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Axillary Reverse Mapping in Breast Cancer: A Canadian Experience
SURGICAL TREATMENT Axillary Reverse Mapping in Breast Cancer: A Canadian Experience Kuusk U, Seyednejad N, McKevitt EC, et al (Univ of British Columbia, Vancouver, Canada; et al) J Surg Oncol 110:791-795, 2014
Background.dThe aim of this study was to evaluate the axillary reverse lymphatic mapping (ARM) procedure for reducing the risk of arm lymphedema after breast cancer surgery. Methods.dThe ARM procedure was carried out with a subareolar injection of technetium-99 sulfur colloid the morning of surgery, and a patent blue dye injection into the upper inner arm after anesthesia. Results.dFifty-two women made up our study population. Thirty-seven patients underwent sentinel lymph node biopsy (SLNB) and 15 patients underwent an axillary lymph node dissection (ALND) for known nodal metastasis. The sentinel lymph node was identified in 36 of the 37 cases who underwent SLNB alone and in 12 of 15 patients who underwent on ALND. In 13 patients, both blue and radioactive lymph nodes or lymphatics were clearly identified (25%) and 5 patients had a clear crossover with nodes being both blue and hot. Only a single patient with crossover lymphatics had metastases present in their sentinel node. Conclusion.dThe ARM technique did not prevent identification of
the SLN and we identified much greater crossover than reported. We had a single patient, who underwent a sentinel node biopsy, with mild arm lymphedema (1.9%) after 2 years of follow up. The success of split mapping is critical for ARM to optimize outcomes: the breast is mapped with technetium and the upper extremity with isosulfan blue dye to distinguish the flow of the arm from that of the breast.1,2 We previously described the different patterns of ARM lymphatics, which in about one-third of cases extend low enough in the axilla to be seen from an sentinel lymph node biopsy incision.3 Approximately 75% can be seen from an ALND incision, as pathways above or behind the axillary vein exist. Several trials of ARM have been attempted without following our dual mapping protocol, which recommends isosulfan blue dye. We consider methylene blue too caustic and less ideal for ARM mapping. Consequently, some of these studies have not been able to duplicate our successful use of ARM. Kang and colleagues4 used our dual mapping technique for the arm and breast and had similar results, showing that the nodes that stain with blue dye alone are rarely positive. They reported a 36% rate of malignancy in the blue nodes with crossover (meaning that those nodes were the sentinel lymph nodes and should be resected) and only 1.3% malignancy rate in non-concordant
axilla. In our own data, we found a malignancy rate of 13.3% (4/30) in crossover (concordant) axilla and 4.5% (2/44) in non-concordant cases, both of which had N2 disease.3 Today in our practice, when there are suspicious nodes, blue nodes are resected and the lymphatics re-anastomosed, which yields an extremely low lymphedema rate, even with ALND. V. S. Klimberg, MD
References 1. Klimberg S, Townsend C, Evers M. Axillary reverse mapping. In Klimberg VS, ed. Atlas of Breast Surgical Techniques. Philadelphia, PA: Saunders; 2010:174-181. 2. Thompson M, Korourian S, HenryTillman R, et al. Axillary reverse mapping (ARM): a new concept to identify and enhance lymphatic preservation. Ann Surg Oncol. 2007; 14:1890-1895. 3. Boneti C, Korourian S, Diaz Z, et al. Scientific Impact Award: axillary reverse mapping (ARM) to identify and protect lymphatics draining the arm during axillary lymphadenectomy. Am J Surg. 2009;198:482-487. 4. Kang SH, Choi JE, Jeon YS, Lee S, Bae Y. Preservation of lymphatic drainage from arm in breast cancer surgery: is it safe? Cancer Res. 2009; 69:201, http://cancerres.aacrjournals. org/content/69/2_Supplement/201. short. Accessed December 8, 2015.
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 1 2016
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Background.dThe aim of this study was to evaluate the axillary reverse lymphatic mapping (ARM) procedure for reducing the risk of arm lymphedema after breast cancer surgery. Methods.dThe ARM procedure was carried out with a subareolar injection of technetium-99 sulfur colloid the morning of surgery, and a patent blue dye injection into the upper inner arm after anesthesia. Results.dFifty-two women made up our study population. Thirty-seven patients underwent sentinel lymph node biopsy (SLNB) and 15 patients underwent an axillary lymph node dissection (ALND) for known nodal metastasis. The sentinel lymph node was identified in 36 of the 37 cases who underwent SLNB alone and in 12 of 15 patients who underwent on ALND. In 13 patients, both blue and radioactive lymph nodes or lymphatics were clearly identified (25%) and 5 patients had a clear crossover with nodes being both blue and hot. Only a single patient with crossover lymphatics had metastases present in their sentinel node. Conclusion.dThe ARM technique did not prevent identification of
the SLN and we identified much greater crossover than reported. We had a single patient, who underwent a sentinel node biopsy, with mild arm lymphedema (1.9%) after 2 years of follow up. The success of split mapping is critical for ARM to optimize outcomes: the breast is mapped with technetium and the upper extremity with isosulfan blue dye to distinguish the flow of the arm from that of the breast.1,2 We previously described the different patterns of ARM lymphatics, which in about one-third of cases extend low enough in the axilla to be seen from an sentinel lymph node biopsy incision.3 Approximately 75% can be seen from an ALND incision, as pathways above or behind the axillary vein exist. Several trials of ARM have been attempted without following our dual mapping protocol, which recommends isosulfan blue dye. We consider methylene blue too caustic and less ideal for ARM mapping. Consequently, some of these studies have not been able to duplicate our successful use of ARM. Kang and colleagues4 used our dual mapping technique for the arm and breast and had similar results, showing that the nodes that stain with blue dye alone are rarely positive. They reported a 36% rate of malignancy in the blue nodes with crossover (meaning that those nodes were the sentinel lymph nodes and should be resected) and only 1.3% malignancy rate in non-concordant
axilla. In our own data, we found a malignancy rate of 13.3% (4/30) in crossover (concordant) axilla and 4.5% (2/44) in non-concordant cases, both of which had N2 disease.3 Today in our practice, when there are suspicious nodes, blue nodes are resected and the lymphatics re-anastomosed, which yields an extremely low lymphedema rate, even with ALND. V. S. Klimberg, MD
References 1. Klimberg S, Townsend C, Evers M. Axillary reverse mapping. In Klimberg VS, ed. Atlas of Breast Surgical Techniques. Philadelphia, PA: Saunders; 2010:174-181. 2. Thompson M, Korourian S, HenryTillman R, et al. Axillary reverse mapping (ARM): a new concept to identify and enhance lymphatic preservation. Ann Surg Oncol. 2007; 14:1890-1895. 3. Boneti C, Korourian S, Diaz Z, et al. Scientific Impact Award: axillary reverse mapping (ARM) to identify and protect lymphatics draining the arm during axillary lymphadenectomy. Am J Surg. 2009;198:482-487. 4. Kang SH, Choi JE, Jeon YS, Lee S, Bae Y. Preservation of lymphatic drainage from arm in breast cancer surgery: is it safe? Cancer Res. 2009; 69:201, http://cancerres.aacrjournals. org/content/69/2_Supplement/201. short. Accessed December 8, 2015.
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 1 2016
53