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Staging

​Revised 08 May 2013 

The BC Cancer Agency employs the TNM system (UICC 7th Edition, 2009) and the Classification of the International Germ Cell Collaborative Group (J Clin Oncol 1997).

4.1 

Testis Staging Diagram
UICC 7th Edition, 2009  (Pls note: pM0 and pMx are no longer valid categories)

To define the clinical stage of a patient with gonadal germ cell tumour the TNM classification of the UICC should be used (1). In addition, most patients with metastatic disease are classified according to the classification of the International Germ Cell Cancer Collaborative Group (IGCCCG) (2) which is based on prognostic factors rather than anatomical distribution of metastases. The individual treatment strategy is based on both the TNM classification and the IGCCCG-prognostic factor-based classification which includes histology, location of primary tumour, location of metastases and level of AFP, ß-HCG and LDH as prognostic markers to categorize patients into "good", "intermediate" and "poor" prognosis. Patients with a mixed seminomatous/ non-seminomatous tumor are considered and treated as non-seminoma.

IGCCCG prognostic grouping classification for metastatic Germ Cell Tumours:

Prognosis

5-year-survival

Non-Seminoma

Seminoma

good

90%

Testis or primary extragonadal retroperitoneal tumour 
and low markers: AFP <1.000 ng/ml
and ß-HCG <5.000 IU/l (<1.000 ng/ml)
and LDH <1.5 x normal level
and no non-pulmonary visceral metastases

Any primary localisation
Any marker level 
and no non-pulmonary visceral metastases

intermediate

75%

Testis or primary extragonadal retroperitoneal tumour
and intermediate markers
AFP 1.000-10.000 ng/ml
and/or ß-HCG 5.000-50.000 IU/l (1.000-10.000 ng/ml)
and/or LDH 1,5 – 10 x normal level
and no presence of non-pulmonary visceral metastases

Any primary localisation
and presence of non-pulmonary visceral metastases (liver, CNS, bone, intestinum)
Any marker level

poor

50%

Primary mediastinal germ cell tumour with or without testis or primary retroperitoneal tumour
and presence of non-pulmonary visceral metastases (liver, CNS, bone, intestinum)
and/or "high markers"
AFP >10.000 ng/ml,
ß-HCG >50.000 IU/l 
(10.000 ng/ml)
or LDH >10 x normal level

4.2 Investigations for Staging

In order to allow accurate staging, all staging investigations should be done within 4 weeks pre- or 4-6 weeks post orchiectomy (in particular for the determination of stage I disease).

CBC, creatinine, liver function tests, bHCG, AFP, LDH. Markers should be followed weekly until normal after initiation of treatment

  • CXR if not done preoperatively (sufficient for stage I seminoma)
  • CT scan of chest (not necessary for stage I seminoma), abdomen and pelvis
  • Additional imaging may be required for specific sites of disease and to localize kidneys (if radiotherapy is being considered).
  • Sperm count (with or without banking as appropriate) if fertility is a concern
  • Pituitary gonadotropins may be measured in patients where there is concern over oligospermia
  • Bone scans should be obtained in patients with elevated levels of alkaline phosphatase or if bone metastases are clinically suspected
  • Imaging of the brain by CT or preferably by MRI is required in patients with clinical signs potentially indicating brain metastases and in patients with extensive lung involvement and/or poor prognosis criteria NSGCT
  • Note: PET scan or CT PET scans ARE NOT RECOMMENDED as part of routine staging.

References:

  1. Testis. In Sobin L, Gospodarowicz M, Wittekind C et al. (eds): UICC Classification of Malignant Tumours, Seventh Edition. Wiley-Blackwell 2009.

  2. Mead G,. International Germ Cell Consensus Classification: a prognostic factor-based staging system for metastatic germ cell cancers. International Germ Cell Cancer Collaborative Group. J Clin Oncol 1997; 15: 594-603.

SOURCE: Staging ( )
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