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research into how to prevent lymphedema with sentinel lymph node dissection-Progress!
Axillary Reverse Mapping Technique Useful in Protecting Lymphatic Drainage: Presented at ASBS [Doctor's Guide]
SAN DIEGO — April 27, 2009 — Surgeons utilising the axillary reverse mapping (ARM) technique find that a significant number of patients are vulnerable to arm lymphatics disruption during axillary lymphadenectomy, which may explain the lymphoedema seen after axillary lymph node dissection (ALND) and/or sentinel lymph node biopsy (SLNB), researchers noted here at the American Society of Breast Surgeons (ASBS) 10th Annual Meeting.
This follow-up study involved patients undergoing SLNB (n = 220), as well as some patients undergoing SLNB +- ALND (n = 37). The study was conducted between May 2006 and September 2008; median patient age was 60.3 +- 11.3 years.
"Since surgeons all do SNLB differently — which is why we see differences in outcome — the clinical significance of the lymphatics identified by ARM may help prevent lymphoedema," stated lead author Cristiano Boneti, MD, University of Arkansas for Medical Sciences and Winthrop P. Rockefeller Cancer Institute, Little Rock, Arkansas, speaking here at an oral presentation on April 26.
Dr. Boneti's group injected technetium sulphur colloid into the subareolar plexus for SLNB procedures. After SLN localisation was assured, 2 to 5 mL of dermal blue dye was injected in the upper inner arm for localisation of lymphatics draining the arm.
SLNB +- ALND was performed through an incision in the axilla.
Data were collected on hot versus blue nodes; variations in ARM lymphatic drainage that may have had an impact on SLNB; any crossover between the hot and the blue lymphatics; incidence of metastases compared to arm lymphatics when crossover was present, and final pathological nodal diagnosis.
Lymphatics draining the arm were near or in the sentinel lymph gland field in 40.6% of the cases, which placed the patient at risk for disruption if not identified and preserved during an SLNB and/or ALND procedure. Crossover of the blue ARM lymphatics with the hot SLN was seen in only 6 patients (2.8%).
Final analysis of ARM results showed that 37.8% of patients were vulnerable to arm lymphatic disruption during axillary lymphadenectomy. The ARM node was rarely the sentinel node; in cases of crossover, none of the lymph nodes contained metastases.
Disruption of the blue ARM node due to proximity with the hot SLN, the study said, explained the high rate of lymphoedema seen after SLNB — a rate that Dr. Boneti termed "phenomenal."
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ASBS 2009: ABSTRACT: Axillary Reverse Mapping to Identify and Protect Lymphatics Draining the Arm During Axillary Lymphadenectomy (PDF) [American Society of Breast Surgeons]
Objectives: Our initial results utilizing the axillary reverse mapping (ARM) procedure to identify lymphatics draining the arm during sentinel lymph node biopsy (SLNB) with or without axillary lymph node dissection (ALND) may explain why lymphedema still occurs during SLNB and, to a greater extent, during ALND. The objective of this study is to provide an update on our initial results with this new technique.
Method: This institutional review board-approved study from May 2006 to September 2008 involved patients undergoing SLNB ± ALND. Technetium sulfur colloid was injected in the subareolar plexus for SLNB. After SLN localization was assured, 2-5 ml of dermal blue dye were injected in the upper inner arm for localization of lymphatics draining the arm (ARM). The SLNB ± ALND was then performed through an incision in the axilla. Data was collected on identification rates of hot versus blue nodes; variations in ARM lymphatic drainage that may impact SLNB; crossover between the hot and the blue lymphatics and, when crossover was present, the incidence of metastases to arm lymphatics; and final pathological nodal diagnosis.
Results: Median age was 60.3 ± 11.3 years. Results: are shown in the table below.... Lymphatics draining the arm were near or in the SLN field 40.6% of the cases, placing the patient at risk for disruption if not identified and preserved during an SLNB and/or ALND. Crossover of the blue ARM lymphatics with the hot SLN was seen in only 6 (2.8%) of the patients. In this initial series, another 12 (5.6%) of blue ARM lymphatics were juxtaposed to the hot SLNB but able to be preserved. Fifteen blue lymph nodes draining the arm were excised and were negative even in positive axillae.
Conclusions: Analysis of ARM results show that a significant number of patients are vulnerable to arm lymphatic disruption (37.8%) during axillary lymphadenectomy. It may explain the cause lymphedema seen after ALND and even SLNB. ARM demonstrated that arm lymphatics cross over with the SLN drainage of the breast only in a minority of cases (2.8%), that is the ARM node is rarely the sentinel node. When crossover was identified, none of these lymph nodes contained metastases. Maturation of ongoing studies will elucidate whether identifying and preserving the ARM blue nodes may translate into a lower incidence of postoperative lymphedema.
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