Germ Cell Tumours III Proceedings of the Third Germ Cell

Tumour Conference Held in Leeds, UK, on 8th10th September

1993

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 Ill
Germ Cell Tumour Conference
Bodington Hall of Residence, Leeds
8-10 September 1993

Conference C h a i r m a n : D r W . G . J o n e s
Consultant in R a d i o t h e r a p y and Oncology
Cookridge Hospital
L E E D S LS16 6 Q B

Y R C O W o r k i n g G r o u p Co-ordinator and Secretary to the Conference:

Miss P. Hodgins
Yorkshire Regional C a n c e r Organisation
Cookridge Hospital
L E E D S LS16 6 Q B

Organising Committee
M r I. A p p l e y a r d Consultant Surgeon, Airedale G e n e r a l Hospital, Keighley
D r C. Bradley Senior Registrar in Clinical Oncology, D e p a r t m e n t of
Cancer Studies, St J a m e s ' s University Hospital, L e e d s
D r S.M. Crawford Director, Cancer Medicine Research U n i t , University of
Bradford
Dr P. Harnden Consultant Histopathologist, Leeds G e n e r a l Infirmary
D r J. Joffe Senior Registrar in Clinical Oncology, D e p a r t m e n t of
Cancer Studies, St J a m e s ' s University Hospital, Leeds
Dr G M . Mead Consultant Medical Oncologist, Royal South H a n t s
Hospital, S o u t h a m p t o n
Dr D. Parker Consultant Physician/Oncologist, Bradford Royal
Infirmary
Mr M . R . G . Robinson Consultant Urologist, Pontefract G e n e r a l Infirmary
Ms S. Stenning Statistician, M R C Cancer Trials Office, Cambridge
 Dedication

T h i s b o o k is d e d i c a t e d t o D r C . K . A n d e r s o n , F R C P a t h , a n d M r R.E.
Williams, F R C S .
K e i t h A n d e r s o n , f o r m e r l y R e a d e r in P a t h o l o g y , U n i v e r s i t y of L e e d s ,
a n d H o n o r a r y C o n s u l t a n t Pathologist, L e e d s G e n e r a l Infirmary, as
f o u n d i n g C h a i r m a n of t h e Y o r k s h i r e T e s t i c u l a r T u m o u r G r o u p , i n s p i r e d
t h e G r o u p a n d its m e m b e r s in its f o r m a t i v e y e a r s t h r o u g h h i s g r e a t e f f o r t s
a n d e n t h u s i a s m in t h e field of g e r m c e l l t u m o u r s .
B o b Williams, formerly C o n s u l t a n t S u r g e o n a n d H o n o r a r y Clinical
S e n i o r L e c t u r e r a t L e e d s G e n e r a l I n f i r m a r y , t h r o u g h h i s e n t h u s i a s m in t h e
s u r g i c a l m a n a g e m e n t of p a t i e n t s w i t h t e s t i c u l a r m a l i g n a n c i e s , h a s c o n t r i b -
u t e d e x t e n s i v e l y t o k n o w l e d g e , r e s e a r c h a n d t h e t r e a t m e n t o f p a t i e n t s in
Yorkshire.
 Preface

T h e T e s t i c u l a r T u m o u r G r o u p of t h e Y R C O w a s f o r m e d i n 1 9 7 9 . T h e
Y o r k s h i r e C a n c e r Regional O r g a n i s a t i o n (YRCO) W o r k i n g G r o u p s
h a v e a remit to organise Conferences, S e m i n a r s a n d S t u d y Days in
a d d i t i o n t o m a n y o t h e r a c t i v i t i e s t o p r o m o t e b e t t e r s t a n d a r d s of c a r e ,
e n a b l e r e s e a r c h a n d a u d i t of c l i n i c a l p r a c t i c e , a n d t o d i s s e m i n a t e
i n f o r m a t i o n b y p r o v i d i n g a f o r u m for t h e e x c h a n g e of k n o w l e d g e a n d
expertise. A s a result three G e r m Cell T u m o u r Conferences h a v e n o w
b e e n held, in 1981 a n d 1985, a n d the 3rd G e r m Cell T u m o u r
C o n f e r e n c e a t B o d i n g t o n H a l l of R e s i d e n c e , U n i v e r s i t y of L e e d s ,
b e t w e e n 8 - 1 0 S e p t e m b e r 1 9 9 3 , t h e p r o c e e d i n g s of w h i c h c o n s t i t u t e
t h i s v o l u m e . ( T h e f o u r y e a r c y c l e of G e r m C e l l T u m o u r C o n f e r e n c e s
w a s b r o k e n i n 1 9 8 9 b e c a u s e of t h e f a c i l i t y t o h o l d t h e F i r s t C o n s e n s u s
M e e t i n g o n T e s t i c u l a r T u m o u r s u n d e r t h e a u s p i c e s of t h e E u r o p e a n
O r g a n i s a t i o n for R e s e a r c h , T r e a t m e n t of C a n c e r ( E O R T C ) . )
A s w i t h p r e v i o u s C o n f e r e n c e s , G C T C III w a s d e s i g n e d t o b r i n g
together not only clinicians but scientists a n d laboratory workers from
m a n y disciplines to promote further collaboration and cooperation.
F e e d b a c k from the Conference participants j u d g e d the Conference to
b e v e r y s u c c e s s f u l a n d h o p e f u l l y it a c h i e v e d t h e s e a i m s . T h e q u a l i t y of
t h e p r e s e n t a t i o n s g i v e n at t h e C o n f e r e n c e w a s e x t r e m e l y h i g h , as c a n
be judged from the following pages. T h e Organising C o m m i t t e e are
e x t r e m e l y g r a t e f u l t o t h o s e w h o t o o k p a r t for t h e i r t r e m e n d o u s h a r d
work, not only towards their lectures a n d posters, but also in the
p r o m p t p r o d u c t i o n of m a n u s c r i p t s t h e r e b y f a c i l i t a t i n g t h e e a r l y
p u b l i c a t i o n of t h e s e p r o c e e d i n g s .
T h e e d i t o r s w o u l d l i k e t o p l a c e o n r e c o r d t h e i r g r e a t d e b t of g r a t i t u d e
t o M r A n t h o n y H i l t o n , G r a p h i c D e s i g n e r , Y R C O , for t h e e l e c t r o n i c
c o n v e r s i o n of p r o f f e r e d m a n u s c r i p t s i n t o t h e v e r s i o n a s it a p p e a r s i n
t h i s b o o k a n d t o o u r p u b l i s h e r E l s e v i e r S c i e n c e for t h e i r c o n s i d e r a b l e
help in this venture.
T h e Organising C o m m i t t e e a n d Editors also w i s h to place on record
their gratitude to the various organisations a n d pharmaceutical
companies w h o sponsored the meeting, without w h o s e generosity the
C o n f e r e n c e w o u l d n o t h a v e t a k e n p l a c e . A l i s t of t h e s e o r g a n i s a t i o n s
a p p e a r s i n t h e n e x t f e w p a g e s . W e p a r t i c u l a r l y w i s h t o t h a n k t h e staff o f
t h e Y R C O for t h e i r e n t h u s i a s t i c i n v o l v e m e n t i n t h e p r e p a r a t i o n for, a n d
r u n n i n g of, t h e C o n f e r e n c e a n d i n p a r t i c u l a r t o M i s s P a t H o d g i n s ,
χ Preface

C o n f e r e n c e S e c r e t a r y , for h e r t r e m e n d o u s h a r d w o r k a n d d e d i c a t i o n i n
a l l m a t t e r s t o d o w i t h t h e C o n f e r e n c e . W e a r e i n d e b t e d t o h e r for t h i s
e x c e p t i o n a l c o m m i t m e n t , w h i c h in n o s m a l l w a y c o n t r i b u t e d to its
success.

W.G. Jones
P. H a r n d e n
I. A p p l e y a r d
West Yorkshire

September 1993
 Acknowledgements

T h e Conference Organisers w i s h to place o n record their appreciation

of t h e s u p p o r t g i v e n b y t h e f o l l o w i n g :

Amgen-Roche
Bristol-Myers Squibb Pharmaceuticals Ltd
Cancer Research Campaign
Glaxo Laboratories Ltd
K y o w a H a k k o UK Ltd
SmithKline Beecham Pharmaceuticals
Yorkshire Cancer Research Campaign
Imperial Cancer Research Fund

Asta Medica
Boehringer Ingelheim
Boots Pharmaceuticals
Chugai P h a r m a UK Ltd
Farmitalia Carlo Erba Ltd
Medical Research Council
Organon Laboratories (Akzo P h a r m a Division)
R h ô n e Poulenc Rorer
Sandoz Pharmaceuticals

Yorkshire Regional Cancer Organisation

T h e C o n f e r e n c e O r g a n i s e r s g r a t e f u l l y a c k n o w l e d g e t h e a s s i s t a n c e of
the following:

The Yorkshire Regional Cancer Organisation Secretariat

The Yorkshire Regional Cancer Organisation Graphic Designer
The M a n a g e r a n d Staff of B o d i n g t o n H a l l , U n i v e r s i t y of L e e d s
The P r i n t i n g D e p a r t m e n t of Y o r k s h i r e H e a l t h
 Advances (π the Biosciences, Vol. 91. pp. 1-6, 1994
Copyright © 1994 Elsevier Science Ltd
Pergamon Printed in Great Britain. All rights reserved
0065-3446/94 $26.00

Embryological Mechanisms of
Maldescent and Tumourigenesis
John M. Hutson, Marilyn L. Baker, Masaru
Terada, Baiyun Zhou and Georgia Paxton
Surgical Research Unit, Royal Children's Hospital
Research F o u n d a t i o n , Melbourne, Victoria, Australia,
3052

ABSTRACT
Testicular descent occurs in t w o stages with separate morphology and hormonal control. T h e key
structure in mediating descent is the gubernaculum, which enlarges in the first phase to anchor the
testes near the inguinal regions as the e m b r y o enlarges. In the second phase, the gubernaculum
migrates from the inguinal region to the scrotum. Non-androgenic h o r m o n e s control the first phase,
with conflicting evidence about whether Mullerian inhibiting substance (MIS) is the active agent.
Testosterone controls the second phase, apparently indirectly via the nervous system. Calcitonin
gene-related peptide ( C G R P ) has been identified recently within the gentofemoral nerve and has
been postulated to act as a final c o m m o n pathway for androgenic control of descent. Animal models
of undescended testes, including the androgen resistant m o u s e , the T S rat, and the flutamide-treated
rat all have an absence or deficiency of gubernacular migration and abnormality of C G R P .

These studies suggest that undescended testes m a y be caused by physiological or anatomical

abnormalities of the gentofemoral nerve. T h e c o m m o n e s t cause of maldescent would appear to be
failure of gubernacular migration, leaving the testes in the groin or so- called "superficial inguinal
pouch".

T h e abnormally high temperature of the undescended testes leads to deficiencies in postnatal

secretion of testosterone and M I S . In addition, germ cell maturation from fetal gonocyte to type
A spermatogonium is significantly inhibited. G o n o c y t e s which fail to u n d e r g o this transformation
either die off leading to infertility, or develop signs of dysplasia, eg. carcinoma-in-situ.

At present, it is not proven in h u m a n s that early surgery can prevent these hormonal and anatomical
changes. H o w e v e r , animal experiments strongly support the view that early surgery, prior to these
changes occurring, can prevent their development.

Introduction
T h e gubernaculum, or genitoinguinal ligament, enlarges in the male fetus between 10 and 15
weeks. T h e enlarged gubernaculum holds the testis near the future inguinal canal as the e m b r y o
enlarges. B y contrast, failure of the h o m o l o g o u s structure in the female to enlarge allows the ovary
to ascend with the kidney, as seen in rodents, or to remain near the enlarging uterus, as seen in
h u m a n s . T h e difference between the ovarian position in rodents and h u m a n s is probably related
to the greater fusion of the Mullerian ducts in h u m a n s to form a solid uterus, thereby preventing
further ovarian ascent. In either m a m m a l i a n species, the long attenuated female gubernaculum is

1
2 J.M. H u t s o n et αϊ.

unable to anchor the ovary near the inguinal region and is preserved postnatally as t w o separate
parts k n o w n as the ligament of the ovary and the round ligament.

T h e second phase, or inguinoscrotal descent, begins at 26-28 w e e k s of gestation, when the

g u b e r n a c u l u m begins to migrate from the future inguinal canal towards the scrotum. A peritoneal
diverticulum k n o w n as the processus vaginalis develops within the gubernaculum, allowing the
testes to descend intra-peritoneally. By 35 w e e k s of gestation the gubernaculum has reached the
scrotum and the testis arrives shortly after. Standard anatomical textbooks describe a gubernaculum
attached to the bottom of the scrotum, but this is not the case until after descent is complete.
Migration from the groin to the scrotum is a precarious journey of 3-5 c m s for a gubernaculum
which is only 1 c m in diameter. T h e gubernaculum after enlargement becomes gelatinous and
m u c o i d at its distal end, and its proximal end is hollowed out by the processus vaginalis. T h e mucoid
caudal end of the g u b e r n a c u l u m remains palpable until descent is complete, and then reabsorption
of the extracellular matrix molecules causes it to regress. T h e postnatal gubernaculum is usually
m a d e up of fibrous attachments of the caudal epididyMIS and testis to the bottom of the processus
vaginalis and adjacent scrotal subcutaneous tissue.

H o r m o n a l Control
At o n e time it w a s believed that testicular descent w a s controlled by androgens from the fetal testis
under maternal or chorionic gonadotrophin stimulation. In 1932, Engle (1) showed that the testis
of immature M a c a q u e m o n k e y s were stimulated to descend with extracts from the anterior pituitary
gland and with pregnancy urine. Since that time, cryptorchidism has been treated in m a n y parts of
the world with h C G and/or L H R H (2, 3). Although there are numerous clinical descriptions of
abnormalities of the hypothalamic-pituitary-testicular axis which cause cryptorchidism, the role
of androgens in controlling testicular descent has been controversial. This is because m a n y natural
mutants and experimental studies showed that the effect of androgen w a s absent or only partial.
In particular, the second o r inguinoscrotal phase of descent is absent in androgen resistant mice and
h u m a n s (4). Furthermore, inguinoscrotal descent is absent in the hypogonadal m o u s e (5). Prenatal
treatment with flutamide, which is an antiandrogen, also blocks the inguinoscrotal phase of descent
( 6 , 7 ) . Although the postnatal or inguinoscrotal phase of descent is blocked in the rat by flutamide,
the flutamide only works when given prenatally. By contrast, n o androgenic effects on descent of
the testis could be observed in the fetus ( 8 , 9). Also, androgens failed to produce the swelling
reaction in the gubernaculum (8), and pituitary disconnection also failed to stop gubernacular
swelling (10).

T h e apparent contradictions in the results of studies of androgens have been reconciled by the
hypothesis that testicular descent occurs in two separate steps under independent hormonal control
(11).

T h e first p h a s e of testicular descent in mice can be inhibited by administering e x o g e n o u s oestrogens

to the pregnant d a m s , and this treatment also causes retention of the Miillerian ducts (5,12). In
addition, in the persistent Miillerian duct syndrome where there is a genetic defect in the synthesis
of M I S or its receptor, the swelling reaction of the gubernaculum is absent in association with high
intraabdominal testis and retained Miillerian ducts ( 1 3 , 1 4 ) . Both the oestrogen-injected m o u s e and
the h u m a n with a mutation in the M I S gene provide evidence for an important role for this testicular
h o r m o n e . H o w e v e r , there is s o m e experimental evidence against a role for M I S , including the fact
that immunisation of pregnant rabbits against purified MIS failed to stop testicular descent (15).
A l s o , purified M I S did not stimulate fetal pig gubernacular fibroblasts in vitro (16).

T h e m e c h a n i s m by which androgens control the second o r inguinoscrotal phase of descent has

 E m b r y o l o g i c a l M e c h a n i s m s of M a l d e s c e n t a n d T u m o u r i g e n e s i s 3

remained obscure (17). T h e m e c h a n i s m whereby the gubernaculum migrates from the inguinal
region to the scrotum is also not understood. Although the gubernaculum w a s thought to be the
primary target for androgens, m e a s u r e m e n t of significant numbers of androgen receptors has been
controversial ( 18-20). A clue to an alternative site for androgen action w a s revealed by a study done
by Lewis (21), w h e r e the gentofemoral nerve w a s transected in neonatal rats. This caused
undescended testes which L e w i s interpreted as evidence for a role by the cremaster muscle.
Recently, w e repeated this study and found a similar result (22). W e went on to investigate the
possibility that the primary action of androgen m a y be indirect on the gubernaculum via the central
nervous system and the gentofemoral nerve. Careful study of gubernacular migration in the rodent
postnatally s h o w e d that nerve transection inhibited migration (23). Looking at children with spina
bifida in the high l u m b a r region where the gentofemoral nerve arises, w e found 3 6 % cryptorchidism
(24). M o r e importantly, when w e did retrograde labelling of the gentofemoral nerve motor neurons,
w e found that the m o t o r nucleus in the anterior horn is sexually dimorphic. Also, w e found that
the neonatal m a l e gentofemoral nerve contains a much higher content of calcitonin gene-related
peptide ( C G R P ) than the female equivalent (25).

In recent years w e h a v e investigated the possible role of C G R P in mediating gubernacular

migration and testicular descent. C G R P receptors were identified within the cremaster muscle
within the gubernaculum, (26). A l s o , in organ culture C G R P was found to induce rapid rhythmic
contraction of the gubernacular cremaster muscle in both the rat (27) and the m o u s e (28) (Table
1).

Table 1 E v i d e n c e for C G R P having a role in gubernacular migration

E x o g e n o u s C G R P causes elongation of T F M gubernaculum (29).

E x o g e n o u s C G R P (8-37) delays descent in mice (30).

Ectopic C G R P causes 9 0 % U D T in flutamide-treated rat (Abe and Hutson, submitted).

G F N spinal nucleus deficient in flutamide-treated rat (Goh et al, submitted).

G F N spinal nucleus enlarged in T S rat (Goh et al, submitted).

Gubernacular contractions deficient in T S flutamide rats (Hutson et al, in press).

U n d e s c e n d e d Testis
W e have looked at three rodent models of undescended testis to see if there is an abnormality of
the gentofemoral nerve and/or C G R P . (Table 2). T h e s e studies show that the androgen resistant
or deficient rodent has decreased C G R P in the nerve and decreased gubernacular contractions,
accompanied by increased sensitivity to exogenous C G R P . By contrast, the mutant (TS) rat has
excess C G R P in the gentofemoral nerve accompanied by decreased sensitivity of the gubernaculum
in culture. T h e r e results suggest a very strong link between a normal gentofemoral nerve and C G R P
m e c h a n i s m and normal testicular descent.

Aetiology of c r y p t o r c h i d i s m in the h u m a n
Undescended testis are caused by a n u m b e r of developmental defects with rare mutations in the
gene for Mullerian inhibiting substance preventing normal transabdominal migration. In the
inguinoscrotal p h a s e of descent where the gubernaculum must migrate across the pubis to the
scrotum, the c o m m o n e s t cause of undescended testis appears to be deficient or abnormal migration.
This m a y be caused by prenatal h o r m o n e deficiency of the hypothalamic pituitary axis. In addition,
w e w o u l d predict that it would also be caused by anatomical and physiological abnormalities of
the gentofemoral nerve or its neurotransmitter C G R P .
4 J . M . H u t s o n e t al.

Effect of U n d e s c e n d e d Testis
Cryptorchidism leads to a cosmetic anomaly, decreased fertility and an increased risk of testicular
cancer (32). T h e r e has been argument about whether the subsequent infertility and risk of
malignancy is a primary or secondary anomaly of the testis. Recent evidence suggests that they are
probably secondary effects of cryptorchidism, as biopsies of testes from children of different ages
show that the histology of the testis is normal in infancy but b e c o m e s progressively m o r e abnormal
with a g e (2). T h e high temperature of the non-scrotal testis is believed to be the c a u s e of the
secondary degeneration.

Early postnatal g e r m cell differentiation, from gonocyte to T y p e A spermatogonium and through

to T y p e Β and primary spermatocytes is deranged in undescended testis. (2). Although the early
postnatal development of the gonocyte was thought to be controlled by androgens, and hence m a y
be treated by g o n a d o t r o p i n s (33), work in our laboratory suggests that gonocyte maturation is
controlled by M I S . (34). In normal h u m a n males the serum level of M I S is elevated in the first year
of life (35). B y contrast, in infants with undescended testis this postnatal increase of M I S secretion
appears to be absent (36).

T a b l e 2 C G R P in animal m o d e l s of cryptorchidism (31)

(i) Androgen-resistant mouse (TFM)
a) absent gubernacular migration (congenital).
b) absent gubernacular contractions in vitro but enhanced contractions with exogenous C G R P .
c) gubernacular C G R P receptors up-regulated.
d) gubernacular elongation in response to exogenous C G R P .
e) G F N motor nucleus with deficiency of C G R P - containing cells.

(ii) Flutamide rat

a) aberrant gubernacular migration (after prenatal flutamide).
b) decreased gubernacular in vitro but enhanced contractions with C G R P .
c) gubernacular C G R P receptors up-regulated.
d) gubernacular migration altered by e x o g e n o u s C G R P (Abe et al, submitted).
e) G F N m o t o r nucleus with deficiency of CGRP-containing cells.

(Hi) "TS" rat

a) aberrant gubernacular migration (congenital)
b) decreased gubernacular contractions in vitro and resistant to exogenous C G R P .
c) gubernacular C G R P receptors down-regulated.
d) gubernacular response to C G R P recovers after G F N transection.
e) G F N m o t o r nucleus with excess CGRP-containing cells.

In undescended testis the g e r m cells fail to transform from gonocytes into T y p e A spermatogonia
and tend to die off by 2-3 years of age. This would lead to oligo- or azoospermia later in life.
H o w e v e r , residual gonocytes within the tubules are likely to b e c o m e dysplastic with increasing
time, and are likely to be the origin of carcinoma-in-situ leading to malignancy subsequently. A s
the gonocyte is normally replaced in the tubule by a m o r e differentiated form of germ cell its
persistence beyond infancy could lead to malignancy by many potential physiological derangements.
F o r instance, the abnormal gonoctye m a y develop polyploidy or begin expressing abnormal
proteins, such as alkaline phosphatase as seen in carcimona-in-situ in older males.

W e have proposed that M I S m a y be used in the future to treat infants with undescended testis to
stimulate g o n o c y t e transformation to T y p e A spermatogonia. O u r intention was to reverse the
o t h e r w i s e significant infertility that these children have in adult life. In addition, it m a y be possible
 E m b r y o l o g i c a l M e c h a n i s m s of M a l d e s c e n t a n d T u m o u r i g e n e s i s 5

to prevent the d e v e l o p m e n t of carcinoma-in-situ germ cells by treatment with M I S . T h e c a r c i n o m a -

in-situ cell itself m a y even be still responsive to M I S which might stimulate it to differentiate into
a more advanced and hence benign g e r m cell. This recent insight into the control of early postnatal
germ cell d e v e l o p m e n t n o w gives us an opportunity to investigate the possible role of germ cell
maturation in tumourigenesis.

References
1. E n g l e , E.T. (1932) Experimentally induced descent of testis in the M a c a c u s m o n k e y by
h o r m o n e s from anterior pituitary and pregnancy urine. Endocrinology 16: 513-520.
2. Hadziselimovic, F . (1983) Cryptorchidism. M a n a g e m e n t and Implications. Springer-
Verlag Berlin.
3. Hutson, J.M., Beasley, S.W. (1992) Descent of the Testis. E d w a r d Arnold, London.
4. H u t s o n , J.M. (1986) Testicular feminization: a model for testicular descent in mice and
men. J. Pediatr Surg 2 1 : 195-198.
5. Grocock, C. Α., Charlton, H.M., Pike, M.C. ( 1988) Role of the fetal pituitary in cryptorchidism
induced by e x o g e n o u s maternal oestrogen during pregnancy in mice. J. Reprod. Fert. 8 3 :
295-300.
6. Spencer, J.R., T o r r a d o , T., Sanchez, R.S. et al. (1991) Effects of flutamide and finasteride
on rat testicular descent. Endocrinology 129: 7 4 1 - 7 4 8 .
7. H u s m a n n , D.A., M c P h a u l , M.J. (1991) Time-specific androgen blockade with flutamide
inhibits testicular descent in the rat. Endocrinology 129: 1409-1416.
8. W e n s i n g , C.J.G., (1973) Testicular descent in some domestic m a m m a l s . Ill Search for the
factors that regulate the gubernacular reaction. Proc. Kon. Nederland. Akad. Wetensch.
Series C 7 6 : 196-202.
9. Habenicht, U . F . , N e u m a n n , F . (1983) H o r m o n a l regulation of testicular descent. Adv.
Anat. E m b r y o l . Cell Biol. 8 1 : 1-54.
10. Colenbrander, B . , van R o s s u m - K o k , C.M.J.E., van Straaten, H . W . M . , W e n s i n g , C J . G .
(1979) T h e effect of fetal decapitation on the testis and other endocrine organs in the pig.
Biol. Reprod. 2 0 : 198-204.
11. H u t s o n , J.M., D o n a h o e , P.K. (1986) T h e hormonal control of testicular descent. Endocr
R e v 7: 2 7 0 - 2 8 3 .
12. Hutson, J.M. (1987) E x o g e n o u s oestrogens prevent transabdominal testicular descent in
m i c e with complete androgen resistance (testicular feminization). Pediatr. Surg. Int. 2 : 2 4 2 -
246.
13. H u t s o n , J.M., C h o w , C.W., Ng, W . D . (1987) Persistent Mullerian duct s y n d r o m e with
transverse testicular ectopia. An experiment of nature with clues of understanding testicular
descent. Pediatr. Surg. Int. 2: 191-194.
14. Josso, N., Cate, R.L., Picard, J.Y., et al. (1993) Anti-Mùllerian h o r m o n e : the Jost factor.
Recent Prog. H o r m . Res. 4 8 : 1-59.
15. T r a n , D . , Picard, J . Y . , V i g i e r , B . , e t a l . (1986) Persistenceof Mullerian ducts in male rabbits
passively i m m u n i z e d against bovine anti-Mullerian hormone during fetal life. Dev. Biol.
116: 160-167.
16. Fentener van Vlissingen, J.M., van Zoelen, E.J.J., U r s e m , P.J.F., W e n s i n g , C J . G . (1988)
In vitro m o d e l of the first phase of testicular descent: identification of a low-molecular
weight factor from fetal testis involved in proliferation of gubernaculum testis cells and
distinct from specified p o l y p e p t i d e growth factors and fetal gonadal h o r m o n e s .
Endocrinology 123: 2868-2877.
17. van der Schoot, P. (1992) Androgens in relation to prenatal development and postnatal
inversion of the gubernacula in rats. J. Repord. Fert. 9 5 : 145-158.
 6 J . M . H u t s o n et al

18. H e y n s , C F . , Pape, V.C. (1991) Presence of a low capacity androgen receptor in the
g u b e r n a c u l u m of the pig fetus. J. Urol. 145: 161-167.
19. Rajfer, J. (1987) H o r m o n a l regulation of testicular descent. Eur. J. Pediatr. 146 (Suppl 2):
56-57.
20. H u s m a n n , D.A., M c P h a u l , M.J. (1991) Localization of the androgen receptors in the
developing rat gubernaculum. Endocrinology 128: 383-387.
21. L e w i s , L.G. (1948) Cryptorchidism. J Urol 60: 345-356.
22. Beasley, S.W., Hutson, J.M. (1987) Effect of division of the genitofemoral nerve on
testicular descent in the rat. Aust. N . Z . J. Surg 57: 4 9 - 5 1 .
23. Fallat, M.E., Williams, M.P.L., Farmer, P.J., Hutson, J.M. (1992) Histologic evaluation of
inguino-scrotal migration of the gubernaculum in rodents during testicular descent and its
relationship to the genitofemoral nerve. Pediatr Surg Int 7: 265-270.
24. Hutson, J.M., Beasley, S.W., Bryan, A . D . (1988) Cryptorchidism in spina bifida and spinal
cord transection: a clue to the mechanism of transinguinal descent of the testis. J. Pediatr.
Surg. 2 3 : 2 7 5 - 2 7 7 .
25. Larkins, S.L., Hutson, J.M., Williams, M.P.L. (1991) Localization of calcitonin gene-
related peptide immunoreactivity within the spinal nucleus of the genitofemoral nerve.
Pediatr. Surg. Int. 6: 176-179.
26. Y a m a n a k a , J., Metcalfe, S.A., Hutson, J.M. (1992) Demonstration of calcitonin gene-
related peptide receptors in the gubernaculum by computerized densitometry. J. Pediatr.
Surg. 2 7 : 876-878.
27. Park, W . H . , Hutson, J.M. (1991) T h e gubernaculum shows rhythmic contractility and
active m o v e m e n t during testicular descent. J. Pediatr. Surg. 26: 615-617.
28. M o m o s e , Y., Griffiths, A.L., Hutson, J.M. (1992) Testicular descent III T h e neonatal
m o u s e gubernaculum shows rhythmic contraction in organ culture in response to calcitonin
gene-related peptide. Endocrinology 131: 2881-2884.
29. Griffiths, A.L., Middlesworth, W., Hutson, J.M. (in press) E x o g e n o u s calcitonin gene-
related peptide ( C G R P ) causes gubernacular development in neonatal mice with complete
androgen resistance ( T F M ) . J Pediatr Surg.
30. S a m a r a k k o d y , U . K . S . , Hutson, J.M. (1992) Intrascrotal C G R P (8-37) causes a delay in
testicular descent in mice. J. Pediatr. Surg. 27: 874-875.
31. M o m o s e , Y., G o h , D . W . , Middlesworth, W . Hutson, J.M. (1993) T h e relationship between
C G R P , androgens and guernacular development in three animal models of cryptorchidism.
J Urol (in press).
32. G i w e r c m a n , Α., Muller, J., Skakkebaek, N . E . (1988) Cryptorchidism and testicular
neoplasia. H o r m o n e Res. 30: 157-163.
33. Huff, D . S . , H a d z i s e l i m o v i c , F., Snyder, H . M . , et al. (1989) Postnatal testicular
m a l d e v e l o p m e n t in unilateral cryptorchidism. J. Urol. 142: 546-548.
34. Zhou, B . , Watts, L . M . , Hutson, J.M. (1993) T h e effect of Miillerian inhibiting substance
(MIS) on g e r m cell development of the neonatal m o u s e testis in vitro. J Urol (in press).
35. Baker, M.L., Metcalfe, S.A., Hutson, J.M. (1990) Serum levels of Mullerian inhibiting
substance in b o y s from birth to 18 years, as determined by e n z y m e immunoassay. J. Clin.
Endocr. M e t a b . 7 0 : 11-15.
36. Y a m a n a k a , J., Baker, M.L., Metcalfe, S.A., Hutson, J.M. (1991 ) Serum levels of Mullerian
inhibiting substance in boys with cryptorchidsm. J Pediatr Surg 26: 6 2 1 - 6 2 3 .
 Advances in the Biosciences, Vol. 91, pp. 7-11. 1994
Copyright © 1994 Elsevier Science Ltd
Pergamon Printed in Great Britain. All rights reserved
0065-3446/94 $26.00

The Epidemiological Association

between Undescended Testis,
Inguinal Hernia and Testicular
Cancer: Results from the U.K.
National Case-Control Study of
Testicular Cancer
D. Forman*, C. Chilvers , G. Davey* and +

C. Coupland +

(on behalf of U.K. Testicular Cancer

Study Group)
* ICRF Cancer E p i d e m i o l o g y Unit, Gibson Building,
Radcliffe Infirmary, Oxford OX2 6HE, UK;
+
D e p a r t m e n t of P u b l i c H e a l t h M e d i c i n e a n d
E p i d e m i o l o g y , U n i v e r s i t y of N o t t i n g h a m M e d i c a l
School, Nottingham NG7 2UH, UK

T h e U . K . National C a s e - C o n t r o l Study of Testicular C a n c e r is a large population-based

epidemiological investigation into the aetiology of germ-cell t u m o u r s of the testis. T h e study was
carried o u t in defined geographic areas within 9 of the U.K Regional Health Authorities and all m e n ,
d i a g n o s e d with a testicular germ-cell t u m o u r between January 1984 and S e p t e m b e r 1986 w h o were
aged b e t w e e n 15 and 4 9 years at diagnosis and resident in these areas, were included in the study.
Controls, m a t c h e d on date of birth to within o n e year, were chosen from the list of the General
Practitioner ( G P ) with w h o m the case w a s registered. Each case-control pair w a s interviewed by
the s a m e interviewer with a questionnaire which included questions on a wide range of potential
risk factors. After interview, ancillary data on medical history were abstracted from the G P notes
for c a s e s a n d controls while details of the c a s e s ' cancers were abstracted from hospital notes.
Pathology reports w e r e centrally reviewed and all tumours were divided into those with " p u r e
s e m i n o m a " and those with " a n y other g e r m - c e i r histology. T u m o u r s with combined histologies
were placed in the latter category.

A diagnosis of u n d e s c e n d e d testis ( U D T ) w a s regarded as definite only if there was evidence of

successful o r c h i d o p e x y o r of surgical investigation at which a testis was found to be missing or
impossible to correct; otherwise the testis had to remain undescended at diagnosis. Testes that were
retractile o r that d e s c e n d e d either spontaneously o r with hormonal therapy w e r e not regarded as
undescended.

Interviews w e r e completed with 7 9 4 case-control pairs. T h i s represents 9 2 % of all eligible cases

within the study areas. T h e c o m p a r a b l e control response rate was 8 3 % . T h e r e were 4 0 0 cases with
a p u r e s e m i n o m a histology a n d 394 cases with other germ-cell histology. Table 1 s h o w s the risk
of testicular c a n c e r associated with U D T and inguinal hernia. Sixty-five cases and 17 controls had
adefinite history of U D T giving an overall o d d s ratio (OR) of 3.8 ( 9 5 % CI=2.2-6.5). Nineteen cases
and n o controls had bilateral U D T (OR=°°, 9 5 % CI=5.9-©o) w h e r e a s 4 6 cases and 17 controls had
unilateral U D T ( O R = 2 . 7 , 9 5 % CI=1.6-4.7).

7
 8 D. F o r m a n et al.

A split of our study group at the median age (31 years) shows that the prevalence of U D T in controls
w a s 3 . 3 % ( 13/395) in the younger m e n and 1.0% (4/399) in the older m e n . Comparable figures for
the cases were 8 . 1 % (32/395) and 8 . 3 % (33/399) respectively, resulting in O R s of 2.5 ( 9 5 % CI=
1.3-4.7) and 8.3 ( 9 5 % CI=2.9-23.3) for younger and older men respectively. T h e risk w a s ,
therefore, reduced considerably in younger men, although the proportion of cases with U D T
remained similar.
Table 2a s h o w s the relationship, in the cases, between the side of U D T and the side of the cancer.
T w e l v e of the 4 6 cases (26.1%) with unilateral U D T had cancer in the contralateral testis to that
which w a s undescended ie an O R of 1.4 in comparison with the 34 cases (73.9%) with cancer in
the ipsilateral testis, an O R of 4.0.

T a b l e 1 N u m b e r (%) of cases a n d controls and o d d s ratios ( 9 5 % confidence intervals) for

diagnosis o f u n d e s c e n d e d testis and inguinal hernia.
Cases Controls O d d s Ratio
No.(%) No.(%) ( 9 5 % CI)

Undescended testis - 794 matched pairs

No 729 (91.8) 777 (97.9) 1.0
Yes 65 (8.2) 17 (2.1) 3.8 (2.2-6.5)
Bilateral 19 (2.4) 0 (0.0) oo (5.9-oc)
Unilateral 46 (5.8) 17 (2.1) 2.7 (1.6-4.7)

Inguinal hernia - 7 7 2 matched

0
pairs
No 686 (94.1) 752 (96.8) 1.0
Yes 43 (5.9) 25 (3.2) 1.9 (1.1-3.2)

Diagnosed:
<15 yrs 29 (4.0) 11 (1.4) 2.6 (1.3-5.3)
> 1 5 yes 14 (1.9) 14 (1.8) 1.1 (0.5-2.6)

•All men with undescended testis (65 cases and 17 controls) were excluded from analysis.

T a b l e 2 N u m b e r of cases with a) undescended testis and b) inguinal hernia and c)

inguinal hernia < 15 yrs by side of cancer and by side of defect
Side of cancer
Right Left Bilateral

a) Side of undescended testis:

Right 16 6 0
Left 6 18 0
Bilateral 11 7 1

b) Side of inguinal hernia:

Right 11 7 0
Left 7 10 1
Bilateral 1 6 0

c) Side of inguinal hernia < 15 yrs

Right 9 5 0
Left 5 6 0
Bilateral 1 3 0

T a b l e 3 s h o w s that the risk of pure seminoma after a diagnosis of U D T w a s significantly greater

than the risk for other histologies (OR = 1 2 . 7 compared with 1 . 9 , ρ = 0 . 0 0 2 ) . This difference was
 U . K . N a t i o n a l C a s e - C o n t r o l S t u d y of T e s t i c u l a r C a n c e r 9

also seen in those with unilateral U D T (OR=7.7 c o m p a r e d with 1.6, p=0.016). T h e s e differences
in risk w e r e largely d u e to differences in the distribution of U D T in the control groups. T h e risk
of pure s e m i n o m a after a diagnosis of U D T was similar for those younger than, and those at or older
than, the median age ( O R = 1 2 . 0 , 9 5 % CI= 1.6-92.3 and 1 3 . 0 , 9 5 % CI=3.1 -54.8 respectively). For
both age groups these risks were greater than the comparable risks for other histologies (OR=1.7,
9 5 % CI=0.8-3.4 and O R = 3 . 5 , 9 5 % CI=0.7-16.8 respectively).

T w e l v e of the 16 cases with uncorrected U D T (unilateral or bilateral) had a pure s e m i n o m a (75.0%)

c o m p a r e d with 2 6 of the 4 9 cases with a corrected U D T (53.1 % ) and 362 of the 7 2 9 cases with a
normally descended testis (49.7%).

Table 3 N u m b e r (%) of cases and controls and o d d s ratios ( 9 5 % confidence intervals) for
diagnosis of u n d e s c e n d e d testis a n d hernia by histological g r o u p (pure
seminoma/all other histologies) of t u m o u r .
Pure seminoma All other histologies
Cases Controls Odds Ratio Cases Controls Odds Ratio Test for
No (%) No (%) (95% CI) No (%) No (%) (95% CI) Interaction

Undescended testis
No 362 (90.5) 397 (99.3) 1.0 367 (93.1) 380 (96.4) 1.0
Yes 38 (9.5) 3 (0.8) 12.7(3.9-41.0) 27 (6.9) 14 (3.6) 1.9 (1.0-3.7) x*=9.59
p=0.002

Unilateral 23 (5.8) 3 (0.8) 7.7 (2.3-25.5) 23 (5.8) 14 (3.6) 1.6 (0.9-3.2) χ =5.79
2

ρ = 0.016
Bilateral 15 (3.8) 0 (0.0) oo (3.9-oo) 4 (1.0) 0 (0.0) oo (0.7-OO)

Inguinal hernia
No 340 (93.9) 380 (95.7) 1.0 346 (94.3) 372 (97.9) 1.0
Yes 22 (6.1) 17 (4.3) 1.4 (0.7-2.7) 21 (5.7) 8 (2.1) 3.2 (1.3-7.9) χ^.09
p=0.15

<15 yrs 17 (4.7) 9 (2.3) 1.9 (0.8-4.2) 12 (3.3) 2 (0.5) 6.0(1.3-26.8) χ^.03
p=0.15
>15yrs 5 (1.4) 8 (2.0) 0.7 (0.2-2.4) 9 (2.5) 6 (1.6) 1.8 (0.5-6.0) χ^Ι.18
p=0.28

T h e results for the risk of testicular cancer subsequent to inguinal hernia in Tables 1,2 and 3 are
shown after exclusion of all subjects with U D T . This was because of the close association between
the t w o conditions and the need to look at hernia independently from U D T . Table 1 shows that there
was a significantly increased risk of cancer in men with inguinal hernia (OR= 1.9,95% CI= 1.1-
3.2) but this risk w a s confined to men w h o had a hernia diagnosed before the age of 15 years
(OR=2.6, 9 5 % CI= 1.3-5.3). As with U D T , in men with a unilateral hernia cancers were more
frequently diagnosed on the same side as the hernia; 21 out of 35 men (60.0%) with unilateral
hernias and 15 out of 25 men (60%) with hernias diagnosed before the age of 15 years having cancer
in the ipsilateral testis (Table 2 b and c). This results in O R s of 2.3 and 1.5 to the ipsilateral and
contralateral testes respectively after an inguinal hernia and O R s of 3.2 and 2.1 respectively after
a hernia diagnosed at less than 15 years.

There were n o significant differences between the risks for the different histological types of cancer
after an inguinal hernia (Table 3). H o w e v e r for all hernias and for hernias diagnosed at less than
15 years, the risks for pure seminoma were less than those for other tumours. This is the opposite
of the effect seen for U D T .
10 D. F o r m a n et al.

T h e risks associated with U D T and inguinal hernia were much as expected from previous studies
( 1 , 2 ) i.e. bilateral U D T carries a substantial risk of cancer, whereas unilateral U D T o r an inguinal
hernia early in life carry m o r e moderate risks (both about three-fold in this study). O u r overall risk
estimate of 3.8 associated with U D T is somewhat lower than that reported previously. Chilvers and
Pike (2) reported a s u m m a r y estimate of 5.8 from an overview of nine studies published since 1979.

There are t w o explanations for this reduction. Previous estimates have been based largely on recall
of the diagnosis by cases and controls. Men m a y recall retractile or late descending testes as U D T
and cases, w h o m a y k n o w of the association between U D T and cancer, m a y be m o r e likely to
misclassify their condition in this way. This could result in an over-estimate of the relative risk.
Misclassification of U D T has been reduced in our study by seeking verification of the diagnosis
in the G P notes.

A second reason for a reduced risk estimate m a y arise from the increasing incidence of U D T over
time ( 3 , 4 ) . If the population prevalence of U D T has increased since earlier studies took place while
the proportion of cases with U D T has remained constant, this will produce a reduced relative risk
(4) as w e have demonstrated by splitting our study group at the median age.

O u r results also suggest that m e n w h o had a unilateral U D T which was successfully corrected
before the age of 10 years, were no longer at increased risk of developing a cancer ( O R = 0 . 6 , 9 5 %
0 = 0 . 2 - 1 . 7 ) . This is consistent with some ( 5 , 6 ) but not all ( 7 , 8 ) studies which have addressed this
issue although there are few data on men with an age at correction below 10 years. If these findings
on unilateral U D T are confirmed, the recent trend to reduce the age at which correction is carried
out should be encouraged and the effect on testicular cancer rates closely monitored.

Although previous studies have shown a stronger association between U D T and seminoma than
between U D T and other histologies ( 9 , 1 0 ) the magnitude of the difference in risk by histological
type which w e observed was substantial ( O R = 12.7 vs 1.9). T h e difference in risk was maintained
after splitting the group at the median age and thus, the greater relative risk did not occur just
because s e m i n o m a develops at a later age than other histologies and the prevalence of U D T is lower
in older m e n . T h e fact that the difference between the histological groups is largely a result of the
distribution of U D T in the controls indicates that chance may explain some or all of the observed
effect. W e also observed an increased proportion of seminomas in men with an uncorrected U D T
than in m e n with normally descended testes or successfully corrected U D T s . This effect is
consistent with several other studies (2, 11), and it has been suggested that orchidopexy, and
resulting trauma, might cause progression of the disease to a m o r e malignant form.

In keeping with m o s t other studies (1), w e found a small increased risk associated with having had
a hernia and, consist ant with several ( 1 0 , 1 2 , 1 3 ) but not all (5) studies, the risk increased for hernias
diagnosed in childhood. Comparison between studies is complicated by the fact that not all analyses
clearly distinguish between U D T and hernia and because there are misclassification problems for
both conditions when relying on self-report.

A c k n o w l e d g e m e n t : This study was funded by the Imperial Cancer Research Fund, the Cancer
Research Campaign and the Medical Research Council.

REFERENCES
1. F o r m a n D . ( 1989) Epidemiology of testis cancer. In : Oliver R T D , Blandy J P , Hope-Stone
H F , e d s . Urological and Genital Cancer. Oxford: Blackwell Scientific Publications, pp.
289-305.