Prospective Evaluation of Pre and Postoperative Lymphoscintigraphy in Axillary Reverse Mapping (ARM) for Breast Cancer Patients.

Abstract

Abstract BackgroundThe sentinel lymph node (SLN) procedure, has been used successfully to detect lymphatic involvement. The expected reduction in morbidity and improvement in the quality of life of patients remains uncertain. In spite of this minimal invasive technique, 40 to 50 % of axilla are explored by classic axillary dissection. The aim of axillary reverse mapping (ARM) is to preserve the main lymphatic chain in relation to lymphatic arm drainage during an axillary dissection, reducing the rate of lymphedema.ObjectivesThe objective of this study is to describe a prospective comparison of pre and post axillary dissection (AD) lymphoscintigraphy, in 15 consecutive breast cancer patients.MethodsIsotope InjectionThe morning of surgery, all patients underwent isotope injection in the ipsilateral hand. Each patients received a single injection of 60 MBq (vol 0.2 ml) into the first interdigital space. The preoperative lymphoscintigraphy was performed 45 min after injection, in surgical position. An average of 2 nodes were visible in the axilla. The postoperative lymphoscintigraphy was planned before starting adjuvant treatment.Surgical TechniqueAfter having performed the lumpectomy or the mastectomy, the surgeon began the AD. The first important step was the identification of the second intercostals brachial nerve. While reserving the nerve, the dissection was carried out from medial to lateral, below the nerve. The gamma probe was then used in order to identify the first radioactive node draining the upper limb. This node was localized in the lateral pillar of the axilla. The ARM nodes were carefully preserved during the dissection with retractors placed over them to protect from inadvertent damage. After completion of AD, the axillary content was examined ex-vivo to identify at least ten nodes within the surgical specimen.ResultsThe mean age is 62.4 years (range 40-81). For all 15 patients, the mean number of axillary nodes removed by means of AD was 10.7 (range 7–14). Of all patients, 3 (87%) had metastatic involvement in the AD with an average of 1.3 (range 1– 2) nodes involved.A lymphoscintigraphic mapping concordance between pre and post, was found in 13 out 15 patients (87%).ConclusionsIsotopic ARM allows identification of radioactive nodes in the axilla in 91% of cases.The very good correlation between pre and postoperative mapping suggests a persistence of the normal LAD, and lets hope for a risk reduction of lymphodema after AD.A longterm follow up is needed to confirm these very promising preliminary results. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1025.