Axillary Reverse Mapping: Mapping and Preserving Arm Lymphatics May Be Important in Preventing Lymphedema During Sentinel Lymph Node Biopsy - 01/11/17

Doi : 10.1016/j.jamcollsurg.2007.12.022

Cristiano Boneti, MD ^a,^{^{1
Drs Boneti and Klimberg are supported by the Fashion Footwear Association of New York}}, Soheila Korourian, MD ^a,^b, Keiva Bland, MD ^a,^{^{2
Drs Bland, Cox, and Klimberg are supported by the Susan G Komen Breast Cancer Clinical Fellowship and the Arkansas Breast Cancer Act.}}, Kristin Cox, MD ^a,^{^{2
Drs Bland, Cox, and Klimberg are supported by the Susan G Komen Breast Cancer Clinical Fellowship and the Arkansas Breast Cancer Act.}}, Laura L. Adkins, MS ^a, Ronda S. Henry-Tillman, MD, FACS ^a, V. Suzanne Klimberg, MD, FACS ^a,^b,^⁎,^{^{1
Drs Boneti and Klimberg are supported by the Fashion Footwear Association of New York},}^{^{2
Drs Bland, Cox, and Klimberg are supported by the Susan G Komen Breast Cancer Clinical Fellowship and the Arkansas Breast Cancer Act.}}
^a Division of Breast Surgical Oncology, Department of Surgery, University of Arkansas for Medical Sciences and the Winthrop P Rockefeller Cancer Institute, Little Rock, AR
^b Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR.

Correspondence address: V Suzanne Klimberg, MD, 4301 West Markham, Slot 725, Little Rock, AR 72205-7199.

Résumé

Background

Several recent reports have shown a lymphedema rate of about 7% with sentinel lymph node biopsy (SLNB) only. We hypothesized that this higher than expected rate of lymphedema may be secondary to disruption of arm lymphatics during an SLNB procedure.

Study Design

This IRB-approved study, from May 2006 to June 2007, involved patients undergoing SLNB with or without axillary lymph node dissection. After sentinel lymph node (SLN) localization with subareolar technetium was assured, 2 to 5 mL of dermal blue dye was injected in the upper inner arm for localization of lymphatics draining the arm (axillary reverse mapping, ARM). The SLNB was then performed through an incision in the axilla. Data were collected on identification rates of hot versus blue nodes, variations in ARM lymphatic drainage that might impact SLNB, crossover between the hot and the blue lymphatics, and final pathologic nodal diagnosis.

Results

Median age was 57.6±12.5 years. Lymphatics draining the arm were near or in the SLN field in 42.7% (56 of 131) of the patients, placing the patient at risk for disruption if not identified and preserved during an SLNB or axillary lymph node dissection. ARM demonstrated that arm lymphatics do not cross over with the SLN drainage of the breast 96.1% of the time and that none of the ARM lymph nodes removed were positive, even when the SLN was (5 of 12). Seven (5.5%) blue ARM lymphatics were juxtaposed to the hot SLNBs.

Conclusions

Disruption of the blue ARM node because of proximity to the hot SLN may explain the surprisingly high rate of lymphedema seen after SLNB. Identifying and preserving the ARM blue nodes may translate into a lower incidence of lymphedema with SLNB and axillary lymph node dissection.

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Abbreviations and Acronyms : ALND, ARM, SLN, SLNB

Plan

Methods

Patients

Sentinel lymph node procedure

Axillary reverse mapping procedure

Axillary lymph node dissection

Pathology

Data collection and statistics

Results

Patients

Sentinel lymph node

Axillary reverse mapping

Axillary lymph node dissection

Competing Interests Declared: Dr Klimberg is a consultant for Ethicon Endo-Surgery.
The study is also funded by the Tenenbaum Breast Cancer Research Fund.