What is Staging?

Once testicular cancer has been diagnosed, the doctor will perform more tests to determine whether the cancer has spread from the testicle to other parts of the body. Classifying a person's cancer by the degree to which it has spread is called staging. Staging is used to determine the available treatment options. Keep in mind that staging is only as accurate as the information available, and the stage of a person's cancer can change as more information or more accurate information is gathered. If the doctor comes out of the operating room and tells you he thinks he got it all, don't be so quick to believe him. It takes urologists, pathologists and radiologists to ultimately determine the stage of the cancer.

There are two type of staging: Clinical and Pathological. Clinical staging uses radiological and physical clues to estimate the stage. Pathological staging uses stronger evidence like tissue samples and blood tests to determine the stage. For example, assume you have gone through the orchiectomy and based on all the test results, your doctor says that you have Clinical Stage I Nonseminoma. At this point you choose to have an RPLND. If they find no cancer during the RPLND, they will change you to Pathological Stage I. If they do find cancer, then you will become Pathological Stage II. As you can see, the Pathological Stage is more accurate since it used actual tissue samples to determine the presence or absence of cancer.

Tests & Procedures

It is one thing for the doctor to do a physical exam and conclude that you probably have cancer. It is another thing to determine the stage. Usually the stage cannot be estimated until after surgery, blood tests and xrays have been done. Here is a list of tests that may be used to determine the stage:

Surgery: Without surgery, in this case an orchiectomy, it is often difficult to conclude that there is cancer there at all, so surgery is usually the first step.

Blood tests: Some testicular cancers secrete something called tumor markers, high levels of certain proteins that can be detected through blood tests. These markers of testicular cancer include alpha-fetoprotein (AFP), beta human chorionic gonadotropin (ß-HCG) and lactate dehydrogenase (LDH). If a guy's AFP or HCG level are above normal AND there is something wrong with his testicle, then you can assume that he has testicular cancer. If the tumor markers do not fall back to normal after an orchiectomy, then you can usually assume that the cancer has spread, even if no other tests show where it has gone. For more information on tumor markers, click here.

Computed Tomography (CT) scanning: This machine uses a rotating X-ray beam to create a series of pictures of the body from many different angles. A computer processes the information and produces a detailed cross-sectional image of selected parts of the body. Sometimes, a dye is injected into a vein to highlight details on the scan. A CT scan is especially valuable for identifying the spread of tumors to lymph nodes. If the tumor markers are high enough, a CT scan may also be done of the brain. Keep in mind, however, that it is hard to see into areas like the abdomen, and just because a CT scan says everything is normal does not mean that the cancer has not spread at all.

Chest X-rays: Simple chest x-rays are often used to determine if the cancer has spread to the lungs. In many cases the doctor will order a CT scan of the chest right after cancer has been diagnosed just to be sure nothing is there. (CT scans can see smaller masses in the lungs than chest x-rays, but in many cases these masses are not tumors.)

Positron Emission Tomography (PET): PET scanning is a relatively new technology that allows doctors to view biological functions. Areas with increased metabolic activity show up as "hot areas" in a PET image. Instead of using an x-ray, they give you a radioactive substance and use the scanner to try to detect where that radioactive material is collecting in the body. The theory is that the radioactive material is more likely to go to solid tumors than other areas of the body. Its use is promising in the future, particularly in evaluating large masses left over after chemotherapy for seminoma. However, at this time it is still experimental, expensive, hard to interpret, not widely available and probably should not be used in staging.

Magnetic Resonance Imaging (MRI): An MRI uses magnetic fields and radio waves to create images of selected areas of the body. These images can show enlarged lymph nodes and abnormal growths in certain organs that may indicate that the cancer has spread. MRI's are typically not used with testicular cancer because the CT scan often produces a better result and costs less.

Lymphangiography: This painful test involves injecting a special radioactive dye into the lymphatic system. Over a period of several hours, the dye collects in areas where cells are dividing and growing quickly. The doctor takes an X-ray, which shows where the dye has gathered and where cancer might be found. This test used to be performed to map out the lymph nodes in the retroperitoneum so the radiation fields could be set up to treat a patient with seminoma tumors. It is rarely used any more because it is not particularly accurate, and it almost certainly is not used for staging. It is a good bet that your doctor is getting on in years if they order this test.

Stages of testicular cancer

After the required testing has been done, the doctors can assign a stage to your cancer. Roughly speaking, here are the Stages used:

• Stage I: Cancer is found only in the testicle. Removing the testicle alone should cure the patient, though many will choose some form of additional treatment just to be sure...
• Stage II: Cancer has spread to the lymph nodes in the abdomen. Removing the testicle alone will not cure the patient, and more treatment is necessary.
• Stage III: Cancer has spread to areas above the diaphragm such as the lungs, neck or brain. There may be also be cancer in parts of the body such as the bones or liver. In this situation, chemotherapy is absolutely required. Surgery may also be needed.
• Stage IV: To the best of my knowledge, there is no such thing as Stage IV testicular cancer. However, it is possible that Stage IV may still be used in some places in Europe. Suffice to say that Stage IV is probably very similar to Stage III.
• Recurrent: Recurrent disease means that the cancer has come back after it has been treated. It may recur in the same place or in another part of the body.

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