Relationship between Upper Extremity Lymphatic Drainage and Sentinel Lymph Nodes in Patients with Breast Cancer

Abstract

Purpose. The purpose of this study was to identify the relationship between upper extremity lymphatics and sentinel lymph nodes (SLNs) in breast cancer patients. Methods. Forty-four patients who underwent axillary reverse mapping (ARM) during axillary lymph node dissection (ALND) with SNL biopsy (SLNB) between February 2017 and October 2017 were investigated. ARM was performed using indocyanine green (ICG) to locate the upper extremity lymphatics; methylene blue dye was injected intradermally for SLN mapping. Results. ARM nodes were found in the ALND fields of all examined patients. The rate of identification of upper extremity lymphatics within the SLNB field was 65.9% (29 of 44). The ARM nodes were involved in metastases arising from primary breast tumors in 7 of the patients (15.9%), while no metastases were detected in pathologic axillary lymph node-negative patients. Lymphatics from the upper extremity drained into the SLNs in 5 of the 44 patients (11.4%); their ARM-detected nodes were found to be in close proximity to the SLNs. Conclusions. The ARM nodes and SLNs are closely related and share lymphatic drainage routes. The ARM procedure using fluorescence imaging is both feasible and, in patients who are SLN negative, oncologically safe. ARM using ICG is therefore effective for identifying and preserving upper extremity lymphatics, and SLNB combined with ARM appears to be a promising surgical refinement for preventing upper extremity lymphoedema. Clinical Trial Registration. This trial is registered with ClinicalTrial.gov: NCT02651142.

Clinical application of axillary reverse mapping in patients with breast cancer: A systematic review and meta-analysis

“…Twenty-nine articles published between January 2007 and January 2020 describing studies of 4954 patients were included in this meta-analysis [ 1 , 2 , [6] , [7] , [8] , [9] , 11 , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] ]. These included four randomized controlled trials [ 1 , [20] , [21] , [22] ] and 25 prospective non-randomized studies [ 2 , [6] , [7] , [8] , [9] , 11 , [14] , [15] , [16] , [17] , [18] , [19] , [23] , [24] , [25] ]. Four randomized controlled trials were at low risk of bias according to the Cochrane Collaboration’s tool( Table S2 ).…”

“…(2019) [ 22 ] RCT Egypt ALND alone (24); ALND + ARM (24) Blue dye ALND: 83%(20/24) NA 0%(0/4) ALND: 10%(5/48) 6 months High quality 06/2017–01/2018 Ma et al. (2019) [ 24 ] Prospective China ALND with SLNB (44) Blue dye + fluorescence SLNB: 29/44(66%) ALND: 96%(44/46) 11%(5/44) 16%(7/44) NA NA Moderate quality 02/2017–10/2017 Yuan et al. (2019) [ 21 ] RCT China ALND alone (665); ALND + ARM (689) Blue dye + fluorescence ALND: 81%(558/689) NA 7%(38/558) ALND: 10%(117/1191) 37 months High quality 02/2013–10/2017 Beek et al.…”

“…3 shows forest plots depicting the feasibility of the ARM technique. Nine studies observed the identification rate of ARM lymph nodes and/or lymphatics in the axilla during SLNB [ 2 , 6 , 11 , 14 , 15 , 18 , 19 , 23 , 24 ]. The aggregate results showed that the identification rate of ARM lymph nodes and/or lymphatics in the SLNB field was 37% (95% CI 31%–44%, I 2 = 83.5%, P < 0.05).…”

“…Eleven studies investigated the crossover rate between the SLN and ARM lymph nodes [ 2 , 6 , 9 , 11 , 14 , 15 , 18 , 19 , [24] , [25] , [26] ]; the overall pooled crossover rate was 12% (95% CI 6%–19%, I 2 = 93.7%, P < 0.05) ( Fig. 4 A).…”

“…Several studies investigated the SLN + axillary status ARM metastatic rate [ 9 , 11 , 24 , 26 , 34 ]. Regardless of the presence of additional metastases in other lymph nodes extracted during ALND, our pooled ARM node metastasis rate within the SLN + patient group was 22% (95% CI 13%–33%, I 2 = 22.8%, P = 0.269) ( Fig.…”