ORIGINAL ARTICLE Factors Determining Adequacy of Axillary Node Dissection in Breast Cancer Patients Anees B. Chagpar, MD, MSc,* Charles R. Scoggins, MD,* Robert C. G. Martin II, MD,* Sunati Sahoo, MD, † David J. Carlson, MD, ‡ Alison L. Laidley, MD, § Souzan E. El-Eid, MD, ¶ Terre Q. McGlothin, MD** and Kelly M. McMasters, MD, PhD,* for the University of Louisville Breast Sentinel Lymph Node Study 1 *Departments of Surgery and † Pathology, University of Louisville, Louisville, Kentucky; ‡ St. Mary’s Medical Center and Deaconess Hospital, Evansville, Indiana; § Breast Surgeons of North Texas, Dallas, Texas; – Hudson Valley Surgical, Kingston, New York; **Richardson Regional Hospital, Richardson, Texas n Abstract: With increased focus on quality assurance, a complete axillary lymph node dissection (ALND) has been defined as the removal of 10 or more lymph nodes (LN). The objective of this study was to determine which patient, physi- cian, and geographic factors predict the adequacy of ALND in breast cancer patients. The University of Louisville Breast Cancer Sentinel Lymph Node Study is a multicenter, prospective study of 4,131 patients, all of whom had a sentinel node biopsy and completion ALND. Univariate and multivariate analyses were performed to determine which factors were inde- pendently associated with the removal of 10 or more LN. Of the 4,131 patients in this study, the median number of LN removed was 11 (range; 3–45). Ten or more LN were removed in 3,213 (77.8%) patients. The median patient age in this study was 60 (range; 27–100), with a median tumor size of 1.5 cm (range; 0.1–11.0 cm). On univariate analysis, patient age, tumor size, and palpability were correlated with adequacy of ALND. Academic affiliation and percentage of breast practice were significant physician factors predictive of adequacy of ALND. Both geographic region and community size were significantly correlated with adequacy of ALND. On multivariate analysis, patient age (p = 0.024), surgeon academic affiliation (p < 0.001), percentage breast practice (p < 0.001), and community size (p = 0.003) were significant determinants of adequacy of ALND. Younger patients were more likely to have an adequate ALND. Surgeons in academic practice had a higher rate of adequate ALND, as did those practicing in larger communities. Surgeons with a more breast experience had a lower rate of adequate ALND. Patient age, surgeon academic affiliation, and breast experience, as well as community size are all significant factors predictive of adequacy of ALND. n Key Words: axillary dissection, breast cancer, management W ith the advent of sentinel lymph node (SLN) biopsy as a minimally invasive technique to accurately stage the axilla in patients with breast can- cer, some have questioned the need for axillary lymph node dissection (ALND) for node positive disease (1). It is well known that ALND does not improve survi- val (2); however, to abandon this procedure for patients with positive sentinel nodes is currently pre- mature. To begin with, ALND provides excellent local control for patients with axillary node positive disease (2–4). In addition, this procedure provides an accurate count of the number of positive nodes in the axilla, which has not only become adopted as a standard part of breast cancer staging (5), but also significantly affects adjuvant therapy decision making (6). It has been well established that the number of pos- itive lymph nodes (LN) identified in the axilla is rela- ted to the adequacy of the axillary dissection and the number of LN removed (7,8). Although somewhat controversial, a number of national and international guidelines have set the standard for ALND as removal of at least 10 LN (9,10). With the current focus on quality assurance in surgical practice, we sought to Address correspondence and reprint requests to: Anees B. Chagpar, MD, Department of Surgery, University of Louisville, 315 East Broadway, Suite 312, Louisville, KY 40202, USA, or e-mail: anees.chagpar@ nortonhealthcare.org. ª 2007 Blackwell Publishing, Inc., 1075-122X/07 The Breast Journal, Volume 13 Number 3, 2007 233–237 1 A complete list of investigators in the University of Louisville Breast Sentinel Lymph Node Study is provided in Am J Surg 2002;184:496–498. Presented at the 30th Annual American Society of Breast Diseases Sympo- sium held in Las Vegas, NV, on April 27–29, 2006.