Axillary reverse mapping for preventing lymphedema in axillary lymph node dissection and/or sentinel lymph node biopsy.

Axillary lymph node dissection (ALND) is a standard surgical treatment in patients with involved axillary lymph nodes. Unfortunately, arm lymphedema develops in 2.7– 5.0% of patients treated by partial ALND (level I and II), in 3.1–9.6% of those undergoing total ALND, and in 26– 38% of patients treated with ALND and radiotherapy [1]. The risk of lymphedema is often used as an argument against ALND. Currently, sentinel lymph node (SLN) biopsy has become a highly utilized and widely accepted method for surgical staging of axillary lymph nodes in breast cancer. It can avoid an unnecessary ALND in patients with node-negative breast cancer, thereby preventing arm lymphedema. Nevertheless, recent short-term studies demonstrated that lymphedema develops in 2–7% of patients even with SLN biopsy alone [2–4]. Transection of the arm lymphatics during ALND most likely results in lymphedema, but the ALND technique has changed little over the decades, and involves purely anatomical dissection. It is generally thought that the lymphatics reside juxtaposed to the vein, and the risk of lymphedema can be minimized if the surgeon takes care to avoid skeletonizing the vein. However, lymphatics with this positioning are rarely seen and SLN biopsy does not correct the problem of lymphedema, although it is less morbid than ALND [2]. Recently, the axillary reverse mapping (ARM) technique was developed to map and preserve arm lymphatic drainage during ALND and/or SLN biopsy. The arm and breast lymphatic drainage can be separated, allowing safe removal of only the lymphatics of the breast (SLN or ALND) and protection of the lymphatic channels draining the upper extremity. This assumption is supported by a recent anatomical description of the lymphatic territories of the upper limb [5]. Several investigators have identified the lymphatics and/or nodes of the ARM using blue dye and/or isotope labeling [6–10]. Thompson et al. [6] injected 2.5 mL blue dye dermally or subcutaneously into the upper inner arm along the medial intramuscular groove of the ipsilateral arm. After injection, the site was massaged and the arm elevated for 5 min to enhance arm lymphatic drainage. Consequently, blue lymphatics and/or nodes in relation with ARM were identified in 11 of 18 (61%) patients, although no blue lymphatics or nodes were identified in the remaining 7 patients. In the same year, Nos et al. [7] identified ARM nodes in 15 of 21 patients (71%) with a similar technique. However, a number of problems remain to be resolved in the practical use of this new concept derived from SLN biopsy for breast cancer. The limitations of this technique included insufficient identification rates of the ARM nodes (61–71%) as well as a persistent blue stain at the injection site [7]. To improve the identification rate of the ARM nodes and to prevent a persistent blue stain at the injection site, Nos et al. [9] injected an isotope into the web space of the ipsilateral hand in another study. During ALND, the radioactive ARM node was localized above the second intercostal brachial nerve, and then blue dye was injected directly into the node to visualize the efferent ducts constituting the lymphatic ARM chain. Consequently, the ARM was identified in 21 of 23 patients (91%). However, this procedure may be somewhat cumbersome and result in longer operating time. The fluorescence imaging technique with subcutaneous injection of indocyanine green (ICG) (Diagnogreen; M. Noguchi (&) Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Uchinada, Ishikawa 920-0293, Japan e-mail: [email protected]