Testicular Cancer Staging

In the event that you or a loved one receives a testicular cancer diagnosis, your doctor will work through the staging process to determine the extent of the cancer. The stage of your cancer can offer incredible insight into how it will impact you personally and how your cancer may respond to treatment.

A common tool that doctors use to describe the stage is the TNM system. For testicular cancer, an S is added to the TNM system. Your doctor will use the results from the biopsy and diagnostic tests and scans to answer these questions:

  • Tumor (T): How large is the primary tumor? Where is it located?
  • Node (N): Has the tumor spread to the lymph nodes in the back of the abdomen (retroperitoneum)?
  • Metastasis (M): Has the cancer spread to other parts of the body? If so, where and how much?
  • Serum tumor marker (S): Are the serum tumor markers AFP, beta-hCG, and LDH elevated? If so, how high are they?

The results are combined to determine whether your cancer is in stage I, II, or III. Stage I is considered to be the least advanced or earlier stage, and stage III is looked upon as the most advanced or later stage. 

Stage may also be divided into smaller, more detailed groups, being noted with a “p” for pathological or a “c” for clinical. 

Tumor (T)

“T” plus a letter or number (0 to 4) is used to describe the size and location of the tumor. 

pTX: The primary tumor cannot be evaluated. If a man has not had the testicle(s) surgically removed, the term “TX” is used.

pT0 (T plus zero): There is no evidence of a primary tumor in the testicles.

pTis: This stage describes germ cell neoplasia in situ (GCNIS). This is a precancerous condition in which there are germ cells that appear cancerous but are not yet behaving the way cancer cells do. GCNIS becomes cancer when the cells grow into parts of the testicle(s) where they do not normally belong.

pT1: The primary tumor is only in the testicle, which may include the rete testis. It has not grown into blood vessels or lymph vessels in the testicles. The tumor may have grown into the inner membrane layer surrounding the testicle, called the tunica albuginea. It has not spread to the outer membrane layer surrounding the testicle, called the tunica vaginalis.

For a pure seminoma, this stage is further divided based on the side of the tumor:

  • pT1a. The tumor is smaller than 3 centimeters (cm) in size.
  • pT1b. The tumor is 3 cm or larger in size.

pT2: The tumor is in the testicle, which may include the rete testis, and it has grown into 1 or more of the following parts of the testicle:

  • Blood vessels or lymphatic vessels in the testicle
  • The epididymis,
  • The fatty tissue next to the epididymis called the hilar soft tissue
  • The tunica vaginalis

pT3: The tumor has grown into the spermatic cord.

pT4: The tumor has grown into the scrotum.

Node (N)

NX: The regional lymph nodes cannot be evaluated.

cN0: There is no spread to regional lymph nodes as seen on imaging tests.

pN0: There is no cancer found in lymph nodes removed during a retroperitoneal lymph node dissection (RPLND; see Types of Treatment).

cN1: Imaging tests show signs that the cancer has spread to 1 or more lymph nodes in the retroperitoneum. None of the lymph nodes are bigger than 2 centimeters (cm).

pN1: There is cancer in 1 to 5 lymph nodes, and none are larger than 2 cm.

cN2: Imaging tests show at least 1 enlarged lymph node or lymph node mass in the retroperitoneum that is larger than 2 cm but not larger than 5 cm.

pN2: Either or both of the following conditions:

  • There is cancer in more than 5 lymph nodes, but none are larger than 5 cm.
  • There is cancer in at least 1 lymph node, and the largest lymph node or lymph node mass is between 2 cm and 5 cm in size.

cN3: Imaging tests show at least 1 enlarged lymph node or a lymph node mass in the retroperitoneum larger than 5 cm.

pN3: There is cancer in at least 1 enlarged lymph node or lymph node mass that is larger than 5 cm.

Metastasis (M)

MX: Distant metastasis (spread) cannot be evaluated.

M0: The disease has not metastasized to distant lymph nodes or other organs.

M1: There is at least 1 distant metastasis.

  • M1a: There is cancer in the lungs or lymph nodes other than the retroperitoneal lymph nodes.
  • M1b: The cancer has spread to organs other than a lung. The lungs may or may not also be involved. For example, a testicular cancer that has spread to the liver or the bones is stage M1b.

Serum Tumor Markers (S)

SX: Tumor marker levels are not available, or the tests have not been done.

S0: Tumor marker levels are normal.

S1: At least 1 tumor marker level is above normal. LDH is less than 1.5 times the upper limit of the normal range, beta-hCG is less than 5,000 mIu/mL, and/or AFP is less than 1,000 ng/mL.

S2: At least 1 tumor marker level is substantially above normal. This means that LDH is 1.5 to 10 times the upper limit of the normal range, beta-hCG is 5,000 to 50,000 mIu/mL, and/or AFP is 1,000 to 10,000 ng/mL. None of the tumor markers are elevated high enough to qualify as S3 (see below).

S3: At least 1 or more tumor marker level is very highly elevated. This means that LDH is more than 10 times the upper limit of the normal range, beta-hCG is more than 50,000 mIu/mL, and/or AFP is more than 10,000 ng/mL.

Cancer Stage Grouping

Your doctor will assign the stage of the cancer by combining the T, N, and M classifications and the S level information.

Stage 0

Stage 0 refers to carcinoma in situ, also called intratubular germ cell neoplasia (pTis, N0, M0, S0). In this stage, the cancer is contained within the small, seminiferous tubules inside the testicle. This means that cancer cells have spread to other parts of the testicles, nearby lymph nodes, or any other parts of the body. This stage can sometimes be difficult to detect since tumor marker levels tend to be within acceptable limits.

Stage I

In stage I, the cancer has grown beyond seminiferous tubules. It may also have grown outside of the testicle and grown to encompass nearby structures. There is no evidence of spread to either lymph nodes or other parts of the body. Serum tumor marker levels have not been done or are not available (any T, N0, M0, SX).

  • Stage IA (pT1, N0, M0, S0)
    • Tumor has grown beyond seminiferous tubules
    • Tumor remains confined to the testicle
    • Tumor has not extended to nearby lymph nodes, blood vessels, or other parts of the body
    • Tumor markers within normal limits 
  • Stage IB (pT2, pT3, or pT4, and N0, M0, S0)
    • Tumor has grown outside of testicle and into nearby areas
    • Cancer has not spread to lymph nodes or to other parts of the body
    • Tumor markers within normal limits 
  • Stage IS  (any T, N0, M0, and S1-S3)
    • Tumor may or may not have grown outside of the testicle
    • Cancer has not spread to lymph nodes or other parts of the body
    • One or more tumor marker levels are higher than average

Stage II

Stage II means that the cancer has spread to any number of nearby lymph nodes but not to lymph nodes in other parts of the body or distant organs. Serum markers are unavailable (any T, N1-N3, M0, SX)

  • Stage IIA (any T, N1, M0, S0 or S1)
    • Tumor may have grown outside of the testicle or not
    • Cancer has spread to at least one nearby lymph node (but no more than five nearby lymph nodes)
      • No lymph nodes are larger than 2 cm across
    • Cancer has not spread to other parts of the body
    • Tumor markers are within acceptable limits
      • Or at least one marker is slightly elevated
  • Stage IIB (any T, N2, M0, S0 or S1)
    • Tumor may have grown outside of the testicle or not
    • Cancer has spread to at least one nearby lymph node
      • Larger than 2 cm, smaller than 5 cm across OR
    • Cancer has spread to more than five lymph nodes
    • Cancer has not spread to other parts of the body
    • Tumor markers are within acceptable limits
      • Or at least one marker is slightly elevated
  • Stage IIC (any T, N3, M0, S0 or S1)
    • Tumor may have grown outside of the testicle or not
    • Cancer has spread to at least one nearby lymph node
      • Larger than 5 cm across
    • Cancer has not spread to other parts of the body
    • Tumor markers are within acceptable limits
      • Or at least one marker is slightly elevated

Stage III

In stage III, cancer may or may not have grown outside of the testicle. It has spread to distant lymph nodes or to any organ. Serum tumor marker levels are unknown (any T, any N, M1, SX).

  • Stage IIIA (any T, any N, M1a, S0 or S1)
    • Tumor may have grown outside of the testicle or not
    • Cancer may or may not have spread to nearby lymph nodes
    • Cancer has spread to the lungs or to distant lymph nodes
    • Tumor markers are within acceptable limits
      • Or at least one marker is slightly elevated
  • Stage IIIB (any T, N1-N3, M0, S2; or any T, any N, M1a, S2)
    • Tumor may have grown outside of the testicle or not
    • Cancer has spread to one or more nearby lymph nodes
    • Cancer has not spread to distant parts of the body
    • At least one tumor marker is significantly higher than usual
  • Stage IIIC (any T, N1-N3, M0, S3; or any T, any N, M1a, S3)
    • Tumor may have grown outside of the testicle or not
    • Cancer may or may not have spread to one or more nearby lymph nodes
    • Cancer has not spread to distant areas in the body
      • OR has spread to distant lymph nodes or the lungs 
      • OR has spread to parts of the body other than the lungs and lymph nodes (any T, any N, M1b, any S)
    • At least 1 tumor marker level is significantly high