Sentinel lymph node biopsy is associated with reduced arm morbidity and better quality of life than standard axillary treatment and should be the treatment of choice for patients who have early-stage breast cancer with clinically negative nodes.

Sentinel node biopsy (SNB) is a minimally invasive procedure to stage the axilla in patients with breast cancer. Like any new surgical procedure, it is associated with a learning curve. This article describes the learning curve as part of the ALMANAC trial. The first phase of this trial is a validation phase in which surgeons perform SNB followed by an immediate axillary dissection in a consecutive series of 40 patients with invasive breast cancer. Each surgeon completes a mandatory program of proctored training during this phase. Surgeons who achieve a localization rate of 90% or more and a false-negative rate of 5% or less are eligible to proceed to the randomized phase. All 13 surgeons who completed 40 procedures as part of the validation phase of the ALMANAC trial achieved the set target. This study shows that a standardized training program allows surgeons to achieve a satisfactory localization rate and an acceptable false-negative rate after 40 SNBs.

IntroductionThe introduction of biological and synthetic meshes has revolutionised the practice of implant-based breast reconstruction (IBBR) but evidence for effectiveness is lacking. The iBRA (implant Breast Reconstruction evAluation) study is a national trainee-led project that aims to explore the practice and outcomes of IBBR to inform the design of a future trial. We report the results of the iBRA National Practice Questionnaire (NPQ) which aimed to comprehensively describe the provision and practice of IBBR across the UK.MethodsA questionnaire investigating local practice and service provision of IBBR developed by the iBRA Steering Group was completed by trainee and consultant leads at breast and plastic surgical units across the UK. Summary data for each survey item were calculated and variation between centres and overall provision of care examined.Results81 units within 79 NHS-hospitals completed the questionnaire. Units offered a range of reconstructive techniques, with IBBR accounting for 70% (IQR:50–80%) of participating units' immediate procedures. Units on average were staffed by 2.5 breast surgeons (IQR:2.0–3.0) and 2.0 plastic surgeons (IQR:1.0–3.0) performing 35 IBBR cases per year (IQR:20-50). Variation was demonstrated in the provision of novel different techniques for IBBR especially the use of biological (n = 62) and synthetic (n = 25) meshes and in patient selection for these procedures.ConclusionsThe iBRA-NPQ has demonstrated marked variation in the provision and practice of IBBR in the UK. The prospective audit phase of the iBRA study will determine the safety and effectiveness of different approaches to IBBR and allow evidence-based best practice to be explored.

Background: The last two decades have seen significant changes in surgical management of breast cancer.The offer of immediate breast reconstruction (IBR) following mastectomy is currently standard practice.Skin sparing and nipple sparing mastectomy with implant-based IBR have emerged as oncologically safe treatment options. Prepectoral implant placement and complete coverage of implant with acellular dermal matrix (ADM) eliminates the need to detach the muscle from underlying chest wall in contrast to the subpectoral technique. We report short-term outcomes of a multicentre study from the United Kingdom (UK) using Braxon ® in women having an IBR. The inpatient hospital stay was 1.48 days. About 23% of patients had a seroma, 30% had erythema requiring antibiotics and the explant rate was 10.2 percent. Bilateral reconstructions were significantly associated with implant loss and peri-operative complications on univariate analysis.Conclusions: Our early experience with this novel prepectoral technique using Braxon ® has shown it to be an effective technique with complication rates comparable to subpectoral IBR. The advantages of prepectoral implant-based IBR are quicker postoperative recovery and short post-operative hospital stay.Long-term studies are required to assess rippling, post-operative animation, capsular contracture and impact of radiotherapy.

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