Tausch, C., Baege, A., Dietrich, D., Vergin, I., Heuer, H., Heusler, R.H., & Rageth, C. (2013). Can axillary reverse mapping avoid lymphedema in node positive breast cancer patients? European Journal of Surgical Oncology, 39, 880–886.

To report the experience with a new technique, axillary reverse mapping (ARM), in patients scheduled for axillary lymph node dissection (ALND) and to evaluate its usefulness for reducing the incidence of lymphedema

For the intervention group, 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. One follow-up was conducted at a median of 19 months.

• N  = 143 
• MEDIAN AGE = 58 years
• AGE RANGE = 29–88 years
• MALES: 2.1%, FEMALES: 97.9%
• KEY DISEASE CHARACTERISTICS: Patients with breast cancer undergoing ALND

• SITE: Single site 
• SETTING TYPE: Inpatient 
• LOCATION: Brust-Zentrum Zurich, Switzerland

• PHASE OF CARE: Mutliple phases of care

• Pre-post design

• Arm volume measured using water replacement method via an arm volumeter

ARM was performed in 143 patients subsequently undergoing ALND. ARM lymph nodes were successfully identified in 112 patients (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. Thirty-five 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, the study found no evidence that it reduces the incidence of lymphedema.

• Risk of bias (no control group)
• Risk of bias (no random assignment)
• Other limitations/explanation: Single0site study, non-RCT design, no baseline arm volume measure, and borderline power of the sample size

Larger studies with rigorous design are needed to evaluate whether preservation of clinically unsuspicious ARM nodes is oncologically safe and effective in preventing secondary lymphedema in patients with breast cancer.