Testicular Cancer Resource Center

About this page: This page explains what a testicular-cancer stage means, how doctors arrive at the stage, and why prognosis is not the same thing as stage. It is the plain-language version. If you want the exact definitions and cutoffs, use the Detailed Staging Reference.

Staging is a way of describing how much cancer is present and where it is in the body. In testicular germ-cell cancer, doctors combine what they know about the tumor in the testicle, the regional lymph nodes, any distant spread, and the blood tumor markers. The stage helps describe the extent of the cancer and is one of the major pieces of information used to plan treatment.

Most men have an orchiectomy before the final stage is assigned because the pathology identifies the tumor and shows how far it extended in and around the testicle. There are unusual situations in which doctors can assign a clinical stage before the orchiectomy, but that is not the usual sequence.

Stage 0

Precancerous germ cells called GCNIS are present, but there is no invasive cancer yet.

Stage I

The cancer is limited to the testicle and nearby structures. Scans show no spread to lymph nodes or distant organs, and the post-orchiectomy tumor-marker blood tests used for staging are normal.

Stage IS

Scans do not show spread, but AFP or beta-hCG remain abnormal, fail to fall as expected, or rise after orchiectomy. That means marker-producing cancer is presumed to remain somewhere even though the scans cannot show it.

Stage II

The cancer has reached the regional lymph nodes in the back of the abdomen, but there is no distant spread. IIA, IIB and IIC describe increasing amounts of lymph-node disease.

Stage III

The cancer has spread farther, such as to distant lymph nodes, the lungs or other organs. Regional lymph-node disease can also be Stage IIIB or IIIC when the post-orchiectomy tumor-marker levels are sufficiently high.

Stage IV

There is no Stage IV testicular germ-cell tumor.

The American Joint Committee on Cancer (AJCC) staging system combines four pieces of information, usually written as TNM-S:

T = Tumor
How far the original tumor has extended in and immediately around the testicle. This usually comes from the orchiectomy pathology report.

N = Nodes
Whether cancer has reached the regional retroperitoneal lymph nodes, and how much is there.

M = Metastasis
Whether cancer has spread beyond the regional nodes to distant lymph nodes, the lungs, or other organs.

S = Serum tumor markers
The AFP, beta-hCG and LDH blood results used in the formal stage. The timing of the blood test matters.

You do not need to memorize those definitions. The Detailed Staging Reference has the full T, N, M and S rules and the complete stage-grouping table.

A clinical stage uses the information available from blood tests, imaging, physical examination and any pathology already available. Most patients will already have orchiectomy pathology when their clinical stage is assigned, but the retroperitoneal lymph nodes are still being judged from scans. That is why a clinical nodal category is written as cN.

A pathological nodal stage becomes possible when retroperitoneal lymph nodes are removed, usually during an RPLND, and examined under the microscope. The nodal category can then be written as pN. A man who looks like Clinical Stage I on CT can turn out to have Pathological Stage II after an RPLND finds microscopic cancer in the nodes. The reverse can happen too: a suspicious node on imaging can turn out not to contain cancer. Distant metastases such as lung nodules are usually staged from imaging and do not need to be biopsied just to assign Stage III.

AFP, beta-hCG and LDH are measured before the orchiectomy and again afterward. The pre-orchiectomy values are useful as a baseline. For the usual post-orchiectomy AJCC stage, however, doctors use blood tests drawn after orchiectomy and before additional treatment.

AFP and beta-hCG do not disappear from the blood the instant the marker-producing cancer is removed. If the first blood test after surgery still shows elevated tumor markers, doctors follow the values with additional blood tests. If they keep falling, the staging value is based on the lowest value reached when the marker normalizes or levels off. If a marker starts rising again, the lowest value before that rise is used. In other words, the first blood draw after surgery is not automatically the blood draw used for staging.

Concept only, not to scale. A blood test close to the orchiectomy gives a more useful baseline than one drawn weeks earlier because a tumor-marker level can change before the cancer is removed. After orchiectomy, AFP and beta-hCG may fall into the normal range, fall to an abnormal plateau, remain high, or rise. Some patients have normal markers throughout. AFP and beta-hCG also clear at different speeds. LDH is part of the formal staging system, but it is less tumor-specific and is not shown here because it does not have the same useful post-orchiectomy half-life interpretation.

As if staging were not confusing enough, patients with metastatic or marker-positive germ-cell cancer who are going to receive first-line chemotherapy are also placed into an IGCCCG prognosis group. IGCCCG stands for the International Germ Cell Cancer Collaborative Group. This does not replace the AJCC stage. It answers a different question: how do patients with this pattern of disease and these tumor-marker levels tend to do with cisplatin-based chemotherapy?

For nonseminoma, the classic IGCCCG groups are good, intermediate and poor prognosis. Seminoma has good and intermediate groups, but no poor-prognosis group. These names are formal categories, not everyday descriptions of whether someone is likely to survive. Even many patients in the poor-prognosis group are cured.

The IGCCCG classification uses the histology, where the germ-cell tumor started, whether cancer has spread to organs other than the lungs, and the tumor-marker blood tests measured immediately before starting first-line chemotherapy for metastatic disease. The Stage & Prognosis Calculators page includes the classic good/intermediate/poor calculator. For metastatic nonseminoma, it also links to the official newer IGCCCG Update tool that gives a more individualized prognosis.

Example 1: Clinical Stage I becomes Pathological Stage II

What is known: Orchiectomy pathology shows pT2 nonseminoma. Post-orchiectomy tumor markers are normal. CT or MRI shows no enlarged retroperitoneal nodes, and chest imaging shows no distant disease.

Classification: pT2 cN0 M0 S0 = Clinical Stage IB. An RPLND later finds two small positive nodes, changing cN0 to pN1 and the result to Pathological Stage IIA.

What this shows: Imaging can miss microscopic nodal disease.

Example 2: Clinical Stage IIA becomes Pathological Stage I

What is known: Orchiectomy pathology shows pT1 nonseminoma. Post-orchiectomy tumor markers are normal. Imaging shows one persistent 1.8 cm retroperitoneal node and no distant disease.

Classification: pT1 cN1 M0 S0 = Clinical Stage IIA. RPLND finds no cancer in the removed nodes, changing cN1 to pN0 and the result to Pathological Stage IA.

What this shows: Imaging can overstage as well as understage.

Example 3: Stage IS

What is known: Imaging shows no regional or distant disease, but AFP stops falling as expected after orchiectomy and remains clearly elevated on serial blood tests.

Classification: N0 M0 with persistent post-orchiectomy tumor-marker elevation = Stage IS.

What this shows: Tumor-marker behavior can demonstrate persistent disease even when imaging is negative.

Example 4: Stage III can still have an excellent prognosis

What is known: Nonseminoma has spread to the lungs, but there are no liver, bone or brain metastases and the tumor markers immediately before first-line chemotherapy remain in the IGCCCG good-prognosis range.

AJCC classification: Stage IIIA.

IGCCCG classification: GOOD prognosis.

What this shows: Stage III does not automatically mean a low chance of cure. Good-prognosis metastatic germ-cell cancer remains highly curable.

Example 5: Very high markers can create poor-prognosis disease without visceral metastases

What is known: Orchiectomy pathology shows nonseminoma. CT shows several retroperitoneal lymph nodes between 2 and 5 cm, so the nodal category is cN2. There are no lung, liver, bone or brain metastases, so M0 applies. Immediately before first-line chemotherapy, beta-hCG is 80,000 mIU/mL.

AJCC classification: beta-hCG above 50,000 is S3, so cN2 M0 S3 = Stage IIIC.

IGCCCG classification: beta-hCG above 50,000 places nonseminoma in the POOR-prognosis group.

What this shows: Very high tumor markers can be important even when scans do not show visceral metastases. Poor prognosis is a formal statistical category and does not mean the cancer cannot be cured.

When expert input matters most: Intermediate- and poor-prognosis disease is less common and more complicated. Current European guidelines report better outcomes for intermediate- and poor-prognosis patients treated at high-volume centers, and recommend that poor-prognosis patients be managed at centers with interdisciplinary germ-cell-tumor expertise whenever possible. If you fall into one of these groups, it is reasonable to ask whether your doctor should consult a testicular-cancer expert or expert center.

Testicular Cancer Info: Staging