Stages of Childhood Extracranial Germ Cell Tumors

After a childhood extracranial germ cell tumor has been diagnosed, tests are done to find out if cancer cells have spread from where the tumor started to nearby areas or to other parts of the body.

The process used to find out if cancer has spread from where the tumor started to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. In some cases, staging may follow surgery to remove the tumor.

The following procedures may be used:

• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body, such as the brain or lymph nodes. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the chest or lymph nodes, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones with cancer and is detected by a scanner.
• Thoracentesis: The removal of fluid from the space between the lining of the chest and the lung, using a needle. A pathologist views the fluid under a microscope to look for cancer cells.
• Paracentesis: The removal of fluid from the space between the lining of the abdomen and the organs in the abdomen, using a needle. A pathologist views the fluid under a microscope to look for cancer cells.

The results from tests and procedures used to detect and diagnose childhood extracranial germ cell tumors may also be used in staging.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

• Tissue. The cancer spreads from where it began by growing into nearby areas.
• Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
• Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

• Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
• Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if an extracranial germ cell tumor spreads to the liver, the cancer cells in the liver are actually cancerous germ cells. The disease is metastatic extracranial germ cell tumor, not liver cancer.

Stages are used to describe the different types of extracranial germ cell tumors.

Testicular germ cell tumors in children younger than 11 years

The following stages are from the Children's Oncology Group.

• Stage I

  In stage I, the cancer is found in the testicle only. The testicle and spermatic cord are completely removed by surgery and all of the following are true:

  • the capsule (outer covering of the tumor) did not rupture (break open) and a biopsy was not done before the tumor was removed; and
  • all lymph nodes are smaller than 1 centimeter in their shortest diameter on a CT scan or MRI.
• Stage II

  In stage II, the testicle and spermatic cord are removed by surgery and one of the following is true:

  • the capsule (outer covering of the tumor) ruptured (broke open) or a biopsy was done before surgery; or
  • cancer that can only be seen with a microscope remains in the scrotum or in the spermatic cord near the scrotum, and after surgery, tumor marker levels do not return to normal or do not decrease.

  Cancer has not spread to the lymph nodes.

• Stage III

  In stage III, one of the following is true:

  • the cancer has spread to one or more lymph nodes at the back of the abdomen; or
  • lymph nodes are at least 2 centimeters wide or are larger than 1 centimeter but smaller than 2 centimeters in their shortest diameter and either have not changed or are growing when a CT scan or MRI is repeated within 4 to 6 weeks.
• Stage IV

  In stage IV, the cancer has spread to other parts of the body, such as the liver, lung, bone, and brain.

Testicular germ cell tumors in adolescents and young adults 11 years and older

In males older than 15 years, there are only stage I tumors and metastatic tumors. For more information about staging used for testicular germ cell tumors in adolescents and young adults 11 years and older, see Testicular Cancer Treatment.

Ovarian germ cell tumors

Two staging systems are used for ovarian germ cell tumors: Children's Oncology Group and the International Federation of Gynecology and Obstetrics (FIGO).

The following stages are from the Children's Oncology Group.

• Stage I

  In stage I, the tumor in the ovary is completely removed by surgery and all of the following are true:

  • the capsule (outer covering of the tumor) did not rupture (break open) and a biopsy was not done before the tumor was removed; and
  • there is no sign that the cancer has spread through the capsule; and
  • no cancer cells are found in fluid taken from the abdomen; and
  • no cancer is seen in tissue that lines the abdomen or found in tissue samples taken during a biopsy; and
  • lymph nodes are smaller than 1 centimeter in their shortest diameter on a CT scan or MRI or no cancer is found in lymph node tissue samples taken during a biopsy.
• Stage II

  In stage II, the tumor in the ovary is completely removed by surgery and a biopsy is done before surgery and one of the following is true:

  • cancer has spread through part or all of the capsule (outer covering of the tumor); or
  • the tumor is larger than 10 centimeters and is removed by laparoscopic surgery; or
  • the tumor is removed by being broken up into small pieces and it is not known if cancer has spread through the capsule.

  Cancer cells are not found in fluid taken from the abdomen. Cancer is not seen in lymph nodes or tissue that lines the abdomen and cancer is not found in tissue samples taken during a biopsy.

• Stage III

  In stage III, there is tumor in the ovary and one of the following is true:

  • lymph nodes are at least 2 centimeters wide or are larger than 1 centimeter but smaller than 2 centimeters in their shortest diameter and either have not changed or are growing when a CT scan or MRI is repeated 4 to 6 weeks after surgery; or
  • the tumor is not completely removed by surgery or a biopsy was done before surgery; or
  • cancer cells (including immature teratoma) are found in fluid taken from the abdomen; or
  • cancer (including immature teratoma) is found in lymph nodes; or
  • cancer (including immature teratoma) is found in tissue that lines the abdomen.
• Stage III-X

  In stage III-X, the tumor can be described as stage I or stage II, except:

  • cells lining the abdomen were not collected; or
  • a biopsy of lymph nodes larger than 1 centimeter in their shortest diameter was not done; or
  • a biopsy of tissue from the lining of the abdomen was not done; or
  • staging was not completed during surgery but will be completed during a second surgery.
• Stage IV

  In stage IV, one of the following is true:

  • the cancer has spread to the liver or outside the abdomen to other areas of the body, such as the bone, lung, or brain.
  • cancer cells are found in the fluid in the lung.

The following stages are from the International Federation of Gynecology and Obstetrics (FIGO).

• Stage I

  In stage I, cancer is found in one or both of the ovaries and has not spread. Stage I is divided into stage IA, stage IB, and stage IC.

  • Stage IA: Cancer is found in one ovary.
  • Stage IB: Cancer is found in both ovaries.
  • Stage IC: Cancer is found in one or both ovaries and one of the following is true:
    • cancer is also found on the outside surface of one or both ovaries; or
    • the capsule (outer covering) of the tumor ruptured (broke open) before or during surgery; or
    • cancer cells are found in fluid taken from the abdomen or in washings of the peritoneal cavity (the body cavity that contains most of the organs in the abdomen).
• Stage II

  In stage II, cancer is found in one or both ovaries and has spread into other areas of the pelvis, or primary peritoneal cancer is found. Stage II is divided into stage IIA and stage IIB.

  • Stage IIA: Cancer has spread to the uterus and/or the fallopian tubes (the long slender tubes through which eggs pass from the ovaries to the uterus).
  • Stage IIB: Cancer has spread to other tissue within the pelvis such as the bladder, rectum, or vagina.
• Stage III

  In stage III, cancer is found in one or both ovaries or primary peritoneal cancer is found. Cancer has spread outside the pelvis to other parts of the abdomen and/or to lymph nodes at the back of the abdomen. Stage III is divided into stage IIIA, stage IIIB, and stage IIIC.

  
  • In stage IIIA, one of the following is true:
    • cancer has spread to lymph nodes at the back of the abdomen only; or
    • cancer cells that can be seen only with a microscope have spread to the surface of the peritoneum outside the pelvis. Cancer may have spread to nearby lymph nodes at the back of the abdomen.
  • Stage IIIB: Cancer has spread to the peritoneum outside the pelvis and the cancer in the peritoneum is 2 centimeters or smaller. Cancer may have spread to lymph nodes at the back of the abdomen.
  • Stage IIIC: Cancer has spread to the peritoneum outside the pelvis and the cancer in the peritoneum is larger than 2 centimeters. Cancer may have spread to lymph nodes at the back of the abdomen or to the surface of the liver or spleen.
• Stage IV

  Stage IV is divided into stage IVA and IVB.

  • Stage IVA: Cancer cells are found in extra fluid that builds up around the lungs.
  • Stage IVB: Cancer has spread to organs and tissues outside the abdomen, including lymph nodes in the groin.

Extragonadal extracranial germ cell tumors

The following stages are from the Children's Oncology Group.

• Stage I

  In stage I, the tumor is completely removed by surgery and all of the following are true:

  • no cancer cells are found in the area where the tumor was removed; and
  • the capsule (outer covering of the tumor) did not rupture (break open) and a biopsy was not done before the tumor was removed; and
  • cancer cells are not found in fluid taken from the abdominal cavity, if the tumor is in the abdomen; and
  • lymph nodes are smaller than 1 centimeter on a CT scan or MRI of the abdomen, pelvis, and chest.
• Stage II

  In stage II, cancer is not completely removed by surgery and one of the following is true:

  • cancer that can only be seen with a microscope remains after surgery; or
  • the capsule (outer covering of the tumor) ruptured (broke open) or a biopsy was done.

  Cancer cells are not found in fluid taken from the abdomen. There is no sign of cancer in lymph nodes in the abdomen, pelvis, or chest on a CT scan or MRI.

• Stage III

  In stage III, one of the following is true:

  • cancer is not completely removed by surgery and cancer that can be seen with the eye remains after surgery or only a biopsy was done; or
  • lymph nodes are at least 2 centimeters wide or are larger than 1 centimeter but smaller than 2 centimeters in their shortest diameter and either have not changed or are growing when a CT scan or MRI is repeated within 4 to 6 weeks.
• Stage IV

  In stage IV, the cancer has spread to other parts of the body, such as the liver, lung, bone, or brain.

Childhood extracranial germ cell tumors usually do not come back after treatment.

Recurrent childhood extracranial germ cell tumor is cancer that has come back after it has been treated. The cancer may come back in the same place or in other parts of the body.

Most germ cell tumors do not recur (come back) after treatment. If they do recur, they usually come back within 3 years of surgery. About half of the teratomas that recur in the sacrum or coccyx are cancer, so follow-up is important.