1. Introduction
Malignant testicular tumor is a rare form of cancer [1] [2] . It accounts for 0.5% of cancers and 5.9 new cases per 100,000 men in the United States [1] . It is the most common cancer among young adults aged 20 to 30 years [2] [3] [4] . Risk factors are dominated by testicular dysgenesis syndrome (cryptorchidism, hypospadias, infertility), testicular atrophy (<12 ml), personal or family history (in first-degree relatives) of germ cell tumor [3] . Patients with a history of germ cell testicular tumor have a relative risk of developing contralateral malignancy approximately 25 times higher than the general population of the same age [4] [5] . Currently, testicular cancer diagnosis is increasingly incidental, at a localized stage, thanks to the frequent demand for scrotal ultrasound [3] , yet in our contexts, patients still present at advanced stages of the disease due to taboos surrounding genital organs. However, testicular cancer remains highly curable when detected early [3] [6] . We conducted this study to report on the diagnostic and evolutionary aspects of testicular cancer cases treated at the University Hospital Center (CHU) of Brazzaville and to supplement with a literature review.
2. Patients and Methods
We conducted a retrospective study in the urology-andrology, medical oncology, and radiotherapy departments of the University Hospital Center (CHU) of Brazzaville from January 2005 to December 2023 (a 19-year period). The Brazzaville University Hospital Center is the single largest health center in the country (Republic of Congo). With barely 5,468,622 inhabitants, the Republic of Congo is a country with low demographic density (on average 13 inhabitants/km2). Its population is predominantly young and 47% is under 18 years old. Brazzaville is the capital of the country with a demographic which increased from 1,373,382 inhabitants in 2007 to 2,638,000 inhabitants in 2023.
We collected data from medical records, hospitalization registers and patients’ operating reports. We included all usable medical records of patients who were admitted for treatment of a testicular tumor. The variables studied were age, circumstances of discovery, clinical and biological examination data, imaging data, anatomopathological results of orchidectomy specimens, diagnostic stage (TNM 2016), and post-therapeutic surveillance elements. Orchidectomy was performed via high inguinal approach after ligature of the spermatic cord in all operated patients. Computed tomography was performed before orchidectomy in patients received at clinically advanced stage. Neoadjuvant treatment was proposed before orchidectomy in advanced stage patients with poor general condition. All forms of therapy received in addition to orchidectomy were grouped into an adjuvant therapy category. Patients were reviewed every three months in the first year, then every six months in the second year, and then once a year from the third year in the absence of carcinological recurrence. The average postoperative surveillance follow-up period was 4.1 years (2.4 and 6 years). A thoraco-abdomino-pelvic CT scan was requested during each consultation during surveillance. Tumor marker sampling was performed before orchidectomy and was checked after surgery within 1 to 2 weeks before the start of adjuvant chemotherapy. Patients’ records were discussed in a multidisciplinary consultation meeting. After orchidectomy, patients were systematically referred to the medical oncology department for adjuvant treatment. Patients were considered in complete remission if tumor markers normalized and there were no suspicious radiological images (on TAP CT) during the two years following orchidectomy.
3. Ethical Consideration
This work was carried out as part of scientific research. As a result, it was approved by the Health Science Research Ethics Committee (CERSSA). Approval from the hospital ethical review board was sought prior to data collection.
4. Results
During the study period, 12 cases of testicular tumors were treated at the University Hospital Center (CHU) of Brazzaville, representing an average annual incidence of 0.6 cases per year. The median age of the patients was 31 years, ranging from 11 to 49 years. The age group of 30 to 49 years was the most represented with 07 cases. Testicular cancer ranked fourth (1.13%) among urological cancers after prostate cancer (77.30%), urinary tract cancers (10.81%), and kidney cancer (8.76%). The main circumstance of discovery was scrotal mass (Figure 1) in 9 cases. The discovery was made during a scrotal ultrasound (Figure 2) in two patients during an assessment for testicular pain. In one patient, the tumor was discovered intraoperatively during a procedure for a large hydrocele. The mean consultation delay was 10.6 months (ranging from 3 to 27 months). Table 1 reports the diagnostic features of the patients at admission. One patient had gynecomastia associated with bilateral testicular tumors. Tumor markers were normal in five patients. LDH was elevated in 7 patients, while alpha-fetoprotein and Beta-HCG were elevated only in 2 of our patients. Thoraco-abdomino-pelvic CT scan revealed two cases of distant
*Operated on at 9 years old and tumor of the same testicule at 36 years old.
metastases, including one pulmonary localization and one dual pulmonary and hepatic localization. Bilateral partial orchidectomy via inguinal approach was performed in one patient with bilateral localization. Sperm preservation before orchidectomy was performed in one patient. The results of anatomopathological analyses of orchidectomy specimens are reported in Table 2. Table 3 reports the distribution of patients according to the discovery stage of testicular cancer.
Chemotherapy involved the BEP protocol (combining Bleomycin 30 mg total dose on days 1, 8, 15; Etoposide 100 mg/m2 on days 1 to 5, and Cisplatin 20
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Table 2. Results of anatomopathological analyzes of operating specimens.
aTwo patients admitted in poor general condition died before orchiectomy.
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Table 3. Histological types and diagnostic stages of testicular cancer of patients.
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Figure 1. Large left bursa related to a testicular tumor in a 20 year old boy.
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Figure 2. Color doppler ultrasound showing a testicular mass linked to a tumor.
mg/m2 on days 1 to 5 every 3 weeks) for patients with germ cell tumors and tubulo-papillary epididymo-testicular adenocarcinoma. For non-Hodgkin’s malignant lymphoma, the CHOP protocol (Cyclophosphamide 600 mg/m2, Doxorubicin 60 mg/m2, Vincristine 1.5 mg/m2, and Prednisone 1 mg/kg) was used. No lymph node dissection was performed, and no patient received radiotherapy. Neoadjuvant chemotherapy was administered in two patients admitted at an advanced stage of unilateral testicular tumor. Poor general condition precluded primary orchidectomy.
In terms of evolution, we noted good progress with complete remission without secondary focus in 9 patients, including 7 cases of germ cell tumors and two cases of non-Hodgkin’s malignant lymphoma. One patient with tubulo-papillary epididymo-testicular adenocarcinoma experienced late recurrence after a remission period of 27 months. The patient died due to complications related to retroperitoneal and pulmonary metastases. The two patients admitted in poor general condition died before orchidectomy during neoadjuvant chemotherapy. One patient experienced neglected torsion of the spermatic cord on the contralateral single testicle at the eleventh month postoperatively. The patient developed symptomatic and biochemical hypogonadism, requiring testosterone treatment. One of the cured patients reported having fathered a full-term pregnancy.
5. Discussion
The incidence of testicular cancer worldwide exhibits geographical and ethnic differences: it is low in African and Asian countries and higher in white populations in Northern European countries [4] [7] . Our incidence of 0.6 cases of testicular cancer per year is comparable to that reported in the literature [1] [2] [8] . Concerning the low number of cases observed in this single-center study, we can confirm that this cancer is rare in Africa because another study, conducted in Burkina Faso by Goumbri [9] , identified 10 cases of testicular cancer over a period of 20-year study, period similar to ours. This pathology is more observed in young subjects [2] [4] [6] [10] , at a peak time for career and reproductive life [11] . In this age group, patients cured of testicular cancer have a long life expectancy. This underscores the importance of not downplaying the long-term effects on reproductive health and quality of life. Knowing the harmful effect of systemic cancer treatments on fertility [3] , sperm cryopreservation should be considered in these patients immediately after diagnosis [6] [8] [12] . Cryopreservation has medicolegal value [3] , it is ideally carried out before orchiectomy and imperatively before any chemotherapy, radiotherapy, or retroperitoneal surgery. In our study only one patient was able to have sperm preserved abroad because we do not have a sperm bank.
In developed countries, the diagnosis of testicular cancers is increasingly being made incidentally, in the form of small asymptomatic and non-palpable testicular tumors, due to the rising demand for scrotal ultrasound [3] [12] [13] [14] . In our context, all patients were symptomatic, and the testicular mass, evident on clinical examination, was the most commonly observed reason for consultation, as reported in African series [10] [15] . In the majority of cases, these symptoms are associated with advanced-stage disease. The low socio-economic level, the limits caused by modesty and the taboos on subjects which affect the genito-external organs mean that patients consult late at the advanced stage of the disease. Yet most germ cell tumors are curable even at an advanced stage [1] [4] [16] .
In the literature, the two main categories of testicular cancer are “germ cell tumors,” accounting for up to 95% of testicular malignancies, compared to “non-germ cell tumors” [1] [2] [4] . Testicular germ cell tumors represent 1% of all male malignancies [4] [17] . Non-seminomatous testicular tumors were the most observed in our series, consistent with Kane’s series [10] in Senegal, which observed 10 cases of non-seminomatous germ cell tumors out of 17 testicular cancer cases. The frequency of lymphomatous testicular tumors is low in our series compared to what was reported in Sow’s series [15] , which reported 43.90% of testicular cancer cases being lymphomatous in Cameroon.
This study has some limitations regarding the detection of serum markers because the measurement of human chorionic gonadotropin (HCG) in plasma was not available for all patients; only beta-HCG measurement was available. All patients who had elevated tumor markers had a high lactate dehydrogenase (LDH) level. Elevated LDH levels favor an advanced tumor [18] [19] . In the literature, only 60% of patients present with elevated serum markers [4] [20] .
Platinum-based chemotherapy has contributed to improving the overall cure rate of germ cell tumors to over 90% [4] . It is indicated in patients with intermediate or poor prognosis disease [6] . In patients with life-threatening metastatic disease, orchidectomy may be deferred. In such cases, orchidectomy should be performed after chemotherapy [3] [6] . Two of our patients were referred for neoadjuvant chemotherapy due to poor general condition precluding surgical intervention. Adjuvant chemotherapy or radiotherapy are standard treatment options [6] . Chemotherapy and radiotherapy achieve similar disease control [21] , with disease-specific overall survival close to 100% with either approach [6] . Although adjuvant therapy reduces the risk of relapse, discussions with patients should go beyond the risk of relapse to include potential long-term toxicities of adjuvant treatment and equivalent cancer-specific survival [6] .
In our series, given the fact that the patients were received at an advanced stage with large tumors, given the lack of lymph node dissection and also given the unavailability of conformal radiotherapy, adjuvant chemotherapy was the only option at our disposal. Patients not consulting until late, by ridding them of the main complaint, they often lack the motivation to adhere to close post-operative monitoring. Kane et al emphasize that once operated, patients no longer consider it necessary to return to the hospital believing they are cured [10] .
The 5-year specific survival rate for this disease is greater than 90%, all stages combined [22] . Late relapses may have disease more resistant to chemotherapy and, therefore, surgical resection is an integral part of this [23] .
6. Conclusion
Testicular cancer is a rare condition in Brazzaville. It occurs in young adults at a time when most men are considering starting a family. In our setting, its management is often carried out at advanced stages of the disease due to late presentations. Platinum-based chemotherapy has improved the management of patients with germ cell tumors, regardless of stage.