title: A Picture is Worth a Thousand Words: Intraoperative Photography as a Quality Metric for Axillary Dissection.
abstract: The adequacy of an axillary lymph node dissection (ALND) is frequently assessed by the number of LNs pathologically identified. We hypothesized that intraoperative photographs facilitate objective measurement of the surgical quality of an ALND.
  
  
  
  Intraoperative photographs of the axilla were obtained prospectively following ALND by four surgeons. An objective scoring system was created based on the visibility of anatomic landmarks, with a maximum score of 7. Photographs of each case were scored independently by the other three surgeons. Factors thought to influence LN count were evaluated for correlation. Interrater variability was calculated.
  
  
  
  A total of 115 cases were evaluated: 98 breast and 17 melanoma. Mean LN count was 25.1 (SD 10.5): 23.2 (SD 7.9) for breast and 36.5 (SD 15.8) for melanoma. Ninety percent of cases had a LN count ≥15. Factors associated with a higher number of LNs were melanoma (p < 0.001), visualization of the axillary vein (p = 0.03), and long thoracic nerve (p = 0.04). There was no association with age, body mass index, number of positive LNs, neoadjuvant chemotherapy, or matted LNs. Mean ALND photograph score was 4.8 (SD 1.3). A 1-point change in total score increased the mean LN count by 2.4 (p = 0.002). Correlations for interrater reliability varied from 0.27 to 0.62.
  
  
  
  Photographic visualization of axillary anatomic structures correlates with the number of LNs identified on pathology. These findings support initiating a larger study with more surgeons to define the optimal photo metrics of an adequate ALND.
authors.affiliation: Department of General Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Brittany L
authors.initials: BL
authors.lastname: Murphy
authors.affiliation: Department of General Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Judy C
authors.initials: JC
authors.lastname: Boughey
authors.affiliation: Department of General Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Amy C
authors.initials: AC
authors.lastname: Degnim
authors.affiliation: Department of General Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Tina J
authors.initials: TJ
authors.lastname: Hieken
authors.affiliation: Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
authors.forename: William S
authors.initials: WS
authors.lastname: Harmsen
authors.affiliation: Department of Pathology, Mayo Clinic, Rochester, MN, USA.
authors.forename: Gary L
authors.initials: GL
authors.lastname: Keeney
authors.affiliation: Department of General Surgery, Mayo Clinic, Rochester, MN, USA. jakub.james@mayo.edu.
authors.forename: James W
authors.initials: JW
authors.lastname: Jakub
mesh_terms: D059925:Anatomic Landmarks; D001365:Axilla; D001367:Axillary Vein; D001943:Breast Neoplasms / Q000473:pathology* / Q000601:surgery*; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D008197:Lymph Node Excision / Q000592:standards*; D008198:Lymph Nodes / Q000601:surgery*; D008297:Male; D008545:Melanoma / Q000556:secondary / Q000601:surgery*; D008875:Middle Aged; D015588:Observer Variation; D010781:Photography; D011446:Prospective Studies; D019984:Quality Indicators, Health Care; D013900:Thoracic Nerves