Laura Adkins

Axillary Reverse Mapping (ARM): A New Concept to Identify and Enhance Lymphatic Preservation

BackgroundVariations in arm lymphatic drainage put the arm lymphatics at risk for disruption during axillary lymph node surgery. Mapping the drainage of the arm with blue dye (axillary reverse mapping, ARM) decreases the likelihood of disruption of lymphatics and subsequent lymphedema.MethodsThis institutional review board (IRB)-approved study from May to October 2006 involved patients undergoing SLNB and/or ALND. Technetium sulfur colloid (4 mL) was injected in the subareolar plexus and 2–5 mL of blue dye intradermally was injected in the ipsilateral upper extremity (ARM). Data were collected on variations in lymphatic drainage that impacted SLNB or ALND, successful identification and protection of the arm lymphatics, any crossover between a hot breast node and a blue arm node, and occurrence of lymphedema.ResultsOf the 40 patients undergoing surgery for breast cancer, 18 required an ALND, with a median age of 49.7 years old. Fourteen patients had a SLNB + ALND, and four patients had ALND alone. In 100% of patients, all breast SLNs were hot but not blue, and the false negative rate was 0. In 11 of 18 ALNDs (61%) blue lymphatics or blue nodes were identified in the axilla. In the initial seven cases with positive lymph nodes in the axilla, the blue node draining from the arm was biopsied and all were negative.ConclusionsARM identified significant lymphatic variations draining the upper extremities and facilitated preservation in all but one case. ARM added to present-day ALND and SLNB further defines the axilla and may be useful to prevent lymphedema.

Axillary Reverse Mapping: Mapping and Preserving Arm Lymphatics May Be Important in Preventing Lymphedema During Sentinel Lymph Node Biopsy

BACKGROUND Several recent reports have shown a lymphedema rate of about 7% with sentinel lymph node biopsy (SLNB) only. We hypothesized that this higher than expected rate of lymphedema may be secondary to disruption of arm lymphatics during an SLNB procedure. STUDY DESIGN This IRB-approved study, from May 2006 to June 2007, involved patients undergoing SLNB with or without axillary lymph node dissection. After sentinel lymph node (SLN) localization with subareolar technetium was assured, 2 to 5 mL of dermal blue dye was injected in the upper inner arm for localization of lymphatics draining the arm (axillary reverse mapping, ARM). The SLNB was then performed through an incision in the axilla. Data were collected on identification rates of hot versus blue nodes, variations in ARM lymphatic drainage that might impact SLNB, crossover between the hot and the blue lymphatics, and final pathologic nodal diagnosis. RESULTS Median age was 57.6+/-12.5 years. Lymphatics draining the arm were near or in the SLN field in 42.7% (56 of 131) of the patients, placing the patient at risk for disruption if not identified and preserved during an SLNB or axillary lymph node dissection. ARM demonstrated that arm lymphatics do not cross over with the SLN drainage of the breast 96.1% of the time and that none of the ARM lymph nodes removed were positive, even when the SLN was (5 of 12). Seven (5.5%) blue ARM lymphatics were juxtaposed to the hot SLNBs. CONCLUSIONS Disruption of the blue ARM node because of proximity to the hot SLN may explain the surprisingly high rate of lymphedema seen after SLNB. Identifying and preserving the ARM blue nodes may translate into a lower incidence of lymphedema with SLNB and axillary lymph node dissection.

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

INTRODUCTION The axillary reverse mapping (ARM) procedure distinguishes lymphatics draining the arm from those draining the breast. The aim of this study was to assess the ability of ARM to identify and preserve lymphatics draining the arm and the impact on lymphedema. METHODS This study included 220 patients undergoing sentinel lymph node (SLN) biopsy (SLNB) with or without axillary lymph node dissection (ALND) from May 2006 to September 2008. After SLN localization with a radioactive tracer, blue dye was used to map ARM lymphatics. Data were collected on identification and variations in lymphatic drainage, crossover rate, the incidence of metastases, and nodal status. RESULTS Crossover (ARM = SLN) occurred in 6 patients (2.8%). ARM lymphatics were near or in the SLN field in 40.6% of patients, placing it at risk for disruption during lymphadenectomy. ARM lymphatics juxtaposed to the hot SLNB (n = 12 [5.6%]) were preserved. Fifteen ARM nodes were excised and were negative even in positive axillae. There were no cases of lymphedema at 6-month follow-up where ARM nodes were preserved. CONCLUSION Confluence of the arm and breast drainage is rarely the SLN, and none of these nodes contained metastases. Preserving the ARM nodes may translate into a lower incidence of postoperative lymphedema.

Intraoperative Subareolar Radioisotope Injection for Immediate Sentinel Lymph Node Biopsy

Objective:To determine the identification of sentinel lymph node biopsy (SLNB) in breast cancer patients after intraoperative injection of unfiltered technetium-99m sulfur colloid (Tc-99) and blue dye. Background:SLNB guided by a combination of radioisotope and blue dye injection yields the best identification rates in breast cancer patients. Radioisotope is given preoperatively, without local anesthesia, whereas blue dye is given intraoperatively. We hypothesized that, because of the rapid drainage noted with the subareolar injection technique of radioisotope, intraoperative injection would be feasible and less painful for SLN localization in breast cancer patients. Methods:Intraoperative injection of Tc-99 and confirmation blue dye was performed using the subareolar technique for SLNB in patients with operable breast cancer. The time lapse between injection and axillary incision, the background count, the preincision and ex vivo counts of the hot nodes, and the axillary bed counts were documented. The identification rate was recorded. Results:Ninety-six SLNB procedures were done in 88 patients with breast cancer employing intraoperative subareolar injection technique for both radioisotope (all 96 procedures) and blue dye (93 procedures) injections. Ninety-three (97%) procedures had successful identification; all SLNs were hot; 91 (of 93 procedures with blue dye) were blue and hot. The mean time from radioisotope injection to incision was 19.9 minutes (SD 8.5 minutes). The mean highest 10 second count was 88,544 (SD 55,954). Three of 96 (3%) patients with failure of localization had previous excisional biopsies: 1 circumareolar and 2 upper outer quadrant incisions that may have disrupted the lymphatic flow. Conclusion:Intraoperative subareolar injection of radioisotope rapidly drains to the SLNs and allows immediate staging of the axilla, avoiding the need to coordinate diagnostic services and a painful preoperative procedure.

Axillary reverse mapping: Five-year experience

BACKGROUND We hypothesize that mapping the lymphatic drainage of the arm with blue dye (axillary reverse mapping, ARM) during axillary lymphadenectomy decreases the likelihood of disruption of lymphatics and subsequent lymphedema. METHODS This institutional review board-approved study from May 2006 to October 2011 involved 360 patients undergoing SLNB and/or ALND. Technetium sulfur colloid (4 mL) was injected subareolarly and 5 mL of blue dye was injected subcutaneously in the volar surface ipsilateral upper extremity (ARM). Data were collected on variations in lymphatic drainage, successful identification and protection of arm lymphatics, crossover, and occurrence of lymphedema. RESULTS A group of 360 patients underwent SLNB and/or ALND. A total of 348 patients underwent a SLNB. Of those, 237/348(68.1%) had a SLNB only and 111/348(31.9%) went on to an ALND due to a positive axilla. An additional 12/360(3.3%) axilla had ALND due to a clinically positive axilla/preoperative core needle biopsy. In 96%(334/348) of patients with SLNB, breast SLNs were hot but not blue; crossover (SLN hot and blue) was seen in 14/348(4%). Blue lymphatics were identified in 80/237(33.7%) of SLN incisions and in 93/123(75.4%) ALND. Average follow-up was 12 months (range 3 to 48 months) and resulted in a SLNB lymphedema rate of 1.7%(4/237) and ALND of 2.4%(3/123). CONCLUSIONS ARM identified significant lymphatic variations draining the upper extremities and facilitated preservation. Metastases in ARM-identified lymph nodes were acceptably low indicating that ARM is safe. ARM added to present-day ALND and SLNB may be useful to lower lymphedema rates.

Intraoperative injection of subareolar or dermal radioisotope results in predictable identification of sentinel lymph nodes in breast cancer

Objective:Our objective is to prove that injection of technetium-99m (Tc99) sulfur colloid in a subareolar manner, after induction of anesthesia, is a safe and effective technique for sentinel lymph node identification in breast cancer patients. Introduction:Preoperative injection of Tc99 and lymphoscintigraphy is standardly performed before sentinel lymph node biopsy (SLNB) for breast cancer. Blue dye is often used to help guide and confirm the localization but tattoos the breast. This method is limited because of painful injections, variable identification rates, added costs and unnecessary scheduling delays. We hypothesized that intraoperative injection alone by the surgeon of dermal or subareolar Tc99 is practical for the identification of sentinel lymph node in breast cancer. Methods:This is a prospective single institution study that was approved by our institutional review board. All patients with operable breast cancer that were eligible for a SLNB from October 2002 to October 2010 were included in our study population. After induction and before sterile preparation of the operative field 1 mCi of Tc-99 unfiltered was administered by a subareolar injection. In patients where the scar was in the periareolar region or in the upper outer quadrant a dermal injection using 0.25mCi was used. Confirmatory Lymphazurin was also injected early on in this series but became unnecessary later in the study. Site and type of injection, injection time, incision time, and extraction time along with other factors for the purposes of the study were recorded. Data comparing injection preoperative and intraoperative were collected. Results:Six hundred ninty-nine patients were accrued for a SLNB with an average age 57.1 ± 12.8 (range 24–92). Seventy-six patients underwent 2 SLNB procedures for a total of 775 intraoperative Tc-99 injections. Six patients underwent intraoperative dermal injection with Tc-99. The average dose of Tc-99 administered was 1.157 ± 0.230 mCi. The sentinel node was localized in 98.6% of the cases (419/425) of subareolar radiotracer alone, 94.8% (326/344) in dual injection and 100% (6/6) in dermal injection. Average time from injection to incision was 41.20 ± 29.56 minutes for radiotracer injection in subareolar region only. For dermal injections it was 40.83 ± 39.64 minutes. For patients with dual injection of Lymphazurin and radiotracer it was 31.74 ± 24.86 minutes. The average ex vivo count was 6474 ± 8395 for dermal injection, 28,250 ± 69,932 for Tc-99 subareolar injection, and 35,501 ± 97,753 for dual subareolar injection. Intraoperative radiotracer alone incurred a charge of

Does Axillary Reverse Mapping Prevent Lymphedema After Lymphadenectomy

189.00; Lymphazurin blue dye added

Long-Term Results of Phase II Ablation after Breast Lumpectomy Added to Extend Intraoperative Margins (ABLATE l) Trial

591.40, whereas preoperative injection had a charge of

eRFA: Excision Followed by RFA—a New Technique to Improve Local Control in Breast Cancer

1257.06 associated with imaging, injection, and interpretation of images. Conclusion:Intraoperative injection of Tc99 alone with a subareolar or dermal injection technique rapidly localizes the sentinel node in breast cancer, is an oncologically sound procedure, is cost effective and facilitates operative room time management.

Axillary reverse mapping (ARM): initial results of phase II trial in preventing lymphedema after lymphadenectomy.

Background: We hypothesized that disconcerting lymphedema rates in both sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) may be because of unrecognized vunerable variations in arm lymphatic drainage within the axilla. Axillary reverse mapping (ARM) facilitates identification and avoidance of arm lymphatics within the axilla and its use may reduce lymphedema. Methods: This institutional review board-approved study from June 2007 to December 2013 involved patients undergoing SLNB with or without ALND, or ALND alone. Technetium is injected subareolarly for localization of the breast SLN and isosulfan blue dye (5 mL) is injected in the ipsilateral upper arm for localization of nonbreast lymphatics. Data were collected on identification and preservation of arm lymphatics, crossover rates, blue node metastases, axillary recurrence, and lymphedema as measured by volume displacement. Results: A total of 654 patients prospectively underwent 685 ARM procedures with a SLNB and/or ALND. Objective lymphedema rates for SLNB and ALND were 0.8% and 6.5% respectively, with 26-month median follow up. Blue lymphatics were identified in 29.2% (138/472) of SLNB and 71.8% (153/213) of ALND. Crossover was seen in 3.8% (18/472) of SLNB and 5.6% (12/213) of ALND. Blue node metastases rate was 4.5% (2/44). Axillary recurrence rate was 0.2% and 1.4% for SLNB and ALND, respectively. Conclusions: ARM allows frequent identification of arm lymphatics in the axilla, which would have been transected during routine surgery. Rates of metastases in noncrossover nodes and axillary recurrences are low. Lymphedema rates are dramatically reduced using ARM when compared with accepted standards.