Audit of complete axillary dissection in early breast cancer

The role of complete axillary dissection (CAD) in the management of breast cancer is controversial and largely unresolved. Acceptance of the results of trials incorporating CAD assumes that the axillary dissection is truly complete. To address this point, and also to define quality control criteria for this operation within our unit, we audited 100 consecutive axillary dissections as follows: the primary surgeon performed what he/she felt to be a thorough CAD and submitted separately the contents of level I, II and III for pathological evaluation; a second surgeon then independently assessed the dissection and arbitrarily labelled any further excised tissue as level IV. Level IV nodes were retrieved in 38% of cases. Tumour involvement of level IV nodes was noted in 5% (2/38) of dissections where lymph nodes were retrieved, but in neither instance was pathological staging altered. There was a significant decrease in the incidence of level IV node retrieval from 47% (28/60) in the first 6 months of audit to 20% (8/40) subsequently. This novel approach to our continuing audit identified quality control criteria for this procedure in our unit and suggested that audit of this kind benefits training.