Only some 15% to 21% of the patients with a tumor-involved sentinel node have other nodes in that field involved as well [1 - 3]. Scintigraphy usually shows drainage of lymph through several superficial lymph nodes before the deep (iliac and obturator) nodes light up. In keeping with the hypothesis of step-wise dissemination, the deep nodes will be free of disease in the majority of patients with a tumor-containing superficial sentinel node. With these thoughts in mind, should a deep (ilio-obturator) node dissection be routinely performed in addition to a superficial inguinal node dissection when the sentinel node contains tumor?

The deep second-tier node visualized on the scintigraphy images of this patient was not removed with the superficial inguinofemoral node dissection. This particular node was most likely the node that proved to be involved later on.

A sensible policy is to perform a deep node dissection when the sentinel node is involved and lymphoscintigraphy shows a second-tier node above Pou-part's ligament or when more than one superficial node is involved.

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