Identification and Preservation of Arm Lymphatic System in Axillary Dissection for Breast Cancer to Reduce Arm Lymphedema Events: A Randomized Clinical Trial

Yuan, Qianqian; Wu, Zeyu; Xiao, Shu‐Yuan; Hou, Jian; Ren, Yuqi; Wang, Hongying; Wang, Kun; Zhang, Dan

doi:10.1245/s10434-019-07569-4

Cited by 43 publications

(50 citation statements)

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“…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] ]. Four randomized controlled trials were at low risk of bias according to the Cochrane Collaboration’s tool( Table S2 ).…”

Section: Resultsmentioning

confidence: 99%

“…(2019) [ 24 ] Prospective China ALND with SLNB (44) Blue dye + fluorescence SLNB: 29/44(66%) ALND: 96%(44/46) 11%(5/44) 16%(7/44) NA NA Moderate quality 02/2017–10/2017 Yuan et al. (2019) [ 21 ] RCT China ALND alone (665); ALND + ARM (689) Blue dye + fluorescence ALND: 81%(558/689) NA 7%(38/558) ALND: 10%(117/1191) 37 months High quality 02/2013–10/2017 Beek et al. (2020) [ 1 ] RCT Netherlands ALND alone (46); ALND + ARM (48) Blue dye ALND: 78%(73/94) NA 3%(1/35) ALND: 27% (18/66) 24 months High quality 06/2013–08/2016 RCT randomized controlled trial; SLN sentinel lymph node; SLNB sentinel lymph node biopsy; ARM axillary reverse mapping; ALND axillary lymph node dissection; NA not applicable.…”

Section: Resultsmentioning

confidence: 99%

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

Wijaya¹,

Peng²,

et al. 2020

The Breast

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Background The axillary reverse mapping (ARM) technique, identify and preserve arm nodes during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND), was developed to prevent breast-cancer related lymphedema (BCRL) remains controversial. Methods A comprehensive search of Medline Ovid, Pubmed, Web of Science and the Cochrane CENTRAL databases was conducted from the inception till January 2020. The key word including “breast cancer”, “axillary reverse mapping”, and “lymphedema”. Stata 15.1 software was used for the meta-analysis. Results As a result, twenty-nine related studies involving 4954 patients met our inclusion criteria. The pooled overall estimate lymphedema incidence was 7% (95% CI 4%–11%, I 2 = 90.35%, P < 0.05), with SLNB showed a relatively lower pooled incidence of lymphedema (2%, 95% CI 1%–3%), I 2 = 26.06%, P = 0.23) than that of ALND (14%, 95% CI 5%–26%, I 2 = 93.28%, P < 0.05) or SLNB and ALND combined (11%, 95% CI 1%–30%). The ARM preservation during ALND procedure could significantly reduce upper extremity lymphedema in contrast with ARM resection (OR = 0.27, 95% CI 0.20–0.36, I 2 = 31%, P = 0.161). Intriguingly, the result favored ALND-ARM over standard-ALND in preventing lymphedema occurrence (OR = 0.21, 95% CI 0.14–0.31, I 2 = 43%, P = 0.153). The risk of metastases in the ARM-nodes was not significantly lower in the patients who had received neoadjuvant chemotherapy, as compared to those without neoadjuvant treatment (OR = 1.20, 95% CI 0.74–1.94, I 2 = 49.4%, P = 0.095). Conclusions ARM was found to significantly reduce the incidence of BCRL. The selection of patients for this procedure should be based on their axillary nodal status. Preoperative neoadjuvant chemotherapy has no significant impact on the ARM lymph node metastasis rate.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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

Wijaya¹,

Peng²,

et al. 2020

The Breast

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“…[15] A re ned ARM technique was proposed in our institution to identify the arm lymphatic system and eliminate postoperative arm lymphedema. [16,17] An intact pathway for lymphatic arm drainage is adjacent to the axillary vein and is usually located above the second intercostobrachial nerve. Hence, a horizontal line in this study was designed as the upper landmark during ALND surgery based on BLL to protect the arm lymphatic system.…”

Section: Discussionmentioning

confidence: 99%

Minimize the Extent and Morbidity of Axillary Dissection for Node-positive Breast Cancer Patients: Implementation of Axillary Lymph Node Dissection Based on Breast Lymphatics Level

Yuan

Hou

et al. 2020

Preprint

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BackgroundBreast cancer-related lymphedema (BCRL) is associated with extensive axillary dissection. Axillary lymph node dissection (ALND) based on breast lymphatics level (BLL) was proposed to minimize the surgical extent for node-positive breast cancer patients.MethodsA total of 156 consecutive sentinel lymph node-positive (SLN+) or clinically node-positive (CN+) patients underwent sentinel lymph node biopsy (SLNB) with indocyanine green and methylene blue (MB). The SLNs were injected with 0.1 ml MB before removal, and a standard ALND was subsequently performed. The nodes adjacent to the blue-stained breast lymph nodes (ABLNs) were sent for pathological examination separately by resecting serial tissue every 0.5 cm away from the marginal blue-stained ABLNs. Then, a pilot study comparing ALND based on BLL and standard ALND was performed.ResultsBLL were successfully identified in 20 SLN+ (100%) and 134 CN+ (98.5%) patients. The median number of BLL was four, ranging from three to six. A horizontal line 1.0 cm away from the superior blue-stained BLN and a vertical line 1.0 cm away from the medial blue-stained BLN formed BLL II, III, and IV. All of the additional positive nodes were within 1.0 cm of the blue-stained ABLNs. The minimized axillary dissection should resect upwards from the lowest breast lymphatic level that contains the first confirmed negative blue-stained ABLNs. In the pilot study, no patient developed axillary recurrence.ConclusionThe ALND surgical procedure based on BLL could minimize the surgical extent for pathological node-positive breast cancer patients and potentially reduce the BCRL rate.Trial registrationChiCTR1800014247

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“…A 37-month follow-up revealed that this procedure reduced the arm lymphedema rate from 15.3% to 3.3% with nonsignificant difference in regional recurrence, which is of significance in improving postoperative quality of life of patients who undergo axillary dissection. 4…”

Section: Presentmentioning

confidence: 99%

ASO Author Reflections: Identification and Preservation of Axillary Lymphatic System

Yuan

2019

Ann Surg Oncol

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Application of axillary reverse mapping (ARM) in axillary dissection was introduced by Thompson from the USA and Nos from France with the aim of reducing the arm lymphedema rate after surgery for breast cancer. 1,2 Several questions remain to be solved, including the unsatisfactory identification rate of arm nodes, uncertain oncological effect in long-term follow-up, and effectiveness in reducing lymphedema. 3 The results of this clinical trial demonstrate that the refined ARM technique, DEPART, is effective and practical in eliminating arm lymphedema without compromising oncological safety.

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Identification and Preservation of Arm Lymphatic System in Axillary Dissection for Breast Cancer to Reduce Arm Lymphedema Events: A Randomized Clinical Trial

Cited by 43 publications

References 29 publications

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

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

Minimize the Extent and Morbidity of Axillary Dissection for Node-positive Breast Cancer Patients: Implementation of Axillary Lymph Node Dissection Based on Breast Lymphatics Level

ASO Author Reflections: Identification and Preservation of Axillary Lymphatic System

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