Axillary reverse mapping with indocyanine fluorescence imaging in patients with breast cancer

Abstract

Fluorescence imaging was sensitive for identification of ARM nodes and/or lymphatics. However, further studies are needed before efforts to preserve these nodes can be safely implemented.

“Reverse axillary mapping in early stage breast cancer Is it oncologically safe? A feasibity study

“…In our study, using methylene blue dye injection, at the start of surgery, blue lymphatics were identified in72.2 % while blue lymph nodes could be identified in 61.1%.The pattern of distribution of arm lymphatics in axilla varies with respect to axillary vein . Bonetti et al described 5 common variations in the distribution of arm lymphatics in the axilla [6], with most of the lymphatics and lymph node being found within the region formed by inferior margin of axillary vein and the second intercostobrachial nerve and thoraco dorsal pedicle [4,5,11,17].In our study, 69.2% of the identified arm lymphatics was within one cm inferior to axillary vein, lateral to thoraco dorsal pedicle.RAM lymphatics were successfully identified in 10 of 13 patients with negative axilla, in 2/2 patients with pN1 disease but only in 1/3 patients with pN3 disease. This may be postulated to be secondary to lymphatic obstruction by extensive disease in axilla as described in literature [9,18] .…”

“…Reverse axillary mapping (RAM) technique, is a recent development, aimed at identifying the arm lymphatics in axilla at the time of axillary surgery for carcinoma breast. Various techniques have been described for the same -using blue dye ,radioisotope or fluorescence imaging [2][3][4][5]. Although arm and breast lymphatics have been postulated to have differential drainage crossover has been documented in 2-18% [1,[5][6][7] with pathologically proven involvement of nodes draining the arm by metastatic carcinoma from breast in 0-43% [5,[7][8][9][10][11].…”

Axillary reverse mapping for breast cancer

“…Consequently, the axillary reverse mapping nodes were identified in 25 (93%) of 27 patients who underwent axillary lymph node dissection alone (Yokoi et al, submitted) (Table 1). Although the fluorescent axillary reverse mapping nodes and/or lymphatics were not observed in 2 patients, they were early cases in the study (Noguchi et al, 2010b). Thus, the fluorescence imaging technique is useful for detecting lymphatic drainage from the upper extremity, and it also permits differentiation of fluorescent axillary reverse mapping nodes and/or lymphatics from blue and/or hot sentinel lymph nodes (Noguchi et al, 2009).…”

“…6 & 7) (Noguchi et al, 2010b;Yokoi et al, submitted). Before the surgical prep, a smaller volume of indocyanine green (0.1 mL, 0.25 mg) (Diagnogreen; Daiichi Pharmaceutical, Tokyo, Japan) was injected into the forearm to decrease the risk of long-term tattooing, and the injection site was massaged until fluorescent axillary reverse mapping lymphatics were observed in the upper inner arm.…”

“…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.…”