Testis

TNM 7 Classification

TNM 6 Classification

1. Rules for Classification

The classification applies only to germ cell tumours of the testis. There should be histological confirmation of the disease and division of cases by histological type. Histopathological grading is not applicable.

The presence of elevated serum tumour markers, including alphafetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH), is frequent in this disease. Staging is based on the determination of the anatomic extent of disease and assessment of serum tumour markers.

The following are the procedures for assessing N, M, and S categories:

• N categories. Physical examination and imaging
• M categories. Physical examination, imaging, and biochemical tests
• S categories. Serum tumour markers

Stages are subdivided based on the presence and degree of elevation of serum tumour markers. Serum tumour markers are obtained immediately after orchiectomy and, if elevated, should be performed serially after orchiectomy according to the normal decay for AFP (half-life 7days) and hCG (half-life 3 days) to assess for serum tumour marker elevation. The S classification is based on the nadir value of hCG and AFP after orchiectomy. The serum level of LDH (but not its half-life levels) has prognostic value in patients with metastatic disease and is included for staging.

2. Regional Lymph Nodes

The regional lymph nodes are the abdominal para-aortic (periaortic), preaortic, interaortocaval, precaval, paracaval, retrocaval, and retroaortic nodes. Nodes along the spermatic vein should be considered regional. Laterality does not affect the N classification. The intrapelvic nodes and the inguinal nodes are considered regional after scrotal or inguinal surgery.

3. TNM Clinical Classification

3.1. T - Primary Tumour

Except for pTis and pT4. where radical orchiectomy is not always necessary for classification purposes, the extent of the primary tumour is classified after radical orchiectomy; see pT. In other circumstances, TX is used if no radical orchiectomy has been performed.

3.2. N - Regional Lymph Nodes

NX. Regional lymph nodes cannot be assessed
N0. No regional lymph node metastasis
N1. Metastasis with a lymph node mass 2 cm or less in greatest dimension or multiple lymph nodes, none more than 2 cm in greatest dimension
N2. Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension, or multiple lymph nodes, any one mass more than 2 cm but not more than 5 cm in greatest dimension
N3. Metastasis with a lymph node mass more than 5 cm in greatest dimension

3.3. M - Distant Metastasis

MX. Distant metastasis cannot be assessed
M0. No distant metastasis
M1. Distant metastasis
M1a. Non-regional lymph node(s) or lung
M1b. Other sites

4. pTNM Pathological Classification

See also: Additional site-specific recommendations for pT and pN

4.1. pT - Primary Tumour

pTX. Primary tumour cannot be assessed (see T - Primary Tumour, above)
pT0. No evidence of primary tumour (e.g. histologic scar in testis)
pTis. Intratubular germ cell neoplasia (carcinoma in situ)
pT1. Tumour limited to testis and epididymis without vascular/lymphatic invasion; tumour may invade tunica albuginea but not tunica vaginalis.
pT2. Tumour limited to testis and epididymis with vascular/lymphatic invasion, or tumour extending through tunica albuginea with involvement of tunica vaginalis.
pT3. Tumour invades spermatic cord with or without vascular/lymphatic invasion.
pT4. Tumour invades scrotum with or without vascular/ lymphatic invasion.

4.2. pN - Regional Lymph Nodes

pNX. Regional lymph nodes cannot be assessed
pN0. No regional lymph node metastasis
pN1. Metastasis with a lymph node mass 2 cm or less in greatest dimension and 5 or fewer positive nodes, none more than 2 cm in greatest dimension
pN2. Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension; or more than 5 nodes positive, none more than 5 cm; or evidence of extranodal extension of tumour
pN3. Metastasis with a lymph node mass more than 5 cm in greatest dimension

4.3. pM - Distant Metastasis

The pM category corresponds to the M category.

4.4. S - Serum Tumour Markers

SX. Serum marker studies not available or not performed
S0. Serum marker study levels within normal limits

LDH hCG (mIU/ml) AFP (ng/ml) S1 <1.5 × N and <5,000 and <1,000 S2 1.5-10 × N or 5,000-50,000 or 1,000-10,000 S3 >10 × N or >50,000 or >10,000 N indicates the upper limit of normal for the LDH assay

5. Stage Grouping

Stage 0 pTis N0 M0 S0,SX Stage I pT1-4 N0 M0 SX Stage IA 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 II Any pT/TX N1-3 M0 SX Stage IIA Any pT/TX N1 M0 S0 Any pT/TX N1 M0 S1 Stage IIB Any pT/TX N2 M0 S0 Any pT/TX N2 M0 S1 Stage IIC Any pT/TX N3 M0 S0 Any pT/TX N3 M0 S1 Stage III Any pT/TX Any N M1. M1a SX Stage IIIA Any pT/TX Any N M1. M1a S0 Any pT/TX Any N M1. M1a S1 Stage IIIB Any pT/TX N1-3 M0 S2 Any pT/TX Any N M1. M1a S2 Stage IIIC Any pT/TX N1-3 M0 S3 Any pT/TX Any N M1. M1a S3 Any pT/TX Any N M1b Any S

6. Summary

Testis pTis Intratubular pT1 Testis and epididymis, no vascular/lymphatic invasion pT2 Testis and epididymis with vascular/lymphatic invasion or tunica vaginalis pT3 Spermatic cord pT4 Scrotum N1 ≤2 cm pN1 ≤2 cm and ≤5 nodes N2 >2 to 5 cm pN2 >2 to 5 cm or >5 nodes or extranodal extension N3 >5 cm pN3 >5 cm M1a Non-regional lymph nodes or lung M1b Other sites