Reverse Axillary Mapping in Breast Cancer Using Blue Dye: A Tertiary Setup Experience

Application of Fluorescence Dye in Combination with Methylene Blue for Axillary Reverse Mapping in Patients with Modified Radical Mastectomy for Breast Cancer

Background. Axillary reverse mapping (ARM) is a novel intraoperative technique developed in recent years. This study was aimed at determining the effect of combined use of fluorescence dye and methylene blue, as well as its feasibility of ARM in patients with breast cancers who undergo modified radical mastectomy. Method. From January 2016 to June 2017, 46 patients with primary breast cancer at stage I-IV (Tis-T3, N0-N3, and M0) who received modified radical mastectomy were enrolled in this study. The exclusion criteria included preoperative radiotherapy/chemotherapy or bilateral disease. Patients were divided into 2 groups: methylene blue group (22 patients, 47.8%) and methylene blue+indocyanine green (ICG) group (24 patients, 52.2%). ARM was performed before surgery. Results. The overall visualization rate of ARM nodes was 80.4% (37/46). The visualization rate was significantly increased in methylene blue+ICG group (91.67%, 22/24) than that in methylene blue group (63.64%, 14/22) ( $P=0.032$ ). There was a statistical difference of visualization rate between clinical groups of N0-N1 and N3-N4 ( $t=2.431$ , $P=0.19<0.05$ ). Although there was no significant difference found in the total drainage volume and arm perimeter of patients between the two groups ( $P>0.05$ ), the harden diameter of the injection site in methylene blue+ICG group was significantly longer than that in methylene blue group ( $P<0.05$ ). Among the 44 patients with different molecular profiling of breast cancer, there was no significant difference of visualization rate of ARM nodes in luminal A group (100%,5/5), luminal B group (75.0%, 18/24, $P=0.21$ ), HER2 group (75.0%, 6/8, $P=0.22$ ), and basal-like group (85.7%, 6/7, $P=0.37$ ). Conclusions. ARM using methylene blue+ICG presented greater identification rate than that with methylene blue alone, especially in patients with more invasive breast cancer. Our finding offers support for the improvement of ARM in future breast cancer management.