Users Online: 2011
Home Print this page Email this page
Home About us Editorial board Search Browse articles Submit article Ahead of Print Instructions Subscribe Contacts Special issues Login 


 
Previous article Browse articles Next article 
ORIGINAL ARTICLE
Adv Biomed Res 2022,  11:36

Evaluation of relative abundance of lymphedema after reverse axillary mapping in patients with breast cancer


1 Department of Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
2 School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission06-Sep-2021
Date of Acceptance08-Nov-2021
Date of Web Publication29-Apr-2022

Correspondence Address:
Dr. Masoumeh Safaee
Department of Surgery, School of Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan
Iran
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/abr.abr_281_21

Rights and Permissions
  Abstract 


Background: The axillary reverse mapping (ARM) technique identifies and preserves arm nodes during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND). Here, we aimed to investigate the prevalence of lymphedema following ARM. Materials and Methods: This is a clinical trial that was performed in 2019-2020 in Isfahan on patients with breast cancer in the early stages. Demographic and initial information of all cases including age and body mass index (BMI) was collected. Patients were then underwent SLNB ± ALND associated with ARM and were followed up for lymphedema every 6 months to a year. The occurrence of lymphedema was assessed. Results: By evaluating data of 102 patients, we found that 10 patients (9.8%) had lymphedema and patients with lymphedema had significantly higher age (P = 0.004), higher BMI (P = 0.001), larger tumor size (P = 0.018), and longer surgery duration (P < 0.001). The frequency of menopausal women was higher in patients with lymphedema compared to other cases (P = 0.001). Conclusion: The prevalence of lymphedema was high among patients undergoing ARM that was associated with factors including higher age, higher BMI, prolonged surgery duration, larger tumor size, and menopause. We believe that further comparative studies should be conducted on this issue.

Keywords: Breast neoplasms, lymphedema, sentinel lymph node biopsy


How to cite this article:
Eshraghi Samani R, Ebrahimi H, Rafiee Zadeh A, Safaee M. Evaluation of relative abundance of lymphedema after reverse axillary mapping in patients with breast cancer. Adv Biomed Res 2022;11:36

How to cite this URL:
Eshraghi Samani R, Ebrahimi H, Rafiee Zadeh A, Safaee M. Evaluation of relative abundance of lymphedema after reverse axillary mapping in patients with breast cancer. Adv Biomed Res [serial online] 2022 [cited 2022 Dec 5];11:36. Available from: https://www.advbiores.net/text.asp?2022/11/1/36/344360




  Introduction Top


Breast cancer is the most common malignancy and the most common cancer leading to death in women. In the United States, 100,000 new cases of the disease are diagnosed each year, and about 30,000 patients die from this cancer.[1] The prevalence of breast cancer accounts for about one-third of all female cancers and is the second most common cancer after lung cancer and the most common cause of cancer death among women. In Iran, breast cancer accounts for 32% of all female cancers.[2],[3]

Many factors such as geography, family history, menstrual status and pregnancy, proliferative breast lesions, and history of radiation have been considered as risk factors for breast cancer.[4],[5] One of the common and effective treatment methods for breast cancer is a surgical operation. Lymph node dissection is also conducted based on the surgeon's decision, especially in cases of sentinel node involvements. Axillary reverse mapping (ARM) was first developed by Thompson and Noss in 2007 to identify lymph nodes and upper lymphatic pathways and to preserve these pathways during breast cancer surgery in patients.[6],[7]

During ARM, the lymph nodes are mapped using methylene blue dye injection subcutaneously and gamma probe. It has been indicated that by using ARM, surgeons could dissect only the selected lymph nodes, and other nodes could be preserved that, in turn, lead to lower incidence of complications.[8]

One of the most important complications of breast cancer surgery and lymph node dissection is lymphedema. Lymphedema is a long-term complication in women who have undergone axillary surgery. The prevalence of this complication has been reported differently based on different classification criteria and measurements.[9] Its prevalence is reported to be 6% in patients undergoing sentinel lymph node biopsy (SLNB) and 20% in patients undergoing axillary lymph node dissection (ALND).[10],[11]

During ARM, the target nodes are identified by injecting a tracer material into the upper limb before surgery, which is similar to the procedure performed in SLNB surgery, which usually uses blue dye, radioisotope, or fluorescence. Initially, it was hypothesized that the lymphatic pathways of the upper limb were separated from the breast and metastatic cells would not enter it, and that preserving this lymph node and lymphatic pathways would reduce lymphedema without increasing the risk of metastasis.[12],[13]

However, some studies have shown that the prevalence of lymphedema in patients with ARM was 6%[14] and 13%,[15] respectively. The prevalence of lymphedema in case of SLNB with radiotherapy was 10%, ALND without radiotherapy was 19%, and in case of ANLD and simultaneous radiotherapy was 30%, which indicates the multifactorial nature of lymphedema in patients after breast surgery.[16]

These data suggest that using ARM could increase the chances of lymph node preservation and decrease the incidence of lymphedema, but further studies are also required in this field. In the present study, we aimed to investigate the prevalence of lymphedema in cases undergoing lymph node dissection using ARM.


  Materials and Methods Top


This is a clinical trial that was performed in 2019-2020 in Omid Hospital affiliated to Isfahan University of Medical Sciences. The current study was conducted on patients with breast cancer in the early stages. The study protocol was approved by the Research Committee of Isfahan University of Medical Sciences, and the Ethics committee has confirmed it (Ethics code: IR.MUI.MED.REC.1399.148, Iranian Registry of Clinical Trials (IRCT) code: IRCT20200909048672N1).

The inclusion criteria were female gender, diagnosis of breast cancer by expert oncologists, being a candidate for SLNB ± ALND, patients candidates of total or partial mastectomy + ALND, patients with operable tumors, and signing the written informed consent to participate in this study. The exclusion criteria were previous chemotherapy or radiotherapy, previous axillary surgery, and patient's will to exit this study.

The sampling method of the present study was accessible and easy so that until the completion of the required sample volume ceiling, the sampling study was performed among eligible patients. We assessed 120 eligible patients for this study. Demographic and initial information of all cases including age, body mass index (BMI), and patient arm volume before surgery was collected. Patients were then underwent SLNB ± ALND associated with ARM.

The ARM was conducted by the following method:

After surgical site prep and draping, 1.0 mCi unfiltered technetium sulfur colloid that was diluted to 4 cc was injected under an areola in the involved site. Then, using a gamma detector hand probe, the exact location of the hot lymph nodes was determined, and then a skin incision was made and the affected lymph nodes were identified and removed. ARM technique was performed by injecting 2–5 mL of methylene blue into the subcutaneous tissue of the upper inner ipsilateral arm before surgery. After the injection, the upper hand was held, and the injection site was massaged for 3 min. After injection, the SLNB technique was continued through mastectomy incision or intra-axillary incision.

Dual mapping (via the upper limb and breast network) identifies possible lymph nodes that overlap between the two networks, in which case the overlapping lymph nodes were also removed. After identifying the overlapping lymph nodes and removing them, the number and anatomical location of these glands during surgery were examined and recorded. Finally, the patient, s skin was suppurated.

It should be noted that in patients in whom ARM lymph nodes were not detectable in this way, the ALND + SLND technique was performed. When the SLN was positive and a complete mastectomy was performed, complete ALND was performed through a previous axillary incision. Zones I and II lymph nodes were completely removed, and the blue glands and lymph nodes that represent the ARM lymphatic system were preserved. At this stage, the lymph nodes, which were both blue and radioactive, were also removed.

After primary surgery, patients were followed up for lymphedema every 6 months to a year. To measure the patient's arm circumference, it was measured from the highest point of the patient's shoulder joint to the lowest point of the patient's elbow joint, and between these two points, the patient's arm was marked and measured using a meter.

The obtained data were entered into the Statistical Package for Social Sciences (SPSS) (version 24, SPSS Inc., Chicago, IL, USA). Quantitative data were reported as mean ± standard deviation and qualitative data as frequency distribution (percentage). Independent t-test and Chi-square test were used to analyze the data. P < 0.05 was considered as a significance threshold.


  Results Top


In this study, 122 patients with breast cancer entered the study. During the study, 20 patients were excluded due to lack of proper cooperation (n = 13), patient's will (n = 5), and previous radiotherapy (n = 2). Data of 102 patients were analyzed.

Based on initial analysis, the mean age of patients was 38.78 ± 9.0 years and the most common type of cancer was invasive ductal carcinoma (78.4%). Sixty-two patients (60.7%) had right breast involvements and the most common involvement location was upper outer quadrant (60.8%). Only 17 patients (16.8%) were in menopausal status and 48 patients (47.1%) had previous oral contraceptive pills (OCPs) usage. The duration of OCP use was over 1 year in all cases. The most common cancer stage was IIA (42.1%). These data are indicated in [Table 1].
Table 1: Evaluation of basic data of patients

Click here to view


Further evaluations showed that 10 patients (9.8%) had lymphedema, 76 patients (74.6%) underwent SLNB, and 46 patients (45.1%) had sentinel lymph node involvements. The mean tumor size among patients was 25.5 ± 10.3 mm, the mean number of involved lymph nodes was 3 ± 3, and the arm circumstance before and after surgeries was 32.6 ± 5.1 and 33.1 ± 7.3 cm, respectively. These data are indicated in [Table 2].
Table 2: Evaluation of patient's information

Click here to view


We compared different variables between patients with or without lymphedema. These data showed that patients with lymphedema had significantly higher age (P = 0.004), higher BMI (P = 0.001), larger tumor size (P = 0.018), and longer surgery duration (P < 0.001). The frequency of menopausal women was higher in patients with lymphedema compared to other cases (P = 0.001). No other differences were observed between two groups regarding the following variables: number of involved lymph nodes, SLNB or ALND administration, and side of involvement, tumor location and OCP usage (P > 0.05 for all). These data are indicated in [Table 3].
Table 3: Comparison of variables between patients with or without lymphedema

Click here to view



  Discussion Top


In the present study, we evaluated the occurrence of lymphedema in patients with breast cancer undergoing SLNB ± ALND associated with ARM. Based on our data, lymphedema occurred in 10% of cases. Furthermore, by assessing different characteristics, we observed that lymphedema was more frequent in patients with higher age, higher BMI, larger tumor size, and longer surgery duration. Based on the results of our study, conduction of ARM had no significant effects in lymphedema.

These data show that ARM could be used as an effective method in mapping the involved lymph nodes, but the frequency of lymphedema was almost high among patients. Previously, studies have evaluated the occurrence of lymphedema in similar cases and various results have been reported. Most of these studies have reported significantly decreased lymphedema among patients undergoing ARM, and in this study, we showed a similar incidence of lymphedema compared to other studies. We should also note that the ARM procedure was conducted successfully in all patients and no complications were reported.

In 2017, Tummel et al. evaluated the effects of ARM on the prevention of lymphedema. By evaluating 654 patients, they reported that lymphedema rates for SLNB and ALND were 0.8% and 6.5%, respectively, and also demonstrated that by ARM, identification of arm lymphatics in the axilla could be conducted successfully that could, in turn, have significant clinical usage.[17] In another study by Yue et al. in 2015, they assessed data of 265 patients with breast cancer. They showed that patients that received ARM before lymph node biopsy and dissection had significant effects in lymph node preservation and contributed to decreasing the frequency of lymphedema. Based on their study, 30.07% of control group and 5.93% of ARM group experienced lymphedema.[18] Boneti et al. also reported that among 114 patients who underwent ARM, lymphedema was diagnosed in 3.5% of the SLNB cases and 7% of the combined SLNB + ALND cases.[19] The results of our study were somehow in line with these reports. As mentioned above, we found that 10% of our cases developed lymphedema after the procedures that are relatively higher than previous reports.

The differences between our results and previous studies could be due to various factors, including the BMI and obesity of patients, radiotherapy of the affected area, and poor postprocedure care strategies such as physical activities or hand elevation. However, these data could not cast doubt on the effectiveness and complication rates of ARM.

Other findings of our study were that lymphedema was more frequent in patients with higher age, higher BMI, larger tumor size, longer surgery duration, and among women with menopause. In a study by Ochoa et al. in 2014, they investigated 360 patients undergoing SLNB and/or ALND. It was mentioned that the incidence of lymphedema was higher among older and obese patients and menopause women.[20] It has also been discussed in previous studies that lymphedema could occur more often in patients with higher BMI and larger tumor size.[21],[22] In another study by Faisal et al., it was mentioned that postprocedure care should be precisely conducted and observed, especially in patients with higher age to prevent lymphedema.[23] Based on a recent systematic review and meta-analysis in 2020, ARM could significantly reduce the occurrence of lymphedema; however, this issue is more probable among patients with previous medical condition, older patients, and those with prolonged surgery duration.[24] These results are consistent with our findings.

We demonstrated that the prevalence of lymphedema was almost higher in our study compared to others, but the important point is that we found the possible correlating factors such as higher age, larger tumor size, higher BMI and prolonged surgery duration. These data were in line with previous studies. The limitations of our study were restricted study population, not comparing the patients with control group and lack of postintervention follow-up evaluation. However, the results of our study could indicate that conducting ARM might not reduce the possibility of lymphedema in patients. We believe that further studies are required in this regard. We recommend that further clinical trials should be conducted to establish the effect of ARM in our regional health-care system.


  Conclusion Top


Taken together, we showed that the prevalence of lymphedema was high among patients undergoing ARM that was associated with factors including higher age, higher BMI, prolonged surgery duration, larger tumor size, and menopause. We believe that further comparative studies should be conducted on this issue.

Financial support and sponsorship

This study was granted by Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Waks AG, Winer EP. Breast cancer treatment: A review. JAMA 2019;321:288-300.  Back to cited text no. 1
    
2.
Sancho-Garnier H, Colonna M. Breast cancer epidemiology. Presse Med 2019;48:1076-84.  Back to cited text no. 2
    
3.
Nafissi N, Khayamzadeh M, Zeinali Z, Pazooki D, Hosseini M, Akbari ME. Epidemiology and histopathology of breast cancer in Iran versus other Middle Eastern countries. Middle East J Cancer 2018;9:243-51.  Back to cited text no. 3
    
4.
Jazayeri SB, Saadat S, Ramezani R, Kaviani A. Incidence of primary breast cancer in Iran: Ten-year national cancer registry data report. Cancer Epidemiol 2015;39:519-27.  Back to cited text no. 4
    
5.
Enayatrad M, Amoori N, Salehiniya H. Epidemiology and trends in breast cancer mortality in Iran. Iran J Public Health 2015;44:430-1.  Back to cited text no. 5
    
6.
Abdelhamid MI, Bari AA, Farid MI, Nour H. Evaluation of axillary reverse mapping (ARM) in clinically axillary node negative breast cancer patients – Randomised controlled trial. Int J Surg 2020;75:174-8.  Back to cited text no. 6
    
7.
Shao X, Sun B, Shen Y. Axillary reverse mapping (ARM): Where to go. Breast Cancer 2019;26:1-10.  Back to cited text no. 7
    
8.
Liu S, Wang N, Gao P, Liu P, Yang H, Xie F, et al. Using the axillary reverse mapping technique to screen breast cancer patients with a high risk of lymphedema. World J Surg Oncol 2020;18:118.  Back to cited text no. 8
    
9.
Rockson SG. Lymphedema after breast cancer treatment. N Engl J Med 2018;379:1937-44.  Back to cited text no. 9
    
10.
Nguyen TT, Hoskin TL, Habermann EB, Cheville AL, Boughey JC. Breast cancer-related lymphedema risk is related to multidisciplinary treatment and not surgery alone: Results from a large cohort study. Ann Surg Oncol 2017;24:2972-80.  Back to cited text no. 10
    
11.
Belmonte R, Messaggi-Sartor M, Ferrer M, Pont A, Escalada F. Prospective study of shoulder strength, shoulder range of motion, and lymphedema in breast cancer patients from pre-surgery to 5 years after ALND or SLNB. Support Care Cancer 2018;26:3277-87.  Back to cited text no. 11
    
12.
Schwarz GS, Grobmyer SR, Djohan RS, Cakmakoglu C, Bernard SL, Radford D, et al. Axillary reverse mapping and lymphaticovenous bypass: Lymphedema prevention through enhanced lymphatic visualization and restoration of flow. J Surg Oncol 2019;120:160-7.  Back to cited text no. 12
    
13.
Foster D, Choy N, Porter C, Ahmed S, Wapnir I. Axillary reverse mapping with indocyanine green or isosulfan blue demonstrate similar crossover rates to radiotracer identified sentinel nodes. J Surg Oncol 2018;117:336-40.  Back to cited text no. 13
    
14.
Han JW, Seo YJ, Choi JE, Kang SH, Bae YK, Lee SJ. The efficacy of arm node preserving surgery using axillary reverse mapping for preventing lymphedema in patients with breast cancer. J Breast Cancer 2012;15:91-7.  Back to cited text no. 14
    
15.
Boneti C, Korourian S, Diaz Z, Santiago C, Mumford S, Adkins L, et al. Scientific impact award: Axillary reverse mapping (ARM) to identify and protect lymphatics draining the arm during axillary lymphadenectomy. Am J Surg 2009;198:482-7.  Back to cited text no. 15
    
16.
Miller CL, Specht MC, Skolny MN, Horick N, Jammallo LS, O'Toole J, et al. Risk of lymphedema after mastectomy: Potential benefit of applying ACOSOG Z0011 protocol to mastectomy patients. Breast Cancer Res Treat 2014;144:71-7.  Back to cited text no. 16
    
17.
Tummel E, Ochoa D, Korourian S, Betzold R, Adkins L, McCarthy M, et al. Does axillary reverse mapping prevent lymphedema after lymphadenectomy? Ann Surg 2017;265:987-92.  Back to cited text no. 17
    
18.
Yue T, Zhuang D, Zhou P, Zheng L, Fan Z, Zhu J, et al. A prospective study to assess the feasibility of axillary reverse mapping and evaluate its effect on preventing lymphedema in breast cancer patients. Clin Breast Cancer 2015;15:301-6.  Back to cited text no. 18
    
19.
Boneti C, Badgwell B, Robertson Y, Korourian S, Adkins L, Klimberg V. Axillary reverse mapping (ARM): Initial results of phase II trial in preventing lymphedema after lymphadenectomy. Minerva Ginecol 2012;64:421-30.  Back to cited text no. 19
    
20.
Ochoa D, Korourian S, Boneti C, Adkins L, Badgwell B, Klimberg VS. Axillary reverse mapping: Five-year experience. Surgery 2014;156:1261-8.  Back to cited text no. 20
    
21.
Ikeda K, Ogawa Y, Kajino C, Deguchi S, Kurihara S, Tashima T, et al. The influence of axillary reverse mapping related factors on lymphedema in breast cancer patients. Eur J Surg Oncol 2014;40:818-23.  Back to cited text no. 21
    
22.
Gennaro M, Maccauro M, Sigari C, Casalini P, Bedodi L, Conti AR, et al. Selective axillary dissection after axillary reverse mapping to prevent breast-cancer-related lymphoedema. Eur J Surg Oncol 2013;39:1341-5.  Back to cited text no. 22
    
23.
Faisal M, Sayed MG, Antonious K, Abo Bakr A, Farag SH. Prevention of lymphedema via axillary reverse mapping for arm lymph-node preservation following breast cancer surgery: A randomized controlled trial. Patient Saf Surg 2019;13:35.  Back to cited text no. 23
    
24.
Wijaya WA, Peng J, He Y, Chen J, Cen Y. Clinical application of axillary reverse mapping in patients with breast cancer: A systematic review and meta-analysis. Breast 2020;53:189-200.  Back to cited text no. 24
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
Previous article  Next article
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed1292    
    Printed50    
    Emailed0    
    PDF Downloaded351    
    Comments [Add]    

Recommend this journal