Modified Royal Marsden Staging System
I tumour confined to the testis II nodes involved below the diaphragm
III nodes involved above the diaphragm—supraclavicular or mediastinal
IV extranodal metastases—lung or brain.
Up to 30% of patients with seminoma have metastases at the time of diagnosis, 50-60% with embryonal carcinoma and the majority with choriocarcinoma.
Clinical staging is based on the determination of the anatomical extent of disease and the assessment of postorchidectomy serum markers LDH, human chorionic gonadotrophin p subunit (HCG) and AFP. High levels (AFP >10 000ng/ml, HCG >50 000 IU/l, LDH >10x normal) indicate worse prognosis and usually a diagnosis of non-seminomatous germ cell tumour.
Metastatic germ cell tumour is an important diagnostic consideration in a young male with evidence of extensive visceral disease but no known primary somatic site carcinoma. This is particularly so if there is cervical, mediastinal or retroperitoneal lymphadenopathy or lung metastases. Ultrasound may show a small or scarred testicular lesion. Biopsy of metastases may only show undifferentiated tumour and chemotherapy is instigated empirically on the basis of elevated serum markers. Occasionally poorly differentiated carcinoma of stomach, lung or bladder may cause a modest elevation in serum HCG. Crucially, the pathologist has to think of the possibility of germ cell tumour and look for the distinctive morphological and immunohistological clues (PLAP, CD30, OCT 3/4).
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