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. This procedure is also called nuclear magnetic resonance imaging.

• 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 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 tumor may also be used in staging.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

• Through tissue. Cancer invades the surrounding normal tissue.
• Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
• Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

The following stages are commonly used for childhood nonseminoma testicular germ cell tumors:

Stage I

In stage I, the cancer is found only in the testicle and is completely removed by surgery. Tumor marker levels return to normal after surgery.

Stage II

In stage II, the cancer is removed by surgery and some cancer cells remain in the scrotum or cancer that can only be seen with a microscope has spread to the scrotum or spermatic cord. Tumor marker levels do not return to normal after surgery and may increase.

Stage III

In stage III, the cancer has spread to one or more lymph nodes in the abdomen and is not completely removed by surgery. The cancer that remains after surgery can be seen without a microscope.

Stage IV

In stage IV, the cancer has spread to distant parts of the body such as the liver.

The following stages may be used for childhood ovarian germ cell tumors:

Stage I

In stage I, the cancer is in the ovary and can be completely removed by surgery.

Stage II

In stage II, one of the following is true:

• The cancer is not completely removed by surgery. The remaining cancer can be seen with a microscope only.
• The cancer has spread to the lymph nodes and can be seen with a microscope only.
• The cancer has spread to the capsule (outer covering) of the ovary.

Stage III

In stage III, one of the following is true:

• The cancer is not completely removed by surgery. The remaining cancer can be seen without a microscope.
• The cancer has spread to lymph nodes and the lymph nodes are 2 centimeters or larger.
• The cancer is found in fluid in the abdomen.

Stage IV

In stage IV, the cancer has spread to the lung, liver, brain, or bone.

Another staging system which may be used for childhood ovarian germ cell tumors is as follows:

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 a single 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 found on the outside surface of one or both ovaries; or
  • the capsule (outer covering) of the tumor has ruptured (broken open); or
  • cancer cells are found in fluid that has collected in the abdomen; or
  • cancer cells are found 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. Stage II is divided into stage IIA, stage IIB, and stage IIC.

• 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 IIC: Cancer has spread to the uterus and/or fallopian tubes and/or other tissue within the pelvis and one of the following is true:
  • cancer is found on the outside surface of one or both ovaries; or
  • the capsule (outer covering) of the tumor has ruptured (broken open); or
  • cancer cells are found in fluid that has collected in the abdomen; or
  • cancer cells are found in washings of the peritoneal cavity (the body cavity that contains most of the organs in the abdomen).

Stage III

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Pea, peanut, walnut, and lime show tumor sizes.

In stage III, cancer is found in one or both ovaries and has spread to other parts of the abdomen. Stage III is divided into stage IIIA, stage IIIB, and stage IIIC as follows:

• Stage IIIA: The tumor is found only in the pelvis, but cancer cells that only can be seen with a microscope have spread to the surface of the peritoneum (tissue that lines the abdominal wall and covers most of the organs in the abdomen) or to the small bowel.
• Stage IIIB: Cancer has spread to the peritoneum but is 2 centimeters or smaller in diameter.
• Stage IIIC: Cancer has spread to the peritoneum and is larger than 2 centimeters in diameter and/or has spread to lymph nodes in the abdomen.

Cancer that has spread to the surface of the liver is also considered stage III disease.

Stage IV

In stage IV, cancer is found in one or both ovaries and has metastasized (spread) beyond the abdomen to other parts of the body.

Cancer that has spread to tissues in the liver is also considered stage IV disease.

The following stages are commonly used for extragonadal extracranial germ cell tumors:

Stage I

In stage I, the cancer is in one place and can be completely removed by surgery. For tumors at the base of the tailbone, the cancer and tailbone are completed removed by surgery. Tumor marker levels return to normal after surgery.

Stage II

In stage II, the cancer has spread to nearby tissues and/or lymph nodes and is not completely removed by surgery. The cancer remaining after surgery can be seen with a microscope only. Tumor marker levels do not return to normal after surgery and may increase.

Stage III

In stage III, one of the following is true:

• The cancer is not completely removed by surgery. The cancer remaining after surgery can be seen without a microscope.
• The cancer has spread to lymph nodes and is larger than 2 centimeters in diameter.

Stage IV

In stage IV, the cancer has spread to distant parts of the body, including the liver.