Even though it is almost intuitively self-evident that GCTs originate from germ cells, this point of view was ardently disputed for many years. In this respect, it is quite instructive to read the 1911 paper of James Ewing, the leading American pathologist of the day. He reviewed the theories of germ cell neoplasia of the testis that were considered at that time and noted that essentially all cells of the testis had been deemed by some authorities as potential progenitors of testicular GCTs.1 For more than 100 years, teratomas, the most intriguing of all germ cell neoplasms, were considered by some pathologists to be derived from germ cells whereas others considered them to be derived from misplaced embryonic cells.2 Finally, even when the gonadal GCT became histogenetically linked to the germ cells residing in the gonads, controversy remained about the exact provenance of GCT in extragonadal sites. Finally, even though most GCTs seem to arise from germ cells, there is no doubt that some of the congenital sacrococcygeal teratomas represent parasitic incompletely separated fetal twins and are not true neoplasms but a form of a fetus in fetu.3

Carcinoma in Situ of the Testis

The earliest forms of testicular GCT have been identified (by Skakkebaek)4 inside the seminiferous tubules of infertile men. Subsequent studies by Skakkebaek and his associates in Denmark, followed by observations in other laboratories in the United States and Europe, proved beyond any reasonable doubt that the atypical germ cells in the seminiferous tubules represent the precursors of

Table 4-1.

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