Inguinal Lymph Node Growing into the Scrotum: Immediate Management Algorithm
This patient requires urgent fine-needle aspiration (FNA) of the inguinal lymph node to determine if this represents metastatic penile cancer, followed by immediate inguinal lymph node dissection (ILND) if positive, as this is the single most important prognostic factor determining survival. 1
Immediate Diagnostic Steps
Perform FNA immediately as the mandatory first diagnostic step, with sensitivity of 91.7% and specificity of 98.2% for detecting malignancy. 2 This takes priority over all imaging studies.
Before FNA, conduct a focused physical examination evaluating:
- Primary penile lesion search - examine the glans, prepuce, and shaft for any nodular, ulcerative, or fungating lesions 3
- Bilateral inguinal assessment - palpate both groins as crossover drainage occurs and bilateral disease is common 1
- Constitutional symptoms - assess for fever, weight loss, and fatigue indicating advanced disease 1, 3
- Node characteristics - document size, mobility versus fixation, skin involvement, and relationship to Cooper's ligament 1
Imaging Strategy
Order CT chest/abdomen/pelvis with contrast to assess for:
- Pelvic lymph node involvement 1
- Distant metastases 1
- Extent of local invasion if primary penile lesion identified 1
MRI is superior to CT for evaluating inguinal nodes when physical examination is difficult, but do not delay FNA for imaging. 1
Management Based on FNA Results
If FNA Positive for Malignancy
Proceed immediately with radical ILND (not modified or superficial dissection) as this is the only curative treatment for inguinal-confined disease. 4 The dissection must include:
- All seven anatomical zones of the inguinal region 4
- Deep inguinal lymph nodes, as 7.1% of patients have isolated deep node metastases 4
- Bilateral dissection even if contralateral side appears normal clinically 1
Consider neoadjuvant chemotherapy with TIP regimen (paclitaxel, ifosfamide, cisplatin) if the node is 2-4 cm, as this achieves 50% response rate and improves progression-free survival. 1 Surgery follows after 3-4 cycles.
If FNA Negative
Do not accept a negative FNA as definitive given the heterogeneous appearance suggesting this is not simple reactive lymphadenopathy. Proceed with excisional biopsy for definitive diagnosis. 2
Critical Pitfalls to Avoid
Do not assume palpable lymphadenopathy equals malignancy - 30-50% of palpable inguinal nodes in penile cancer are inflammatory. 1, 2 However, given the scrotal extension described, this represents high suspicion for malignancy requiring tissue diagnosis.
Do not perform modified or superficial ILND if malignancy is confirmed. Single positive nodes and first-station metastases occur in any region including deep nodes, and only radical ILND ensures complete resection. 4
Do not delay treatment for symptom resolution - if this represents penile cancer metastasis, early ILND is the primary determinant of survival, and delays worsen prognosis. 1
Surgical Approach Considerations
Robotic-assisted or laparoscopic ILND can be considered as alternatives to open surgery, with comparable nodal yield but reduced wound complications (44% fluid collections with open radical ILND). 5, 6, 7 However, this should not delay treatment if expertise is unavailable.
Preserve the saphenous vein when technically feasible to reduce lymphedema risk, which occurs in up to 36% of radical lymphadenectomies. 5, 7
High-Risk Features Requiring Adjuvant Therapy
If pathology after ILND shows any of the following, administer adjuvant chemotherapy (TIP regimen) or chemoradiotherapy: 1
- Pelvic lymph node metastases
- Extranodal extension
- Bilateral inguinal involvement
- ≥5 cm tumor in lymph nodes
- ≥2 positive nodes 1
Follow-Up Protocol
After treatment, follow every 3 months for years 1-2, then every 6 months for years 3-5 with: 1