Seyednejad, N., Kuusk, U., & Wiseman, S.M. (2014). Axillary reverse lymphatic mapping in breast cancer surgery: A comprehensive review. Expert Review of Anticancer Therapy, 14, 771–781. 

DOI Link

Purpose

STUDY PURPOSE: To evaluate the literature with the reported use of identifying arm and breast lymphatics using the axillary reverse mapping (ARM) procedure, and the utility of using ARM with sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND), as well as the oncologic safety of its use, by reviewing ARM lymph node metastasis and the convergence of SLN and ARM nodes

TYPE OF STUDY: General review/\"semi\" systematic

Search Strategy

DATABASES USED: MEDLINE and PubMed
 
INCLUSION CRITERIA: All available literature regarding ARM published in English
 
EXCLUSION CRITERIA: None stated

Literature Evaluated

TOTAL REFERENCES RETRIEVED: Not stated
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: No evaluation method was used, and a meta-analysis was not done.

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED: N (studies) = 15 studies
  • TOTAL PATIENTS INCLUDED IN REVIEW = 747 (566 ALND studies, 181 SLNB studies)
  • SAMPLE RANGE ACROSS STUDIES: 12–143 patients
  • KEY SAMPLE CHARACTERISTICS: Patients undergoing ALND or SLNB for breast cancer were included in the study; however, varying inclusion criteria existed between studies.

Phase of Care and Clinical Applications

PHASE OF CARE: Diagnostic

Results

The identification rates of ARM nodes and lymphatics during ALND ranged from 17%–91% and for SLNB, 38%–50%. The applicability in the clinical setting is questionable, given the low rates of ARM/lymphatics identification during both procedures. The broad ranges in ARM/lymphatic identification necessitates improvement in the procedure through standardization of procedure protocols. Metastatic involvement was reported higher in ARM nodes in patients with cancer burden that is extensive in the axilla (0%–43%) and in patients with SLN/ARM node convergence (up to 64%); therefore, further study to understand the connectivity of breast and arm lymphatics is necessary to improve the rate of clinical applicability with the ARM procedure. The outcome measure of lymphedema incidence with or without the ARM procedure varied with no conclusive evidence. Length of follow-up, small follow-up samples, and differences in lymphedema measures and definitions made the outcome measure relative to lymphedema incidence unattainable.

Conclusions

The rates of ARM and SLN node identification as well as the presence of metastasis in the studies reviewed were low, with broad ranges. The low rates of ARM node identification give rise to the question of clinical applicability, and the broad rate ranges suggest a need for improvement and further study using a standardized protocol. A lack of standardization of criteria and method of assessment for lymphedema also exist. 
 
Reviewer conclusion: In addition to the authors’ conclusions, the variability with the length of follow-up used in the studies to assess for lymphedema were inadequate according to contemporary literature.

Limitations

  • Limited number of studies included
  • No quality evaluation
  • Low sample sizes
  • Knowledge regarding the most commonly reported times to onset of lymphedema was not evident by the length of follow-up reported in most of the studies.
  • No standardization
  • No evaluation of evidence
  • The need for standardization of study protocols are necessary to facilitate treatment fidelity and overall rigor of the research.

Nursing Implications

The implications for nursing would be in the area of patient education, if and when the ARM procedure becomes a standard of care. For the present, nurses need to be knowledgeable of clinical trials involving ARM.

Legacy ID

6120