56 Breast Diseases: A Year Book®

Quarterly56 Vol 19 No 1 2008

Axillary Reverse Mapping(ARM): A New Concept toIdentify and Enhance LymphaticPreservationThompson M, Korourian S, Henry-TillmanR, et al (Univ of Arkansas for MedicalSciences, Little Rock)

Ann Surg Oncol 14:1890-1895, 2007

Background.—Variations in armlymphatic drainage put the arm lymphat-ics at risk for disruption during axillarylymph node surgery. Mapping thedrainage of the arm with blue dye (axil-lary reverse mapping, ARM) decreasesthe likelihood of disruption of lymphaticsand subsequent lymphedema.

Methods.—This institutional reviewboard (IRB)-approved study from May toOctober 2006 involved patients undergo-ing SLNB and/or ALND. Technetiumsulfur colloid (4 mL) was injected in thesubareolar plexus and 2–5 mL of blue dyeintradermally was injected in the ipsilater-al upper extremity (ARM). Data werecollected on variations in lymphaticdrainage that impacted SLNB or ALND,successful identification and protection ofthe arm lymphatics, any crossover be-tween a hot breast node and a blue armnode, and occurrence of lymphedema.

Results.—Of the 40 patients under-going surgery for breast cancer, 18 re-quired an ALND, with a median age of49.7 years old. Fourteen patients had aSLNB + ALND, and four patients had

ALND alone. In 100% of patients, allbreast SLNs were hot but not blue, andthe false negative rate was 0. In 11 of 18ALNDs (61%) blue lymphatics or bluenodes were identified in the axilla. In theinitial seven cases with positive lymphnodes in the axilla, the blue node drainingfrom the arm was biopsied and all werenegative.

Conclusions.—ARM identified sig-nificant lymphatic variations draining theupper extremities and facilitated preser-vation in all but one case. ARM added topresent-day ALND and SLNB furtherdefines the axilla and may be useful toprevent lymphedema.

In this very interesting study,Thompson and colleagues hypothe-sized that mapping the lymphaticdrainage of the arm with blue dyewould decrease the likelihood of lym-phatic disruption and subsequent lymphedema.

In this study, 40 patients were en-rolled, and 10 patients underwent bilat-eral procedures. Of these 50 proce-dures, 32 were SLNB, 4 were ALND,and 14 were SLNB + ALND. SLNB wasperformed with radiocolloid only,whereas arm drainage was mapped us-ing isosulphan blue, which was injectedin the inner arm during the latter partof the procedure.

The authors found a 61% identifi-cation rate: 11 blue nodes or channels(5 blue lymphatics, 3 blue nodes, and 3

blue nodes and lymphatics) were identi-fied among the 18 patients who under-went ALND. The arm lymphatics werelocated above and below the vein, adja-cent to the SLN, and even draped overthe SLN. In the initial 7 patients withpositive axillary nodes, the nodes identi-fied by blue ARM were removed andwere negative for tumor.

The authors proposed a very inno-vative concept: that the lymphaticdrainage of the arm can be identifiedand potentially preserved. Lymphedemais a common complication of axillarysurgery and is dreaded by most patients.Thus, axillary drainage preservation isdefinitely worth pursuing. That beingsaid, it is important to emphasize thatthis study was small: only 7 patients un-derwent removal of nodes identified byARM, and all of these nodes were unin-volved. Larger studies are needed to de-termine the likelihood of ARM-identifiednode involvement in breast cancer pa-tients before efforts to preserve thesenodes can be safely implemented.Notably, the study also does not addresswhether ARM can prevent lymphedema.However, ARM holds much promise. Iffuture studies demonstrate that ARM iseffective at preventing lymphedema andis safe, this technique will be the mostimportant technological advancementsince sentinel node mapping.

F. Meric-Bernstam, MD