Testicular Cancer: Staging and Treatment

What is staging?

Staging is the process of learning how much cancer is in your body and where it is. Tests like ultrasound, chest x-ray, CT scan, MRI, bone scan, PET scan, and blood tests for tumor markers (such as alpha-fetoprotein [AFP], beta human chorionic gonadotropin [Beta-HCG], and lactate dehydrogenase [LDH]) may be done to help stage your cancer. Your providers need to know about your cancer and your health so that they can plan the best treatment for you.

Cancer staging looks at the size of the tumor and where it is, and if it has spread to other organs. The staging system for testicular cancer is called the “TNM system.” It has four parts:

• T-describes the size/location/extent of the "primary" tumor in the testicle.
• N-describes if the cancer has spread to the lymph nodes.
• M-describes if the cancer has spread to other organs (called metastases).
• S-describes the level of serum tumor markers.

How is testicular cancer staged?

Staging for testicular cancer is based on:

• The size of your tumor seen on imaging tests.
• What is found after surgery (if you have had surgery), including if there is cancer in your lymph nodes.
• Any evidence of spread to other organs (metastasis).
• Your age is also considered in staging.

The staging system is very complex. Below is a summary of the staging. Talk to your provider about the stage of your cancer.

Stage 0 (pTis, N0, M0, S0): The cancer is only in the seminiferous tubules (small tubes inside each testicle). It has not grown into other parts of the testicle (pTis). It hasn't spread to nearby lymph nodes (N0) or to distant parts of the body (M0). All tumor marker levels are within normal limits (S0).

Stage I (pT1-pT4, N0, M0, SX): The tumor has grown beyond the seminiferous tubules and might have grown outside the testicle and into nearby structures (pT1-pT4). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0). Tumor marker test results aren’t available, or the tests haven’t been done (SX).

Stage IA (pT1, N0, M0, S0): The tumor has grown beyond the seminiferous tubules, but is still within the testicle, and it hasn't grown into nearby blood vessels or lymph nodes (pT1). The cancer hasn't spread to nearby lymph nodes (N0) or to distant parts of the body (M0). All tumor marker levels are within normal limits (S0).

Stage IB (pT2-pT4, N0, M0, S0): The tumor has grown outside of the testicle and into nearby structures (pT2-pT4). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0). All tumor marker levels are within normal limits (S0).

Stage IS (Any pT or TX, N0, M0, S1-S3): The tumor may or may not have grown outside the testicle (any pT), or the extent of the tumor can’t be assessed for some reason (TX). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0). At least one tumor marker level is higher than normal (S1-S3).

Stage II (Any pT or TX, N1-N3, M0, SX): The tumor may or may not have grown outside the testicle (any pT), or the extent of the tumor can’t be assessed for some reason (TX). The cancer has spread to 1 or more nearby lymph nodes (N1-N3), but it hasn't spread to distant parts of the body (M0). Tumor marker test results aren’t available, or the tests haven’t been done (SX).

Stage IIA (Any pT or TX, N1, M0, S0 or S1): The tumor may or may not have grown outside the testicle (any pT), or the extent of the tumor can’t be assessed for some reason (TX). The cancer has spread to at least 1 nearby lymph node (but no more than 5, if checked by surgery), and none of the lymph nodes are larger than 2 cm across (N1). The cancer has not spread to distant parts of the body (M0). All tumor marker levels are within normal limits (S0), or at least 1 tumor marker level is slightly higher than normal (S1).

Stage IIB (Any pT or TX, N2, M0, S0 or S1): The tumor may or may not have grown outside the testicle (any pT), or the extent of the tumor can’t be assessed for some reason (TX). The cancer has spread to at least 1 nearby lymph node that's larger than 2 cm but no larger than 5 cm across, OR it has grown outside of a lymph node, OR more than 5 nodes have cancer (found during surgery) (N2). The cancer has not spread to distant parts of the body (M0). All tumor marker levels are within normal limits (S0), or at least 1 tumor marker level is slightly higher than normal (S1).

Stage IIC (Any pT or TX, N3, M0, S0 or S1): The tumor may or may not have grown outside the testicle (any pT), or the extent of the tumor can’t be assessed for some reason (TX). The cancer has spread to at least 1 nearby lymph node that's larger than 5 cm across (N3). The cancer has not spread to distant parts of the body (M0). All tumor marker levels are within normal limits (S0), or at least 1 tumor marker level is slightly higher than normal (S1).

Stage III (Any pT or TX, Any N, M1, SX): The tumor may or may not have grown outside the testicle (any pT), or the extent of the tumor can’t be assessed for some reason (TX). The cancer might or might not have spread to nearby lymph nodes (any N). It has spread to distant parts of the body (M1). Tumor marker test results aren’t available, or the tests haven’t been done (SX).

Stage IIIA (Any pT or TX, Any N, M1a, S0 or S1): The tumor may or may not have grown outside the testicle (any pT), or the extent of the tumor can’t be assessed for some reason (TX). The cancer might or might not have spread to nearby lymph nodes (any N). It has spread to distant lymph nodes or to the lungs (M1a). All tumor marker levels are within normal limits (S0), or at least 1 tumor marker level is slightly higher than normal (S1).

Stage IIIB:

• Any pT or TX, N1-N3, M0, S2: The tumor may or may not have grown outside the testicle (any pT), or the extent of the tumor can’t be assessed for some reason (TX). The cancer has spread to 1 or more nearby lymph nodes (N1-N3), but it hasn't spread to distant parts of the body (M0). At least 1 tumor marker level is much higher than normal (S2).
• Any pT or TX, Any N, M1a, S2: The tumor may or may not have grown outside the testicle (any pT), or the extent of the tumor can’t be assessed for some reason (TX). The cancer might or might not have spread to nearby lymph nodes (any N). It has spread to distant lymph nodes or to the lungs (M1a). At least 1 tumor marker level is much higher than normal (S2).

Stage IIIC:

• Any pT or TX, N1-N3, M0, S3: The tumor may or may not have grown outside the testicle (any pT), or the extent of the tumor can’t be assessed for some reason (TX). The cancer has spread to 1 or more nearby lymph nodes (N1-N3), but it hasn't spread to distant parts of the body (M0). At least 1 tumor marker level is very high (S3).
• Any pT or TX, Any N, M1a, S3: The tumor may or may not have grown outside the testicle (any pT), or the extent of the tumor can’t be assessed for some reason (TX). The cancer might or might not have spread to nearby lymph nodes (any N). It has spread to distant lymph nodes or to the lungs (M1a). At least 1 tumor marker level is very high (S3).
• Any pT or TX, Any N, M1b, Any S: The tumor might or might not have grown outside the testicle (any pT), or the extent of the tumor can’t be assessed for some reason (TX). The cancer might or might not have spread to nearby lymph nodes (any N). It has spread to distant parts of the body other than the lymph nodes or to the lungs (M1b). Tumor marker levels might or might not be higher than normal (any S).

How is testicular cancer treated?

Treatment for testicular cancer depends on many things, like your cancer stage, age, overall health, and testing results. Your treatment may include some or all the following:

• Surgery.
• Radiation therapy.
• Chemotherapy.
• Clinical trials.

Surgery

Surgery to remove the testicle with cancer is called an orchiectomy (or a radical inguinal orchiectomy). For the most part, all cases of testicular cancers are treated with surgery (even if it has spread). An incision (surgical cut) is made within the groin. The affected testicle is removed from the scrotum through the incision. The surgeon then removes the tumor, the testicle, and the spermatic cord. The spermatic cord has blood and lymph vessels that can help testicular cancer spread, so these vessels are tied off early in the operation.

Some patients may also need lymph nodes removed. There are two ways to remove lymph nodes:

• Retroperitoneal lymph node dissection (RPLND): This can be done at the same time as the orchiectomy, or it can be done as a second surgery. If the cancer has spread to the lymph nodes at the back of your abdomen (belly), they will need to be removed. This is a long and complex surgery. Talk with your provider about if a RPLND is needed and who will be performing the surgery.
• Laparoscopic lymph node removal: Many small incisions are made. A laparoscope (a lighted tube with a camera) is placed into one of these incisions. The lymph nodes are removed through one of the small incisions in the abdomen.

Radiation Therapy

Radiation therapy is the use of high-energy x-rays to kill cancer cells. Radiation is mostly used in testicular cancer to treat spread to lymph nodes. Radiation may be used after orchiectomy surgery to help kill any remaining cancer cells in the lymph nodes at the back of the abdomen. Radiation may also be used to treat metastasis (spread) to other organs, like the brain.

Chemotherapy

Chemotherapy is the use of anti-cancer medications to kill cancer cells. Chemotherapy medications used to treat testicular cancer are often given into a vein (IV, intravenously) so that it travels throughout the body. Chemotherapy is used when the cancer has spread outside of the testicle. It is also used to help keep the cancer from coming back (recurring).

Which medications you receive depends on your age, overall health, and your tumor type and stage. Some common chemotherapy medications used to treat testicular cancer are: cisplatin, bleomycin, ifosfamide, paclitaxel, vinblastine, and etoposide. In some tumors, immunotherapy medications, such as pembrolizumab or nivolumab may be an option for metastatic testicular cancer. As with surgery, sexuality and fertility issues should be discussed before treatment is started.

In rare cases, high dose chemotherapy may be given, followed by an autologous stem cell transplant. High dose chemotherapy uses combinations of carboplatin, etoposide, paclitaxel, ifosfamide, gemcitabine and oxaliplatin. After the chemotherapies are given, cells are collected from the patient and then reinfused intravenously (IV). This therapy is still being studied in clinical trials.

Clinical Trials

You may be offered a clinical trial as part of your treatment plan. To find out more about current clinical trials, visit the OncoLink Clinical Trials Matching Services.

Making Treatment Decisions

Your care team will make sure you are included in choosing your treatment plan. This can be overwhelming as you may be given a few options to choose from. It feels like an emergency, but you can take a few weeks to meet with different providers and think about your options and what is best for you. You should also talk with your care team about options for fertility preservation if that is something that interests you. Treatment is a personal decision. Friends and family can help you talk through the options and the pros and cons of each kind of treatment, but they cannot make the decision for you. You need to be comfortable with your decision – this will help you move on to the next steps. If you ever have any questions or concerns, be sure to call your team.

You can learn more about testicular cancer at OncoLink.org.