Axillary Reverse Mapping (ARM)

Axillary Reverse Mapping (ARM)

PEP Topic 
Lymphedema
Description 

Axillary reverse mapping (ARM) is an intraoperative technique developed to delineate the lymphatic drainage in the upper extremity during a sentinel lymph node biopsy or axillary lymph node dissection. This procedure involves injection of dye to identify lymphatic drainage from the arm to enable preservation of the lymphatic vessels. This technique has been examined for the prevention of upper extremity lymphedema in patients undergoing surgery for breast cancer.

Likely to Be Effective

Research Evidence Summaries

Boneti, C., Badgwell, B., Robertson, Y., Korourian, S., Adkins, L., & Klimberg, V. (2012). Axillary reverse mapping (ARM): Initial results of phase II trial in preventing lymphedema after lymphadenectomy. Minerva Ginecologica, 64, 421–430.

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Study Purpose:

To evaluate lymphedema rates when axillary reverse mapping (ARM) is added to lymphadenectomy

Intervention Characteristics/Basic Study Process:

After sentinel lymph node localization, ARM was performed by injecting blue dye subcutaneously to localize lymphatics draining the arm. Standard level I and II lymph node dissection was done to include blue lymph nodes as appropriate. Otherwise, blue nodes were preserved. Average follow-up was 14.6 ± 9.4 months.

Sample Characteristics:

  • The study reported on 148 patients.
  • Mean age was 56.9 years with a range of 44.4–69.4 years.
  • The sample was 100% female.
  • The majority of patients (95%) had stage I or II disease.

Setting:

This was a single-site study conducted in Arkansas.

Phase of Care and Clinical Applications:

Patients were undergoing the active antitumor treatment phase of care.

Study Design:

This was an bservational, descriptive study.

Measurement Instruments/Methods:

Arm volume was measured; the method of measurement was not described.

Results:

Almost a third (30%) of patients had axillary staging done prior to neoadjuvant chemotherapy; the remaining patients had the ARM procedure done during their definitive surgical treatment. Overall incidence of lymphedema when the ARM node was preserved was 2.9% compared to 18.7%  in patients who had ARM lymphatics resected.

Conclusions:

Findings suggest that ARM with preservation of lymph nodes when possible can result in lower incidence of lymphedema.

Limitations:

  • A risk of bias exists because there was no control group, no blinding, and no random assignment. The sample characteristics also present potential bias.
  • Unintended interventions or applicable interventions that were not described could have influenced results.
  • Measurement methods were not well described.
  • This was a descriptive type of design only.
  • The follow-up duration was shorter than the length of time it takes some patients to develop lymphedema. 
  • No information was provided regarding whether other preventive measures for lymphedema were done and if these were consistent among patients.

Nursing Implications:

Findings suggest that the addition of ARM to standard surgical procedures might enable preservation of some lymph nodes with resulting lowered prevalence of lymphedema in patients with breast cancer. This study provides minimal support because of study design and limitations.  Long-term effects of lymph node preservation need to be explored.

Yue, T., Zhuang, D., Zhou, P., Zheng, L., Fan, Z., Zhu, J., ... & He, Q. (2015). A prospective study to assess the feasibility of axillary reverse mapping and evaluate its effect on preventing lymphedema in breast cancer patients. Clinical Breast Cancer, 15, 301–306. 

doi: 10.1016/j.clbc.2015.01.010
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Study Purpose:

To determine if lymphedema prevention is affected by the use of the axillary reverse mapping (ARM) procedure

Intervention Characteristics/Basic Study Process:

Two groups of patients with breast cancer receiving modified radical mastectomies were randomized to a standard axillary lymph node dissection (ALND) or ALND with ARM.

Sample Characteristics:

  • N = 265
  • AVERAGE AGE = 50.14 years
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Breast cancer diagnosis; invasive and in situ ductal carcinomas; metastatic lymph nodes from 1–10+ included; any hormone receptor or HER2 status; all tumor sizes for staging
  • OTHER KEY SAMPLE CHARACTERISTICS: Exclusion of neoadjuvant treatment patients and those with bilateral breast cancer; removal from study if experimental (ARM) group had positive ARM nodes on a pathology study

Setting:

  • SITE: Single site    
  • SETTING TYPE: Outpatient    
  • LOCATION: Jinan Military Hospital in Jinan, China

Phase of Care and Clinical Applications:

PHASE OF CARE: Active antitumor treatment

Study Design:

Randomized, controlled trial

Measurement Instruments/Methods:

  • Preoperative Tc-Nanocoll injections with lymphoscintigraphy
  • Methylene blue injections
  • Intraoperative gamma probe
  • Student T test
  • Fisher exact test
  • Arm circumference measurement

Results:

Between the experimental and the control group, there was a significant difference (p < 0.001) for both areas of circumference measurement in postoperative lymphedema evaluations. The experimental ARM group had less occurrence of lymphedema.

Conclusions:

Based on the data presented by the investigators the incidence of lymphedema and the severity of lymphedema can be reduced by evaluating which lymph nodes really need to be removed to allow for the best lymphatic flow.

Limitations:

  • Risk of bias (no blinding)
  • Other limitations/explanation: Patient weight and height or body surface area not collected (can affect lymphedema risk); no mention of prior history of breast cancer or radiation to upper body; risk factors not included such as diabetes, vascular disease, or other cancers; risk of bias; no blinding; there was no blinding for the ARM versus standard procedure; but for follow-up measurement of arm circumference for lymphedema assessment; the person measuring was blinded

Nursing Implications:

Although this intervention doesn't change what staff nurses may do for patients on a day to day basis, it does allow nurses to educate patients about options as well as to open discussion with the oncology team as to the use of this newer intervention.

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