Feasibility of Axillary Reverse Mapping and Clinicopathological Features Predicting ARM Node Metastasis in Breast Cancer—a Pilot Study

Abstract

The axillary reverse mapping (ARM) technique has been described as an attempt to map and preserve the upper extremity lymphatic drainage during axillary lymph node dissection (ALND) and/or SLNB. This technique is based on the hypothesis that the lymphatic pathway from the upper extremity is not involved by metastasis from primary breast cancer. The ARM node/s however, has been found, in various studies, to be involved with metastatic foci in patients with extensive axillary lymph node metastases. Therefore, the oncological safety of this procedure has not yet been determined. In this pilot study, we assessed the ARM node intraoperatively for various parameters and compared it to final HPR, to try and determine the oncologic safety of preserving the ARM node. Seventy-two breast cancer patients were screened for this prospective pilot study which was planned to recruit 20 patients. The study was initiated on May 2014, 20 patients were recruited till July 2015. Eligibility criterion was as follows: patients requiring primary axillary lymph node dissection based on a clinically positive axilla. Forty-five patients were ineligible because they had either received neoadjuvant chemotherapy or underwent previous axillary surgery or axillary radiation (exclusion criteria). Seven patients refused to give consent. ARM node identification rate was 75%. The most common location of the ARM node was lateral to the latissimus dorsi pedicle (42.10%), none of them being malignant. None of the oval or firm nodes were malignant. Tumor deposits were identified in 13%. Fine-needle aspiration cytology (FNAC) had 100% specificity, 94.4% negative predictive value, 100% positive predictive value, and 50% sensitivity. ARM is feasible using blue dye alone, with an acceptable identification rate. Location, consistency, and intraoperative FNAC of the ARM node, put together, may be reliable parameters to predict involvement of the ARM node with metastasis.

Clinical application of axillary reverse mapping in patients with breast cancer: A systematic review and meta-analysis

“…Twenty-nine articles published between January 2007 and January 2020 describing studies of 4954 patients were included in this meta-analysis [ 1 , 2 , [6] , [7] , [8] , [9] , 11 , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] ]. These included four randomized controlled trials [ 1 , [20] , [21] , [22] ] and 25 prospective non-randomized studies [ 2 , [6] , [7] , [8] , [9] , 11 , [14] , [15] , [16] , [17] , [18] , [19] , [23] , [24] , [25] ].…”

“…(2016) [ 34 ] Prospective France ALND alone (172) Radioisotope ALND: 100%(172/172) NA 31%(54/172) SLNB + ALND: 27% 34 months Moderate quality 12/2009–12/2012 Kumar et al. (2017) [ 35 ] Prospective India ALND alone (20) Blue dye ALND: 75%(15/20) NA 13%(2/15) NA NA Moderate quality 05/2014–07/2015 Tummel et al. (2017) [ 6 ] Prospective USA SLND alone (472), ALND with or without SLNB (213) Blue dye + radioisotope SLND: 29%(138/472) ALND: 72%(153/213) 4%(18/472) 8%(7/74) SLNB: 3%(12/350) ALND: 21%(33/154) 26 months Moderate quality 06/2007–12/2013 Faisal et al.…”

A study on the feasibility of axillary reverse mapping with blue dye only in breast cancer patients

“…In the study by Shivakumar et al, the most common location was lateral to the subscapular pedicle. 9 Though the location of the node was not so significant clinically, this parameter helps us to look for the nodes in the same location in subsequent cases. In the study by Nos et al, the nodes were seen above and below the intercostal nerves and in relation to the subscapular pedicle.…”

“…In a study by Shivakumar et al, intraoperative FNAC was used to detect metastatic ARM nodes. 9 It was concluded that nodes that are reported benign by intraoperative FNAC could be preserved safely to reduce lymphedema.…”

“…In the study by Shivakumar et al, the complications described included pain, itching, induration, pigmentation, cellulitis. 9 There are not much literature describing about the complications of ARM as most studies included radiocolloid and in studies where both are used, the dose of the dye injected was very less and intradermal. Injecting high volume intradermally will again result in overlying skin morbidity and hence the injections were given subcutaneously.…”