P5-16-01: Are We Going To Be Able To Train Future Surgeons How To Perform Axillary Lymph Node Dissection?

Abstract

Abstract Background: Axillary lymph node dissection (ALND) has been performed regularly by surgeons for several decades. The sentinel lymph node era has led to a reduction in ALND procedures as node negative women are now spared further surgery and morbidity. Following the publication of the ACOSOG Z0011 trial, it is conceivable that completion ALND (cALND) may be rendered unnecessary for many women who have breast conserving surgery and have 1 to 2 positive sentinel lymph node disease. If there is a substantial drop in ALND procedures, this may impact on our ability to train surgeons in the future. Material and Methods: We retrospectively reviewed the breast cancer practice for 2 consultant surgeons in a busy UK centre. In this centre all patients with a positive diagnosis of invasive breast cancer had preoperative axillary ultrasound scanning (USS) and needle biopsy (fine needle aspiration or core biopsy) if enlarged or suspicious axillary lymph nodes were seen. Hence sentinel lymph node biopsy (SLNB) was only performed on patients with both clinically and radiologically negative axillary lymph nodes. Results: In 2009 and 2010 the 2 consultants treated a total of 255 patients with invasive breast cancer. Thirty one patients (12.2%) had positive axillary lymph disease identified by USS and axillary needle biopsy; these women were treated with ALND. The remaining 224 patients had clinically and radiologically negative axillary lymph nodes and proceeded to SLNB. Of these, 58 patients had at least one positive sentinel lymph node (25.9%) and proceeded to cALND; 39 women had breast conserving surgery and 19 women had mastectomy. If our centre were to adopt a policy of observation only in those women having breast conserving surgery and whom had no more than 2 positive sentinel lymph nodes (as per ACOSOG Z0011 trial), then 33 fewer ALND would have been performed. This would leave a new total of 56 ALND procedures being performed over a 2 year period in women with pre-operatively identified positive axillary lymph nodes, those undergoing mastectomy and those women with 3 or greater positive sentinel lymph nodes on SLNB. On our service we have 2 residents which would result in a maximum number of 14 ALND procedures per year that each resident may be trained to perform. It is likely that the actual number will be less due to commitments away from the elective operating room, such as emergency duties and annual leave etc. Is this an adequate number of ALND procedures for a resident to gain competence in the technique? Discussion: The training of surgical residents is competence based and if our centre is representative of most centres treating breast cancers in the UK, will the teaching of ALND procedures be limited to specialist, ultra-high volume centres if the ACOSOG Z0011 trial findings are to be adopted? Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-16-01.