Prevention of lymphedema via axillary reverse mapping for arm lymph-node preservation following breast cancer surgery: a randomized controlled trial

Utilizing Reverse Axillary Mapping in the Surgical Treatment of Axillary Hidradenitis Suppurativa: A Novel Approach

Hidradenitis suppurativa (HS) is a chronic inflammatory cutaneous disease that imposes a surgical challenge and mandates radical, full-thickness excision of involved skin to achieve remission. Upper limb lymphedema can be a complication of HS chronic infection or radical surgery due to the violation of lymphatics. Reverse axillary mapping (RAM) was developed to reduce upper limb lymphedema after axillary surgery for breast cancer. We aim to demonstrate a novel approach by utilizing RAM during radical excision of axillary HS in 2 cases treated at Cleveland Clinic Abu Dhabi. By injecting isosulfan blue dye in the upper inner arm before surgery and observing the dye to map the lymphatic ducts, we clearly identified the blue lymphatic ducts in the surgical field and successfully preserved the dyed ducts while performing radical excision for axillary HS. In this report, we demonstrated the use of RAM in 2 patients with Hurley stage 3 axillary HS undergoing radical excisions. Identification of upper limb lymphatics with the aid of RAM was easy and instrumental in preventing damage to these ducts. Short-term follow-up did not show evidence of lymphedema or relapse of HS. The RAM technique enabled clear visualization of the lymphatic ducts located in our surgery field and prevented any possible lymphatic system damage in our cases. We suggest that RAM may be used as a routine in the surgical treatment of HS as well as in the popular bromhidrosis surgery to reduce the possibility of postsurgery upper limb lymphedema.

Comprehensive strategies in breast cancer-related lymphedema prevention: insights from a multifaceted program

Background

Breast cancer-related lymphedema (BCRL) profoundly impacts patients' quality of life, causing heightened depression, anxiety, and physical limitations. Surgical removal of the axillary nodes, combined with radiation therapy, is a significant risk factor for BCRL. Smarter axillary surgery, coupled with early detection and fostering lymphedema education, significantly improves BCRL management, promoting timely diagnosis and treatment. A lymphedema prevention program encompassing all these factors can significantly aid in preventing, treating, and reducing the severity of BCRL cases. Therefore, our study aims to share our insights and experiences gained from implementing a lymphedema prevention program at our institution.

Methods & Results

At our institution, axillary reverse mapping (ARM) is performed on all patients undergoing axillary surgery. We surveil these patients with pre- and postoperative SOZO® measurements using bioimpedance spectroscopy to detect sub-clinical lymphedema. Concerning education, we use a 3-pronged approach with surgeons, nurse practitioners, and video representation for patients. We have had 212 patients undergo the ARM procedure since 2019, with three (1.41%) developing persistent lymphedema.

Conclusion

Our study underscores the significance of a comprehensive lymphedema prevention program, integrating smarter axillary surgery, early detection, and patient education. The lymphedema rate of 1.41% not only validates the success rate of these interventions but also advocates for their widespread adoption to enhance the holistic care of breast cancer survivors. As we continue to refine and expand our program, further research, and long-term follow-up are crucial to improve prevention strategies continually and enhance the overall well-being of individuals at risk of BCRL.

Surgical management of breast cancer-related lymphedema: a narrative review of contemporary practices

Background and Objective

Breast cancer-related lymphedema (BCRL) represents a colossal burden in terms of health and patient-reported outcomes. Surgical management plays a prominent role in the psychological and physical well-being of women suffering from BCRL. Therefore, we performed a narrative review of the current surgical management of BCRL and analyzed the postoperative results.

Methods

A literature search was conducted across PubMed MEDLINE, Scopus, and Web of Science from database inception through January 2, 2023. We included English-written studies evaluating postoperative outcomes of lymphatic surgery for the management of BCRL.

Key Content and Findings

The surgical management of lymphedema can be classified into two approaches: (I) physiologic procedures and (II) debulking or ablative procedures. While ablative procedures are intended to lessen the symptomatic burden of lymphedema via the removal of pathological tissues, physiologic procedures are performed to restore the abnormal lymphatic flow by creating bypasses into the venous or lymphatic circulation, or by creating new lymphatic connections by means of lymphangiogenesis. Physiologic procedures generate better outcomes in the early stages of lymphedema as there is some residual physiologic flow and vessels are less fibrotic, while ablative procedures are regarded to be the best alternative in very advanced lymphedema stages. A combination of physiologic and ablative procedures provides more comprehensive surgical management to BCRL.

Conclusions

Lymphedema is a common complication of breast cancer treatment with an extensive incidence range. Postoperative outcomes of the surgical management of BCRL are heterogeneous despite most studies indicating favorable results after lymphatic surgery.

Conservative Axillary Surgery May Prevent Arm Lymphedema without Increasing Axillary Recurrence in the Surgical Management of Breast Cancer

Axillary lymph node dissection (ALND) has been associated with postoperative morbidities, including arm lymphedema, shoulder dysfunction, and paresthesia. Sentinel lymph node (SLN) biopsy emerged as a method to assess axillary nodal status and possibly obviate the need for ALND in patients with clinically node-negative (cN0) breast cancer. The majority of breast cancer patients are eligible for SLN biopsy only, so ALND can be avoided. However, there are subsets of patients in whom ALND cannot be eliminated. ALND is still needed in patients with three or more positive SLNs or those with gross extranodal or matted nodal disease. Moreover, ALND has conventionally been performed to establish local control in clinically node-positive (cN+) patients with a heavy axillary tumor burden. The sole method to avoid ALND is through neoadjuvant chemotherapy (NAC). Recently, various forms of conservative axillary surgery have been developed in order to minimize arm lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, conventional ALND may not be necessary in either cN0 or cN+ patients. Further studies with a longer follow-up period are needed to determine the safety of conservative axillary surgery.

Axillary Reverse Mapping in Clinically Node-Positive Breast Cancer Patients

BACKGROUND

Axillary reverse mapping (ARM) nodes are involved in a significant proportion of clinically node-positive (cN+) breast cancer patients. However, neoadjuvant chemotherapy (NAC) is effective at decreasing the incidence of nodal metastases in cN+ patients.

PATIENTS AND METHODS

One hundred forty-five cN+ patients with confirmed nodal involvement on ultrasound-guided fine needle aspiration cytology were enrolled in this study: one group underwent axillary lymph node dissection (ALND) without NAC (upfront surgery group), and the other group underwent ALND following NAC (NAC group). The patients underwent 18F-FDG-positron emission tomography/computed tomography (18F-FDG-PET/CT) before surgery, as well as an ARM procedure during ALND.

RESULTS

the rates of involvement of ARM nodes in the NAC group were significantly lower than those of the upfront surgery group (36.6% vs. 62.2%, p < 0.01). Notably, involvement was significantly decreased after NAC in non-luminal-type tumors as compared to the luminal-type (18.4% vs. 48.5%: p < 0.01). Moreover, there was a significant difference in ARM node involvement after NAC between patients with or without axillary uptake of 18F-FDG (61.5% vs. 32.5%: p < 0.01).

CONCLUSIONS

NAC significantly decreased the risk of ARM node metastases in cN+ patients, but 18F-FDG-PET/CT was not suitable to detect residual metastatic disease of the axilla after NAC.

The involvement of axillary reverse mapping nodes in patients with node-positive breast cancer

INTRODUCTION

Axillary reverse mapping (ARM) procedure is useful in reducing lymphedema. However, concerns regarding oncologic safety have limited the adoption of the ARM procedure. This study aimed to evaluate the involvement of ARM nodes in node-positive breast cancer patients.

MATERIALS AND METHODS

Two hundred twenty-three node-positive patients were enrolled in this study: 90 were clinically node-negative, but had one or more positive sentinel lymph nodes (SLNs) (SLN-positive group); 68 were clinicopathologically node-positive (CpN-positive group); and 65 had confirmed nodal involvement and received neoadjuvant chemotherapy (NAC) (NAC group). All patients underwent axillary lymph node dissection with fluorescent ARM.

RESULTS

ARM nodes were involved in 33 (36.7%) patients of the SLN-group. Residual ARM nodes after SLN biopsy were involved in 11 patients (12.2%), including 5 patients (19.2%) with crossover type nodes and 6 patients (9.4%) with non-crossover type nodes. However, the difference in involvement rates between the two types was not high enough to be significant. Of these 11 patients, moreover, four patients had three or more than 3 involved SLNs. On the other hand, the involvement rate of ARM nodes in the NAC group was significantly lower than that of the CpN-positive group (35.4% vs. 64.7%: p < 0.01). Despite lower involvement, the risk of metastases in the ARM nodes was still too high to spare ARM nodes in both the NAC group and CpN-positive group.

CONCLUSIONS

Suspicious or involved ARM nodes should be removed even when detected in ARM procedure, particularly in NAC-group and CpN-positive-group patients.

Impact of Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy on Upper Limb Morbidity in Breast Cancer Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the impact of axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) on upper limb (UL) morbidity in breast cancer patients.

BACKGROUND

Axillary de-escalation is motivated by a desire to reduce harm of ALND. Understanding the impact of axillary surgery and disparities in operative procedures on postoperative arm morbidity would better direct resources to the point of need and cement the need for de-escalation strategies.

METHODS

Embase, MEDLINE, CINAHL, and PsychINFO were searched from 1990 until March 2020. Included studies were randomized-controlled and observational studies focusing on UL morbidities, in breast surgery patients. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The prevalence of UL morbidity comparing SLNB and ALND at <12 months, 12 to 24 months, and beyond 24 months were analyzed.

RESULTS

Sixty-seven studies were included. All studies reported a higher rate of lymphedema and pain after ALND compared with SLNB. The difference in lymphedema and pain prevalence between SLNB and ALND was 13.7% (95% confidence interval: 10.5-16.8, P <0.005) and 24.2% (95% confidence interval: 12.1-36.3, P <0.005), respectively. Pooled estimates for prevalence of reduced strength and range of motion after SLNB and ALND were 15.2% versus 30.9% and 17.1% versus 29.8%, respectively. Type of axillary surgery, greater body mass index, and radiotherapy were some of the predictors for UL morbidities.

CONCLUSIONS

Prevalence of lymphedema after ALND was higher than previously estimated. ALND patients experienced greater rates of lymphedema, pain, reduced strength, and range of motion compared with SLNB. The findings support the continued drive to de-escalate axillary surgery.

Axillary Reverse Mapping in the Prevention of Lymphoedema: A Systematic Review and Pooled Analysis

BACKGROUND

This is a systematic review of randomized controlled trials (RCT) comparing the use of axillary reverse mapping (ARM) with conventional technique for axillary dissection (AD) in breast cancer surgery.

METHODS

This review was written in line with the PRISMA protocol. Articles were retrieved from PubMed, EMBASE, CINAHL and Cochrane databases, using keywords ..úaxillary reverse mapping..Ñ and "axillary lymph node dissection". Non-RCT were excluded. Abstracts were screened independently by 2 reviewers. Data from eligible studies were retrieved for qualitative synthesis and pooled analysis. 73 publications were identified for initial screening.

RESULTS

68 articles were excluded from analysis according to the pre-defined systematic review protocol. 5 RCTS with 1696 subjects were included for analysis. 802 patients received ARM, 894 patients received AD. Pooled ARM node detection rate was 84.9% (Range 79.2 - 94.9%). There was a lower rate of post-operative lymphedema in ARM group patients across all 5 RCTs. The pooled lymphedema incidence in the ARM group was 4.8% (37/766) when compared to 18.8% (164/873) in the AD group (P < .0001). Axillary recurrence rate with median followof 37 months was 1.03% (8/778) in the ARM group, which was identical to 1.03% (9/870) in the AD group (P = 1).

CONCLUSION

ARM resulted in decreased incidence of lymphedema. There was no significant increase in axillary recurrence at 37 months post-operation.

Utility of Axillary Reverse Mapping (ARM) and Incidence of Metastasis in Arm Draining Lymph Nodes in Patients with Breast Cancer

Objective Lymphedema of the upper limb is the most common complication in patients with breast cancer, who require axillary lymph node (LN) dissection. Proposition of identifying upper limb draining LN and preserving it, during axillary dissection can reduce significant postoperative morbidity, but it has the risk of inadequate oncological resection. This study was planned to find out metastatic rate in axillary reverse mapping (ARM) nodes in our population.

Materials and Methods Lymphoscintigraphy (LSG) was performed using intradermal injection of 99mTc Sulfur Colloid into ipsilateral second and third interdigital web spaces of hand in patients with breast cancer. Planar, single-photon emission computed tomography-computed tomography images were acquired followed by intraoperative localization of arm draining LNs using Gamma Probe. All identified ARM nodes were dissected and sent for histopathological examination to confirm metastatic involvement.

Results Twenty eligible patients were prospectively analyzed. The identification rate of arm draining LN with LSG was 90% (18/20). Among 14 eligible patients included in the study, ARM node metastasis was seen in two patients. A total of 64 ARM nodes were dissected from 14 patients, 4/64 nodes (2 patients) were positive for metastases (6.25%). Of the six patients excluded from the study, in 1 patient ARM node could not be identified on Gamma Probe, in two cases, it could not be retrieved surgically, in next two cases ARM could not be identified on LSG and remaining one case was removed because of previous surgical intervention.

Conclusion In the current study, LSG showed the identification rate of 90% for ARM nodes in patients with carcinoma breast and metastatic involvement was seen in 6.25% (4/64) of these nodes in 2/14 (14.2%) patients, which is in agreement with previously published data. Oncological safety of preserving ARM nodes needs to be evaluated in the larger population.

Breast cancer-related lymphoedema: Risk factors and prediction model

AIMS

To identify the risk factors for lymphoedema following axillary lymph node dissection (ALND) in a European sample and to propose a lymphoedema prediction model for this population.

DESIGN

Predictive retrospective cohort study comparing women who developed lymphoedema in 2 years of undergoing ALND with those who did not developed lymphoedema.

METHODS

We reviewed the clinical records of 504 women who, between January 2008 and May 2018, underwent surgery for breast cancer that involved ALND. Logistic regression was used to identify significant risk factors for lymphoedema. The prediction accuracy of the model was assessed by calculating the area under the receiver operating characteristic curve.

RESULTS

Of the 504 women whose records were analysed, 156 developed lymphoedema. Significant predictors identified in the regression model were level of lymph node dissection, lymph node status, post-operative complications, body mass index (BMI) and number of lymph nodes extracted. The prediction model showed good sensitivity (80%) in the study population.

CONCLUSIONS

The factor contributing most to the risk of lymphoedema was the level of lymph node dissection, and the only patient-related factor in the prediction model was BMI. The model offers good predictive capacity in this population and it is a simple tool that breast care units could use to assess the risk of lymphoedema following ALND. Nurses with specialist knowledge of lymphoedema have a key role to play in ensuring that women receive holistic and individualized care.

IMPACT

What problem did the study address? Secondary lymphoedema is one of the main complications in the treatment of breast cancer. What were the main findings? The prediction model included five factors associated with the risk of lymphoedema following ALND. The strongest predictor was the level of lymph node dissection, and the only patient-related factor was BMI. Where and on whom will the research have an impact? The prediction model offers breast care units a tool for assessing the risk of lymphoedema in women undergoing surgery involving ALND. The results highlight the importance of weight reduction as a preventive measure and support a more conservative surgical approach.

The effectiveness of axillary reverse mapping in preventing breast cancer-related lymphedema: a meta-analysis based on randomized controlled trials

Background

Here, we carried out an extensive meta-analysis to investigate the effectiveness of the use of axillary reverse mapping (ARM) during axillary lymph node dissection (ALND) in preventing breast cancer-related lymphedema (BCRL).

Methods

Database searches to identify relevant randomized controlled trials (RCTs) were performed of MEDLINE (PubMed), Web of Science, Embase, and the Cochrane Library. Eligible articles with a publication date from database establishment to December 2020 were retrieved by combining keywords including: "breast cancer", "breast carcinoma", "breast neoplasm", "axillary reverse mapping", "axillary lymph node dissection", "lymphatic arm drainage", and "lymphedema". Independent data extraction was conducted, and Review Manager (version 5.3) was used for statistical analyses.

Results

Five eligible RCTs were included in the meta-analysis. A total of 37 patients suffered arm lymphedema (37/786, 4.71%) in the experimental group (ARM during ALND), compared with 164 arm lymphedemas (164/873, 18.79%) in the control group (ALND alone). The results showed that ARM during ALND was superior to ALND alone in reducing the incidence of BCRL [OR =0.20, 95% confidence intervals (CI): 0.13-0.29, P<0.00001]; however, the 2 procedures did not differ significantly in terms of oncological safety or shoulder movement (OR =0.30, 95% CI: 0.03-2.96, P=0.30; OR =0.44, 95% CI: 0.14-1.40, P=0.17).

Conclusions

ARM during ALND can prevent and reduce the occurrence of BCRL in patients with early-stage BC during long-term follow-up. Due to the limited number of RCTs available, more in-depth, high-quality RCTs are urgently needed to provide a reliable and convincing basis for the application of ARM during ALND.

Prevention of Breast Cancer-Related Lymphedema

Tremendous progress has been made over the past several decades in the treatment of breast cancer. Mortality and recurrence rates continue to decline. Our ability to tailor patient- and tumor-specific treatments has rapidly advanced. The vast majority of our patients can safely have breast conservation. Unfortunately, for many patients, survivorship is burdened by ongoing quality-of-life issues. Most breast cancer patients are asymptomatic at presentation, and the onus is on us to preserve this. Surgery, radiation, and systemic therapy can result in long-term toxicities that can be amplified with multimodality approaches. We must strive to apply minimally effective therapies rather than a maximally tolerated approach. Breast cancer-related lymphedema (BCRL) is a particularly dreaded chronic complication. This review strives to give the reader a better understanding of BCRL and shed light on wisely choosing an integration of treatment modalities that minimizes BCRL risk. Key literature on emerging concepts is highlighted.

Axillary surgery for breast cancer: past, present, and future

In breast cancer surgery, there has been a major shift toward less invasive local treatment. Although axillary lymph node dissection (ALND) was an integral part of surgical treatment for breast cancer, sentinel lymph node (SLN) biopsy was developed as an accurate method for axillary staging. ALND can be avoided not only in patients with negative SLNs but also in those with one or two positive SLNs receiving breast and/or axillary radiation. On the other hand, ALND has remained the standard treatment for patients with clinically positive nodes. However, axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND and/or SLN biopsy. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients receive postoperative chemotherapy and high-risk patients undergo axillary radiation. Standard ALND may not be necessary even for patients with clinically positive nodes who receive axillary radiation and systemic therapy. Thus, the extent of axillary surgery in breast cancer has been decreased with increased use of systemic and radiation therapy.

Axillary reverse mapping in patients undergoing axillary dissection -a short review of the literature

Axillary lymph node dissection (ALND) can be avoided not only in patients with negative sentinel lymph nodes (SLNs) but also in those with one or two positive SLNs receiving breast or axillary radiation. However, ALND has remained the standard treatment for patients with clinically positive nodes (cN+). Although axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND, it could not be indicated for cN + patients because metastatic rate of ARM nodes is high. However, a new type of conservative ALND with ARM attempts to preserve ARM lymphatics and nodes except SLNs and other suspicious palpable nodes, including suspicious ARM nodes. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients received postoperative chemotherapy and high-risk patients underwent axillary radiation. Thus, a traditional full ALND may not be necessary for cN + patients in the era of effective multimodality therapy.

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

BACKGROUND

The axillary reverse mapping (ARM) technique, identify and preserve arm nodes during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND), was developed to prevent breast-cancer related lymphedema (BCRL) remains controversial.

METHODS

A comprehensive search of Medline Ovid, Pubmed, Web of Science and the Cochrane CENTRAL databases was conducted from the inception till January 2020. The key word including "breast cancer", "axillary reverse mapping", and "lymphedema". Stata 15.1 software was used for the meta-analysis.

RESULTS

As a result, twenty-nine related studies involving 4954 patients met our inclusion criteria. The pooled overall estimate lymphedema incidence was 7% (95% CI 4%-11%, I² = 90.35%, P < 0.05), with SLNB showed a relatively lower pooled incidence of lymphedema (2%, 95% CI 1%-3%), I² = 26.06%, P = 0.23) than that of ALND (14%, 95% CI 5%-26%, I² = 93.28%, P < 0.05) or SLNB and ALND combined (11%, 95% CI 1%-30%). The ARM preservation during ALND procedure could significantly reduce upper extremity lymphedema in contrast with ARM resection (OR = 0.27, 95% CI 0.20-0.36, I² = 31%, P = 0.161). Intriguingly, the result favored ALND-ARM over standard-ALND in preventing lymphedema occurrence (OR = 0.21, 95% CI 0.14-0.31, I² = 43%, P = 0.153). The risk of metastases in the ARM-nodes was not significantly lower in the patients who had received neoadjuvant chemotherapy, as compared to those without neoadjuvant treatment (OR = 1.20, 95% CI 0.74-1.94, I² = 49.4%, P = 0.095).

CONCLUSIONS

ARM was found to significantly reduce the incidence of BCRL. The selection of patients for this procedure should be based on their axillary nodal status. Preoperative neoadjuvant chemotherapy has no significant impact on the ARM lymph node metastasis rate.