Axillary Reverse Mapping in Breast Cancer: Can we Spare what we Find?

Abstract

Two recent articles published in the Annals of Surgical Oncology describe the injection of blue dye into the arm to map and spare the lymphatic drainage of the arm in breast cancer patients submitted to axillary dissection (AD). Since the lymphatic pathway from the arm (at least, until it enters the axillary nodal basin) cannot be involved by the metastatic process of the primary breast tumor, its preservation should not imply any risk of leaving undetected disease in the axilla. Conversely, the preservation of arm lymphatics should lead to a decrease of lymphoedema, which is the most severe morbidity following AD. Both authors conclude that the technique is feasible, with a detection rate of blue lymphatics and/or nodes of 61–71% and, when attempted, a preservation rate of 47%. The lymphatic pathway of the arm is described as usually crossing the lower part of the axilla, and the blue node as lying in the lateral pillar of the axillary dissection, under the axillary vein and just above the second intercostal brachial nerve. Both authors suggest that arm lymphatics can be preserved by avoiding an excessive skeletonization of the axillary vein, especially when they are located far outside of the axis of the thoracodorsal neurovascular bundle (approximately one third of the cases). We have started a pilot study, at our institution, to confirm the feasibility of the technique and the proof of principle that arm lymphatics are never involved by the metastatic process. As yet, using 1 mL of Patent Blue dye injected subdermally in the inner part of the arm, we have detected blue lymphatics and/or nodes in two out of the four procedures performed. Failed detection was associated with both a short interval (less than 30 minutes) between tracer injection and surgery, and lack of arm elevation and massage, confirming that lymphatic flow of the arm is slower than that from the breast. Our first successful case is a patient who underwent AD after a positive sentinel node biopsy. We could visualize two separate lymphatic pathways above and below the axillary vein leading to two blue nodes, but no lymphatics departing from the blue node (efferent lymphatics). At final histology, both nodes were found to be negative for metastatic cells, as were all of the other 15 axillary nodes retrieved. The other successful case is a patient who underwent axillary dissection upfront, due to a clinically suspicious node, which revealed breast cancer cells at preoperative ultrasound-guided fine-needle cytological evaluation. A blue lymphatic was isolated, leading to a blue node adjacent to an enlarged suspicious node (Fig. 1). Again, no efferent lymphatic could be visualized. At final histology, the adjacent suspicious node was the only axillary metastatic node, while the blue node and the other 16 nodes excised were negative for cancer cells. We believe that the rationale behind this application of nodal mapping is sound and its potential impact on the quality of life of breast cancer patients Received August 13, 2007; accepted September 3, 2007; published online: November 8, 2007. Address correspondence and reprint requests to: Riccardo Ponzone, MD; E-mail: rponzone@mauriziano.it