Quality Indicators for Sentinel Node Surgery

Abstract

Surgical quality has historically been measured on the basis of the short-term morbidity and mortality. However, mortality from and immediate complications associated with breast and axillary surgery are extremely low and, therefore, are not adequate indicators of the quality of a particular operation for a patient with a breast malignancy. Unlike the introduction of novel laparoscopic techniques for abdominal surgery, for which clinical trial evaluation has been infrequent, the sentinel node mapping and nodal dissection (SLND) procedure has undergone intense retrospective and prospective clinical scrutiny throughout its development and widespread inclusion in surgical practice. SLND for breast cancer was introduced over 20 years ago and was performed in association with axillary dissection to identify the sentinel nodes and determine the number of false negatives, thereby ensuring low incidence of inaccurate oncologic staging. The original studies used a single mapping agent; this progressed to use of combination techniques with more than one mapping agent over the next five years. Sentinel lymph node mapping and dissection is now the operation of choice for patients with early-stage breast cancer. Outcomes can now be measured without requiring measurement of the number of false negatives, because use of axillary dissection is now infrequently co-associated with SLND. As novel dyes and agents are being introduced and as indications for SLND among patients with advanced breast cancer after neoadjuvant systemic treatment are expanding, evaluation of alternative indicators will be needed to determine the best indicators of quality for adequate staging and continued low procedural morbidity. Indicators of quality of SLND are reviewed in this paper. How these indicators will aid evaluation of innovative nodal techniques for patients with a breast malignancy is also discussed.