Testicular Cancer

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What is Testicular Cancer ?

Testicular cancer begins when normal cells in a testicle change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). Testicular cancer is almost always curable if found early, and it is usually curable even when at an advanced stage. Another name for testicular cancer is testis cancer.

About the testicles

The testicles are part of a man’s reproductive system. Each man has two testicles, and they are located under the penis in a sac-like pouch called the scrotum. They can also be called testes or gonads. The testicles produce sperm and testosterone, a hormone which plays a role in the development of a man’s reproductive organs and characteristics specific to men.

Types of testicular cancer

Most types of testicular cancer develop in the sperm-producing cells known as germ cells, and are referred to as germ cell tumors.

Germ cell tumors in men most commonly start in the testicles but can also develop in other parts of the body, such as the retroperitoneum (the back of the abdomen near the spine), the mediastinum (the central portion of the chest between the lungs), the lower spine, and very rarely, the pineal gland (a small gland in the brain).

There are two different categories of germ cell tumors that occur in the testicles: seminomas and non-seminomas. Generally, non-seminomas tend to grow and metastasize (spread) more quickly than seminomas, but prompt diagnosis and treatment are important for both types of tumors.

Teratoma is a unique type of non-seminoma germ cell tumor. Unlike the other types of germ cell tumors, chemotherapy is not very effective for a teratoma. The primary treatment for teratoma is to remove it with surgery. Although a teratoma is less likely to spread, it needs to be removed because it can turn into a much more dangerous cancer if it is not removed. 

This article provides information only on germ cell tumors (seminomas and non-seminomas) of the testicles in men who have reached puberty. Other, less common types of testicular tumors include Leydig cell tumor, Sertoli cell tumor, and carcinomas of the rete testis (a part of the testicles). These can often be successfully treated by surgically removing the affected tissue; however, if they spread to other areas of the body, they are more difficult to treat. Testicular cancer is uncommon in boys who have not yet reached puberty; childhood testicular cancer is approached differently than cancer in teenagers who have been through puberty and adult men. Other types of cancer, such as lymphoma and leukemia, occasionally spread to the testicles. 

Risk Factors : A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The following factors can raise a man’s risk of developing testicular cancer. However, it is important to note that the cause of testicular cancer is not known.

Age. Testicular cancer is most common in men between the ages of 20 to 45. However, men of any age can develop this disease, and it’s important that any man with symptoms of testicular cancer visit the doctor.

Cryptorchidism (undescended testicle). Men with this condition, in which one or both testicles do not descend into the scrotum before birth as they normally should, have an increased risk of developing testicular cancer. This risk may be lowered if surgery is performed to correct the condition before the boy reaches puberty. Some doctors have recommended that cryptorchidism be corrected when a boy is very young, between six and 15 months, in order to reduce the risk of infertility (inability to produce children). Because cryptorchidism is often corrected at a young age, many men may not know if they had the condition.

Family history. A man who has a close relative (particularly a brother) who has had testicular cancer has an increased risk of developing testicular cancer.

Personal history. Men who have had cancer in one testicle have an increased risk of developing cancer in the other testicle. It is estimated that out of every 100 men with testicular cancer, two will develop cancer in the other testicle.

Race. Although men of any race can have testicular cancer, white men are more likely than men of other races to be diagnosed with testicular cancer. Testicular cancer is rare in black men, but black men with testicular cancer are more likely to die of the cancer than white men, particularly if the cancer has spread beyond the testicle to the lymph nodes or other parts of the body when it is diagnosed.

Human immunodeficiency virus (HIV) infection. Men with HIV or AIDS (acquired immune deficiency syndrome caused by the HIV virus) have a slightly higher risk of developing seminoma.

Symptoms and Signs  : Men with testicular cancer may experience a variety of symptoms or signs. Sometimes, men with testicular cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer, such as a spermatocele (noncancerous cyst that develops in the epididymis, which is near the top of the testicle), varicocele (enlargement of the blood vessels from the testicle), hydrocele (a buildup of fluid in the membrane around the testicle), and hernia (opening in the abdominal muscle).

The first sign of testicular cancer is often enlargement of the testicle or a small lump or area of hardness on the testicle, which can be either painless or painful. Other symptoms may go unnoticed until the cancer is advanced and has spread to other parts of the body. Regular testicular self-examinations and examinations by doctors can help detect the cancer at an early stage, when it is more likely to be successfully treated. If you are concerned about a symptom or sign, please talk with your doctor.         

Symptoms of testicular cancer may include:

Painless lump or swelling on either testicle. If detected early, a testicular tumor may be about the size of a pea or a marble, but it can grow much larger. Any lump, enlargement, hardness, pain, or tenderness of the testicle should be evaluated by a doctor as soon as possible.

Pain or discomfort (with or without swelling) in a testicle or the scrotum. Pain can be caused by many different conditions, including infections, injury, twisting, and cancer. Infection of the testicle is called orchitis. Infection of the epididymis is called epididymitis. The epididymis is a small organ attached to the testicle that is made up of coiled tubes that carry sperm away from the testicle. If infection is suspected, a patient may be given a prescription for antibiotics. If antibiotics do not solve the problem, tests for testicular cancer are often performed.

Change in the way a testicle feels. For example, one testicle may also become more firm than the other testicle. Or, testicular cancer may cause the testicle to grow bigger or to become smaller.

Feeling of heaviness in the scrotum. For example, a testicle that feels very firm or hard may be a sign of a problem.

Dull ache in the lower abdomen or groin

Sudden buildup of fluid in the scrotum

Breast tenderness or growth. Although rare, some testicular tumors produce hormones that cause breast tenderness or growth of breast tissue (a condition called gynecomastia).

Lower back pain, shortness of breath, chest pain, and bloody sputum (phlegm) can be symptoms of later-stage testicular cancer, but many other diseases can also cause these symptoms.

Men with testicular cancer have an increased risk of blood clots in the veins that can cause swelling in one or both legs and shortness of breath. Swelling or shortness of breath from a blood clot in a large vein (called deep venous thrombosis or DVT) or a pulmonary (lung) artery (called pulmonary embolism) in a young or middle-aged man may be the first sign of a testicular cancer.

Finding testicular cancer early : Most often, testicular cancer can be detected at an early stage, and men often find the cancer themselves while performing self-examinations. Some doctors recommend that men ages 15 to 55 perform a monthly self-examination to identify any changes. However, some testicular cancers may not cause symptoms and may go undetected until they reach an advanced stage. Men who notice a lump, hardness, enlargement, pain, or any other change in one or both of their testicles should visit their doctor immediately.

Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

Diagnosis : Doctors use many tests to diagnose cancer and find out if it has metastasized. Some tests may also determine which treatments may be the most effective.

When a man develops a testicular lump or something else that could be testicular cancer, it is important that he see his primary doctor, who may send him to a urologist (the doctor who specializes in treating a man with testicular cancer). A physical examination and an ultrasound (see below) of the testicles are usually the first tests performed. If these tests show an abnormality that appears to be a tumor, then blood tests are done. It may be necessary to surgically remove the testicle, so it can be examined under a microscope to find out whether cancer is present. Imaging tests, such as computed tomography (CT or CAT) scans and x-rays, may also be used to find out whether the cancer has spread. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

Type of cancer suspected

Severity of symptoms

Previous test results

If the doctor suspects testicular cancer, he or she will ask about a man's medical history and general health. The following tests may be used to diagnose testicular cancer:

Physical examination. The doctor will feel the testicles for any sign of swelling, tenderness, or hardening. The doctor will also feel the abdomen, neck, upper chest, armpits and groin for evidence of enlarged lymph nodes, which may indicate that the cancer has spread. The breasts and nipples will also be examined to look for enlargement.

Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. The sound waves produced by the ultrasound bounce off tissue in the scrotum. The echoes of the sound waves produce a series of images called a sonogram. These images of the testicle help the doctor find any tumors or other abnormalities. If a tumor is found and is large enough to be seen on an ultrasound, then the sonogram will show the size, location, and solidness of the tumor. A solid tumor inside the testicle is very likely to be cancerous.

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer, but biopsies of a testicle is almost never used to diagnose testicular cancer. Instead, if cancer is suspected in a testicle, the standard procedure is to surgically remove the entire testicle (called an orchiectomy; see below). In fact, a biopsy of the testicle using a needle through the skin of the scrotum should NOT be performed because this can complicate future treatment options. Occasionally, a biopsy may be taken from the lung or the retroperitoneum or other location in the body if it appears that cancer may have spread.

Orchiectomy/surgical pathology tests. If testicular cancer is suspected, a surgeon will perform a radical inguinal orchiectomy, in which the entire testicle is removed through an incision in the groin. Then, a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease) will examine very thin slices of tissue from the testicle under a microscope to diagnose the type of cancer. For a cancer to be considered a seminoma, it must be pure seminoma. Non-seminoma is diagnosed if any of the following are found in the tissue: choriocarcinoma, embryonal carcinoma, yolk sac tumor, or teratoma. Each of these can occur alone or in any combination. Sometimes, seminoma cancer can be found as a part of non-seminoma at any percentage level. For example, a tumor that is 99% seminoma and 1% yolk sac tumor is still diagnosed and treated as non-seminoma.

If the man has one testicle to begin with or the diagnosis is uncertain, the surgeon may remove only a small sample of tissue from the testicle. The testicle may still need to be removed if there is evidence of cancerous cells. If the tissue sample does not show cancer, it may be possible to repair the damage from the tissue removal and replace the testicle back into the scrotum during the same surgery. However, this procedure is very rare.

Blood tests/tumor markers.  If a decision is made to perform an orchiectomy, a sample of blood will be collected before surgery to test for levels of serum tumor markers, which are substances made by a cancer that are found at abnormally high levels in the blood of a person with cancer. Serum tumor marker levels do not help decide whether or not the orchiectomy is recommended, but they can help confirm whether a tumor is a pure seminoma and help determine the stage of the cancer. Different types of cancer make different tumor markers. High levels of any one of three tumor markers (see below) may indicate testicular cancer. It is also possible to have this type of cancer and have normal tumor marker levels.

The three tumor markers used to help diagnose and plan treatment for testicular cancer are alpha-fetoprotein (AFP), beta human chorionic gonadotropin (beta-hCG), and lactase dehydrogenase (LDH). AFP is a tumor marker that is not made by seminomas, so an elevated level of AFP indicates the tumor is not a pure seminoma, even if it looks like a pure seminoma when examined by a pathologist. The tumor marker beta-hCG can be high from either seminoma or non-seminoma. However, it is important to note that AFP and beta-hCG levels are normal in up to 40% of men with non-seminomas and in most men with seminomas. LDH can be elevated in any type of testicular cancer, as well as in many other cancers and non-cancerous diseases, such as liver disease or heart disease. Placental alkaline phosphatase (PLAP) is another tumor marker doctors may test for, although it is not commonly measured. 

If cancer is found, other tests will be needed to determine the stage of the cancer and whether it has spread to other parts of the body. Usually, doctors recommend imaging tests of the abdomen, pelvis and chest. Images of the brain or bones are not as common. Imaging tests may include:

X-ray. An x-ray is a way to create a picture of the structures inside of the body, using a small amount of radiation. A chest x-ray is used to determine the stage of the cancer and for follow-up screening. If a more detailed picture of the lung is needed, then the doctor may recommend a chest CT scan (see below) but in many situations an x-ray is preferred.

CT scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that can be examined to look for any abnormalities or tumors. Often, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail. CT scans are the most common imaging test for men with testicular cancer, and they can be used to evaluate the abdomen, pelvis, chest (including the lungs), brain and other areas. For men who have a normal CT scan of the abdomen and pelvis and normal serum tumor markers, a CT scan of the chest is usually not needed and a chest x-ray (see above) is used instead. CT scans of the brain are rarely needed for men with testicular cancer because it is uncommon for it to spread to the brain. However, if a scan of the brain is needed, MRI (see below) is generally preferred because the skull bones interfere with the ability of CT scans to show certain parts of the brain.

MRI scan. An MRI scan uses magnetic fields to create a three-dimensional picture of the inside of the body. A computer then combines the images in a detailed, cross-sectional view that shows any abnormalities or tumors. For men with testicular cancer, CT scans (see above) are generally preferred to MRI for viewing the abdomen because accurately reading MRI scans of the abdomen requires extensive experience.

MRI is used only in specific situations. For instance, an MRI of the brain might be recommended if the patient has neurological symptoms or abnormalities on a physical examination that suggest that the cancer may have spread to the brain. In addition, brain MRIs are often recommended for men who have poor-risk metastatic testicular cancer with very high serum tumor markers or if the cancer has spread to the liver or bones. Rarely, an MRI may be used to look at the abdomen, pelvis, or other parts of the body. Your doctor will explain which test is appropriate for you.

PET scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. Studies of PET scans have shown that they are not helpful for diagnosing or staging testicular cancer. However, they may be helpful for men with metastatic pure seminoma that does not entirely disappear after chemotherapy, but should not be done until at least six weeks after chemotherapy ends.

Stages : Staging is a way of describing where a cancer has spread. Doctors use diagnostic tests, including CT scans and blood tests, to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and helps predict a patient's prognosis. Patients with early stage cancers are more likely to be cured and often need less aggressive treatment than patients with more advanced stage cancers. There are different stage descriptions for different types of cancer. 

There are also two different types of staging in testicular cancer: clinical staging and pathological staging. In clinical staging, the stage is based on a physical examination of the patient or x-rays, CT scans, and other imaging tests . In pathological staging, the stage is based on evaluating tissue under a microscope after it has been removed during surgery. Pathological staging for testicular cancer is especially important when there is cancer in the retroperitoneal lymph nodes. For example, clinical stage II testicular cancer means that the retroperitoneal lymph nodes are enlarged when viewed with a CT or MRI scan. Whereas, pathological stage II testicular cancer means that cancer has been found when tissue removed from the retroperitoneal lymph nodes is examined under a microscope. Pathological staging is more accurate than clinical staging, but it is not always necessary.

One tool that doctors use to describe the stage is the TNM system. This system judges three factors: the initial tumor in the organ where the cancer started (sometimes referred to as the primary tumor), whether the cancer has spread to the lymph nodes in the back of the abdomen (retroperitoneum), and whether the tumor has spread to other parts of the body.

For testicular cancer, the TNM staging system also includes information on the levels of the three serum (S) tumor markers: AFP, beta-hCG, and LDH . For staging purposes, these blood tests are done before the surgical removal of the affected testicle(s). For patients receiving chemotherapy for metastatic cancer, the tumor marker levels on the first day of chemotherapy are the values used for staging.

The results of the different tests described in the Diagnosis section are combined to determine the stage of the cancer. There are three stages of testicular cancer: stages I, II, and III (one, two, and three). The stage provides a common way of describing how advanced the cancer is so that doctors can work together to plan the best treatments. Stage I is the least advanced and stage III is the most advanced. The staging process is described in more detail below.

TNM staging system : TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors, plus serum tumor markers (S), to determine the stage of testicular cancer:

How much has the primary tumor grown and where is it located? (Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer metastasized to other parts of the body? (Metastasis, M)

Are serum tumor markers elevated and, if so, how high are they? (Serum, S)

Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. For testicular cancers, the T stage can only be determined when tissue removed during surgery is examined under a microscope. This means that the T stage is only determined after the testicle is removed, and the T stage is always a pathological stage and never a clinical stage. The “p” before the T stage indicates that it is a pathological stage. Specific tumor stage information is below.

pTX: The primary tumor cannot be evaluated. If a man has not had a radical inguinal orchiectomy (surgical removal of the testicle[s]), the term "TX" is used.

pT0: There is no evidence of a primary tumor in the testicles.

pTis: In this stage, there is intratubular germ cell neoplasia (a precancerous condition in which there are germ cells that appear cancerous but are not yet behaving the way cancer cells do), also called carcinoma in situ (CIS). CIS becomes cancer when the cells spread to areas of the testicle(s) where they do not normally belong.

pT1: The primary tumor is only in the testicle (with or without involvement of the epididymis or rete testis), and it has not invaded blood vessels or lymph vessels in the testicles. The tumor may have invaded the tunica albuginea (the inner membrane layer surrounding the testicle) but not the tunica vaginalis (the outer membrane layer surrounding the testicle).

pT2: The tumor is in the testicle (with or without involvement of the epididymis or rete testis) and has invaded blood vessels or lymphatic vessels, and/or the tumor has grown through the tunica albuginea and into the tunica vaginalis.

pT3: The tumor has invaded the spermatic cord.

pT4: The tumor has invaded the scrotum.

Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph is a fluid that flows from the different tissues and organs of the body and eventually drains into the blood stream. It passes through specialized tubes called lymphatic vessels and is filtered along the way by the lymph nodes. Cancer cells often buildup and grow in lymph nodes before they spread to other parts of the body. The first place the lymphatic fluid from the testicles drains is the retroperitoneal lymph nodes located in the retroperitoneum. These are called the regional lymph nodes for testicular cancer. Lymph nodes in the pelvis, chest or other parts of the body are called distant lymph nodes.

In men with testicular cancer, lymph nodes are usually neither biopsied nor removed. Instead, the “N” stage is most often estimated by using CT scans. Lymph node stage (N stage) that is based on CT scans is a clinical stage and N stage based on a biopsy or removal of the lymph nodes is a pathological stage. When a stage has been determined pathologically, the letter “p” is added as the first letter of the stage (for example pN1).

NX: The regional lymph nodes cannot be evaluated.

cN0: There is no spread to regional lymph nodes as seen on imaging tests.

pN0: There is no cancer found in lymph nodes removed during RPLND .

cN1: Imaging tests show at least one enlarged lymph node in the retroperitoneum but none of the enlarged lymph nodes are bigger than 2 centimeters (cm).

pN1:There is cancer in one to five lymph nodes and none is larger than 2 cm.

cN2: Imaging tests show at least one enlarged lymph node (or lymph node mass) in the retroperitoneum that is larger than 2 cm but not larger than 5 cm.

pN2: Either or both of the following conditions:

There is cancer in more than five lymph nodes but none are larger than 5 cm.

There is cancer in at least one lymph node that is bigger than 2 cm and smaller than 5 cm

cN3: Imaging tests show at least one enlarged lymph node or a lymph node mass in the retroperitoneum larger than 5 cm.

pN3:There is cancer in at least one enlarged lymph node or lymph node mass that is larger than 5 cm.

Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body. When testicular cancer spreads, it most commonly spreads to the lung and the lymph nodes of the chest, pelvis, and the base of the neck. More advanced stages may have spread to the liver and bones. Testicular cancer rarely spreads to the brain unless the primary tumor is a choriocarcinoma. 

MX: Distant metastasis cannot be evaluated.

M0: The disease has not metastasized to distant lymph nodes or other organs.

M1: There is at least one distant metastasis.

M1a: There is cancer in distant lymph nodes and/or the lungs.

M1b: The cancer has spread to organs other than the lung (the lungs may or may not also be involved). For example, a testicular cancer that has spread to the liver or the bones is stage M1b.

Serum tumor markers (S). Serum tumor markers also help to stage testicular cancer. As noted in the Diagnosis section, blood tests for tumor markers will be done before and after surgical removal of the testicle(s). The levels taken before the testicle(s) are removed are used for staging. For patients with metastatic testicular cancer who will receive chemotherapy, the tumor marker levels on the first day of chemotherapy are used to determine the patient’s risk group (see below).

SX: Tumor marker levels are not available or tests have not performed.

S0: Tumor marker levels are normal.

S1: At least one tumor marker level is above normal (LDH less than 1.5 times the upper limit of the normal range; and beta-hCG [mIu/mL] less than 5,000, and AFP [ng/mL] less than 1,000).

S2: At least one tumor marker level is substantially above normal (LDH 1.5 to 10 times the upper limit of the normal range, or beta-hCG. [mIu/mL]) 5,000 to 50,000 or AFP [ng/mL] 1,000 to 10,000) and none of the tumor markers is elevated high enough to qualify as S3 (see below).

S3: One or more tumor marker level is very highly elevated (LDH more than 10 times the upper limit of the normal range, or beta-hCG [mIu/mL] more than 50,000 or AFP [ng/mL] more than 10,000).

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications and the S level information.

Stage 0: Refers to carcinoma in situ, also called intratubular germ cell neoplasia (pTis).

Stage I: Cancer is at any T level, and there is no evidence of spread to either lymph nodes or other organs. Serum tumor marker levels have not been performed or are not available (any T, N0, M0, SX).

Stage IA: Cancer is in the testicle and may have invaded the rete testis and the epididymis but has not invaded the lymphatic or blood vessels in the testis or spread to lymph nodes or distant sites. The tumor in the testis may have invaded the inner membrane surrounding the testis (the tunica albuginea) but not the outer membrane (the tunica vaginalis). Serum markers are normal (pT1, N0, M0, S0).

Stage IB: The testicular tumor has invaded the outer membrane surrounding the testicle (the tunica vaginalis), invaded blood or lymphatic vessels within the testicle, spread to the spermatic cord or invaded the scrotum. The cancer has not spread to lymph nodes or distant sites. Serum markers are normal (pT2, pT3, or pT4, and N0, M0, S0).

Stage IS: Cancer is of any T stage (T1, 2, 3 or 4) and has not spread to lymph nodes or distant sites. Serum markers remain above normal levels after the cancerous testicle has been removed (any T, N0, M0, and S1-3). Stage IS non-seminoma testicular cancer is treated the same as stage III testicular cancer.

Stage II: The cancer has spread to any number of regional lymph nodes but not to lymph nodes in other parts of the body or distant organs. Serum markers are unavailable (any T, N1-3, M0, SX).

Stage IIA: Cancer has spread to retroperitoneal lymph nodes, either clinical or pathological stage N1, but none is larger than 2 cm and, if a lymph node dissection has been performed, no more than five lymph nodes contain cancer. In addition, serum tumor markers are at normal levels or slightly high (S0 or S1), and there is no evidence of cancer having spread anywhere other than the retroperitoneum (any T, N1, M0, S0-1).

Stage IIB: Cancer has spread to lymph nodes in the retroperitoneum, at least one of which is greater than 2 cm and none of which are greater than 5 cm (N2); or, if a lymph node dissection has been performed, cancer has spread to at least one lymph node (or lymph node mass) between 2cm and 5cm or to more than five nodes, none more than 5 cm. Serum markers are at normal levels or slightly high (S0 or S1) and there is no evidence of cancer having spread anywhere other than the retroperitoneum (any T, N2, M0, S0-1).

Stage IIC: Cancer has spread to at least one lymph node (or lymph node mass) that is larger than 5 cm (N3). Serum markers are at normal levels or slightly high (S0 or S1) and there is no evidence of cancer having spread anywhere other than the retroperitoneum (any T, N3, M0, S0-1).

Stage III: Cancer has spread to distant lymph nodes or to any organ, and serum tumor marker levels are unknown (any T, N0-3, M1, SX).

Stage IIIA: Cancer has spread to distant lymph nodes or the lungs. Serum markers are at normal levels or slightly elevated (any T, N0-3, M1a, S0-1).

Stage IIIB: Cancer has spread to any lymph nodes (N1, N2, or N3) and/or the lungs but not to any other organs, and serum markers are at substantially and persistently elevated levels (S2) (any T, N1-3, M0, S2; or any T, N0-3, M1a, S2).

Stage IIIC: Either or both of the following: 

Serum marker levels are highly elevated (S3), and the cancer has spread to at least one lymph node or organ (any T, N1-3, M0, S3; or any T, N0-3, M1a, S3).

The cancer has spread to an organ other than the lungs (M1b) (any T, any N, M1b, any S).

Recurrent: Recurrent cancer is cancer that comes back after treatment. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.

Later-stage testicular cancer: risk group classification

If the disease has spread to lymph nodes or other organs, the following system is used to classify a germ cell tumor into a good-risk, intermediate-risk, or poor-risk group. This helps to determine the treatment plan and the likelihood of cure. Patients in the intermediate and poor-risk groups usually receive more chemotherapy than patients in the good-risk category. Even patients with poor-risk disease have about a 50% chance of successful treatment

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