Blog

Chest Wall Recurrence after Mastectomy – Calor Trial

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Patients with chest wall recurrence:
    • Are at high risk for:
      • Concurrent systemic recurrences:
        • Therefore, obtaining systemic staging and receptor information on the recurrence should be the first consideration
  • Often, there may be extensive local regional involvement in several areas along the chest wall and in the nodal regions
  • According to National Comprehensive Cancer Network guidelines:
    • Systemic staging generally consists of either a PET/CT scan or a CT of the chest, abdomen, and pelvis, as well as a bone scan
  • Surgical excision with negative margins:
    • Followed by comprehensive chest wall and nodal radiotherapy may be indicated in the absence of widespread systemic disease
  • These patients should be managed by a multidisciplinary team, including:
    • The surgical oncologist, medical oncologists, radiologists, pathologists, and potentially a plastic surgeon
  • Patients may or may not benefit from chemotherapy:
    • In the CALOR trial:
      • Chemotherapy was found to benefit patients with resected ER negative isolated locoregional recurrence:
        • But not ER positive isolated local regional recurrence
  • References

Evaluation of Hypothyroidism

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Signs and Symptoms of Hypothyroidism:
    • Commons signs and symptoms of hypothyroidism are mostly nonspecific, and some patients may not display any signs or symptoms
    • Symptoms may be insidious, and in the elderly and middle-aged women:
      • Nonspecific complaints may be interpreted as signs of normal aging or depression
    • Symptoms of hypothyroidism depend on the degree and duration of the disease:
      • But most frequently include:
        • Weight gain
        • Fatigue
        • Constipation
        • Menstrual irregularities / infertility
    • General signs and symptoms of hypothyroidism:
      • Weight gain
      • Fatigue
      • Cold Intolerance
      • Hyponatremia
      • Hypothermia
      • Increased body mass index
    • Skin:
      • Dry and coarse skin
      • Dry and coarse hair
      • Pretibial myxedema (non pitting edema)
      • Hair loss
    • Head and Neck:
      • Hoarse voice
      • Enlarged tongue
      • Periorbital edema
      • Goiter
    • Gastrointestinal:
      • Constipation
      • Reduced esophageal motility
      • Nonalcoholic fatty liver
    • Musculoskeletal:
      • Myalgia
      • Muscle cramps
      • Muscle weakness
      • Carpel tunnel syndrome
      • Elevation of serum creatine phosphokinase
      • Hoffman’s syndrome:
        • Rare form of hypothyroid myopathy:
          • Characterized by pseudohypertrophy (increased muscle mass) and proximal muscle weakness:
            • Particularly in the legs
    • Nervous system:
      • Depression
      • Impaired concentration
      • Memory loss
      • Changes in vision, hearing, and taste
      • Dementia
      • Impaired congitive function
      • Neurophathy
      • Cochlear dysfunction
      • Decreased gustartory and olfactory sensitivity
      • Delayed relaxation of tendon reflexes
    • Cardiovascular:
      • Fatigue on exertion
      • Shortness of breath
      • Bradycardia
      • Diastolic hypertension
      • Dyslipidemia
      • Electrocardiogram changes
      • Hyperlipidemia
      • Pericardial effusion
      • Congestive heart failure
    • Reproductive:
      • Irregular menstrual periods
      • Amenorrhea
      • Galactorrhea:
        • If accompiend by elevated prolactin levels
      • Infertility
      • Miscarriage
    • Hematological:
      • Bleeding
      • Fatigue
      • Mild anemia
      • Acquired von Willebrand disease
      • Decreased protein C and S
      • Increased red blood cell distribution width
      • Increased mean platelet volume
  • Etiologies of Hypothyroidism:
    • The most common etiologies of decreased serum thyroid hormone concentrations are those associated with primary hypothyroidism:
      • Which is defined as underproduction of thyroid hormone at the thyroid gland
    • Excluding postsurgical and postablative hypothyroidism:
      • The most common cause of adult hypothyroidism worldwide is:
        • Hashimoto’s thyroiditis
    • Causes of hypothyroidism associated with secondary and tertiary disease:
      • When hypothyroidism arises from pituitary and hypothalamic insults, respectively:
        • Are much less common
  • It is important that hypothyroidism arising from Hashimoto’s thyroiditis:
    • Be distinguished from transient forms of hypothyroidism:
      • Such as excess iodine exposure
      • The hypothyroid phase of subacute thyroiditis
    • Hypothyroidism arising from Hashimoto’s thyroiditis:
      • Is an indication for lifelong thyroid hormone replacement:
        • The transient forms of hypothyroidism may not necessarily require this
  • The most common forms of subacute thyroiditis are:
    • Postpartum thyroiditis
    • Painful subacute thyroiditis
    • Painless subacute or silent thyroiditis
  • All forms of subacute thyroiditis:
    • Are characterized by the triphasic pattern of transient thyrotoxicosis (i.e., 1 to 3 months):
      • Followed by transient hypothyroidism (i.e., lasting up to 6 months):
        • With the eventual return to the euthyroid state:
          • Although not all patients will experience all phases
    • Postpartum thyroiditis:
      • Occurs in the few months after a:
        • Miscarriage, therapeutic abortion, or delivery
    • Subacute painful thyroiditis:
      • Is associated with:
        • An enlarged and tender thyroid gland
        • Variably presents with flulike symptoms:
          • High fever, myalgia, and a high serum erythrocyte sedimentation rate (ESR)
    • Painless or silent lymphocytic subacute thyroiditis:
      • Is associated with an enlarged thyroid gland
    • All three types of subacute thyroiditis:
      • Can be diagnosed by a:
        • Very low radioactive iodine uptake
    • In most cases, the hypothyroid phase of subacute thyroiditis does not require treatment with thyroid hormone replacement:
      • Unless the patient is symptomatic or the hypothyroidism is biochemically severe
Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The long-awaited B51 has been published. A study that opens door, but doesn’t close them all. Should we irradiate nodal areas in cN1 patients who achieve ypN0 after NAC?
  • Evidence might be solid to omit RNI in HER2+ patients with good response. This group appears to be the most promising.
  • The triple-negative cohort shows a puzzling signal: higher risk with irradiation. Statistical noise? Selection bias? Serendipity?
  • In pure luminal cases—5% in practice but only 20% in the trial there’s a trend toward benefit with RNI.
  • Limited follow-up, low representation, and no data on grade or LVI make it hard to change practice based on this evidence.
  • Also, I wonder if this was actually two studies in one:
    • In mastectomy, it’s all or nothing—irradiate everything or nothing at all.
    • In breast-conserving surgery, it’s about adding or omitting RNI from standard treatment.
  • B51 is a step toward personalized treatment but not the final word.
  • Sometimes, less is not less—but more.
  • Yet omission must always be thoughtful.

Morbidity of Lymph Node Surgery in Melanoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Complications associated with sentinel lymph node biopsy (SLNB) for melanoma:
    • Were evaluated in 2,120 patients in an analysis of data from the Sunbelt Melanoma Trial:
      • Overall, 96 (4.6%) of the patients developed major or minor complications associated with SLNB:
        • Whereas 103 (23.3%) of 444 patients experienced complications associated with SLNB plus completion lymph node dissection
      • The authors concluded that:
        • SLNB alone is associated with significantly less morbidity compared to SLNB plus completion lymph node dissection
    • Similar to the Sunbelt Melanoma Trial, in MSLT-1:
      • SLNB did not significantly add to the morbidity of melanoma surgery when compared to wide excision of the primary melanoma alone
  • Formal lymphadenectomy is associated with higher complication rates than SLNB, and includes:
    • Seroma
    • Wound infection
    • Cellulitis
    • Lymphedema
    • Skin flap problems:
      • That may on occasion require surgical revision
  • Complication rates are higher in the:
    • Inguinal region than in the axilla or neck:
      • Cormier et al. prospectively followed 53 patients at MD Anderson who underwent inguinal lymphadenectomy for melanoma:
        • Using liberal objective criteria, investigators found the:
          • Acute wound complication rate to be 77.4% with a wound infection rate of 54.7% and a wound dehiscence rate of 52.8%
        • In multivariate analysis, only body mass index was found to be associated with an increase in complications
    • The infection rate reported after lymphadenectomy in MSLT-1 was 12%:
      • They noted that lymphedema rates varied significantly depending on the lymph nodes basins that were dissected:
        • 9.0% for axillary lymphadenectomy vs. 26.6% for inguinal lymphadenectomy)
  • Lymphedema is among the most serious long-term complications of formal lymphadenectomy:
    • Inguinal lymphadenectomy associated lymphedema:
      • Was not altered significantly by the addition of a deep groin dissection
    • In addition, the number of lymph nodes removed:
      • Did not appear to alter the lymphedema rate significantly
  • In the study by Cormier et al:
    • The lymphedema rate at 3 months was 85% using qualitative measures and 45% by quantitative measures for patients who underwent inguinal lymphadenectomy
  • Lower extremity edema after groin dissection:
    • Can be decreased by preventive measures, including:
      • Perioperative antibiotics
      • Elastic stockings
      • Leg elevation exercises
      • On occasion, diuretics
    • Even with preventive measures, patients should be counseled that lymphedema can still develop
  • Nonetheless, prophylactic measures are important:
    • Because reversing the progression of lymphedema is difficult
  • The complication rate for axillary lymph node dissections is lower than that for inguinal dissection:
    • The most frequent complication is wound seroma:
      • Varying from 3% to 23%
    • Other common complications include:
      • Cellulitis and lymphedema (approximately 10%)

UPDATE from the American Association of Clinical Endocrinology 2025 Annual Meeting

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Radiofrequency Ablation will be a viable treatment for Papillary Thyroid Carcinoma
    For low-risk patients with papillary thyroid carcinoma interested in something other than surgery or surveillance, radiofrequency ablation may be an option.
  • At the AACE Annual Scientific and Clinical Conference the experience of the Thyroid Institute of Southern California in Newport Beach was presented.
  • A single-arm study of 24 patients with papillary thyroid carcinoma who underwent one session of radiofrequency ablation.
  • All 24 patients declined surgery and refused the Watch & Wait approach to treating microcarcinomas and did not have a tumor more than 2 cm in its greatest dimension lymph node metastasis or an aggressive subtype of tumor.
  • Papillary thyroid carcinoma is one of the most common thyroid cancers.
  • Traditional management has been surgery or active surveillance.
  • Minimally invasive therapy such as radiofrequency ablation can be an emerging therapy for our patients.
  • The objective of the study was to evaluate radiofrequency ablation and compare it to active surveillance.
  • Eleven patients had a T1a tumor (< 1 cm) 12 had a T1b tumor (1 cm to < 2 cm) and one had a T2 tumor (2 cm to < 4 cm), and four patients had a BRAF mutation.
  • At 12 months tumor size was reduced by more than 80% in those with T1a tumors (86%) and those with T1b tumors (82.5%).
  • Percent volume reduction at 12 months was slightly greater in patients with a BRAF mutation.
  • Maybe it’s operator-dependent they may use more aggressive radiofrequency in those regions.
  • The percent volume reduction at 12 months was 64.2% in patients with T1a tumors and 78% in patients with T1b tumors.
  • Among those with T1a tumors those with a BRAF mutation had an 86.3% reduction and those without one had a 72.31% reduction.
  • These results are quite pleasing for first-year data. By contrast in a 2020 study of 50 patients who were under active surveillance 30 of them eventually had surgery.
  • Radiofrequency is a very viable option for low-risk papillary thyroid carcinomas in those who decline surgery or surveillance with very precise selection of your patient.
  • Despite the significant tumor reduction has been seen here over 12 months the physicians are going to look at the 2, 3 and 4-year data because this looks very promising.
  • Careful screening of these patients will be very important.
  • This is a very good alternative to active surveillance because of significant patient anxiety.
  • Further studies are necessary & needed.

  • Nikravan SP. Radiofrequency ablation of T1a and T1b papillary thyroid carcinoma: A North American outpatient endocrinologist experience. Presented at AACE Annual Scientific and Clinical Conference; May 2025; Orlando.

Neck Dissection for Cutaneous Melanoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Lymph node metastases from melanomas in the head and neck were previously believed to follow a predictable pattern:
    • However, it is established that lymphatic drainage from melanomas of the head and neck can be multidirectional and unpredictable
  • SLNB may be misdirected in as many as 59% of patients:
    • If the operation is based on classic anatomical studies without preoperative lymphoscintigraphy:
      • These findings strongly support the use of lymphoscintigraphy in patients with melanomas in the head and neck
  • My approach for patients with melanoma in the head and neck region and clinically involved nodes is:
    • Wide excision of the primary lesion with either modified radical neck dissection or selective neck dissection
  • Melanomas arising on the scalp or face anterior to the pinna of the ear and superior to the commissure of the lip:
    • Can metastasize to intraparotid lymph nodes because these nodes are contiguous with the cervical nodes:
      • When intraparotid nodes are clinically involved, it is advisable to combine neck dissection with parotid lymph node dissection

Metastatic Melanoma of Unknown Primary Site

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Approximately 1% to 8% of patients with melanoma:
    • Present with metastatic disease from melanoma of unknown primary (MUP) site
  • The most common presentation is:
    • In the axillary lymph node basin (> 50%):
      • Followed by the cervical lymph node basin
  • Various reasons have been proposed for the phenomenon of MUP site:
    • Anbari et al. suggested the following possibilities for primary lesions:
      • An unrecognized melanoma
      • A treated melanoma that had been initially misdiagnosed
      • A spontaneously regressed melanoma
      • Malignant transformation of a melanocyte that had traveled to a metastatic location
  • For metastatic melanoma to be classified as MUP site:
    • The histologic diagnosis must be confirmed
    • Previous biopsies and / or excisions, if any, should be evaluated for a possible diagnosis of melanoma
    • Less common primary sites for melanoma should be thoroughly evaluated
  • A thorough history may also identify prior lesion that was excised or destroyed:
    • But never pathologically examined
  • If the metastatic lesion is to a lymph node basin:
    • The drainage areas of that basin should be rigorously examined
    • Furthermore, patients should undergo staging evaluation with:
      • CT of the chest, abdomen, and pelvis (also including neck CT if anatomically appropriate), and MRI of the brain
      • PET / CT can also be considered, particularly in the setting of extremity soft tissue metastasis associated with unknown primary
  • Several studies have compared the survival of these patients to similar cohorts having equivalent nodal status and a known primary site:
    • Although patients with unknown primary tumors were historically believed to have worse prognoses:
      • Recent studies have contradicted earlier findings by demonstrating that patients with MUP have a natural history that is similar to (if not better than) the survival of many patients with stage III disease:
        • Given their survival profile, such patients with nodal disease should be staged as stage III and treated like stage III patients with a known primary melanoma, including consideration for stage III clinical trials

Dissection of the Iliac and Obturator Nodes in Melanoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • General:
    • I generally perform a deep groin dissection (dissection of the iliac and obturator nodes) for the following indications:
      • Known involvement of the nodes revealed by preoperative imaging studies
      • More than three grossly positive nodes in the superficial lymph node dissection specimen
      • Metastatic disease in Cloquet node:
        • If performed
  • Incision:
    • To gain access to the deep nodes, we extend the skin incision superiorly if performed concomitantly with a superficial groin dissection
    • If a deep groin dissection only is to be performed:
      • I generally use a dedicated right lower quadrant incision
  • Lymph Node Dissection:
    • The external oblique muscle:
      • Is split from a point superomedial to the anterior superior iliac spine to the lateral border of the rectus sheath
    • The internal oblique and transversus abdominis muscles:
      • Are divided, and the peritoneum is retracted superiorly
    • An alternative approach:
      • Sometimes used when extensive disease populates this region:
        • Is to split the inguinal ligament vertically:
          • Medial to the femoral vein
    • The ureter is exposed:
      • As it courses over the iliac artery
    • The inferior epigastric artery and vein are divided, if necessary
    • The bifurcation of the common iliac artery marks the cephalad extent of the dissection:
      • All nodes are taken along the external iliac artery to the inguinal ligament caudally
    • Nodes overlying the external iliac vein:
      • Are dissected to the point at which the internal iliac vein courses under the internal iliac artery
    • The plane of the peritoneum is traced along the wall of the bladder:
      • The fatty tissues and lymph nodes are dissected off the perivesical fat starting at the internal iliac artery
    • Dissection is completed on the medial wall of the external iliac vein, and the nodal chain is further separated from the pelvic fascia until the obturator nerve is seen
    • Obturator nodes:
      • Are located in the space between the external iliac vein and the obturator nerve (in an anteroposterior direction) and between the internal iliac artery and the obturator foramen (in a cephalad–caudad direction)
    • The obturator artery and vein usually need not be disturbed
  • Wound Closure:
    • The transversus abdominis, internal oblique, and external oblique muscles:
      • May be closed with running sutures
    • The inguinal ligament, if previously divided:
      • Is approximated with interrupted nonabsorbable sutures to Cooper ligament medially and to the iliac fascia lateral to the femoral vessels
    • A closed suction drain is placed in the deep pelvic space exiting through a separate small incision
  • Postoperative Management:
    • Suction drainage is continued until output is less than 20 mL to 30 mL per day for 2 consecutive days
    • The pelvic drain is usually removed prior to hospital discharge
    • Ambulation is encouraged the day after surgery
    • Patients are hospitalized postoperatively for expectant management of potential ileus after deep pelvic surgery and for pain control, usually for a duration of 2 to 3 days

ASCO 2025 Guidelines for Head and Neck Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Practice Guideline:
    • The American Society of Clinical Oncology recommends programmed death ligand 1 (PD-L1) combined positive score (CPS) testing by immunohistochemistry:
      • For all patients with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) to guide first-line immunotherapy selection
  • For first-line treatment:
    • Pembrolizumab monotherapy is recommended for patients with PD-L1 CPS ≥ 1
      • While pembrolizumab plus platinum-based chemotherapy is recommended for those with symptomatic or rapidly progressive disease, regardless of PD-L1 status
    • For patients with platinum-refractory recurrent or metastatic HNSCC:
      • Either nivolumab or pembrolizumab is appropriate regardless of PD-L1 status:
        • Based on improved overall survival compared to standard chemotherapy
  • The guideline also notes that tumor mutational burden (TMB) is not routinely used:
    • But may be considered in rare cases where PD-L1 CPS is unavailable or for rare head and neck cancers:
      • For rare head and neck cancers with high TMB (≥ 10 mutations / megabase):
        • Pembrolizumab may be considered
  • The American Society of Clinical Oncology:
    • Does not currently recommend immunotherapy in the curative-intent (locoregionally advanced) setting outside of clinical trials:
      • As evidence is insufficient to support its routine use in combination with chemoradiation or as neoadjuvant / adjuvant therapy
  • The rationale for these recommendations:
    • Is based on randomized trials demonstrating survival benefit of immune checkpoint inhibitors in the recurrent / metastatic setting, and the predictive value of PD-L1 CPS for response to anti–PD-1 therapy
  • Building on these recommendations:
    • Recent clinical trial data and expert reviews:
      • Further clarify the evolving role of immunotherapy in head and neck squamous cell carcinoma (HNSCC)
  • Immune checkpoint inhibitors (ICIs):
    • Specifically anti–PD-1 agents such as pembrolizumab and nivolumab:
      • Have become the standard of care for recurrent or metastatic HNSCC:
        • With objective response rates in the range of 14% to 22% and durable responses in a minority of patients
    • The KEYNOTE-048 trial:
      • Established the benefit of pembrolizumab, either as monotherapy in PD-L1 positive tumors or in combination with platinum-based chemotherapy:
        • As first-line therapy for recurrent / metastatic disease, and this approach is now widely adopted in clinical practice
  • Despite these advances, attempts to incorporate ICIs into the curative-intent setting:
    • Such as concurrent administration with chemoradiation or as neoadjuvant / adjuvant therapy:
      • Have not demonstrated clear survival benefit and are not standard outside clinical trials
    • Early-phase studies of neoadjuvant immunotherapy have shown promising signals of response:
    • But larger trials are ongoing to determine their impact on long-term outcomes
  • The use of tumor mutational burden (TMB) as a biomarker remains investigational:
    • With PD-L1 combined positive score (CPS) being the primary biomarker guiding immunotherapy selection in routine practice
  • In summary, the integration of immunotherapy into the management of HNSCC is most firmly established in the recurrent / metastatic setting, with biomarker-driven selection based on PD-L1 CPS
  • The use of ICIs in the curative-intent setting remains investigational, and ongoing research aims to refine patient selection and optimize combination strategies
  • References:

Superficial (Inguinal) Groin Dissection for Melanoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • General:
    • For groin dissection the patient is placed in a slight frog-leg position with hip externally rotated and the knee partially flexed
  • Incision:
    • A lazy-S incision is made from superomedial to the anterior superior iliac spine, vertically down to the inguinal crease:
      • Obliquely across the crease, and then vertically down to the apex of the femoral triangle (Figure)
    • Previous SLNB incisions and underlying cavities:
      • Should be excised en bloc with the specimen
  • Skin Flaps:
    • The limits of the skin flaps are:
      • Medially:
        • To the pubic tubercle and the midbody of the adductor magnus muscle
      • Laterally:
        • To the lateral edge of the sartorius muscle
      • Superiorly:
        • To approximately 5 cm above the inguinal ligament
      • Inferiorly:
        • To the apex of the femoral triangle
  • Lymph Node Dissection:
    • Dissection is carried down to the:
      • Muscular fascia superiorly
    • All fatty, node-bearing tissue is swept down to the inguinal ligament and off the external oblique fascia
    • Medially, the spermatic cord or round ligament is exposed, and nodal tissue is swept laterally
    • Nodal tissue is swept off the adductor fascia to the femoral vein
    • At the apex of the femoral triangle, the saphenous vein is identified:
      • If the saphenous vein can be preserved:
        • Nodal tissue is removed from the vessel circumferentially; otherwise, it is sacrificed
    • Laterally, nodal tissue is dissected off the sartorius muscle and the femoral nerve
    • With dissection in the plane of the femoral vessels:
      • The nodal tissue is elevated up to the level of the fossa ovalis:
        • Where the saphenous vein is suture-ligated at the saphenofemoral junction if it is sacrificed
      • The specimen is dissected to the inguinal ligament:
        • Although excision of Cloquet node (the lowest iliac node), accompanied by intraoperative frozen-section examination, has historically sometimes been employed to inform concomitant iliac-obturator node dissection in patients without clinically apparent or suspicious deep groin metastasis, this approach is uncommonly employed currently
  • Sartorius Muscle Transposition:
    • If the sartorius muscle is to be transposed:
      • It is divided at its origin on the anterior superior iliac spine
    • The lateral femoral cutaneous nerve:
      • Is preserved if possible
    • The proximal neurovascular bundles going to the sartorius muscle:
      • Are divided to facilitate transposition, with care to preserve others to the maximal extent possible to ensure a vascularized pedicle
    • The rotated muscle is placed over the femoral vessels:
      • Its is tacked to the inguinal ligament, fascia of the adductor, and vastus muscle groups
  • Wound Closure:
    • The skin edges are examined for viability and trimmed back to healthy skin, if necessary:
      • Intravenous administration of fluorescein followed by examination using a Wood lamp:
        • May be used to identify poorly perfused skin edges
    • Two closed-suction drains are generally placed through separate small incisions superiorly:
      • One is laid medially, and the other is laid laterally within the operative wound
    • The wound is closed with interrupted # 3-0 undyed absorbable sutures in the dermis and followed by skin staples or a running # 4-0 subcuticular suture
    • In some patients, interrupted nylon sutures are used overlying the area of skin crease
  • Postoperative Management:
    • The patient begins ambulating the day following surgery
    • A custom-fit elastic stocking may be used during the day for 6 months
    • After this period, the stocking may be discontinued if no leg swelling occurs
    • Suction drainage is continued until output is less than 20 mL to 30 mL per day for 2 consecutive days
    • By approximately 4 weeks, the suction catheters are removed, regardless of the amount of drainage, to mitigate risk of infection
Figure 1: Skin Incisions for Superficial Groin Dissection
Technique of inguinal lymph node dissection.
A: The borders of the femoral triangle are the inguinal ligament superiorly, the sartorius laterally, and the adductor longus medially.
B: The lymphatic contents removed during a superficial inguinal lymphadenectomy include the lymphatic contents of the femoral triangle as well as nodal tissue that lies superficial to the external oblique superior to the inguinal ligament.
C: The lazy-S incision used for an inguinal lymphadenectomy.
D: The anatomy visualized during an inguinal lymphadenectomy. (From Balch CM, Milton GW, Shaw HM, et al., eds. Cutaneous Melanoma. Lippincott; 1985.)
A: Lymphatic anatomy of the inguinal and iliac-obturator area demonstrating the superficial and deep lymphatic chains. Cloquet node lies at the transition between the superficial and deep inguinal nodes. It is located beneath the inguinal ligament in the femoral canal.
B: The iliac-obturator nodes include those distal to the common iliac bifurcation, and around the external and internal iliac vessels, and the obturator nodes. Obturator nodes should be excised as part of an iliac-obturator nodal dissection. (From Balch CM, Milton GW, Shaw HM, et al., eds. Cutaneous Melanoma. Lippincott; 1985.)
Transection of the sartorius muscle at its origin on the anterior superior iliac spine in preparation for transposition over the femoral vessels and nerves. (From Balch CM, Milton GW, Shaw HM, et al., eds. Cutaneous Melanoma. Lippincott; 1985, with permission.)