Arm Lymph Nodes Research Articles

Evaluation of the Axillary Reverse Mapping Technique in Preventing Breast Cancer-Related Post Operative Lymphedema, Ain Shams University Initial Experience

Abstract Background Management of breast cancer patients with clinically positive nodes is a field of research and axillary lymph nodes dissection is still an acceptable option for them. However it affects the patient quality of life in the form of breast cancer related lymphedema. Axillary reversed mapping technique is used to spare the arm lymph nodes during Axillary surgery aiming to reduce the rate of breast cancer related lymphedema. Objective To study the feasibility of using patent blue dye to perform axillary reverse mapping procedure in breast cancer patients with positive axillary lymph nodes scheduled for axillary lymph node dissection. Patients and Methods A prospective study including 20 patient with clinically positive axillary lymph nodes planed by MDT Committee at Ain Shams university hospital to perform axillary lymph nodes dissection. Results Identification rate of lymphatics and lymph nodes was 75% and 80% respectively and 60% of the stained LNS were seen below the axillary vein and lateral to the thoracodorsal bundle. Correlation between identification rate of the lymphatics and the lymph nodes with regard to N-staging and Neoadjuvant therapy wasn't statistically significant. BMI and number of lymph nodes removed were a confounding variables related to lymphedema. Conclusion Axillary Reverse mapping procedure using patent blue dye is simple idea to preserve arm lymph nodes and so, decreases the incidence of lymphedema, however there are a lot of variables related to lymphedema development which needs to be investigated well on larger group of patients and further multicentrs studies with long term follow up. The operative technique is quite challenging and need longer learning curve with well orientation to the axillary anatomy.

Identification and preservation of arm lymphatics in axillary lymph node dissection to prevent arm lymphedema: a single center randomized controlled trial

Objective: To evaluate the feasibility of identification and preservation of arm lymphatics (DEPART) in axillary lymph node dissection (ALND) for breast cancer to prevent arm lymphedema. Methods: A randomized controlled study method was used. Two hundred and sixty-five patients who underwent breast cancer surgery at the Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University from November 2017 to June 2018 were included, and the patients were randomly divided into ALND+ DEPART group (132 patients) and standard ALND group (133 patients) by random number table method. In the ALND+ DEPART group, indocyanine green and methylene blue were injected as tracers before surgery, and the arm sentinel nodes was visualized by staged tracing during intraoperative dissection of axillary lymph nodes. Partial frozen sections were made of arm lymph nodes >1 cm in length and hard and suspicious of metastasis, and arm lymph nodes and lymphatic vessels were selectively preserved. Patients in the standard ALND group underwent standard ALND. Objective and subjective indexes of arm lymphedema were evaluated by 5-point circumference measurement and Norman questionnaire. Results: Among 132 breast cancer patients in the ALND+ DEPART group, 121 (91.7%) completed DEPART. There were no statistically significant differences in age, body mass index, pathological type, dissection number of axillary lymph node, N stage, TNM stage, molecular typing, and regional radiotherapy between the ALND+ DEPART and standard ALND groups (P>0.05). At a median follow-up of 24 months, assessment by the 5-point circumference measurement showed that the incidence rates of lymphedema in the ALND+ DEPART and standard ALND groups were 5.0% (6/121) and 15.8% (21/133), respectively, with statistically significant differences (P=0.005). Assessment by the Norman questionnaire showed that the incidence rates of lymphedema in the ALND+ DEPART and standard ALND groups were 5.8% (7/121) and 21.8% (29/133), respectively, with a statistically significant difference (P<0.001). No local regional recurrence was observed in either group during the follow-up period. Conclusion: For breast cancer patients with positive axillary lymph nodes, the administration of DEPART during ALND can reduce or avoid the occurrence of arm lymphedema without compromising oncology safety.

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

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

Integrative chemo-immune-radiological treatment of HER2 positive breast cancer combined with a review of potential microRNAs involved and analysis of experimental results from sub-THz vibrational spectroscopy

In this paper we present the results of a Breast Cancer study by integrative analysis of a NIH approved treatment for HER2 positive breast cancer. This study is combined with analysis of Micro-RNA involvement from application of sub-THz spectroscopy for visualization of molecules circulating in blood by measuring saliva. The combination of Taxol-Generic Name-Paclitaxel (PT-J9267) and Trastuzumab-ANNS 0/0 and KadcylaTM (Genetic Name Ado-Trastuzumab Emtansine) were used in 3-stages of combined chemotherapeutic and immune-treatments followed by Radiation treatment. The goal of using PT was to stop spread of the disease to other organs outside of the breast and under arm lymph nodes, as well as to shrink the size of the tumor to facilitate surgery and radiology in continuation of the treatment. Trastuzumab (TZ) was added to PT in the 2nd step to prevent the development of chemoresistance. Intravenous infusion of Kadcyla was used mainly to prevent metastasis. Integrative analysis of microRNA participation was conducted based on literature review and sub-Terahertz vibrational spectroscopy measurements of absorption spectra from samples taken weekly before and after each treatment, using Vibratess’ spectrometer. The results from sub-THz spectroscopy in this work demonstrate dramatical modification of spectroscopic signatures from patient samples following disease development and the initial steps in the course of treatment. These changes reflect the deep global regulation (reduction) of the initially participating microRNAs amounts and changes in the microRNAs contributing to the spectra.

Evaluation of axillary reverse mapping (ARM) in clinically axillary node negative breast cancer patients - Randomised controlled trial.

Axillary lymph node dissection (ALND) is an important procedure for control of axillary nodal metastasis in breast cancer patients. Lymphedema, restriction of shoulder movement and axillary nodal recurrence are the most disabling complications of the procedure. Axillary reverse mapping (ARM) procedure for arm lymph node identification emerged as a step for their preservation during ALND. Here we are testing the effect of ARM on lymphedema development and whether it compromises oncological safety in early breast cancer patients. 98 clinically node free breast cancer female patients undergoing completion ALND after positive sentinel lymph node biopsy were recruited in the study. They were put into group A (49 patients with ARM+ve preservation ALND) and group B (49 patients in the conventional ALND group). ARM procedure was performed in both groups, ARM positive nodes were preserved in group A, marked and taken out with other axillary LN in group B. The outcome was histopathology of ARM+ve LN, development of arm lymphedema, and restriction of shoulder movement on follow-up. ARM was positive in 46 patients (93.8%) in group A and 43 patients (87.8%) in group B, ARM+ve LN revealed positive metastasis only in 1 patient (2.3%) in group B. Lymphedema developed in 3 (6.5% patients in group A and 9 patients (20.9%) in group B. Restriction of shoulder movement showed a non-significant difference between the two groups. Axillary reverse mapping and preservation of arm lymphatics helped to decrease the lymphedema rate without compromising oncological safety in early breast cancer.

Prevention of lymphedema via axillary reverse mapping for arm lymph-node preservation following breast cancer surgery: a randomized controlled trial

BackgroundBreast cancer, with an incidence of 32%, is the most frequent cancer among Egyptian women. The frequency of arm lymphedema after axillary surgery for breast cancer ranges from 7 to 77%. Axillary reverse mapping is a technique aimed to distinguish and conserve upper-limb lymphatics and lymph nodes during the course of axillary surgery and could help to prevent arm lymphedema.MethodsPatients (n = 48) were prepared for axillary lymph-node dissection. The study group and the control group each contained 24 individuals. In the study group, following dye injection, stained arm lymph nodes and lymphatics were conserved during axillary dissection, whereas control-group participants underwent the conventional procedure. All participants were re-evaluated after 6 months, and the incidence of lymphedema was recorded by measuring arm circumference at a level 10 cm proximal to the medial epicondyle. Arm lymphedema was defined as a change in the circumference of the ipsilateral upper extremity > 2 cm during the follow-up period.ResultsAge, tumor size and N stage were not significantly different between the study and control groups. Lymph-node visualization was achieved in 20 participants (83.3%) in the study group. Suspicious stained lymph nodes were surgically removed from four individuals but showed no metastatic involvement. In 20 individuals in the study group, no stained lymph nodes were removed. The incidence of lymphedema in the control group was 16.7%, and the incidence in the study group was 4.2%.ConclusionsAxillary reverse mapping is a minimally invasive technique that can be performed during axillary lymph-node dissection, helping to prevent the subsequent development of arm lymphedema.Trial registration#SCURCTN3276, retrospectively registered on 11 April 2017 at Research Ethics Committee at the Faculty of medicine-Suez Canal University.

Axillary Reverse Mapping Using Methylene Blue Subcutaneous Injection Can Identify Arm Lymph Nodes and Vessels, Measuring Arm Size for Lymphedema, Histopathological Examination of Arm Lymph Nodes Included With Axillary Lymph Node Dissection

Axillary Reverse Mapping Using Methylene Blue Subcutaneous Injection Can Identify Arm Lymph Nodes and Vessels, Measuring Arm Size for Lymphedema, Histopathological Examination of Arm Lymph Nodes Included With Axillary Lymph Node Dissection

Identification and Preservation of Arm Lymphatic System in Axillary Dissection for Breast Cancer to Reduce Arm Lymphedema Events: A Randomized Clinical Trial.

Controversy in axillary reverse mapping in axillary lymph node dissection (ALND) possibly results from incomplete recognition of the arm lymphatic system (ALS) and its compromise to oncological safety. The iDEntification and Preservation of ARm lymphaTic system (DEPART) technique facilitates complete identification of ALS; therefore, its use may decrease the occurrence of arm lymphedema. This study aimed to examine the arm lymphedema rate, locoregional recurrence, and feasibility to perform DEPART in ALND. Patients from February 2013 to October 2017 from two tertiary referral centers were randomly assigned to two groups. In the study group, indocyanine green and methylene blue (MB) were utilized to identify arm sentinel nodes, and 0.1ml MB was injected into the arm sentinel nodes to reveal the subsequent-echelon nodes and lymphatics. Gross arm lymph nodes were examined by intraoperative partial frozen section and were removed if positive. Arm lymphedema, local recurrence, regional recurrence, and distant metastasis were recorded at different follow-up examinations. Arm sentinel nodes were identified in 573 (83.2%) patients. Subsequent-echelon nodes and lymphatics were visualized in 558 (97.4%) patients. Metastatic arm nodes were identified in 38 (6.8%) patients. The arm lymphedema rate was 3.3% (18/543) in the study group versus 15.3% (99/648) in the control group (p < 0.001) after 37-month median follow-up. Regional recurrence showed no difference between the two groups (1.4% and 1.2%, respectively) (p = 0.392). DEPART can benefit breast cancer patients who undergo ALND, reducing the arm lymphedema rate without adversely affecting the morbidity of regional recurrence.

Merkel cell carcinoma occurring in a black woman: a case report

BackgroundMerkel cell carcinoma is a rare, very aggressive neuroectodermal tumor of the skin. It is typically located on sun-exposed skin and frequently found in white men aged between 70 and 80 years.Case presentationWe report a case of a 58-year-old black woman diagnosed with Merkel cell carcinoma of the posterior face of the right elbow. She had biopsy excision and was lost to follow-up. Four months later, she presented with recurrent disease on the inferior third of the right arm with three ipsilateral axillary lymph node metastases. Amputation of the right arm and ipsilateral axillary lymph node dissection were performed, followed by adjuvant radiotherapy. Six months later, the patient died as a result of respiratory failure caused by lung metastasis. To the best of our knowledge, no specific studies have been done comparing the course and the characteristics of Merkel cell carcinoma in white and black populations, and no similar case has been reported in the literature.ConclusionsThe Merkel cell carcinoma is very rare in black people. As described elsewhere in the literature, our patient had a poor outcome despite radical management. To date, to the best of our knowledge, there has been no comparison of the prognosis of this tumor in white and black populations.

Clinical impact of breast MRI with regard to axillary reverse mapping in clinically node positive breast cancer patients following neo-adjuvant chemotherapy

BackgroundAxillary reverse mapping (ARM) is a technique that discerns axillary lymphatic drainage of the arm from the breast. In the current study, we retrospectively evaluated the incidence of metastatic axillary lymph node involvement, including ARM lymph nodes, in clinically node positive breast cancer patients (cN+ patients) in whom neo-adjuvant chemotherapy (NAC) was administered followed by primary ALND using breast MRI. Patients and methodsData from 98 cN+ breast cancer patients were analysed retrospectively. Patients without residual axillary disease at breast MRI following NAC (RAD−, n = 64) were compared with patients with residual axillary disease (RAD+, n = 34). Presence of suspect axillary lymph nodes on pre-NAC and post-NAC breast MRI was determined by experienced breast radiologists and was correlated to histopathological findings. ResultsIn the RAD-group residual axillary disease on pathological analysis following NAC was found in 25 patients (39.1%), as compared to 24 patients (70.6%) in the RAD + group (p = 0.003). Metastatic involvement of ARM lymph nodes following NAC was demonstrated in 5 patients (7.8%) in the RAD-group as compared to 10 patients (29.4%) in the RAD + group (p = 0.005). ConclusionBreast MRI following NAC is not suitable to detect residual metastatic disease of the axilla. However, breast MRI post-NAC may be of use to identify cN+ patients with a low risk of ARM lymph node metastases. This may help to select a subgroup of cN+ patients in whom sparing of ARM lymph nodes during axillary lymph node dissection can be considered.

Prospective Study Evaluating Oncological Safety of Axillary Reverse Mapping

BackgroundAxillary reverse mapping (ARM) is a new technique developed with the aim of reducing lymphedema rates by preserving lymphatic drainage of the upper limbs during sentinel lymph node biopsy and axillary lymph node dissection (ALND). However, it is unclear whether preservation of these lymph nodes affects oncological risk. The present study evaluated the presence of metastases in ARM nodes.MethodsA total of 45 patients underwent ARM during ALND. Blue dye was used for ARM nodes localization. All axillary lymph nodes, including ARM nodes, were removed and sent separately for pathological evaluation of metastases.ResultsARM identification was achieved in 40/45 patients (88.9 %). The average number of removed ARM nodes was 1.9. ARM nodes metastasis occurred in 10 of 40 patients (25 %). Patients with an axilla extensively affected by cancer had an elevated risk of metastasis to the arm’s lymph nodes (p < 0.001).ConclusionsThe rate of arm lymph nodes compromised by metastases calls into question the viability of the ARM technique. Larger studies may point to particular patient profiles for which ARM can be safely use.

Can axillary reverse mapping avoid lymphedema in node positive breast cancer patients?

Tracing lymphatic drainage of the ipsilateral arm of node positive breast cancer patients, termed "axillary reverse mapping" (ARM), has recently been described in several reports. We analyzed our experience with this new technique in patients scheduled for axillary lymph node dissection (ALND) and evaluated its usefulness for reducing the incidence of lymphedema. Blue dye was injected subcutaneously along the intermuscular groove of the upper inner arm; radioisotope was injected subcutaneously in the interdigital webspace of the hand. All blue and radioactive lymph vessels and lymph nodes were recorded. Only unsuspicious "ARM lymph nodes" located in the lateral part of the axillary basin were preserved. All other level I and II axillary lymph nodes were removed. Resected ARM nodes were immediately separated from all other lymph nodes. ARM was performed in 143 patients subsequently undergoing ALND. ARM lymph nodes were successfully identified in 112 cases (78%). In 55 patients at least one ARM lymph node had to be removed. In 14 of these, tumor involvement was confirmed. In 71 patients one or more ARM nodes were preserved. During a median follow-up time of 19 months no axillary recurrence was noted. 35 of 114 evaluated patients developed lymphedema. Preservation of ARM lymph nodes did not significantly decrease the incidence of lymphedema. ARM is feasible for patients with node positive breast cancer. However, we found no evidence that it reduces the incidence of lymphedema.

Safety study of axillary reverse mapping in the surgical treatment for breast cancer patients

With the purpose of minimizing arm lymphedema after axillary staging surgeries in breast cancer patients, the axillary reverse mapping (ARM) technique has been developed to identify and preserve arm drainage system during axillary surgery. This study aimed to clarify risk factors for metastasis in arm lymphatic drainage system in breast cancer patients with clinically negative axillary nodes. Sixty-nine patients who underwent successful both sentinel lymph node (SLN) biopsy (SLNB) and ARM from October 2009 to August 2010 were enrolled in this study. Radioactive tracer was used for SLN localization and blue dye was used for ARM. All of the identified SLNs and ARM nodes were sent for pathological assessment. ARM nodes metastasis occured in 6 of 69 patients. Age, pathological tumor size (pT) and pathological lymph node status (pN) were not associated with ARM nodes metastasis (P>0.01). Interestingly, in these 6 patients, all metastatic ARM nodes coincided with SLN-ARM nodes (hot SLN and blue ARM node were the same lymph node). In 50 of 69 patients whose ARM nodes did not coincided with SLNs, all ARM nodes were negative, even in 12 patients with metastatic SLNs. Crossover between breast and ipsilateral arm lymphatic drainage system contributes for ipsilateral arm lymph node metastasis. When ARM and SLNB are simultaneously performed in a patient, selectively preservation of the ARM nodes that do not coincided with SLNs would be safe, even if the SLNs are positive. Pathological lymph node status does not account for the occurrence of metastasis in ARM nodes. ARM nodes could be preserved safely, independent of the pathological lymph node status.

Axillary Reverse Mapping: Mapping and Preserving Arm Lymphatics May Be Important in Preventing Lymphedema During Sentinel Lymph Node Biopsy

Several recent reports have shown a lymphedema rate of about 7% with sentinel lymph node biopsy (SLNB) only. We hypothesized that this higher than expected rate of lymphedema may be secondary to disruption of arm lymphatics during an SLNB procedure. This IRB-approved study, from May 2006 to June 2007, involved patients undergoing SLNB with or without axillary lymph node dissection. After sentinel lymph node (SLN) localization with subareolar technetium was assured, 2 to 5 mL of dermal blue dye was injected in the upper inner arm for localization of lymphatics draining the arm (axillary reverse mapping, ARM). The SLNB was then performed through an incision in the axilla. Data were collected on identification rates of hot versus blue nodes, variations in ARM lymphatic drainage that might impact SLNB, crossover between the hot and the blue lymphatics, and final pathologic nodal diagnosis. Median age was 57.6+/-12.5 years. Lymphatics draining the arm were near or in the SLN field in 42.7% (56 of 131) of the patients, placing the patient at risk for disruption if not identified and preserved during an SLNB or axillary lymph node dissection. ARM demonstrated that arm lymphatics do not cross over with the SLN drainage of the breast 96.1% of the time and that none of the ARM lymph nodes removed were positive, even when the SLN was (5 of 12). Seven (5.5%) blue ARM lymphatics were juxtaposed to the hot SLNBs. Disruption of the blue ARM node because of proximity to the hot SLN may explain the surprisingly high rate of lymphedema seen after SLNB. Identifying and preserving the ARM blue nodes may translate into a lower incidence of lymphedema with SLNB and axillary lymph node dissection.