Axillary reverse lymphatic mapping in breast cancer surgery: a comprehensive review

Abstract

Axillary reverse lymphatic mapping (ARM) is a surgical technique that was first described in 2007 as a method for preserving the lymphatic drainage of the arm during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) for breast cancer. We found that the ARM technique had several limitations that include a poor success rate for identification of arm lymph nodes (ARM nodes) and lymphatics. The occurrence of common lymphatic drainage pathways of the arm and the breast in a subset of patients also raises concerns regarding its oncological soundness. Furthermore, the effectiveness of the ARM procedure in reducing lymphedema risk in breast cancer patients that undergo a variety of treatments, has yet to be clearly defined.

Keywords::

• ARM procedure
• axillary lymph node dissection
• axillary reverse lymphatic mapping
• biopsy
• breast cancer
• lymphedema
• sentinel lymph node
• sentinel lymph node biopsy

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Axillary lymph node status is a critical predictor of breast cancer prognosis and guides treatment.

• Sentinel lymph node biopsy (SLNB) is currently the method of choice for the staging of axillary lymph nodes in breast cancer patients who have no gross clinical evidence of axillary metastasis.

• Axillary reverse lymphatic mapping (ARM) is a surgical technique that has been developed in order to distinguish the arm and breast lymphatics/lymph nodes during axillary lymph node dissection or SLNB.

• The rationale for the ARM procedure is that it allows for identification and preservation of the arm lymphatic system and thereby reduces the risk of developing postoperative lymphedema.

• A failure to identify ARM nodes in some cases, as well as the presence of common pathways of lymphatic drainage for ARM nodes and SLNs, raises questions regarding the oncological safety and appropriateness of the ARM procedure.

• Further clinical studies, with adequate long-term follow-up, are required before a standardized protocol can be developed, and the specific indications for the ARM procedure to reduce the risk of arm lymphedema in breast cancer patients undergoing axillary lymph node dissection or SLNB can be clearly established.