Implementation of new surgical technology: Outcome measures for lymphatic mapping of breast carcinoma

Background: Recent advances in technology and the subsequent development of minimally invasive surgical techniques have heralded a new era in the surg ical treatment of breast cancer. The dilemma of how to train surgeons in ne w technologies requires teaching, certification, and outcomes reporting in a non-threatening and non-economically damaging manner. This study examines 700 cases of lymphatic mapping and sentinel lymph node (SLN) biopsy for br east cancer and documents surgeon-specific and institution-specific learnin g curves. Methods: Seven hundred cases of lymphatic mapping and SLN biopsy were exami ned. All procedures were performed using a combination of vital blue dye an d radiolabeled sulfur colloid. Learning curves were generated for each surg eon as a plot of failure rate versus number of cases. Results: Examination of the learning curves in this study demonstrates simi lar characteristics. Following a high initial failure rate, there is a rapi d decrease after the first twenty cases. The learning curve, representing t he mean of the five surgeons' experience, indicates that 23 cases and 53 ca ses are required to achieve success rates of 90% and 95%, respectively. Conclusions: The initial reports regarding lymphatic mapping combined with this experience of 700 cases confirm the presence of a significant learning curve. Although this procedure may have an inherent failure rate, it is im portant to identify those factors that are under the control of the surgeon and, therefore, subject to improvement. We believe that these data provide surgeons performing lymphatic mapping and SLN biopsy with a new paradigm f or assessing their skill and adequacy of training.