Reverse Axillary Mapping in Breast Cancer using Double Dye: A Tertiary Cancer Center Experience

Abstract

Background: Among the various methods in minimizing Limb Lymphoedema following ALND in Breast cancer, Axillary reverse mapping is a novel approach. Attempt to preserve the ARM node without threatening Oncological safety is a further step. Aim: To identify Blue ARM Node, intra operatively whether harbors metastases or not, defined by Radioactivity comparing with Histo pathological Examination. Materials and Method: The 30 cases of Breast cancer patients undergoing surgery along with Axillary dissection were considered for Double dye technique of ARM study with Radio colloid injection in subareolar region and 3ml of 5% methylene blue to the Arm,1 hour before starting surgery. At Axillary dissection, level I and level II nodal clearance done and the blue thin, tortuous lymphatics entering axilla are identified are followed medially, where blue nodes are usually identified below inferior to Axillary vein. The Blue nodes are considered belonging to upper limb called ARM node, whose radioactivity is recorded invivo, are dissected and sent for Histo pathological Examination. Results: The identification rate of blue lymphatics is about 77% (26 cases out of 30), the location of blue ARM node (70% identification rate, 21 out of 30 cases) were within 2cms inferior to Axillary vein lateral to Latissimus dorsi pedicle. The Radioactivity of the Blue ARM node more the 10% of the count at Subareolar region considered as Cross over Node (Blue+Hot) is observed among 2 patients, which confirmed with histopathologicaly positive for metastases, but rest of 19 (95.3%) Blue ARM node with less than 10% radioactivity (Blue +Cold), were Histopathologicaly Negative for metastases. Among 21 Blue ARM nodes, 2 nodes were metastatic amounting to 9.4% cases having cross over Lymphatics, identified by radioactivity. Conclusion: The Double dye Axillary Reverse Mapping study is a valuable armamentarium for the surgeons, during Breast Cancer surgery undergoing Axillary Lymphnode dissection to preserve uninvolved ARM Lymph node, thereby avoid Limb lymphedema without compromising Oncological safety.1