Testis and epididymis
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Pathologic TNM staging of Testis Germ Cell Tumor and Malignant Sex Cord Stromal Tumor (AJCC 8th edition)


Topic Completed: 1 January 2018

Revised: 30 December 2019

Copyright: 2002-2019, PathologyOutlines.com, Inc.

PubMed Search: Staging[title] testis

Debra Zynger, M.D.
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Cite this page: Zynger, D. Pathologic TNM staging of Testis Germ Cell Tumor and Malignant Sex Cord Stromal Tumor (AJCC 8th edition). PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/testisstaging.html. Accessed April 3rd, 2020.
Definition / general
  • All testicular postpubertal germ cell tumors and malignant sex cord stromal tumors are covered by this staging system
  • These topics are not covered: spermatocytic tumor, nonmalignant sex cord stromal tumor, prepubertal germ cell tumor, hematopoietic tumors and paratesticular tumors
Essential features
  • AJCC 7th edition staging was sunset on December 31, 2017; as of January 1, 2018, use of the 8th edition is mandatory
Primary tumor (pT)
  • pTX: cannot be assessed
  • pT0: no evidence of primary tumor
  • pTis: germ cell neoplasia in situ
  • pT1: nonpure seminoma confined to testis / tunica albuginea / rete and no lymphovascular invasion (LVI)
  • pT1a: seminoma < 3 cm confined to testis / tunica albuginea / rete and no LVI
  • pT1b: seminoma ≥ 3 cm confined to testis / tunica albuginea / rete and no LVI
  • pT2: lymphovascular, hilar fat, epididymal or tunica vaginalis invasion
  • pT3: direct spermatic cord soft tissue invasion
  • pT4: direct scrotum invasion

Notes:
  • LVI of the spermatic cord without soft tissue invasion is not pT3
Regional lymph nodes (pN)
  • pNX: cannot be assessed
  • pN0: no regional lymph node metastasis
  • pN1: 1 - 5 involved nodes with node size ≤ 2 cm
  • pN2: > 5 involved nodes OR extranodal extension OR involved nodes > 2 cm and ≤ 5 cm
  • pN3: lymph node mass > 5 cm

Notes:
  • Regional lymph nodes = interaortocaval, para / periaortic, paracaval, preaortic, precaval, retroaortic and retrocaval nodes
Distant metastasis (pM)
  • pM1a: nonregional lymph node (ex: iliac, inguinal, pelvic NOS) or lung metastasis
  • pM1b: distant metastasis (includes discontinuous spermatic cord, not lymph node / lungs)
Serum markers (S)
  • SX: serum tumor markers not available or not performed
  • S0: markers within normal limits
  • S1: LDH < 1.5 x upper limit of normal, hCG < 5,000 mIU/mL and AFP < 1000 ng/mL
  • S2: LDH 1.5 - 10 x upper limit of normal OR hCG 5,000 - 50,000 mIU/mL OR AFP 1,000 - 10,000 ng/mL
  • S3: LDH > 10 x upper limit of normal OR hCG > 50,000 mIU/mL OR AFP > 10,000 ng/mL
AJCC prognostic stage groups
  • Stage group 0:pTis N0 M0 S0
  • Stage group I:pT1 - 4 N0 M0 SX
  • Stage group IA:pT1 N0 M0 S0
  • Stage group IB:pT2 - 4 N0 M0 S0
  • Stage group IS:pT1 - 4,X N0 M0 S1 - 3
  • Stage group II:pT1 - 4,X N1 - 3 M0 SX
  • Stage group IIA:pT1 - 4,X N1 M0 S0 - 1
  • Stage group IIB:pT1 - 4,X N2 M0 S0 - 1
  • Stage group IIC:pT1 - 4,X N3 M0 S0 - 1
  • Stage group III:pT1 - 4,X N0 - 3 M1 SX
  • Stage group IIIA:pT1 - 4,X N0 - 3 M1a S0 - 1
  • Stage group IIIB:pT1 - 4,X N1 - 3M0 S2;pT1 - 4,XN0 - 3M1aS2
  • Stage group IIIC:pT1 - 4,X N1 - 3M0S3; pT1 - 4,XN0 - 3 M1aS3; pT1 - 4,X N0 - 3M1bS0 - 3
Registry data collection variables
  • Serum tumor markers (AFP, HCG, LDH)
Histologic grade (G)
  • Germ cell tumors are not graded
Histopathologic type
  • Seminoma
  • Nonseminoma
    • Embryonal carcinoma
    • Yolk sac tumor
    • Teratoma
    • Choriocarcinoma
  • Mixed germ cell tumor
  • Malignant Leydig cell tumor
  • Malignant Sertoli cell tumor
  • Malignant sex cord stromal tumors, other types
Gross images

Contributed by Debra Zynger, M.D.

Teratoma (pT1)

Seminoma (pT1a)

Seminoma (pT1b)

Mixed germ cell tumor (pT2)

Seminoma (pT2)

Lymph node with residual tumor (ypN3)

Microscopic (histologic) images

Contributed by Debra Zynger M.D.

Epididymal invasion (pT2)

Lymphovascular invasion (pT2)

Tunica vaginalis invasion (pT2)


Hilar soft tissue invasion (pT2)

Discontinuous spermatic cord invasion (pM1b)

Lymph node metastasis (pN1)

Board review style question #1

    In a postpubertal testicular germ cell tumor, lymphovascular (shown here), hilar fat, epididymal and tunica vaginalis invasion are all a part of which pT category?

  1. pT1
  2. pT1a
  3. pT1b
  4. pT2
  5. pT3
Board review answer #1
D. pT2. Lymphovascular, hilar fat, epididymal and tunica vaginalis invasion are all a part of the pT2 category for testicular germ cell tumors. Lymphovascular invasion by embryonal carcinoma is shown in the image.

Reference: Pathologic TNM staging of Testis Germ Cell Tumor and Malignant Sex Cord Stromal Tumor (AJCC 8th edition)

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Board review style question #2

    The postpubertal teratoma shown in the gross photo is 1.7 cm and is confined to the testis and did not have lymphovascular invasion. Which is the correct pT category?

  1. pT1
  2. pT1a
  3. pT1b
  4. pT2
  5. pT3
Board review answer #2
A. pT1. Postpubertal germ cell tumors that are confined to the testicular parenchyma and lack lymphovascular invasion are pT1, pT1a or pT1b. Pure seminoma is stratified as pT1a and pT1b based on a 3 cm threshold. Nonpure seminomas are not stratified and therefor this tumor is pT1.

Reference: Pathologic TNM staging of Testis Germ Cell Tumor and Malignant Sex Cord Stromal Tumor (AJCC 8th edition)

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