Clinical stage (and therefore prognosis and initial management) is determined by the pT stage, regional N and distant M disease, and post-orchiectomy serum markers (S). Repeat AFP/hCG/LDH at appropriate half-life intervals after orchiectomy to establish the nadir for staging — monitoring to nadir before treatment is warranted only when the nadir would change management.
TNM (AJCC 8th edition)
T — Primary Tumour (pathologic)
| Category | Definition |
|---|---|
| pTis | Germ cell neoplasia in situ (GCNIS) |
| pT1 | Limited to testis (including rete testis) without LVI. Pure seminoma: pT1a <3 cm, pT1b ≥3 cm |
| pT2 | Limited to testis with LVI, or invading hilar soft tissue, epididymis, or tunica vaginalis |
| pT3 | Direct (continuous) spermatic cord soft-tissue invasion (LVI of the cord without soft-tissue invasion is not pT3) |
| pT4 | Direct scrotal invasion |
N — Regional Lymph Nodes
| Stage | Clinical (cN) | Pathologic (pN) |
|---|---|---|
| N1 | Node mass ≤2 cm, or multiple nodes each ≤2 cm | Node mass ≤2 cm and ≤5 positive nodes, none >2 cm |
| N2 | Node mass >2 cm but ≤5 cm, or any node >2 cm but ≤5 cm | Node mass >2 cm but ≤5 cm, or >5 positive nodes (none >5 cm), or extranodal extension |
| N3 | Node mass >5 cm | Node mass >5 cm |
M — Distant Metastasis
- M1a: non-regional nodal (iliac, inguinal, pelvic) or lung metastasis.
- M1b: non-lung visceral metastasis.
S — Serum Markers (post-orchiectomy nadir)
| Stage | LDH | hCG (mIU/mL) | AFP (ng/mL) |
|---|---|---|---|
| S1 | <1.5× ULN and | <5,000 and | <1,000 |
| S2 | 1.5–10× ULN or | 5,000–50,000 or | 1,000–10,000 |
| S3 | >10× ULN or | >50,000 or | >10,000 |
(S1 requires all three criteria; S2/S3 take the highest abnormal marker.)
Clinical Stage Groupings
| Stage | pT | N | M | S |
|---|---|---|---|---|
| 0 | pTis | N0 | M0 | S0 |
| IA | pT1 | N0 | M0 | S0 |
| IB | pT2–pT4 | N0 | M0 | S0 |
| IS | Any | N0 | M0 | S1–3 |
| IIA | Any | N1 | M0 | S0–1 |
| IIB | Any | N2 | M0 | S0–1 |
| IIC | Any | N3 | M0 | S0–1 |
| IIIA | Any | Any | M1a | S0–1 |
| IIIB | Any | N1–N3 or M1a | M0/M1a | S2 |
| IIIC | Any | N1–N3 or any | M0/M1a | S3; or any N, M1b, any S |
In brief: CS I is confined to the testis; CS II has regional (retroperitoneal) nodal metastasis; CS III has non-regional nodal and/or visceral metastasis — and post-orchiectomy marker elevation (S2–S3) can upstage a patient from CS II to CS III.
Self-Test
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How does LVI change the T stage of a testis tumour confined to the testis? Without LVI it is pT1; with LVI it becomes pT2 (which also includes invasion of hilar soft tissue, epididymis, or tunica vaginalis).
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What is the pT1 subdivision unique to pure seminoma? pT1a (<3 cm) vs pT1b (≥3 cm) by tumour size.
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What distinguishes S1 from S2/S3 logically? S1 requires all three markers below threshold (AND); S2 and S3 are assigned by the single highest abnormal marker (OR).
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What nodal mass size separates N1, N2, and N3? ≤2 cm (N1), >2–5 cm (N2), >5 cm (N3).
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What defines M1b? Non-lung visceral metastasis (lung or non-regional nodal disease is M1a).