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Does Axillary Reverse Mapping Prevent Lymphedema After Lymphadenectomy?

Tummel, Evan MD*; Ochoa, Daniela MD*; Korourian, Soheila MD; Betzold, Richard MD*; Adkins, Laura MS*; McCarthy, Maureen OCN, RN; Hung, Stephanie MD*; Kalkwarf, Kyle MD*; Gallagher, Kristalyn DO*; Lee, Jeannette Y. PhD; Klimberg, V. Suzanne MD*,†

doi: 10.1097/SLA.0000000000001778
Original Articles

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.

*Departments of Surgery, University of Arkansas for Medical Sciences, Winthrop P. Rockefeller Institute, Little Rock, AR

Departments of Pathology, University of Arkansas for Medical Sciences, Winthrop P. Rockefeller Institute, Little Rock, AR

Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR.

Reprints: V. Suzanne Klimberg, MD, Departments of Pathology, Winthrop P. Rockefeller Cancer Institute UAMS Slot 725 Little Rock, AR 72212. E-mail:

Disclosure: D. O. receives a grant from the Arkansas Breast Cancer Research Program and the University of Arkansas for Medical Sciences Translational Research Institute (CTSA Grant Award #1UL1RR029884)

V. S. K. receives a grant from the Fashion Footwear Association of New York

Financial Disclosures: None

The authors declare no conflicts of interest.

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