Scientific Impact Award: Axillary reverse mapping (ARM) to identify and protect lymphatics draining the arm during axillary lymphadenectomy

Anatomy of the Lymphatic Drainage of the Upper Limb and Breast and its Role in Lymphedema Prevention after Breast Cancer Treatment

“…Some showed a positive view of the benefits and morbidity reduction by using this technique, even though further studies are necessary to affirm anything (Gobardhan et al, 2012) others defend the use of this technique in all cases, except in patients whose sentinel lymph node (SLN) is too close to the ARM lymph node and when there are too many compromised nodes (Boneti et al, 2009) and there are some who question the real effectiveness and therapeutic safety of this technique (Ikeda et al, 2012).…”

Axillary reverse mapping for breast cancer

“…If the sentinel lymph node draining the breast were the same node as the axillary reverse mapping node draining the upper extremity, it would be impossible to preserve the axillary reverse mapping node at sentinel lymph node biopsy. Boneti et al (2009) reported that crossover (axillary reverse mapping node = sentinel lymph node) occurred in only 6 (2.2%) of 220 patients, although axillary reverse mapping lymphatics were near or within the sentinel lymph node biopsy field in 40.6% of patients. However, Britton et al (2009) reported that sentinel lymph node from the breast was the same as the axillary reverse mapping node from the upper extremity in 2 (13%) of 15 patients, indicating convergence of the two drainage pathways through the same node.…”

“…Therefore, patients with suspected extensive nodal disease at clinical examination, ultrasonography of the axilla, or intraoperative pathologic assessment should not be candidates for preservation of axillary reverse mapping nodes and lymphatics (Ponzone et al, 2009). On the other hand, the SLN draining the breast is the same node as the axillary reverse mapping node draining the upper extremity in some patients (Boneti et al, 2009;Britton et al, 2009;Kang et al, 2009;Noguchi et al, 2010;Yokoi et al, submitted). It is impossible to preserve converged sentinel lymph node -axillary reverse mapping node, although the excision of one converged node does not always translate into lymphedema, because multiple lymphatic channels drain the arm.…”

“…However, it has been suggested that patients with clinically uninvolved nodes might derive the most benefit from the axillary reverse mapping procedure (Ponzone et al, 2009). In a previous study by Boneti et al (2009), 220 patients with clinically uninvolved nodes underwent sentinel lymph node biopsy and axillary reverse mapping procedure. Forty of these patients subsequently underwent axillary lymph node dissection because of positive sentinel lymph nodes.…”

“…The assumption is that the lymphatic drainage from the upper arm is different from that of the breast, allowing safe removal of only the lymphatics of the breast and protection of the lymphatic channels draining the upper extremity during axillary lymph node dissection or sentinel lymph node biopsy, thereby preventing arm lymphedema. However, several studies have shown that there are limits to the principle of non-overlap between breast and arm nodes, including: (a) the axillary reverse mapping nodes may be involved with metastatic foci in patients with extensive axillary lymph node metastases (Bedrosian et al, 2010;Kang et al, 2009;Noguchi et al, 2010b;Nos et al, 2008;Ponzone et al, 2009), and (b) the sentinel lymph node draining the breast may be the same as the axillary reverse mapping node draining the upper extremity in some patients (Boneti et al, 2009;Britton et al, 2009;Kang et al, 2009;Noguchi et al, 2010b). Therefore, the oncological safety of this procedure has not yet determined.…”