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

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Abstract
The objective of axillary reverse mapping (ARM) is to preserve the main lymphatic chain—with both the nodes and the ducts—in relation to lymphatic arm drainage (LAD) during an axillary dissection (AD). From July 2006 to March 2008, 23 patients with stage II or III breast carcinoma requiring an AD underwent an ARM procedure. Identification of the ARM nodes relied on an isotope injection into the web space of the ipsilateral hand. During AD, the radioactive ARM node was localized above the second intercostal brachial nerve, and blue dye was directly injected inside the node to visualize the efferent ducts, constituting the lymphatic ARM chain. The blue and radioactive nodes constituted the ARM sampling, while other nodes were considered part of the AD. Metastatic lymph node involvement was identified in the AD in 20 of 23 patients, with an average of 4.4 (1–11) nodes involved and an average of 10.7 (7–20) lymph nodes removed. The ARM sampling was performed in 21 of 23 patients (91%), with an average of 1.6 ARM nodes removed. In 18 of these 21 patients (86%), the nodes relating to ARM sampling had no metastatic involvement. There were 3 patients (14%) who demonstrated metastatic involvement of the ARM sampling, and all had pN3a (N+ > 9) involvement of the axilla. This technique of combined isotopic and blue dye ARM and findings must now be validated. A multicentric study is planned to confirm this data.