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NLN
NATIONAL LYMPHEDEMA NETWORK
LYMPHLink Article Reprint
Vol 23 No 4
October - December 2011
RESEARCH PERSPECTIVE
Advances in the surgical treatment of breast cancer:
Can the risk of lymphedema be reduced?
Sentinel lymph node biopsy and Axillary Reverse Mapping
By: Janice N. Cormier, MD, MPH, Kate Cromwell, MS, Sheila Ridner, PhD, RN, FAAN
S
entinel lymph node biopsy (SLNB) has
been the standard of care for the
assessment of lymph node metastases in
breast cancer patients since the 1990s.1
Sentinel lymph node mapping is a technique in which the region surrounding a
patient’s primary breast tumor is injected
with a traceable blue dye (e.g., isosulfan
blue) and/or a radioisotope (e.g., technetium-labeled sulfur colloid). The tracer
then travels through the lymphatic system
to the regional lymph node basin to identify the first tumor-draining lymph node(s),
the sentinel node(s). Sentinel nodes are
identified using a probe to detect the
radioactive tracer within the node and/or
by direct visualization of a blue sentinel
node through a small surgical incision.2
The identification, excision, and pathologic assessment of the sentinel node(s),
which together is called a SLNB, is a
commonly performed surgical procedure
that has been shown to be highly effective
in detecting micrometastatic disease in
breast cancer patients.2 Patients whose
nodes test negative for disease or have
minimal metastatic disease can be spared
a complete axillary node dissection.3
While SLNB has been shown to
reduce the likelihood of lymphedema
compared with axillary lymph node dissection, SLNB does not completely eliminate the risk of lymphedema.4-11 An evaluation of lymphedema studies from 2000
to 2007 revealed that 253 (about 6%) of
4,241 patients who had undergone SLNB
subsequently developed lymphedema.4-11
With an estimated 207,090 cases of
breast cancer diagnosed in 2010 and
20% to 30% of these patients requiring
SLNB, as many as 3,700 could develop
lymphedema.
Axillary reverse mapping (ARM) was
recently introduced as a procedure for
identifying upper extremity lymphatics so
surgeons can preserve them at the time
of axillary lymph node dissection or SLNB
in order to potentially reduce the risk of
postsurgical lymphedema.13-15 During
ARM, blue dye is injected in the ipsilateral
(same side) upper inner arm along the
intramuscular groove,16 travels in the lymphatics to the axilla, and serves to identify
the lymphatic channels of the arm. It is
believed that the identification of the
upper extremity lymph nodes is possible
because of the anatomic variation of the
lymphatics of the upper extremity and
breast.13 The ARM procedure was first
evaluated by Klimberg et al.; during this
evaluation, an initial group of 18 patients
underwent the ARM procedure with the
injection of 2.5 to 5.0 mL of isosulfan blue
dye in the upper inner arm at the time of
axillary lymph node dissection.14 In a subsequent group of patients undergoing
SLNB, with radioactive tracer used to
inject the tumor site and blue dye used to
identify ARM nodes, only 3% of blue
nodes contained radioactive tracer (from
SNLB)17 and metastases were not
detected in any of the blue ARM nodes.
This is important because tumor involved
nodes should not be left behind during the
SLNB staging procedure even if they are
demonstrated to also drain lymphatics
from the upper extremity.
However, while the feasibility of the
ARM procedure has been demonstrated in
several small studies,1, 14, 16, 18, 19 the
efficacy of ARM and its reduction of the
incidence of lymphedema have yet to be
confirmed. More recent ARM studies have
reported the identification of metastatic
disease in up to 18% of the blue (ARM)
lymph nodes which if preserved may lead
to disease progression.18, 20 These results
call into question the oncologic safety of
the ARM technique. Studies evaluating
ARM at the time of SLNB have had similar
findings; a concordance between SLNB
radioactive lymph nodes and ARM blue
nodes of 18.9%, with one-third of those
nodes containing metastases.21 Most
studies report that ARM can identify lymphatics and nodes in 60% to 88% of
patients. Other studies indicate that
despite the identification of the nodes
and/or lymphatics by ARM, it is not
always possible to preserve these lymphatics.22 An additional problem with the
technique is that some patients have
reported temporary blue tattooing of the
injection site, which has lasted from a few
days to several months.16 Most importantly, the ARM technique has not been
longitudinally studied with objective extremity measures; therefore the primary
National Lymphedema Network, Inc. • 116 New Montgomery St., Suite 235 • San Francisco, CA 94105
Infoline: 1-800-541.3259 • Tel: 415-908-3681 • Fax: 415-908-3813 • Email: [email protected] • Website: www.lymphnet.org
PAGE 1 OF 2
ARM-related benefit associated with a
proposed reduction in the incidence of
lymphedema has yet to be determined.18
For patients with breast cancer, SLNB
has been shown to be a highly accurate
staging procedure that reduces but does
not eliminate the risk of lymphedema
compared with axillary node dissection.
However, given the annual incidence of
breast cancer and the frequency with
which SLNB is performed, even a small
risk translates into thousands of women
developing lymph-edema. These figures
have prompted clinicians to investigate
additional techniques such as the ARM
procedure for lymphatic preservation.14
Although there is not sufficient evidence
for the widespread adoption of ARM,
further study is warranted to determine its
safety, efficacy, and long-term benefits.
1.Noguchi M, Yokoi M, Nakano Y. Axillary
reverse mapping with indocyanine fluorescence imaging in patients with breast cancer. J Surg Oncol; 101(3):217-21.
2.O’Hea BJ, Hill AD, El-Shirbiny AM, et al.
Sentinel lymph node biopsy in breast cancer: initial experience at Memorial SloanKettering Cancer Center. J Am Coll Surg
1998; 186(4):423-7.
3.Giuliano AE, Hunt KK, Ballman KV, et al.
Axillary dissection vs no axillary dissection
in women with invasive breast cancer and
sentinel node metastasis: a randomized
clinical trial. JAMA 2011; 305(6):569-75.
4.Noguchi M. Axillary reverse mapping for
breast cancer. Breast Cancer Res Treat
2009; 119(3):529-35.
5.Langer I, Guller U, Berclaz G, et al. Morbidity of sentinel lymph node biopsy (SLN)
alone versus SLN and completion axillary
lymph node dissection after breast cancer
surgery: a prospective Swiss multicenter
study on 659 patients. Ann Surg 2007;
245(3):452-61.
6.Mansel RE, Fallowfield L, Kissin M, et al.
Randomized multicenter trial of sentinel
node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst 2006;
98(9):599-609.
7.Francis WP, Abghari P, Du W, et al. Improving surgical outcomes: standardizing the
reporting of incidence and severity of acute
lymphedema after sentinel lymph node
biopsy and axillary lymph node dissection.
Am J Surg 2006; 192(5):636-9.
8.Wilke LG, McCall LM, Posther KE, et al.
Surgical complications associated with
sentinel lymph node biopsy: results from a
prospective international cooperative group
trial. Ann Surg Oncol 2006; 13(4):491-500.
9.Lucci A. Re: Clinical implications of sentinel
nodes outside the axilla and internal mammary chain in patients with breast cancer,
by van Rijk MC, Tanis PJ, Nieweg OE, et al.
J Surg Oncol 2006; 94(4):266-8.
10.Purushotham AD, Upponi S, Klevesath
MB, et al. Morbidity after sentinel lymph
node biopsy in primary breast cancer:
results from a randomized controlled trial. J
Clin Oncol 2005; 23(19):4312-21.
11.Leidenius MH. Sentinel node biopsy in
breast cancer. Acta Radiol 2005;
46(8):791-801.
12.Howlader N, Noone A, Krapcho M, et al.
SEER cancer statistics review, 1975-2008.
In Institute NC, ed., Vol. 2011. Bethesda,
MD: SEER, 2011.
13.Noguchi M. Axillary reverse mapping for
preventing lymphedema in axillary lymph
node dissection and/or sentinel lymph
node biopsy. Breast Cancer; 17(3):155-7.
14.Klimberg VS. A new concept toward the
prevention of lymphedema: axillary reverse
mapping. J Surg Oncol 2008; 97(7):563-4.
15.Toi M, Winer EP, Inamoto T, et al. Identifying Gaps in the Locoregional Management
of Early Breast Cancer: Highlights from the
Kyoto Consensus Conference. Ann Surg
Oncol 2011.
16.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(4):482-7.
17.Boneti C, Korourian S, Bland K, et al.
Axillary reverse mapping: mapping and
preserving arm lymphatics may be important in preventing lymphedema during
sentinel lymph node biopsy. J Am Coll Surg
2008; 206(5):1038-42; discussion 1042-4.
18.Bedrosian I, Babiera GV, Mittendorf EA, et
al. A phase I study to assess the feasibility
and oncologic safety of axillary reverse
mapping in breast cancer patients. Cancer
2010; 116(11):2543-8.
PAGE 2 OF 2
19.Thompson M, Korourian S, Henry-Tillman
R, et al. Axillary reverse mapping (ARM): a
new concept to identify and enhance lymphatic preservation. Ann Surg Oncol 2007;
14(6):1890-5.
20.Nos C, Kaufmann G, Clough KB, et al.
Combined axillary reverse mapping (ARM)
technique for breast cancer patients requiring axillary dissection. Ann Surg Oncol
2008; 15(9):2550-5.
21.Kang SH, Choi JE, Jeon YS, al. E. Preservation of lymphatic drainage from arm in
breast cancer surgery: is it safe? San Antonio Breast Cancer Symposium. San Antonio, Texas, 2008.
22.Casabona F, Bogliolo S, Valenzano
Menada M, et al. Feasibility of axillary
reverse mapping during sentinel lymph
node biopsy in breast cancer patients. Ann
Surg Oncol 2009; 16(9):2459-63.
University of Texas MD Anderson
Cancer Center, Houston, TX
Vanderbilt University School of Nursing
[email protected]