Combined Axillary Reverse Mapping (ARM) Technique for Breast Cancer Patients Requiring Axillary Dissection

Abstract

This technique of combined isotopic and blue dye ARM and findings must now be validated. A multicentric study is planned to confirm this data.

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

“…The positive RAM node was identified in pN3 axilla(high stage axillary disease). The same pattern had been described in various studies in literature, which have shown a positive relation between high nodal positivity and chance of arm lymphatics also being involved by the disease [9,10,17,19,20] Schunemann Jr et al, found a statistically significant association between occurrence of metastasis in RAM nodes and high nodal disease(P<.0.001) [19]. Most studies thus suggest that performing RAM in patients with high nodal disease, is not oncologically sound [10,11,17,19] .…”

“…Rate of Identification of arm lymphatics varies from 33.3% in initial studies to as high as 91% with use of radio isotopes, [8,9]. 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] .…”

“…A number of techniques have been described in literature for the identification of arm lymphatics in the axilla, using blue dye [4,6,8], radio isotope [9] and fluorescence [17]. Rate of Identification of arm lymphatics varies from 33.3% in initial studies to as high as 91% with use of radio isotopes, [8,9].…”

“…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]. Most common complication associated with this procedure has been local tattoing lasting from few weeks to as long as 6 months.…”