Chest X-rays: Simple chest x-rays are often used to determine if the cancer has spread to
the lungs. In many cases the doctor will order a CT scan of the chest right after cancer has
been diagnosed just to be sure nothing is there. (CT scans can see smaller masses in the
lungs than chest x-rays, but in many cases these masses are not tumors.)
Positron Emission Tomography (PET): PET scanning is a relatively new technology that
allows doctors to view biological functions. Areas with increased metabolic activity show up as
"hot areas" in a PET image. Instead of using an x-ray, they give you a radioactive substance
and use the scanner to try to detect where that radioactive material is collecting in the body.
The theory is that it is more likely to go to solid tumors than other areas of the body. Its use is
promising in the future, particularly in evaluating large masses left over after chemotherapy
for seminoma. However, at this time it is still experimental, expensive, hard to interpret, not
widely available and probably should not be used in staging.
Magnetic Resonance Imaging (MRI): An MRI uses magnetic fields and radio waves to
create images of selected areas of the body. These images can show enlarged lymph nodes
and abnormal growths in certain organs that may indicate that the cancer has spread. MRI's
are typically not used with testicular cancer because the CT scan often produces a better
result and costs less.
Lymphangiography: This painful test involves injecting a special radioactive dye into the
lymphatic system. Over a period of several hours, the dye collects in areas where cells are
dividing and growing quickly. The doctor takes an X-ray, which shows where the dye has
gathered and where cancer may be found. This test used to be performed to map out the
lymph nodes in the back of the abdomen so the radiation fields can be set up to treat a patient
with seminoma tumors. It is rarely used any more because it is not particularly accurate, and it
almost certainly is not used for staging. It is a good bet that your doctor is getting on in years
if they order this test.
Stages of testicular cancer
After the required testing has been done, the doctors can assign a stage to your cancer.
Roughly speaking, here are the Stages used:





Stage I: Cancer is found only in the testicle. Removing the testicle alone should
cure the patient, though many will choose some form of additional treatment just
to be sure...
Stage II: Cancer has spread to the lymph nodes in the abdomen. Removing the
testicle alone will not cure the patient, and more treatment is necessary.
Stage III: Cancer has spread to areas above the diaphragm such as the lungs,
neck or brain. There may be also be cancer in parts of the body such as the
bones or liver. In this situation, chemotherapy is absolutely required. Surgery
may also be needed.
Stage IV: To the best of my knowledge, there is no such thing as Stage IV
testicular cancer. However, it is possible that Stage IV may still be used in some
places in Europe. Suffice to say that Stage IV is probably very similar to Stage III.
Recurrent: Recurrent disease means that the cancer has come back after it has
been treated. It may recur in the same place or in another part of the body.
In reality, however, there are many subclasses as well, so it can get kind of complicated.
What follows is the complete TNM Staging Protocol used by most doctors in the world today,
as defined by the American Joint Committee on Cancer (AJCC). [1]
TNM definitions
Primary tumor (T) - The extent of primary tumor is classified after radical orchiectomy.







pTX: Primary tumor cannot be assessed (if no radical orchiectomy has been
performed, TX is used.)
pT0: No evidence of primary tumor (e.g., histologic scar in testis)
pTis: Intratubular germ cell neoplasia (carcinoma in situ)
pT1: Tumor limited to testis and epididymis without lymphatic/vascular invasion
pT2: Tumor limited to 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
Regional lymph nodes (N)





NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in a single lymph node, 2 cm or less in greatest dimension
N2: Metastasis in a single lymph node, more than 2 cm but not more than 5 cm
in greatest dimension; or multiple lymph nodes, none more than 5 cm in greatest
dimension
N3: Metastasis in a lymph node more than 5 cm in greatest dimension
Distant metastasis (M)





MX: Presence of distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis
M1a: Non-regional nodal or pulmonary metastasis
M1b: Distant metastasis other than to non-regional nodes and lungs
Serum tumor markers (S)





Stage 0
SX: Tumor marker studies not available or not performed
S0: Tumor marker levels within normal limits
S1: LDH < 1.5 X Normal and HCG (mIu/ml) < 5000 and AFP (ug/ml) < 1000
S2: LDH 1.5-10 X Normal or HCG (mIu/ml) 5000-50,000 or AFP (ug/ml) 100010,000
S3: LDH > 10 X Normal or HCG (mIu/ml) > 50,000 or AFP (ug/ml) > 10,000
Stage I
AJCC stage groupings
Stage II
pTis, N0, M0, S0 pT1-4, N0, M0, SX
Stage III
Any pT/Tx, N1-3, M0, Any pT/Tx, Any N, M1,
SX
SX
Stage IA
Stage IIA
Stage IIIA
Any pT/Tx, N1, M0,
S0
Any pT/Tx, N1, M0,
S1
Any pT/Tx, Any N, M1a,
S0
Any pT/Tx, Any N, M1a,
S1
Stage IIB
Stage IIIB
Any pT/Tx, N2, M0,
S0
Any pT/Tx, N2, M0,
S1
Any pT/Tx, N1-3, M0, S2
Any pT/Tx, Any N, M1a,
S2
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 IIIC
Stage IIC
Any pT/Tx, N3, M0,
S0
Any pT/Tx, N3, M0,
S1
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 stages I and 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 5 nodes are involved, if the size of 1 or more
involved nodes is larger than 2 centimeters, or if there is extranodal fat involvement. Bulky
stage II disease describes patients with extensive retroperitoneal nodes (>5 centimeters) who
require primary chemotherapy and who have a less favorable prognosis. This stage
corresponds to AJCC stages III and 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 larger than 2 centimeters in diameter. Bulky stage III includes extensive retroperitoneal
nodal involvement, plus lung nodules or spread to other organs such as 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.
Philadelphia, Pa: Lippincott-Raven Publishers, 5th ed., 1997, pp 225-230.