What is the appropriate workup for a left inguinal (groin area) mass?

From the Guidelines

For a left inguinal mass workup, I recommend starting with a thorough history and physical examination to assess for suspicious lymph nodes (LNs) and determine if the patient is clinically node-negative (cN0) or node-positive (cN+), as this distinction is crucial in guiding further management 1.

When evaluating a left inguinal mass, it is essential to consider the possibility of lymphadenopathy, which may be indicative of underlying malignancy or infection. Given the limitations of noninvasive staging options such as computed tomography (CT) and positron emission tomography (PET)/CT in detecting micrometastatic disease 1, a more targeted approach is necessary.

• The initial assessment should include a careful palpation of both groins to categorize patients into those with or without suspicious lymph nodes.
• For patients with a high-risk tumor profile, surgical staging is recommended due to the significant risk of nodal metastases 1.
• In cases where the risk of LN metastasis is intermediate, the decision to proceed with surgical staging should be made on a case-by-case basis, weighing the risks against the potential benefits 1.
• Dynamic sentinel node biopsy (DSNB) is a valuable tool in the staging process, offering high diagnostic accuracy with lower morbidity compared to inguinal LN dissection (ILND) 1.
• If the inguinal mass is suspected to be of lymphatic origin, further workup may include inguinal US + fine-needle aspiration cytology (FNAC) of sonographically abnormal nodes to potentially reduce the need for DSNB 1.
• Additional imaging for staging, such as CT scans of the abdomen and pelvis with contrast, should be considered based on the clinical context and the results of initial evaluations.
• Laboratory tests, including complete blood count, comprehensive metabolic panel, and inflammatory markers, can provide valuable information on the patient's overall condition and help guide further management.
• The urgency and specifics of the workup should be tailored to the individual patient's presentation, including the presence of symptoms such as pain, rapid growth, or systemic symptoms like fever or weight loss.

From the Research

Left Inguinal Mass Workup

• The diagnosis of an inguinal mass, such as a hernia, can often be made through history and physical examination alone 2.
• Symptoms of an inguinal hernia may include groin pain, a burning or aching sensation, and a heavy or dragging sensation that worsens throughout the day 2.
• Ultrasonography can be a useful tool in diagnosing inguinal hernias, particularly in cases where the diagnosis is uncertain or in athletes without a palpable impulse or bulge on physical examination 2, 3, 4.
• Other imaging modalities, such as magnetic resonance imaging (MRI) or computed tomography (CT) scans, may also be used in certain cases, such as suspected complications or hernia recurrence 2, 4.

Differential Diagnosis

• Inguinal masses can have a variety of causes, including hernias, hydroceles, spermatic cord tumors, and lymph node enlargement 3, 5.
• Ultrasonography can help differentiate between these various causes, and clinical history and certain sonographic details can assist in making the correct diagnosis 3, 5.

Management

• Symptomatic inguinal hernias should be treated surgically, while asymptomatic or minimally symptomatic hernias may be managed with watchful waiting 6.
• The choice of surgical technique, such as open or laparoscopic repair, should be tailored to the individual patient and surgeon's expertise 6.
• Mesh repair is recommended as the first choice for inguinal hernia repair, and the use of low-weight mesh may have slight short-term benefits but is not associated with better long-term outcomes 6.