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Staging of testicular cancer

The clinical staging of testicular cancer in Norway is based on the Royal Marsden Hospital staging system.

Classification of testicular cancer in clinical stages (Royal Marsden)

Stage Disease extensiveness
I No detected metastases, either clinically, radiologically, or biochemically
IMk+ Pathological values of the serum markers AFP and/or hCG beta, without other signs of metastases
II

Lymph node metastases under the diaphragm. The size is measured in horizontal diameter (A < 2cm, B 2-5 cm, C ³ 5 cm)

III Lymph node metastases above the diaphragm
IV

Extralymphatic metastases (most often to the lungs)

L1 3 metastases to the lungs, none > 2 cm
L2 > 3 - ≤ 20 metastases to the lungs, none > 2 cm
L3 < 20 metastases to the lungs, one or more > 2 cm
L4 > 20 metastases to the lungs

 

For the classification of testicular cancer, in addition to the staging, it should also be taken into account which risk profile or prognostic group the patient belongs to. Stage I has histological profiles while the other stages have prognostic groups. This applies to both seminal and nonseminal cancers. Risk profiles describe spreading while prognostic groups describe prognosis when the disease has metastasized.

Seminoma

Risk profiles for no metastatic disease, Stage I

  • Low risk profile - no invasion of rete testis and tumor size < 4 cm 
  • High risk profile - invasion of rete testis and/or tumor size ³ 4 cm
  • Locally advanced - infiltration of capsule

 

Prognosis groups for metastatic disease, Stage II, III, IV. International Germ Cell Cancer Collaborative Group’s classification (10).

Good prognosis (90% of patients) ® 86% 5 year survival 

  • Any primary site, and
  • No nonpulmonary visceral metastases, and
  • Any elevation of hCG and LD and normal AFP

Intermediary prognosis (10% of the patients) ® 72% 5 year survival

  • Any primary site, and 
  • Nonpulmonary visceral metastases, and
  • Any elevation of hCG and LD and normal AFP

For seminoma, there is not a poor prognostic group.

Non-seminoma

Risk profiles for no metastatic disease, Stage I

  • Low risk profile - no blood vessel infiltration
  • High risk profile - blood vessel infiltration  
  • Locally advanced - infiltration of capsule

Prognosis groups for metastatic disease, Stage II, III, IV. International Germ Cell Cancer Collaborative Group’s classification (10 ).

Good prognosis (56% of the patients) ® 92 % 5 year survival

  • Primary tumor in the testicles/retroperitoneum, and
  • No nonpulmonary visceral metastases, and
  • AFP < 1000 ng/ml, and
  • hCG < 5000 IE/l, and
  • LD < 1.5 x upper reference area

Intermediary prognosis (28% of the patients) ® 80% 5 year survival

  • Primary tumor in the testicles/retroperitoneum, and 
  • No nonpulmonary visceral metastases, and 
  • AFP > 1000 and < 10 000 ng/ml, or
  • hCG > 5000 and < 50 000 IE/l, or
  • LD > 1,5 and < 10 x upper reference area 

Poor prognosis (16% of the patients) ® 48% 5 year survival

  • Extragonadal primary tumor in the mediastinum, or
  • Nonpulmonary visceral metastases, or 
  • AFP > 10,000 ng/ml, or
  • hCG > 50 000 IE/l, or
  • LD > 10 x upper reference area  

Spreading occurs more often for nonseminomal tumors. About 50% of the patients have metastases at the time of diagnosis (4).

Different units are used internationally. The conversion factor from biological units (IE) to the SI-system for AFP is: 1kIE/l = 1.4 ng/ml.

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