From the Guidelines
The next steps for this 22-year-old male with a nontender left groin mass and CT findings suspicious for neoplasm should include a thorough physical examination, additional imaging with MRI, and laboratory tests such as complete blood count, comprehensive metabolic panel, and tumor markers. Given the location of the mass in the groin region, which is an area difficult to evaluate radiographically, and the suspicion of a neoplasm, further evaluation with MRI without and with IV contrast is usually appropriate, as suggested by the ACR Appropriateness Criteria for soft-tissue masses 1. The initial CT pelvis showing increased vascularity suspicious for neoplasm already provides valuable information, but MRI can offer better characterization of the mass and its relationship to surrounding structures, which is crucial for surgical planning and determining the extent of the disease. Some key points to consider in the management of this patient include:
- A thorough physical examination, including testicular examination, to rule out a primary testicular tumor
- Additional imaging with MRI to better characterize the mass
- Laboratory tests such as complete blood count, comprehensive metabolic panel, and tumor markers (such as alpha-fetoprotein, beta-HCG, and LDH) to help narrow the differential diagnosis
- Consideration of a surgical consultation for excisional biopsy to provide definitive tissue diagnosis, which is essential for determining the exact nature of the mass and guiding further treatment. The differential diagnosis for this patient's presentation includes testicular cancer with lymph node metastasis, lymphoma, soft tissue sarcoma, or other less common neoplasms, and management would depend on the specific pathology findings, potentially involving surgery, radiation, chemotherapy, or a combination approach depending on the type and stage of malignancy identified.
From the Research
Next Steps for Diagnosis
The patient presents with a nontender mass on the left groin region, and a CT pelvis shows increased vascularity suspicious for neoplasm. The next steps in diagnosis and management could involve:
- Further imaging studies to better characterize the mass and its relationship to surrounding structures
- Biopsy to obtain a tissue diagnosis, as seen in studies such as 2 which suggests that transvenous biopsy is a safe and accurate method for intravascular and perivascular mass tissue sampling
- Consultation with a multidisciplinary team, including vascular specialists and oncologists, to determine the best course of management
Importance of Tissue Diagnosis
A tissue diagnosis is crucial in determining the nature of the mass, whether it is benign or malignant. Studies such as 3 highlight the importance of maintaining a high index of suspicion for malignancy, even in cases where the initial diagnosis is a benign vascular anomaly. A low threshold for biopsy is recommended, especially in cases with rapid growth or increasing symptoms.
Classification of Vascular Lesions
The classification of vascular lesions has undergone revisions, with the International Society for the Study of Vascular Anomalies adopting a new classification system in 2014 4. This system divides vascular lesions into neoplasms and malformations, with further subcategories to guide management and treatment.
Role of Imaging in Diagnosis
Imaging plays a critical role in the diagnosis and management of vascular lesions. Studies such as 5 emphasize the importance of actionable imaging reports that provide accurate and timely information to guide clinical management. The use of information technology tools can improve the quality and consistency of imaging reports, leading to better patient outcomes.