Training in Breast Surgery in Spain | Cirugía Española (English Edition)

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Miguelena, Fernando Domínguez Cunchillos" "autores" => array:2 [ 0 => array:4 [ "nombre" => "José M." "apellidos" => "Miguelena" "email" => array:1 [ 0 => "jmmibo@unizar.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Fernando" "apellidos" => "Domínguez Cunchillos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Cirugía Endocrina y Mama, Sección de Formación AEC, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cirugía de Mama, Sección de Patología de la mama AEC, Servicio Navarro de Salud–Osasumbidea, Pamplona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Formación en cirugía mamaria en España" ] ] "textoCompleto" => "IntroductionBreast surgery is part of the classical training nucleus and skill set of general and gastrointestinal surgeons, together with endocrine, abdominal wall, esophagogastric, hepatobiliary–pancreatic and colorectal surgery. It involves surgical treatment of both benign as well as malignant breast pathologies.Currently, several important aspects involved in this type of surgery must also be considered:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Surgical treatment of breast pathologies has become fully incorporated into the “portfolio of services” and training spectrum of Obstetrics and Gynecology.</li><li class="elsevierStyleListItem" id="lsti0010">2.The increasing use of reconstructive surgical techniques after mastectomy and oncoplastic surgery involved in breast-conserving surgery has justified the involvement of Plastic Surgery in these areas. This often promotes efficient surgical synergies and teamwork, although occasionally conflicts do arise.</li><li class="elsevierStyleListItem" id="lsti0015">3.The fundamental nucleus of this pathology involves the treatment of breast cancer, aspects of its clinical diagnosis, early diagnosis (from screening programs) and prophylactic surgery (hereditary cancer, genetic counseling).</li><li class="elsevierStyleListItem" id="lsti0020">4.This type of surgery, which is currently a frontier in our specialty, is currently being performed most often by general surgeons and gynecologists in the surgical setting of regional, general or reference hospitals as well as teaching oncology hospitals, whether or not they are equipped with specific “organic” or “functional” breast surgery units. Therapeutic decisions are established by multidisciplinary breast tumor committees in all cases following protocols.In fact, in our country, there are still very few hospitals that have certified breast treatment units. In 2003, a survey was published about the surgical departments of 241 Spanish hospitals in order to confirm the existence of functional breast treatment units in Spain, and the involvement of the surgery departments. The response rate was 68% (164 responses), and it was observed that breast cancer treatment was coordinated by general surgeons in most hospitals (n=131) and in association with gynecologists in 51 cases. Structured, functional breast treatment units had been created in 82 hospitals.<a class="elsevierStyleCrossRef" href="#bib0070">1</a></li><li class="elsevierStyleListItem" id="lsti0025">5.In recent years, significant modifications have taken place in the surgical treatment of breast cancer, fundamentally with the application and proposition of oncoplastic and reconstructive breast procedures whose main objective has been to improve the quality of breast-conserving surgery and immediate breast reconstruction. These changes have been led by a fair number of surgical specialists (surgeons or gynecologists) who have decidedly become involved in obtaining specific certified training in breast reconstruction and remodeling, with optimal results.Breast-conserving surgery and oncoplastic/reconstructive techniques are currently part of the therapeutic arsenal and current portfolio of services in the treatment of patients with malignant breast pathologies. The designation of the medical professionals responsible for performing oncoplastic and reconstructive procedures should be an agreed decision based on the services available, training and the history of the institution itself. It is also necessary to continuously promote training in these procedures to guarantee their use in the highest number possible of patients.</li><li class="elsevierStyleListItem" id="lsti0030">6.The countries of the European Union face similar challenges when offering appropriate, high-quality treatment to oncological patients. In their extensive review, Merck et al.,<a class="elsevierStyleCrossRef" href="#bib0075">2</a> described the different approaches to multidisciplinary treatment of breast disease in certain European countries (United Kingdom, Sweden, Italy, France or Spain) and concluded that they are basically systematized into two unit models: the first is a functional unit, proposed by EUSOMA, and the second could be included within the concept of oncology institutes.</li></ul>Therefore, and given the organizational diversity within the healthcare system in Spain, common European guidelines would be beneficial in order to harmonize and improve the surgical/therapeutic process in this pathology.In this situation, we have proposed conducting an analysis (or, better put, a “snapshot”) of the current situation of breast surgery training in Spain, without any intention of dogmatizing or developing a specific training model. The proposition, establishment and suitability of such a training model should be the responsibility of official institutions and specific scientific societies.In general, it is necessary to consider several different levels of surgical training in this area, given the scope that it involves: (1) General Surgery and Gastrointestinal Surgery residents; (2) maintaining specialists involved in breast pathology treatment, and their skills, up to date (continuing education and professional development); and, (3) guidelines and requirements for access to and achievement of specialized diplomas (fellow) in breast surgery for specialists integrated in specific breast units who are dedicated to this area of surgery.Current training of residents in SpainSpecialized training in general and surgical training in particular are both based on the MIR training system and proper coordination of its three pillars: the training program, certified training units, and tutors. The MIR process is an efficient educational program that is able to transform medical graduates into specialists, with similar learning outcomes regardless of the place of residency. Afterwards, specialized training can be completed in a specific area, such as breast surgery, in accordance with the specifications of the program itself and the Law for Healthcare Professions.<a class="elsevierStyleCrossRef" href="#bib0080">3</a>In our country, breast surgery is conducted efficiently and safely in both general surgery departments without structured functional units as well as those that do have such units, whether or not there is an “accredited” breast surgery unit.Breast surgery is a fundamental aspect in general and specialized surgical training for two basic reasons: first of all, due to the frequency of this pathology; and, secondly, due to the accessibility and systematization of this anatomical area, together with techniques that entail a medium level of complexity, which provide for optimal learning, progression and later autonomous or tutored reproduction of these techniques.The training objectives of the specialty program<a class="elsevierStyleCrossRef" href="#bib0090">5</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) are similar to those of the European Board of Surgery.<a class="elsevierStyleCrossRef" href="#bib0085">4</a> Regarding breast surgery, the program requires a series of theoretical knowledge that residents should acquire during training: breast pathologies, inflammatory and infectious processes (mastitis), benign breast tumors, preneoplastic lesions, malignant breast tumors and breast reconstruction.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In this context, and referring to the results observed in surgical training, the program dictates the minimum number of surgeries that residents should perform during training: 15 benign breast surgeries and 15 breast cancer surgeries.<a class="elsevierStyleCrossRef" href="#bib0085">4</a>According to the content of the training program, it is not until the 4th year of MIR training when residents begin training in breast pathologies and surgery, with a rotation in a specific breast surgery unit for 2–3 months. And although in general surgical training the activity of residents in breast surgery seems to be done adequately, with a mean of between 29 and 25 surgical interventions of each type,<a class="elsevierStyleCrossRef" href="#bib0090">5</a> it would be more desirable for training in this area to be initiated earlier on and within different areas of the training itinerary.The program also contemplates completing at least one accredited breast surgery course, such as those proposed by the Breast Pathology Section of the Spanish Association of Surgeons (Association Española de Cirujanos, or AEC) (<a id="intr0015" class="elsevierStyleInterRef" href="http://www.aecirujanos.es/secciones/patolog%26iacute;a">http://www.aecirujanos.es/secciones/patología</a> de la mama.php/, both basic and advanced). <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the sites, objectives and programs of these courses.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Meanwhile, certain surgical procedures in major ambulatory surgery programs, such as benign breast pathologies, harpoon-guided biopsies, selective sentinel lymph node biopsies, and some types of oncoplastic surgeries, are not systematically included in the current official program. However, they would be beneficial to the training process, even in light of the technical, organizational and educational implications involved in this “healthcare circuit”.Thus, while taking into account that patients are usually selected and the programs standardized, possibly the structured participation of residents in these programs and techniques (apart from specific rotations) would possibly be one of the most appropriate aspects that is still pending in breast surgery training.However, in many occasions, the performance, learning process and perfecting of more specialized oncoplastic techniques by the staff, at different points of the learning curve, in specific breast surgery units or in departments or units with important involvement in this type of surgery, could temporarily displace residents or those from other departments or units to learn these techniques.The recently published Royal Decree for Core Requirements and Specific Training Areas (STA)<a class="elsevierStyleCrossRef" href="#bib0095">6</a> will result in a drastic modification of the training program for the specialty of General and Gastrointestinal Surgery.<a class="elsevierStyleCrossRef" href="#bib0100">7</a> It is therefore a transcendental moment for the AEC and its Breast Pathology Section to take a stand and to propose and promote specific modifications to the new General and Gastrointestinal Surgery program.Maintaining Specialists’ Training up to DateAlthough the current training program specifies among its objectives “to initiate complementary training in some areas according to the circumstances of each resident and hospital”, the final result is that of a Specialist in General and Gastrointestinal Surgery who should be able to demonstrate specific clinical and surgical competence.According to the Spanish Law for Healthcare Professions,<a class="elsevierStyleCrossRef" href="#bib0105">8</a> maintained professional competence and continuous training refers to the permanent process of teaching and active learning that is initiated upon finalizing the specialization period. It is aimed at updating and improving the knowledge, skills and approaches of healthcare professionals given the constant evolution of science, technology, requirements and needs, both for society as well as for the healthcare system itself. Medical professionals have the right and obligation to participate in this training, regardless of their status, years of work or setting in which they carry out their clinical/hospital activity.With regard to breast pathologies, it is essential that adequate means be available in order to obtain, maintain and/or perfect skills in this area of practice, for surgical specialists in general or for those especially involved in this pathology, whether or not they work in specific units.Currently, the development of breast surgery training criteria for general surgeons (or gynecologists), in our country as well as in Europe, where there is no specific specialty, can be defined by Syllabus 2014 of the UEMS (<a id="intr0020" class="elsevierStyleInterRef" href="http://www.uems.net/">www.uems.net</a>), which specifies the training and curricular requirement for obtaining specific certification (BOARD) in the area of specialization (Fellow of European Board of Surgery (FEBS)/Breast Surgery), as well as the criteria proposed by the European Society of Mastology (EUSOMA),<a class="elsevierStyleCrossRef" href="#bib0110">9</a> which would define the requirements of the surgical specialists involved in breast units and would generally be as follows: (a) knowledge and treatment of benign and malignant breast pathologies; (b) capacity to perform at least 40 surgical interventions of the breast; (c) dedication of at least 50% of the work week to aspects related with breast pathologies; (d) capacity to perform basic breast construction techniques and oncoplasty.<a class="elsevierStyleCrossRef" href="#bib0115">10</a>The different methods for meeting these criteria, which would be complementary in many cases, would include:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035">1.Specific courses, such as the advanced level courses proposed by the Breast Pathology Section of the AEC (<a id="intr0025" class="elsevierStyleInterRef" href="http://www.aecirujanos.es/secciones/patologiadelamama.php">http://www.aecirujanos.es/secciones/patologiadelamama.php</a>) and/or the most specialized oncoplastic surgery courses at different reference hospitals (<a id="intr0030" class="elsevierStyleInterRef" href="http://www.aecima.com/">http://www.aecima.com</a>)</li><li class="elsevierStyleListItem" id="lsti0040">2.A master's degree or expert diploma obtained from an accredited university or institute</li><li class="elsevierStyleListItem" id="lsti0045">3.Official assignation to a specific breast surgery unit, preferably accredited, in accordance with the recommendations of EUSOMA<a class="elsevierStyleCrossRef" href="#bib0090">5</a> or the Spanish Society of Senology and Breast Pathologies (<a id="intr0035" class="elsevierStyleInterRef" href="http://www.sespm.es/unidades/">http://www.sespm.es/unidades/</a>)</li><li class="elsevierStyleListItem" id="lsti0050">4.Integration in a specific unit or special dedication in a surgery department</li><li class="elsevierStyleListItem" id="lsti0055">5.Regular assistance to and participation at medical conferences, symposiums, national and international meetings organized by scientific societies and entities: Spanish Society of Surgeons (<a id="intr0040" class="elsevierStyleInterRef" href="http://www.aecirujanos.es/secciones/patologiadelamama.php">http://www.aecirujanos.es/secciones/patologiadelamama.php</a>), Spanish Society of Senology and breast Pathologies (<a id="intr0045" class="elsevierStyleInterRef" href="http://www.sespm.es/">http://www.sespm.es/</a>), Spanish Society of Breast Surgeons (<a id="intr0050" class="elsevierStyleInterRef" href="http://www.aecima.com/">http://www.aecima.com/</a>).</li></ul>In many instances, it is a justification of the requirements proposed by EUSOMA regarding the minimum criteria required for surgery and the accreditation of specialized units<a class="elsevierStyleCrossRef" href="#bib0110">9</a> (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>One fundamental aspect in the specific preparation of surgeons in oncological breast surgery should refer to conventional oncoplastic surgery and basic reconstructive surgery using expanders or prostheses in subcutaneous, total and “skin-saving” mastectomies. Conventional techniques and more complex breast reconstruction could be general skills acquired by plastic surgeons. This would allow for increased indications of breast preservation with adequate control of the process, and good esthetic results could be achieved to reduce the psychological impact of the disease.Competence in these oncoplastic techniques will comprise the following aspects: appropriate oncological techniques for the removal of the tumor; immediate remodeling of the resulting defect/deformity; repositioning of the nipple–areolar complex and correction of the asymmetry of the contralateral breast.<a class="elsevierStyleCrossRef" href="#bib0120">11</a> Indications and techniques are presented in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<a class="elsevierStyleCrossRef" href="#bib0125">12</a><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Obtaining Specific Certification: European Board of Surgery QualificationAccess to and achievement of a an official European diploma as Specialist in Breast Surgery (European Board in Breast Surgery), granted and certified by the Division of Breast Surgery of the Section of Surgery of the European Union of Medical Specialists, although with no correlation with an official specialty degree, means that the Specific Training Area Diplomas from our country are not established or officially approved. These documents are prestigious and transcendental for surgeons who are especially involved or dedicated in breast units.<a class="elsevierStyleCrossRef" href="#bib0130">13</a>The Division of Breast Surgery advises in matters related with professional practice and training as well as patient care in breast surgery in Europe, working in close collaboration with EUSOMA and the European Society of Surgical Oncology. The main objective of the Division is to promote a high level of care for breast surgery in Europe, including high-quality training and certification. This involves a study plan, evaluation protocol and certification. Access to the training program, training requirements and evaluation testing are specified in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Finally, one point of interest in special cases is the possibility to obtain an Honorary Diploma in Breast Surgery from the European Union of Medical Specialists, which recognizes the experience and prestige of certain breast surgeons who actively contribute and/or have contributed with their activity, contributions and prestige to the development of the field of breast surgery. General requirements for obtaining these diplomas can be found at: <a id="intr0055" class="elsevierStyleInterRef" href="http://www.uemssurg.org/divisions/breast-surgery/honorary-diploma">http://www.uemssurg.org/divisions/breast-surgery/honorary-diploma</a>.Core Requirements and Specific Training AreasRoyal Decree 639/2014<a class="elsevierStyleCrossRef" href="#bib0095">6</a> defines, among other things, the so-called specific training areas (STA), which “cover a set of knowledge, skills, and approaches added as an extension to those required by the official program of one or several specialties, provided this group of competencies are of relevant scientific, medical, social and organizational interest”. It regulates the procedure for requesting and obtaining an STA specialization diploma.The request to create an STA should be justified by the following requirements: (1) a significant increase in the professional competencies required by the official programs of the specialties involved; (2) a relevant medical, scientific, social and organizational interest that requires the dedication of a significant number of professionals; and (3) the inability to satisfy these competencies through training in other specialties, other specific qualification diplomas or advanced certification.Once the STA has been approved, admittance and later certification will be regulated by a specific training program that is monitored and evaluated. Physicians’ positions will be reserved for them, and they will be considered resident specialists in training. Access to the training process for the acquisition of an STA diploma will be done through annual public selection processes, and it will be necessary to be in possession of a corresponding degree as specialist and to certify a minimum of 2 years of effective professional practice in the specialty since the start of the constitution of the STA.<a class="elsevierStyleCrossRef" href="#bib0100">7</a>In this context, it would be coherent for the Spanish Association of Surgeons through the Breast Pathology Section to propose a project that is coherent and appropriate for the current clinical, hospital and legislative situation, which should include a structured training program for residents (in the new core training program) as well as specialists for their different expectations: keeping themselves up-to-date (continuous training and professional development) and access to obtaining a Specific Training Area Diploma in Breast Surgery. The training proposal would precisely define the training program objectives and establish the “roadmap” to optimize the access and preparation of residents and surgeons in this area.Finally, in accordance with all the previous considerations and premises, aside from any official position and assuming a priori possible criteria discrepancies, a proposed general structured model could be helpful to define the skills to acquire at different levels: cognitive, behavioral and practical during the training period, at each level of training, as well as the method for their evaluation.Although many of the ideas have been previously discussed, the requirements could be broken down into the following aspects:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060">•Theoretical knowledge, as specified in the current MIR program in the theoretical program of the basic and advanced courses of the Breast Pathology Section of the AEC (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) and in the “Breast Surgery Syllabus” of the Fellow of European Board of Breast Surgery</li><li class="elsevierStyleListItem" id="lsti0065">•Management knowledge (based on EUSOMA recommendations)</li><li class="elsevierStyleListItem" id="lsti0070">•Training in specific techniques (specified in the MIR program, in the theoretical program of the basic and advanced course of the Breast Pathology Section of the AEC (<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 4</a>) and in the “Breast Surgery Syllabus”). Said techniques would include: stereotactic/“harpoon-guided” biopsy; sentinel node biopsy; breast-conserving surgical techniques; mastectomies (total, modified radical, “skin-saving”, radical; implants (prostheses and expanders); oncoplastic techniques; breast reconstruction techniques (latissimus dorsi, TRAM)</li><li class="elsevierStyleListItem" id="lsti0075">•Teaching and research</li></ul>Evaluation would be based on the use of the following methodology:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080">•Written exams–multiple-choice tests and the Script Concordance Test are considered the best instruments, as they can evaluate abstract knowledge, contextualized knowledge, clinical reasoning, decision making.</li><li class="elsevierStyleListItem" id="lsti0085">•Structured observation of clinical practice using Mini-CEX (miniature clinical examination) as well as observation in simulated contexts, in order to evaluate the following skills: clinical interview, professional practice, clinical judgment, communication, organization and effectiveness</li><li class="elsevierStyleListItem" id="lsti0090">•Medical record audits to analyze the quality of the records generated by the physician evaluated in terms of indictors used and quality standards.</li><li class="elsevierStyleListItem" id="lsti0095">•Officially accredited activity records/portfolio</li><li class="elsevierStyleListItem" id="lsti0100">•Research and teaching curriculum</li></ul>Because explaining the development of all these aspects for the three training levels would be overwhelming, <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a> systematizes and specifies this proposal in detail by contemplating a general program in extenso and specifies for each the objectives to be reached and the methods to obtain, evaluate and certify them.<elsevierMultimedia ident="tbl0030"></elsevierMultimedia>Authorship/CollaboratorsBoth authors have contributed equally to the preparation of this manuscript, from the design and structure to the analysis and interpretation of the data and final composition.Conflict of InterestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres709827" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec719517" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres709828" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec719516" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Current training of residents in Spain" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Maintaining Specialists’ Training up to Date" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Obtaining Specific Certification: European Board of Surgery Qualification" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Core Requirements and Specific Training Areas" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Authorship/Collaborators" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of Interests" ] 11 => array:2 [ "identificador" => "xack237122" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-07-24" "fechaAceptado" => "2016-01-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec719517" "palabras" => array:3 [ 0 => "Training in breast surgery" 1 => "Surgical training" 2 => "Breast surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec719516" "palabras" => array:3 [ 0 => "Formación en cirugía mamaria" 1 => "Formación quirúrgica" 2 => "Cirugía de la mama" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Breast surgery is a key part of training and competency in general surgery in Spain and is a “frontier area” that can be efficiently managed by general surgeons and gynecologists. The main objective of the training process consists of the surgical treatment of breast cancer, including conservative surgery, oncoplastic and reconstructive techniques.This article analyses the current status of breast surgery training in Spain and schematically proposes potential targets of the different training programs, to improve access and training for surgeons and residents in this area, taking into account the RD 639/2014 and European regulation. The priority is to specify the level of training that should be achieved, in relation to the group of professionals involved, considering their area of competency: surgery resident, educational programs, and surgeons with special dedication to this area." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La cirugía de la mama forma parte fundamental en la formación y competencia de la cirugía general en España, constituyendo un «área frontera» asumida eficientemente por cirujanos y ginecólogos. El objetivo fundamental del proceso formativo está constituido por el tratamiento quirúrgico del cáncer de mama, que incluye la cirugía conservadora y las técnicas oncoplásticas y reconstructivas.En este artículo, se realiza un análisis de la situación actual de la formación en cirugía mamaria en nuestro país y se plantean esquemáticamente los posibles objetivos de los diversos programas formativos, para optimizar el acceso y la capacitación de los residentes y cirujanos en esta área teniendo en cuenta el RD 639/2014 y la normativa europea. Resulta prioritario concretar el nivel de formación que se pretende alcanzar, en relación con el grupo de profesionales a quien va dirigido, teniendo en cuenta su ámbito competencial: residente de cirugía, formación continuada y especial dedicación a esta área." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Miguelena JM, Domínguez Cunchillos F. Formación en cirugía mamaria en España. Cir Esp. 2016;94:323–330." ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Source: BOE no. 110.<a class="elsevierStyleCrossRef" href="#bib0085">4</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Breast Surgery</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Theoretical content of the program \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Breast pathology, inflammatory and infectious processes (mastitis), benign breast tumors, preneoplastic lesions, malignant breast tumors, breast reconstruction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Practical content (R4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– Rotation for 2–3 months in the Endocrine and Breast Surgery Unit – Involvement and participation in all the sessions of the Breast Tumor Committee – Structured course in breast surgery organized by the AEC – Surgical activity: Benign breast surgery (surgeon): 15 Breast cancer surgery (surgeon): 15 Breast reconstruction (assistant): 5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1171574.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Program for the General and Gastrointestinal Surgery Specialty (2007)." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CNB, core needle biopsy; SLNB, sentinel lymph node biopsy; PET, positron emission tomography; MRI, magnetic resonance imaging; ROLL, radioguided occult lesion localization; SNOLL, sentinel node and occult lesion localization." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><a class="elsevierStyleInterRef" id="intr0005" href="http://www.aecirujanos.es/secciones/patologiadelamama.php">http://www.aecirujanos.es/secciones/patologiadelamama.php</a></th></tr><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Basic Course for R1, R2, R3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Advanced Course for R4, R5, General Surgeons \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospitals: Complejo Hospitalario Univ. de Vigo, H. U. Virgen del Rocío, Fundación Jiménez Díaz, Hospital de Sagunto, Hospital de Calatayud, H. U. La Fe Valencia, Complejo Hospitalario de Navarra, Hospital de Sant Pau, Barcelona \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hospitals: Hospital de Badajoz, Hospital de Torrecárdenas., H. U. Insular de G. Canaria, H.U. de Torrejón, H.C.U. de Valencia, Consorcio Hospital General de Valencia, H. U. de Ciudad Real \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Theoretical program: 1 Introduction to breast pathologies: training for specialists in breast pathologies, breast units, main reasons for consultation in breast pathologies, how to communicate information to a patient 2 Surgical anatomy and physiology of the mammary glands 3 Basic diagnostic imaging aspects in breast pathologies 4 Nuclear Medicine in breast pathology: SLNB, PET, ROLL, SNOLL 5 Basic aspects of pathologic breast anatomy 6 Benign breast pathology and its multidisciplinary management 7. Breast cancer: generalities and historical evolution of surgical treatment 8 Basic surgical techniques in the treatment of breast pathology–How do I do it**** 9 complementary therapies: Medical Oncology from the surgeon's standpoint, and radiotherapy 10 Lymphedema and its treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Theoretical program: 1 Population screening programs 2 Breast anatomy from a practical and oncoplastic standpoint 3 Genetic counseling 4 Brief summary of benign pathologies and scheduling 5 Types of surgical programs (local, short-term, general, etc.) 6 Updated information on breast cancer diagnosis 7 Surgery of non-palpable lesions 8 Oncoplastic surgery, pattern design, indications, complications 9 Axillary surgery in breast cancer 10 Clinical diagnostic and treatment methods 12 Role of Oncology in breast cancer (hormone therapy, induction and adjuvancy) 13 Genomic platforms and molecular classification 14 Planning overall breast cancer treatment 15 Practical planning of surgical interventions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Practical content: interventions Removal of benign tumors, treatment of periareolar fistula Breast surgery: tumorectomy, mastectomy, localization of non-palpable lesions Axillary surgery: selective sentinel lymph node biopsy, axillary lymph node biopsy Diagnostic imaging studies: mammogram and ultrasound, mammary interventions (CNB, stereotactic biopsy, presurgical localization of non-palpable lesions, MRI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Practical content: interventions Breast cancer surgery in non-palpable lesions: Harpoon-ECO-ROLL, SNOLL, conservative oncoplastic surgery, use of different patterns, immediate breast reconstruction Autologous fat grafting \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1171575.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Courses Organized by the Spanish Association of Surgeons, Breast Pathology Section." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Source: BOE no. 190.<a class="elsevierStyleCrossRef" href="#bib0100">7</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="center" valign="top" scope="col">Breast Units, EUSOMA Requirements \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• The unit should treat at least 150 new cases/year to maintain the experience of the team and ensure performance. • It should include at least 2 surgeons who are exclusively dedicated to these surgeries and perform more than 50 surgeries each per year. • Treatment of benign diseases Team surgeons should be able to perform the fundamental techniques of oncoplastic surgery and at least one basic reconstruction technique. • Sentinel lymph node biopsy conducted according to protocol It should provide educational courses for professionals and students. It should organize annual training courses either locally or nationally. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1171572.png" ] ] ] ] "descripcion" => array:1 [ "en" => "EUSOMA Requirements: Minimal Criteria in the Surgical Setting." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Oncoplastic Surgery</th></tr><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Indications \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Techniques \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type I: the treated breast presents a normal appearance without deformity, but there is asymmetry in the volume or appearance compared to the contralateral breast. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vertical mammoplasties Inferior rotation mammoplasty Horizontal mammoplasty Lateral mammoplasty Reduction mammoplasty (contralateral breast) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type II: the treated breast presents a deformity that can be corrected with partial breast reconstruction using existing tissue. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1171571.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "According to the proposal by Clough et al.<a class="elsevierStyleCrossRef" href="#bib0125">12</a>" ] ] ] "descripcion" => array:1 [ "en" => "Indications and general techniques in oncoplastic surgery.<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>" ] ] 4 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Source: BOE no. 280.<a class="elsevierStyleCrossRef" href="#bib0110">9</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Official Certification in the Specialty (Surgery/Gynecology) and Clinical Activity \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Certification of having worked in a breast surgery unit that treats at least 150 new cases of breast cancer per year \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Justification/certification of having attended at least one national/international training course in breast surgery and having attended at least one international medical conference about breast pathologies in the last 3 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Presentation of a breast surgery register of the procedures done, signed by the department/unit head, hospital director, or president of the national surgical or gynecological society. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Having published a scientific article about breast pathology in an indexed journal, or having written a chapter in a national/international textbook about breast surgery or pathology, or having presented a communication at an international conference about breast pathology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• The specialist should be able to demonstrate that he/she meets with the requirements for theoretical knowledge and clinical practical skills. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1171573.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Criteria Required in the Process to Obtain European BOARD Certification in Breast Surgery." ] ] 5 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at6" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "AEC, Association Española de Cirujanos (Spanish Association of Surgeons); AECIMA, Association Española de Cirujanos de la Mama (Spanish Association of Breast Surgeons); FEBS, Fellow of European Board of Surgery; JCR, journal citation reports; TRAM, transverse rectus abdominis myocutaneous flap.(1): area/(diploma) specific training/European Board." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">MIR \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Continuous Professional Development (1) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">STA (1)/(BOARD) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Organism: program proposals, evaluation, certification \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">National Commission for Specialties<a class="elsevierStyleCrossRef" href="#bib0085">4</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scientific societies: AEC, AECIMA<a class="elsevierStyleCrossRef" href="#bib0110">9</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Health Care Ministry<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a><a class="elsevierStyleCrossRef" href="#bib0095">6</a> www.uemssurg.org<a class="elsevierStyleCrossRef" href="#bib0125">12</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Training</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Theoretical program (conceptual knowledge) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Official program (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Theoretical program: advanced course (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Breast surgery – syllabus 2014 (European Board of Surgery (FEBS)/Breast Surgery)<a class="elsevierStyleCrossRef" href="#bib0125">12</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinical management (Breast Unit): rotation (R), duration (D), habitual participation/staff (S), Unit Management (M) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">R (2months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D (7days)/S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S/M \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Course and other training activities: attendance at accredited courses (C), attendance at conferences, national/international accredited symposiums (CS) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C(1/year) vs CS (1/year) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C(1/year) vs CS (1/year) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Teaching</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Organizer (O) or professor (P) of accredited courses, organizer (OC) or speaker (SC) at accredited conferences/symposiums \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(P) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">O/P:(1/year)/PC:(1/year) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Procedures and techniques</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Observed (Tr1), assisted (Tr2), performed with tutor (Tr3), taught (Tr4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tr1: (8-5), (9-5), (10-2) Tr2: (1-5) (2-5), (5-2) (6-2) (8-2), (9-2) Tr3: (1-3) (3-8), (4,5-4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tr2: (10-5)/year Tr3: (9-25)/year Tr4: (1,2,3,4,5,6,7):50/year, (8,9): 10-15/year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> Tr4: (1,2,3,4,5,6,7):<50)/year, (8,9): <50)/year, (10): <15)/year \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Techniques: Each technique is identified (=) with a number (1–10). Quantification of the number of procedures: Stereotactic/harpoon-guided breast biopsies = 1; Sentinel lymph node biopsies = 2; Breast-conserving techniques = 3. Mastectomies: Total = 4; modified radical = 5; skin-saving = 6; radical = 7. Implants: prostheses and expanders = 8. Oncoplastic techniques = 9. Breast reconstruction techniques (latissimus dorsi, TRAM) = 10.</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Research activities</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Specific articles in JCR publications = Art-no. of articles published Communications at national or international conferences = Com-no. of communications presented Competitive research projects: main researcher (MR), Associated researcher (AR) - no. of projects \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> Art-1 (in the MIR period) Com-1 (in the MIR period) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> Art-1 (at least every 2 years) Com-1(at least each year) (AR-1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> Art-1/year Com -< 1/year (MR-1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Evaluation</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exam (Ex), Observation (Ob), Audit of clinical records (AR), Portfolio (Pf), Curriculum (Cu) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ex, Ob, AR, Pf (resident book) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ex, Pf, Cu \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ex, Ob, AR, Pf, Cu Vs (structured official training) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1171570.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Articles 22-26 RD 639/2014, BOE no. 190, 6 August 2014." ] ] ] "descripcion" => array:1 [ "en" => "Proposal for Training." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adecuación de las unidades de mama españolas a los criterios de EUSOMA" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. 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Available from: <a id="intr0060" class="elsevierStyleInterRef" href="http://www.uemssurg.org/divisions/breast%20surgery">http://www.uemssurg.org/divisions/breast surgery</a>" ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack237122" "titulo" => "Acknowledgements" "texto" => "Part of the information contained in the manuscript was sent for inclusion in the 2nd Edition of the Breast Pathology Manual of the AEC. The Editor of the Manual, Dr. F. Domínguez Cunchillos, has authorized its presentation in this manuscript. The authors would like to acknowledge this authorization." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735077/0000009400000006/v1_201608021007/S2173507716300643/v1_201608021007/en/main.assets" "Apartado" => array:4 [ "identificador" => "7418" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Special article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735077/0000009400000006/v1_201608021007/S2173507716300643/v1_201608021007/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507716300643?idApp=UINPBA00004N"]

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Training in Breast Surgery in Spain

Formación en cirugía mamaria en España

José M. Miguelenaa,

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jmmibo@unizar.es

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, Fernando Domínguez Cunchillosb

a Unidad de Cirugía Endocrina y Mama, Sección de Formación AEC, Hospital Universitario Miguel Servet, Zaragoza, Spain

b Unidad de Cirugía de Mama, Sección de Patología de la mama AEC, Servicio Navarro de Salud–Osasumbidea, Pamplona, Spain

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and training spectrum of Obstetrics and Gynecology&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0020" class="elsevierStylePara elsevierViewall">The increasing use of reconstructive surgical techniques after mastectomy and oncoplastic surgery involved in breast-conserving surgery has justified the involvement of Plastic Surgery in these areas&#46; This often promotes efficient surgical synergies and teamwork&#44; although occasionally conflicts do arise&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0025" class="elsevierStylePara elsevierViewall">The fundamental nucleus of this pathology involves the treatment of breast cancer&#44; aspects of its clinical diagnosis&#44; early diagnosis &#40;from screening programs&#41; and prophylactic surgery &#40;hereditary cancer&#44; genetic counseling&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">This type of surgery&#44; which is currently a frontier in our specialty&#44; is currently being performed most often by general surgeons and gynecologists in the surgical setting of regional&#44; general or reference hospitals as well as teaching oncology hospitals&#44; whether or not they are equipped with specific &#8220;organic&#8221; or &#8220;functional&#8221; breast surgery units&#46; Therapeutic decisions are established by multidisciplinary breast tumor committees in all cases following protocols&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In fact&#44; in our country&#44; there are still very few hospitals that have certified breast treatment units&#46; In 2003&#44; a survey was published about the surgical departments of 241 Spanish hospitals in order to confirm the existence of functional breast treatment units in Spain&#44; and the involvement of the surgery departments&#46; The response rate was 68&#37; &#40;164 responses&#41;&#44; and it was observed that breast cancer treatment was coordinated by general surgeons in most hospitals &#40;n&#61;131&#41; and in association with gynecologists in 51 cases&#46; Structured&#44; functional breast treatment units had been created in 82 hospitals&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">In recent years&#44; significant modifications have taken place in the surgical treatment of breast cancer&#44; fundamentally with the application and proposition of oncoplastic and reconstructive breast procedures whose main objective has been to improve the quality of breast-conserving surgery and immediate breast reconstruction&#46; These changes have been led by a fair number of surgical specialists &#40;surgeons or gynecologists&#41; who have decidedly become involved in obtaining specific certified training in breast reconstruction and remodeling&#44; with optimal results&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Breast-conserving surgery and oncoplastic&#47;reconstructive techniques are currently part of the therapeutic arsenal and current portfolio of services in the treatment of patients with malignant breast pathologies&#46; The designation of the medical professionals responsible for performing oncoplastic and reconstructive procedures should be an agreed decision based on the services available&#44; training and the history of the institution itself&#46; It is also necessary to continuously promote training in these procedures to guarantee their use in the highest number possible of patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">The countries of the European Union face similar challenges when offering appropriate&#44; high-quality treatment to oncological patients&#46; In their extensive review&#44; Merck et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> described the different approaches to multidisciplinary treatment of breast disease in certain European countries &#40;United Kingdom&#44; Sweden&#44; Italy&#44; France or Spain&#41; and concluded that they are basically systematized into two unit models&#58; the first is a functional unit&#44; proposed by EUSOMA&#44; and the second could be included within the concept of oncology institutes&#46;</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">Therefore&#44; and given the organizational diversity within the healthcare system in Spain&#44; common European guidelines would be beneficial in order to harmonize and improve the surgical&#47;therapeutic process in this pathology&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In this situation&#44; we have proposed conducting an analysis &#40;or&#44; better put&#44; a &#8220;snapshot&#8221;&#41; of the current situation of breast surgery training in Spain&#44; without any intention of dogmatizing or developing a specific training model&#46; The proposition&#44; establishment and suitability of such a training model should be the responsibility of official institutions and specific scientific societies&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In general&#44; it is necessary to consider several different levels of surgical training in this area&#44; given the scope that it involves&#58; &#40;1&#41; General Surgery and Gastrointestinal Surgery residents&#59; &#40;2&#41; maintaining specialists involved in breast pathology treatment&#44; and their skills&#44; up to date &#40;continuing education and professional development&#41;&#59; and&#44; &#40;3&#41; guidelines and requirements for access to and achievement of specialized diplomas &#40;fellow&#41; in breast surgery for specialists integrated in specific breast units who are dedicated to this area of surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Current training of residents in Spain</span><p id="par0070" class="elsevierStylePara elsevierViewall">Specialized training in general and surgical training in particular are both based on the MIR training system and proper coordination of its three pillars&#58; the training program&#44; certified training units&#44; and tutors&#46; The MIR process is an efficient educational program that is able to transform medical graduates into specialists&#44; with similar <span class="elsevierStyleItalic">learning outcomes</span> regardless of the place of residency&#46; Afterwards&#44; specialized training can be completed in a specific area&#44; such as breast surgery&#44; in accordance with the specifications of the program itself and the Law for Healthcare Professions&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In our country&#44; breast surgery is conducted efficiently and safely in both general surgery departments without structured functional units as well as those that do have such units&#44; whether or not there is an &#8220;accredited&#8221; breast surgery unit&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Breast surgery is a fundamental aspect in general and specialized surgical training for two basic reasons&#58; first of all&#44; due to the frequency of this pathology&#59; and&#44; secondly&#44; due to the accessibility and systematization of this anatomical area&#44; together with techniques that entail a medium level of complexity&#44; which provide for optimal learning&#44; progression and later autonomous or tutored reproduction of these techniques&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The training objectives of the specialty program<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; are similar to those of the European Board of Surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> Regarding breast surgery&#44; the program requires a series of theoretical knowledge that residents should acquire during training&#58; breast pathologies&#44; inflammatory and infectious processes &#40;mastitis&#41;&#44; benign breast tumors&#44; preneoplastic lesions&#44; malignant breast tumors and breast reconstruction&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">In this context&#44; and referring to the results observed in surgical training&#44; the program dictates the minimum number of surgeries that residents should perform during training&#58; 15 benign breast surgeries and 15 breast cancer surgeries&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">According to the content of the training program&#44; it is not until the 4th year of MIR training when residents begin training in breast pathologies and surgery&#44; with a rotation in a specific breast surgery unit for 2&#8211;3 months&#46; And although in general surgical training the activity of residents in breast surgery seems to be done adequately&#44; with a mean of between 29 and 25 surgical interventions of each type&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a> it would be more desirable for training in this area to be initiated earlier on and within different areas of the training itinerary&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The program also contemplates completing at least one accredited breast surgery course&#44; such as those proposed by the Breast Pathology Section of the Spanish Association of Surgeons &#40;<span class="elsevierStyleItalic">Association Espa&#241;ola de Cirujanos</span>&#44; or AEC&#41; &#40;<a id="intr0015" class="elsevierStyleInterRef" href="http://www.aecirujanos.es/secciones/patolog%26iacute;a">http&#58;&#47;&#47;www&#46;aecirujanos&#46;es&#47;secciones&#47;patolog&#237;a</a> de la mama&#46;php&#47;&#44; both basic and advanced&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the sites&#44; objectives and programs of these courses&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Meanwhile&#44; certain surgical procedures in major ambulatory surgery programs&#44; such as benign breast pathologies&#44; harpoon-guided biopsies&#44; selective sentinel lymph node biopsies&#44; and some types of oncoplastic surgeries&#44; are not systematically included in the current official program&#46; However&#44; they would be beneficial to the training process&#44; even in light of the technical&#44; organizational and educational implications involved in this &#8220;healthcare circuit&#8221;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Thus&#44; while taking into account that patients are usually selected and the programs standardized&#44; possibly the structured participation of residents in these programs and techniques &#40;apart from specific rotations&#41; would possibly be one of the most appropriate aspects that is still pending in breast surgery training&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">However&#44; in many occasions&#44; the performance&#44; learning process and perfecting of more specialized oncoplastic techniques by the staff&#44; at different points of the learning curve&#44; in specific breast surgery units or in departments or units with important involvement in this type of surgery&#44; could temporarily displace residents or those from other departments or units to learn these techniques&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The recently published Royal Decree for Core Requirements and Specific Training Areas &#40;STA&#41;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> will result in a drastic modification of the training program for the specialty of General and Gastrointestinal Surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> It is therefore a transcendental moment for the AEC and its Breast Pathology Section to take a stand and to propose and promote specific modifications to the new General and Gastrointestinal Surgery program&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Maintaining Specialists&#8217; Training up to Date</span><p id="par0125" class="elsevierStylePara elsevierViewall">Although the current training program specifies among its objectives &#8220;to initiate complementary training in some areas according to the circumstances of each resident and hospital&#8221;&#44; the final result is that of a Specialist in General and Gastrointestinal Surgery who should be able to demonstrate specific clinical and surgical competence&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">According to the Spanish Law for Healthcare Professions&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> maintained professional competence and continuous training refers to the permanent process of teaching and active learning that is initiated upon finalizing the specialization period&#46; It is aimed at updating and improving the knowledge&#44; skills and approaches of healthcare professionals given the constant evolution of science&#44; technology&#44; requirements and needs&#44; both for society as well as for the healthcare system itself&#46; Medical professionals have the right and obligation to participate in this training&#44; regardless of their status&#44; years of work or setting in which they carry out their clinical&#47;hospital activity&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">With regard to breast pathologies&#44; it is essential that adequate means be available in order to obtain&#44; maintain and&#47;or perfect skills in this area of practice&#44; for surgical specialists in general or for those especially involved in this pathology&#44; whether or not they work in specific units&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Currently&#44; the development of breast surgery training criteria for general surgeons &#40;or gynecologists&#41;&#44; in our country as well as in Europe&#44; where there is no specific specialty&#44; can be defined by Syllabus 2014 of the UEMS &#40;<a id="intr0020" class="elsevierStyleInterRef" href="http://www.uems.net/">www&#46;uems&#46;net</a>&#41;&#44; which specifies the training and curricular requirement for obtaining specific certification &#40;BOARD&#41; in the area of specialization &#40;Fellow of European Board of Surgery &#40;FEBS&#41;&#47;Breast Surgery&#41;&#44; as well as the criteria proposed by the European Society of Mastology &#40;EUSOMA&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> which would define the requirements of the surgical specialists involved in breast units and would generally be as follows&#58; &#40;a&#41; knowledge and treatment of benign and malignant breast pathologies&#59; &#40;b&#41; capacity to perform at least 40 surgical interventions of the breast&#59; &#40;c&#41; dedication of at least 50&#37; of the work week to aspects related with breast pathologies&#59; &#40;d&#41; capacity to perform basic breast construction techniques and oncoplasty&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The different methods for meeting these criteria&#44; which would be complementary in many cases&#44; would include&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">1&#46;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Specific courses&#44; such as the advanced level courses proposed by the Breast Pathology Section of the AEC &#40;<a id="intr0025" class="elsevierStyleInterRef" href="http://www.aecirujanos.es/secciones/patologiadelamama.php">http&#58;&#47;&#47;www&#46;aecirujanos&#46;es&#47;secciones&#47;patologiadelamama&#46;php</a>&#41; and&#47;or the most specialized oncoplastic surgery courses at different reference hospitals &#40;<a id="intr0030" class="elsevierStyleInterRef" href="http://www.aecima.com/">http&#58;&#47;&#47;www&#46;aecima&#46;com</a>&#41;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">2&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall">A master&#39;s degree or expert diploma obtained from an accredited university or institute</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">3&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Official assignation to a specific breast surgery unit&#44; preferably accredited&#44; in accordance with the recommendations of EUSOMA<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a> or the Spanish Society of Senology and Breast Pathologies &#40;<a id="intr0035" class="elsevierStyleInterRef" href="http://www.sespm.es/unidades/">http&#58;&#47;&#47;www&#46;sespm&#46;es&#47;unidades&#47;</a>&#41;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">4&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Integration in a specific unit or special dedication in a surgery department</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">5&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Regular assistance to and participation at medical conferences&#44; symposiums&#44; national and international meetings organized by scientific societies and entities&#58; Spanish Society of Surgeons &#40;<a id="intr0040" class="elsevierStyleInterRef" href="http://www.aecirujanos.es/secciones/patologiadelamama.php">http&#58;&#47;&#47;www&#46;aecirujanos&#46;es&#47;secciones&#47;patologiadelamama&#46;php</a>&#41;&#44; Spanish Society of Senology and breast Pathologies &#40;<a id="intr0045" class="elsevierStyleInterRef" href="http://www.sespm.es/">http&#58;&#47;&#47;www&#46;sespm&#46;es&#47;</a>&#41;&#44; Spanish Society of Breast Surgeons &#40;<a id="intr0050" class="elsevierStyleInterRef" href="http://www.aecima.com/">http&#58;&#47;&#47;www&#46;aecima&#46;com&#47;</a>&#41;&#46;</p></li></ul></p><p id="par0175" class="elsevierStylePara elsevierViewall">In many instances&#44; it is a justification of the requirements proposed by EUSOMA regarding the minimum criteria required for surgery and the accreditation of specialized units<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">One fundamental aspect in the specific preparation of surgeons in oncological breast surgery should refer to conventional oncoplastic surgery and basic reconstructive surgery using expanders or prostheses in subcutaneous&#44; total and &#8220;skin-saving&#8221; mastectomies&#46; Conventional techniques and more complex breast reconstruction could be general skills acquired by plastic surgeons&#46; This would allow for increased indications of breast preservation with adequate control of the process&#44; and good esthetic results could be achieved to reduce the psychological impact of the disease&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Competence in these oncoplastic techniques will comprise the following aspects&#58; appropriate oncological techniques for the removal of the tumor&#59; immediate remodeling of the resulting defect&#47;deformity&#59; repositioning of the nipple&#8211;areolar complex and correction of the asymmetry of the contralateral breast&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> Indications and techniques are presented in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Obtaining Specific Certification&#58; European Board of Surgery Qualification</span><p id="par0190" class="elsevierStylePara elsevierViewall">Access to and achievement of a an official European diploma as Specialist in Breast Surgery &#40;European Board in Breast Surgery&#41;&#44; granted and certified by the Division of Breast Surgery of the Section of Surgery of the European Union of Medical Specialists&#44; although with no correlation with an official specialty degree&#44; means that the Specific Training Area Diplomas from our country are not established or officially approved&#46; These documents are prestigious and transcendental for surgeons who are especially involved or dedicated in breast units&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The Division of Breast Surgery advises in matters related with professional practice and training as well as patient care in breast surgery in Europe&#44; working in close collaboration with EUSOMA and the European Society of Surgical Oncology&#46; The main objective of the Division is to promote a high level of care for breast surgery in Europe&#44; including high-quality training and certification&#46; This involves a study plan&#44; evaluation protocol and certification&#46; Access to the training program&#44; training requirements and evaluation testing are specified in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">Finally&#44; one point of interest in special cases is the possibility to obtain an Honorary Diploma in Breast Surgery from the European Union of Medical Specialists&#44; which recognizes the experience and prestige of certain breast surgeons who actively contribute and&#47;or have contributed with their activity&#44; contributions and prestige to the development of the field of breast surgery&#46; General requirements for obtaining these diplomas can be found at&#58; <a id="intr0055" class="elsevierStyleInterRef" href="http://www.uemssurg.org/divisions/breast-surgery/honorary-diploma">http&#58;&#47;&#47;www&#46;uemssurg&#46;org&#47;divisions&#47;breast-surgery&#47;honorary-diploma</a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Core Requirements and Specific Training Areas</span><p id="par0205" class="elsevierStylePara elsevierViewall">Royal Decree 639&#47;2014<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> defines&#44; among other things&#44; the so-called specific training areas &#40;STA&#41;&#44; which &#8220;cover a set of knowledge&#44; skills&#44; and approaches added as an extension to those required by the official program of one or several specialties&#44; provided this group of competencies are of relevant scientific&#44; medical&#44; social and organizational interest&#8221;&#46; It regulates the procedure for requesting and obtaining an STA specialization diploma&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The request to create an STA should be justified by the following requirements&#58; &#40;1&#41; a significant increase in the professional competencies required by the official programs of the specialties involved&#59; &#40;2&#41; a relevant medical&#44; scientific&#44; social and organizational interest that requires the dedication of a significant number of professionals&#59; and &#40;3&#41; the inability to satisfy these competencies through training in other specialties&#44; other specific qualification diplomas or advanced certification&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Once the STA has been approved&#44; admittance and later certification will be regulated by a specific training program that is monitored and evaluated&#46; Physicians&#8217; positions will be reserved for them&#44; and they will be considered resident specialists in training&#46; Access to the training process for the acquisition of an STA diploma will be done through annual public selection processes&#44; and it will be necessary to be in possession of a corresponding degree as specialist and to certify a minimum of 2 years of effective professional practice in the specialty since the start of the constitution of the STA&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">In this context&#44; it would be coherent for the Spanish Association of Surgeons through the Breast Pathology Section to propose a project that is coherent and appropriate for the current clinical&#44; hospital and legislative situation&#44; which should include a structured training program for residents &#40;in the new core training program&#41; as well as specialists for their different expectations&#58; keeping themselves up-to-date &#40;continuous training and professional development&#41; and access to obtaining a Specific Training Area Diploma in Breast Surgery&#46; The training proposal would precisely define the training program objectives and establish the &#8220;roadmap&#8221; to optimize the access and preparation of residents and surgeons in this area&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Finally&#44; in accordance with all the previous considerations and premises&#44; aside from any official position and assuming a priori possible criteria discrepancies&#44; a proposed general structured model could be helpful to define the skills to acquire at different levels&#58; cognitive&#44; behavioral and practical during the training period&#44; at each level of training&#44; as well as the method for their evaluation&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Although many of the ideas have been previously discussed&#44; the requirements could be broken down into the following aspects&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Theoretical knowledge&#44; as specified in the current MIR program in the theoretical program of the basic and advanced courses of the Breast Pathology Section of the AEC &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; and in the &#8220;Breast Surgery Syllabus&#8221; of the Fellow of European Board of Breast Surgery</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Management knowledge &#40;based on EUSOMA recommendations&#41;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Training in specific techniques &#40;specified in the MIR program&#44; in the theoretical program of the basic and advanced course of the Breast Pathology Section of the AEC &#40;<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 4</a>&#41; and in the &#8220;Breast Surgery Syllabus&#8221;&#41;&#46; Said techniques would include&#58; stereotactic&#47;&#8220;harpoon-guided&#8221; biopsy&#59; sentinel node biopsy&#59; breast-conserving surgical techniques&#59; mastectomies &#40;total&#44; modified radical&#44; &#8220;skin-saving&#8221;&#44; radical&#59; implants &#40;prostheses and expanders&#41;&#59; oncoplastic techniques&#59; breast reconstruction techniques &#40;latissimus dorsi&#44; TRAM&#41;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0250" class="elsevierStylePara elsevierViewall">Teaching and research</p></li></ul></p><p id="par0255" class="elsevierStylePara elsevierViewall">Evaluation would be based on the use of the following methodology&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Written exams&#8211;multiple-choice tests and the Script Concordance Test are considered the best instruments&#44; as they can evaluate abstract knowledge&#44; contextualized knowledge&#44; clinical reasoning&#44; decision making&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Structured observation of clinical practice using Mini-CEX &#40;miniature clinical examination&#41; as well as observation in simulated contexts&#44; in order to evaluate the following skills&#58; clinical interview&#44; professional practice&#44; clinical judgment&#44; communication&#44; organization and effectiveness</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0270" class="elsevierStylePara elsevierViewall">Medical record audits to analyze the quality of the records generated by the physician evaluated in terms of indictors used and quality standards&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Officially accredited activity records&#47;portfolio</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0280" class="elsevierStylePara elsevierViewall">Research and teaching curriculum</p></li></ul></p><p id="par0285" class="elsevierStylePara elsevierViewall">Because explaining the development of all these aspects for the three training levels would be overwhelming&#44; <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a> systematizes and specifies this proposal in detail by contemplating a general program <span class="elsevierStyleItalic">in extenso</span> and specifies for each the objectives to be reached and the methods to obtain&#44; evaluate and certify them&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Authorship&#47;Collaborators</span><p id="par0290" class="elsevierStylePara elsevierViewall">Both authors have contributed equally to the preparation of this manuscript&#44; from the design and structure to the analysis and interpretation of the data and final composition&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of Interests</span><p id="par0295" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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          "titulo" => "Current training of residents in Spain"
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          "titulo" => "Maintaining Specialists&#8217; Training up to Date"
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          "titulo" => "Obtaining Specific Certification&#58; European Board of Surgery Qualification"
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            2 => "Breast surgery"
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          "palabras" => array:3 [
            0 => "Formaci&#243;n en cirug&#237;a mamaria"
            1 => "Formaci&#243;n quir&#250;rgica"
            2 => "Cirug&#237;a de la mama"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Breast surgery is a key part of training and competency in general surgery in Spain and is a &#8220;frontier area&#8221; that can be efficiently managed by general surgeons and gynecologists&#46; The main objective of the training process consists of the surgical treatment of breast cancer&#44; including conservative surgery&#44; oncoplastic and reconstructive techniques&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This article analyses the current status of breast surgery training in Spain and schematically proposes potential targets of the different training programs&#44; to improve access and training for surgeons and residents in this area&#44; taking into account the RD 639&#47;2014 and European regulation&#46; The priority is to specify the level of training that should be achieved&#44; in relation to the group of professionals involved&#44; considering their area of competency&#58; surgery resident&#44; educational programs&#44; and surgeons with special dedication to this area&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La cirug&#237;a de la mama forma parte fundamental en la formaci&#243;n y competencia de la cirug&#237;a general en Espa&#241;a&#44; constituyendo un &#171;&#225;rea frontera&#187; asumida eficientemente por cirujanos y ginec&#243;logos&#46; El objetivo fundamental del proceso formativo est&#225; constituido por el tratamiento quir&#250;rgico del c&#225;ncer de mama&#44; que incluye la cirug&#237;a conservadora y las t&#233;cnicas oncopl&#225;sticas y reconstructivas&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En este art&#237;culo&#44; se realiza un an&#225;lisis de la situaci&#243;n actual de la formaci&#243;n en cirug&#237;a mamaria en nuestro pa&#237;s y se plantean esquem&#225;ticamente los posibles objetivos de los diversos programas formativos&#44; para optimizar el acceso y la capacitaci&#243;n de los residentes y cirujanos en esta &#225;rea teniendo en cuenta el RD 639&#47;2014 y la normativa europea&#46; Resulta prioritario concretar el nivel de formaci&#243;n que se pretende alcanzar&#44; en relaci&#243;n con el grupo de profesionales a quien va dirigido&#44; teniendo en cuenta su &#225;mbito competencial&#58; residente de cirug&#237;a&#44; formaci&#243;n continuada y especial dedicaci&#243;n a esta &#225;rea&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Miguelena JM&#44; Dom&#237;nguez Cunchillos F&#46; Formaci&#243;n en cirug&#237;a mamaria en Espa&#241;a&#46; Cir Esp&#46; 2016&#59;94&#58;323&#8211;330&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; BOE no&#46; 110&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Breast Surgery</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Theoretical content of the program&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Breast pathology&#44; inflammatory and infectious processes &#40;mastitis&#41;&#44; benign breast tumors&#44; preneoplastic lesions&#44; malignant breast tumors&#44; breast reconstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Practical content &#40;R4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211; Rotation for 2&#8211;3 months in the Endocrine and Breast Surgery Unit<br>&#8211; Involvement and participation in all the sessions of the Breast Tumor Committee<br>&#8211; Structured course in breast surgery organized by the AEC<br>&#8211; Surgical activity&#58;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Benign breast surgery &#40;surgeon&#41;&#58; 15<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Breast cancer surgery &#40;surgeon&#41;&#58; 15<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Breast reconstruction &#40;assistant&#41;&#58; 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Program for the General and Gastrointestinal Surgery Specialty &#40;2007&#41;&#46;</p>"
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      1 => array:8 [
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at2"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">CNB&#44; core needle biopsy&#59; SLNB&#44; sentinel lymph node biopsy&#59; PET&#44; positron emission tomography&#59; MRI&#44; magnetic resonance imaging&#59; ROLL&#44; radioguided occult lesion localization&#59; SNOLL&#44; sentinel node and occult lesion localization&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><a class="elsevierStyleInterRef" id="intr0005" href="http://www.aecirujanos.es/secciones/patologiadelamama.php">http&#58;&#47;&#47;www&#46;aecirujanos&#46;es&#47;secciones&#47;patologiadelamama&#46;php</a></th></tr><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Basic Course for R1&#44; R2&#44; R3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Advanced Course for R4&#44; R5&#44; General Surgeons&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hospitals</span>&#58; Complejo Hospitalario Univ&#46; de Vigo&#44; H&#46; U&#46; Virgen del Roc&#237;o&#44; Fundaci&#243;n Jim&#233;nez D&#237;az&#44; Hospital de Sagunto&#44; Hospital de Calatayud&#44; H&#46; U&#46; La Fe Valencia&#44; Complejo Hospitalario de Navarra&#44; Hospital de Sant Pau&#44; Barcelona&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Hospitals</span>&#58; Hospital de Badajoz&#44; Hospital de Torrec&#225;rdenas&#46;&#44; H&#46; U&#46; Insular de G&#46; Canaria&#44; H&#46;U&#46; de Torrej&#243;n&#44; H&#46;C&#46;U&#46; de Valencia&#44; Consorcio Hospital General de Valencia&#44; H&#46; U&#46; de Ciudad Real&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Theoretical program</span>&#58;<br>1 Introduction to breast pathologies&#58; training for specialists in breast pathologies&#44; breast units&#44; main reasons for consultation in breast pathologies&#44; how to communicate information to a patient<br>2 Surgical anatomy and physiology of the mammary glands<br>3 Basic diagnostic imaging aspects in breast pathologies<br>4 Nuclear Medicine in breast pathology&#58; SLNB&#44; PET&#44; ROLL&#44; SNOLL<br>5 Basic aspects of pathologic breast anatomy<br>6 Benign breast pathology and its multidisciplinary management<br>7&#46; Breast cancer&#58; generalities and historical evolution of surgical treatment<br>8 Basic surgical techniques in the treatment of breast pathology&#8211;How do I do it&#42;&#42;&#42;&#42;<br>9 complementary therapies&#58; Medical Oncology from the surgeon&#39;s standpoint&#44; and radiotherapy<br>10 Lymphedema and its treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Theoretical program</span>&#58;<br>1 Population screening programs<br>2 Breast anatomy from a practical and oncoplastic standpoint<br>3 Genetic counseling<br>4 Brief summary of benign pathologies and scheduling<br>5 Types of surgical programs &#40;local&#44; short-term&#44; general&#44; etc&#46;&#41;<br>6 Updated information on breast cancer diagnosis<br>7 Surgery of non-palpable lesions<br>8 Oncoplastic surgery&#44; pattern design&#44; indications&#44; complications<br>9 Axillary surgery in breast cancer<br>10 Clinical diagnostic and treatment methods<br>12 Role of Oncology in breast cancer &#40;hormone therapy&#44; induction and adjuvancy&#41;<br>13 Genomic platforms and molecular classification<br>14 Planning overall breast cancer treatment<br>15 Practical planning of surgical interventions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Practical content&#58; interventions</span><br><br>Removal of benign tumors&#44; treatment of periareolar fistula<br>Breast surgery&#58; tumorectomy&#44; mastectomy&#44; localization of non-palpable lesions<br>Axillary surgery&#58; selective sentinel lymph node biopsy&#44; axillary lymph node biopsy<br>Diagnostic imaging studies&#58; mammogram and ultrasound&#44; mammary interventions &#40;CNB&#44; stereotactic biopsy&#44; presurgical localization of non-palpable lesions&#44; MRI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Practical content&#58; interventions</span><br><br>Breast cancer surgery in non-palpable lesions&#58;<br>Harpoon-ECO-ROLL&#44; SNOLL&#44; conservative oncoplastic surgery&#44; use of different patterns&#44; immediate breast reconstruction<br>Autologous fat grafting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Courses Organized by the Spanish Association of Surgeons&#44; Breast Pathology Section&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; BOE no&#46; 190&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a></p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="center" valign="top" scope="col">Breast Units&#44; EUSOMA Requirements&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; The unit should treat at least 150 new cases&#47;year to maintain the experience of the team and ensure performance&#46;<br>&#8226; It should include at least 2 surgeons who are exclusively dedicated to these surgeries and perform more than 50 surgeries each per year&#46;<br>&#8226; Treatment of benign diseases<br>Team surgeons should be able to perform the fundamental techniques of oncoplastic surgery and at least one basic reconstruction technique&#46;<br>&#8226; Sentinel lymph node biopsy conducted according to protocol<br>It should provide educational courses for professionals and students&#46;<br>It should organize annual training courses either locally or nationally&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">EUSOMA Requirements&#58; Minimal Criteria in the Surgical Setting&#46;</p>"
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        "etiqueta" => "Table 4"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Oncoplastic Surgery</th></tr><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Indications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Techniques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Type I</span>&#58; the treated breast presents a normal appearance without deformity&#44; but there is asymmetry in the volume or appearance compared to the contralateral breast&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vertical mammoplasties<br>Inferior rotation mammoplasty<br>Horizontal mammoplasty<br>Lateral mammoplasty<br>Reduction mammoplasty &#40;contralateral breast&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Type II</span>&#58; the treated breast presents a deformity that can be corrected with partial breast reconstruction using existing tissue&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "notaPie" => array:1 [
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              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">According to the proposal by Clough et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a></p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Indications and general techniques in oncoplastic surgery&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>"
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      4 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at5"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; BOE no&#46; 280&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Official Certification in the Specialty &#40;Surgery&#47;Gynecology&#41; and Clinical Activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Certification of having worked in a breast surgery unit that treats at least 150 new cases of breast cancer per year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Justification&#47;certification of having attended at least one national&#47;international training course in breast surgery and having attended at least one international medical conference about breast pathologies in the last 3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Presentation of a breast surgery register of the procedures done&#44; signed by the department&#47;unit head&#44; hospital director&#44; or president of the national surgical or gynecological society&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Having published a scientific article about breast pathology in an indexed journal&#44; or having written a chapter in a national&#47;international textbook about breast surgery or pathology&#44; or having presented a communication at an international conference about breast pathology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; The specialist should be able to demonstrate that he&#47;she meets with the requirements for theoretical knowledge and clinical practical skills&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Criteria Required in the Process to Obtain European BOARD Certification in Breast Surgery&#46;</p>"
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      5 => array:8 [
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        "etiqueta" => "Table 6"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">AEC&#44; <span class="elsevierStyleItalic">Association Espa&#241;ola de Cirujanos</span> &#40;Spanish Association of Surgeons&#41;&#59; AECIMA&#44; <span class="elsevierStyleItalic">Association Espa&#241;ola de Cirujanos de la Mama</span> &#40;Spanish Association of Breast Surgeons&#41;&#59; FEBS&#44; Fellow of European Board of Surgery&#59; JCR&#44; journal citation reports&#59; TRAM&#44; transverse rectus abdominis myocutaneous flap&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">&#40;1&#41;&#58; area&#47;&#40;diploma&#41; specific training&#47;European Board&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">MIR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Continuous Professional Development &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">STA &#40;1&#41;&#47;&#40;BOARD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Organism</span>&#58; program proposals&#44; evaluation&#44; certification&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">National Commission for Specialties<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Scientific societies&#58;<br>AEC&#44; AECIMA<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Health Care Ministry<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a><a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> www&#46;uemssurg&#46;org<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Training</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Theoretical program</span> &#40;conceptual knowledge&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Official program<br>&#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Theoretical program&#58; advanced course &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Breast surgery &#8211; syllabus 2014<br>&#40;European Board of Surgery &#40;FEBS&#41;&#47;Breast Surgery&#41;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Clinical management &#40;Breast Unit&#41;</span>&#58; rotation <span class="elsevierStyleBold">&#40;R&#41;</span>&#44; duration <span class="elsevierStyleBold">&#40;D&#41;</span>&#44; habitual participation&#47;staff <span class="elsevierStyleBold">&#40;S&#41;</span>&#44; Unit Management <span class="elsevierStyleBold">&#40;M&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">R</span> &#40;2<span class="elsevierStyleHsp" style=""></span>months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">D</span> &#40;7<span class="elsevierStyleHsp" style=""></span>days&#41;&#47;S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">S&#47;M</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Course and other training activities&#58; attendance at accredited courses <span class="elsevierStyleBold">&#40;C&#41;</span>&#44; attendance at conferences&#44; national&#47;international accredited symposiums <span class="elsevierStyleBold">&#40;CS&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">C</span> &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">C</span>&#40;1&#47;year&#41; vs <span class="elsevierStyleBold">CS</span> &#40;1&#47;year&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">C</span>&#40;1&#47;year&#41; vs <span class="elsevierStyleBold">CS</span> &#40;1&#47;year&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Teaching</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Organizer <span class="elsevierStyleBold">&#40;O&#41;</span> or professor <span class="elsevierStyleBold">&#40;P&#41;</span> of accredited courses&#44; organizer <span class="elsevierStyleBold">&#40;OC&#41;</span> or speaker <span class="elsevierStyleBold">&#40;SC&#41;</span> at accredited conferences&#47;symposiums&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">&#40;P&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">O&#47;P&#58;&#40;1&#47;year&#41;&#47;PC&#58;&#40;1&#47;year&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Procedures and techniques</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Observed <span class="elsevierStyleBold">&#40;Tr1&#41;</span>&#44; assisted <span class="elsevierStyleBold">&#40;Tr2&#41;</span>&#44; performed with tutor <span class="elsevierStyleBold">&#40;Tr3&#41;</span>&#44; taught <span class="elsevierStyleBold">&#40;Tr4&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Tr1&#58;</span> &#40;8-5&#41;&#44; &#40;9-5&#41;&#44; &#40;10-2&#41;<br><span class="elsevierStyleBold">Tr2&#58;</span> &#40;1-5&#41; &#40;2-5&#41;&#44;<br>&#40;5-2&#41; &#40;6-2&#41; &#40;8-2&#41;&#44;<br>&#40;9-2&#41;<br><span class="elsevierStyleBold">Tr3</span>&#58; &#40;1-3&#41; &#40;3-8&#41;&#44;<br>&#40;4&#44;5-4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Tr2</span>&#58; &#40;10-5&#41;&#47;year<br><span class="elsevierStyleBold">Tr3</span>&#58; &#40;9-25&#41;&#47;year<br><span class="elsevierStyleBold">Tr4</span>&#58; &#40;1&#44;2&#44;3&#44;4&#44;5&#44;6&#44;7&#41;&#58;<span class="elsevierStyleBold">50&#47;year</span>&#44; &#40;8&#44;9&#41;&#58; <span class="elsevierStyleBold">10-15&#47;year</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br><br><span class="elsevierStyleBold">Tr4</span>&#58; &#40;1&#44;2&#44;3&#44;4&#44;5&#44;6&#44;7&#41;&#58;<span class="elsevierStyleBold">&#60;50&#41;&#47;year</span>&#44; &#40;8&#44;9&#41;&#58; <span class="elsevierStyleBold">&#60;50&#41;&#47;year</span>&#44; &#40;10&#41;&#58; <span class="elsevierStyleBold">&#60;15&#41;&#47;year</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleBold">Techniques&#58;</span> Each technique is identified <span class="elsevierStyleBold">&#40;&#61;&#41;</span> with a number <span class="elsevierStyleBold">&#40;1&#8211;10&#41;</span>&#46; Quantification of the number of procedures&#58;<br>Stereotactic&#47;harpoon-guided breast biopsies <span class="elsevierStyleBold">&#61; 1</span>&#59; Sentinel lymph node biopsies <span class="elsevierStyleBold">&#61; 2</span>&#59; Breast-conserving techniques <span class="elsevierStyleBold">&#61; 3</span>&#46; Mastectomies&#58; Total <span class="elsevierStyleBold">&#61; 4&#59;</span> modified radical <span class="elsevierStyleBold">&#61; 5</span>&#59; skin-saving <span class="elsevierStyleBold">&#61; 6&#59;</span> radical <span class="elsevierStyleBold">&#61; 7&#46;</span> Implants&#58; prostheses and expanders <span class="elsevierStyleBold">&#61; 8</span>&#46; Oncoplastic techniques <span class="elsevierStyleBold">&#61; 9</span>&#46; Breast reconstruction techniques &#40;latissimus dorsi&#44; TRAM&#41; <span class="elsevierStyleBold">&#61; 10</span>&#46;</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Research activities</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Specific articles in JCR publications<br><span class="elsevierStyleBold">&#61; Art-no&#46; of articles published</span><br>Communications at national or international conferences <span class="elsevierStyleBold">&#61; Com-no&#46; of communications presented</span><br><span class="elsevierStyleBold">Competitive research projects&#58; main researcher &#40;MR&#41;&#44; Associated researcher &#40;AR&#41; - no&#46; of projects</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br><span class="elsevierStyleBold">Art</span>-1 &#40;in the MIR period&#41;<br><br><span class="elsevierStyleBold">Com</span>-1 &#40;in the MIR period&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br><span class="elsevierStyleBold">Art</span>-1 &#40;at least every 2 years&#41;<br><br><span class="elsevierStyleBold">Com</span>-1&#40;at least each year&#41;<br><br>&#40;<span class="elsevierStyleBold">AR</span>-1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br><span class="elsevierStyleBold">Art</span>-1&#47;year<br><br><span class="elsevierStyleBold">Com</span> -&#60; 1&#47;year<br><br>&#40;<span class="elsevierStyleBold">MR</span>-1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Evaluation</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exam <span class="elsevierStyleBold">&#40;Ex&#41;</span>&#44; Observation <span class="elsevierStyleBold">&#40;Ob&#41;</span>&#44; Audit of clinical records <span class="elsevierStyleBold">&#40;AR&#41;</span>&#44; Portfolio <span class="elsevierStyleBold">&#40;Pf&#41;</span>&#44;<br>Curriculum <span class="elsevierStyleBold">&#40;Cu&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Ex</span>&#44; <span class="elsevierStyleBold">Ob</span>&#44; <span class="elsevierStyleBold">AR</span>&#44;<br><span class="elsevierStyleBold">Pf</span> &#40;resident book&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Ex</span>&#44; <span class="elsevierStyleBold">Pf</span>&#44; <span class="elsevierStyleBold">Cu</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Ex</span>&#44; <span class="elsevierStyleBold">Ob</span>&#44; <span class="elsevierStyleBold">AR</span>&#44; <span class="elsevierStyleBold">Pf</span>&#44; <span class="elsevierStyleBold">Cu</span><br>Vs &#40;structured official training&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                          "etal" => false
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                          "etal" => false
                          "autores" => array:5 [
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                  "referenciaCompleta" => "European Union of Medical Specialists&#58; Division of Breast Surgery of the Section of Surgery &#38; European Board of Surgery&#46; Brussels &#8211; BELGIUM&#46; 20134&#46; Available from&#58; <a id="intr0060" class="elsevierStyleInterRef" href="http://www.uemssurg.org/divisions/breast%20surgery">http&#58;&#47;&#47;www&#46;uemssurg&#46;org&#47;divisions&#47;breast surgery</a>"
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        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0300" class="elsevierStylePara elsevierViewall">Part of the information contained in the manuscript was sent for inclusion in the 2nd Edition of the Breast Pathology Manual of the AEC&#46; The Editor of the Manual&#44; Dr&#46; F&#46; Dom&#237;nguez Cunchillos&#44; has authorized its presentation in this manuscript&#46; The authors would like to acknowledge this authorization&#46;</p>"
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Article information

ISSN: 21735077
Original language: English

DOI:10.1016/j.cireng.2016.01.001

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 October	17	1	18
2024 September	28	5	33
2024 August	25	8	33
2024 July	17	4	21
2024 June	21	4	25
2024 May	14	11	25
2024 April	60	20	80
2024 March	36	7	43
2024 February	48	7	55
2024 January	59	4	63
2023 December	30	2	32
2023 November	26	1	27
2023 October	43	12	55
2023 September	22	2	24
2023 August	11	0	11
2023 July	37	5	42
2023 June	21	6	27
2023 May	41	2	43
2023 April	39	3	42
2023 March	32	1	33
2023 February	21	3	24
2023 January	25	3	28
2022 December	21	11	32
2022 November	24	5	29
2022 October	22	6	28
2022 September	28	19	47
2022 August	32	10	42
2022 July	19	10	29
2022 June	19	8	27
2022 May	33	13	46
2022 April	35	6	41
2022 March	41	6	47
2022 February	39	15	54
2022 January	75	11	86
2021 December	39	13	52
2021 November	50	7	57
2021 October	38	10	48
2021 September	34	9	43
2021 August	37	10	47
2021 July	28	8	36
2021 June	24	14	38
2021 May	31	6	37
2021 April	81	12	93
2021 March	67	19	86
2021 February	43	8	51
2021 January	31	11	42
2020 December	45	10	55
2020 November	50	2	52
2020 October	35	3	38
2020 September	41	8	49
2020 August	33	2	35
2020 July	19	2	21
2020 June	24	5	29
2020 May	23	17	40
2020 April	23	5	28
2020 March	49	2	51
2020 February	49	5	54
2020 January	50	16	66
2019 December	91	9	100
2019 November	49	10	59
2019 October	57	9	66
2019 September	55	5	60
2019 August	42	4	46
2019 July	46	20	66
2019 June	77	7	84
2019 May	227	29	256
2019 April	88	17	105
2019 March	17	7	24
2019 February	37	3	40
2019 January	20	5	25
2018 December	14	7	21
2018 November	29	11	40
2018 October	35	0	35
2018 September	42	7	49
2018 August	25	0	25
2018 July	12	1	13
2018 June	19	0	19
2018 May	17	1	18
2018 April	12	4	16
2018 March	19	0	19
2018 February	7	4	11
2018 January	14	1	15
2017 December	19	0	19
2017 November	9	0	9
2017 October	27	3	30
2017 September	10	1	11
2017 August	15	0	15
2017 July	24	0	24
2017 June	36	2	38
2017 May	42	1	43
2017 April	22	1	23
2017 March	21	8	29
2017 February	18	2	20
2017 January	19	1	20
2016 December	17	2	19
2016 November	30	2	32
2016 October	23	11	34
2016 September	17	5	22
2016 August	0	1	1
2016 July	1	1	2

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