Structured training program improves lymph node biopsy standards

An established training program in sentinel lymph node biopsy (SLNB) ensures patient safety during the adoption of a new technique by enabling surgeons to achieve a very high localization rate and low false-negative rate throughout their training.

"The most striking finding in the program was the lack of any learning curve, with no additional risk associated with the surgeon's first procedure," write Robert Mansel (Cardiff University, UK) and colleagues in the British Journal of Surgery.

Overall, the sentinel lymph node (SLN) localization rate was 98.9% while the false-negative rate (FNR) was 9.1%. FNR was indirectly related to nodal yield, being 14.8% for one node and dropping to 9.7%, 6.6%, 4.7%, and 4.1% for two, three, four, and above four SLNs, respectively.

"This data… suggest that no more than four nodes need to be removed at SLNB; further retrieval is unlikely to be useful and will potentially result in more axillary disruption, defeating one of the aims of SLNB…," observe the authors.

Over the course of a little over 4 years, 210 SLNB-naïve surgeons from multiple disciplines in 103 centers performed 6685 standard SLNB procedures after taking part in the New Start program, an education and training course with standard learning materials as well as a standard dual-localization SLNB technique.

New Start consisted of three phases that began with a 1-day regional theory course. This was followed by mentoring that consisted of practical training with a minimum of 30 consecutive SLNB procedures and either catered to SLNB-naïve breast units and surgeons (model A) or SLNB-naïve surgeons in breast units where SLNB was standard of care (model B).

The last phase of the program conducted an audit and validation procedure until standards were achieved, which were set at a localization rate of at least 90%, as well as an FNR of 10% or less for model A participants who had to assess at least 10 node-positive patients.

The standard SLNB technique used intradermal injection of a radioisotope at a single pariareolar site in the tumor quadrant the day before or same day of surgery followed by a subdermal blue dye injection at the same site just before surgery.

"The [New Start] programme successfully trained a wide range of UK breast teams to perform safe SLNB and suggested that a standard injection protocol and structured multidisciplinary training can abolish learning curves," the research team concludes.

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