1. Clinical Evaluation


Presenting Complaint

Most non-seminomatous germ cell tumours (NSGCTs) will present with a painless testicular lump, in a similar way to seminoma.

  • Pure choriocarcinoma may often present with symptoms related to metastatic disease, including haemoptysis (lung metastasis), headaches/confusion (brain metastasis) or back pain (bony metastasis)

Occasionally patients may complain of scrotal pain or discomfort.

Past Medical History

Important questions include:

  • Past history of crypto-orchidism (undescended testis)
  • Past history of inguinal surgery (due to alterations in lymphatic flow)
  • Presence of chromosomal abnormalities (Down's, Kleinfelter's)


No special questioning required

Family History

About 1-2 percent of germ cell tumours have a genetic component and this is important to inquire into.

Social History

The patient's current family situation is critically important. The desire for future children should be explored. If it has not already occurred, patients should be encouraged to explore sperm banking.
The patient's ability to attend treatment regularly should also be inquired into.


A focussed physical examination should be performed based on patient symptoms.
At the very least, examination of the scrotum, inguinal regions and abdomen should be performed. Chest examination may detect abnormal signs due to metastatic lung deposits.



Three tumour markers are performed to evaluate testicular tumours:

  • AFP is elevated in a number of testicular germ cell tumours, and suggests the presence of embryonal carcinoma or yolk sac carcinoma.
  • β-hCG is produced by syncytiotrophoblastic cells, which can be found in a small number of otherwise 'pure' germ cell tumours (including seminoma). They are always found in choriocarcinoma and this must be excluded if the β-hCG is elevated
  • LDH is not a specific test but, if elevated, can be used to estimate tumour burden and response to disease


CT of the chest, abdomen and pelvis is essential for staging purposes. If a patient has cerebral symptoms or choriocarcinoma then a CT brain is also warranted.


Australian guidelines on staging can be found here.

TNM Staging

The TNM system is used to stage testicular malignancy. Importantly, there are only three levels of overall stage (I, II, III) and serum markers are also considered in the staging system (S stage).

T Stage

T0 - No evidence of primary tumour
Tis - Intratubular Germ Cell Neoplasia
T1 - Tumour limited to testis/epididymis; no invasion into tunica vaginalis; no lymphovascular invasion
T2 - As for T1 but with lymphovascular invasion or involvement of tunica vaginalis
T3 - Invasion of spermatic cord
T4 - Invasion of scrotum

N Stage

N0 - No regional node involvement
N1 - Lymph node metastases, less than 2 cm AND no more than 5 nodes involved
N2 - Lymph node metastases, 2 - 5 cm, OR more than 5 nodes involved
N3 - Lymph node metastases > 5 cm

M Stage

M0 - No distant metastasis
M1a - Non-regional lymph node or lung metastases
M1b - Other metastases

S Stage

Stage β-hCG AFP LDH
S0 Not elevated Not elevated Not elevated
S1 < 5,000 < 1,000 < 1.5 × normal
S2 5,000 - 10,000 1,000 - 10,000 1.5 - 10 × normal
S3 > 10,000 > 10,000 > 10 × normal

Final Stage

Stage T stage N stage M stage S stage
0 Tis N0 M0 S0
IA T1 N0 M0 S0
IB T2-4 N0 M0 S0
IS Any N0 M0 S1-3
IIA Any N1 M0 S0-1
IIB Any N2 M0 S0-1
IIC Any N3 M0 S0-1
IIIA Any Any M1a S0-1
IIIB Any Any M1a S2
IIIC Any Any M1a S3
IIIC Any Any M1b Any

IGCCCG Staging

The International Germ Cell Cancer Collaborative Group (IGCCCG) have determined an additional staging method for germ cell tumours, dividing prognosis into 'good', 'intermediate' and 'poor' depending on staging investigations. It is often recommended that the IGCCCG system be used for determining therapy for metastatic disease.

Stage Seminoma NSGCT TNM Equivalent
Good Any primary site AND
normal tumour markers AND
no non-pulmonary metastases
Testis/Retroperitoneal Primary AND
no non-pulmonary metastases AND
low tumour markers
I -
Intermediate Elevated β-hCG Testis/Retroperitoneal Primary AND
no non-pulmonary metastases AND
medium tumour markers
Poor Not applicable Mediastinal Primary OR
non-pulmonary metastases OR
high tumour markers

The latest release of the TNM staging criteria incorporates the IGCCCG recommendations by splitting Stage III into three sub-stages depending on tumour markers (S stage).