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

Systematic Review/Meta-Analysis

Ahmed, M., Rubio, I.T., Kovacs, T., Klimberg, V.S., & Douek, M. (2016). Systematic review of axillary reverse mapping in breast cancer. The British Journal of Surgery, 103, 170–178. 

doi: 10.1002/bjs.10041
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Purpose:

STUDY PURPOSE: To discuss the usefulness and safety of axillary reverse mapping (ARM) of the arm and breast during surgery on the development of breast cancer-related lymphedema

TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: PubMed, Embase, and Cochrane Library
 
INCLUSION CRITERIA: Original studies published up until March 2015, using only the search terms axillary reverse mapping and breast cancer. Reference lists were hand searched. Studies were chosen if (a) they included the performance of ARM with or without completion of axillary node clearance (ANC) or ANC alone, (b) data were collected prospectively, (c) had a minimum of 50 patients, (d) oncologic and lymphedema outcomes were assessed, (e) patient follow-up was performed at a minimum of six months, (f) a satisfactory quality assessment score was attained (4 of 6 or greater for cohort, 5 of 8 for randomized controlled trials [RCTs]), and (g) they were written in English.
 
EXCLUSION CRITERIA: Review articles, letters to editor, editorial reports, case reports, abstracts, and duplicate publications were excluded. Studies that did not report outcomes of interest or did not include full text were excluded.

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 109
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: STROBE recommendations were used to assess the quality of cohort studies. Six statements were considered suitable for quality evaluation. The studies included had an overall STROBE score of 4–6. Cochrane risk-of-bias was used to determine the suitability of RCTs. A data extraction tool was developed to include publication details, study design, number of patients, number of patients undergoing either sentinel node biopsy (SNB) alone or followed by ANC, or ANC alone; ARM technique; follow-up period; ARM node or lymphatics identification and preservation rate; ARM crossover node-positive rate; incidence of lymphedema; and breast cancer recurrence rate information from selected studies. A total of eight studies were included for review.

Sample Characteristics:

FINAL NUMBER STUDIES INCLUDED = 8 (7 prospective cohort, 1 randomized, controlled trial [RCT])
 
TOTAL PATIENTS INCLUDED IN REVIEW = 1,142
 
SAMPLE RANGE ACROSS STUDIES: 52–360 patients
 
KEY SAMPLE CHARACTERISTICS: Studies published between 2009–2015. Technical differences existed in all studies of the ARM technique. All subjects were breast cancer survivors. Definitions of lymphedema, follow-up period, SNB, ARM feasibility (%) nodes found, ARM crossover, and tumor cells in ARM were provided.

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Late effects and survivorship

Results:

This review showed that the ARM technique is feasible and can result in low rates of lymphedema, and identification of ARM lymphatics and nodes was higher with ANC than SNB. The rate of lymphedema during SNB was 0%–6% and 5.9%–24% during lymphatic preservation at ANC, both of which are still lower than previously stated rates. Ochoa et al. reported a lymphedema rate of 2.5% for SNB alone and 2% with ARM. Casabona et al. reported no cases of lymphedema. Crossover nodes were identified in four studies assessing ARM in SNB, two of which were metastases. Kuusk et al. identified 1/ 5 nodes, and Ochoa et al. identified 2/14 nodes, thereby suggesting that crossover nodes are not common during ARM and however many metastases are present (0%–20%). Metastases were detected at the same rate (0%–19%) in patients where ARM nodes were not preserved when identified. Ochoa et al. reported 5/27 ARM positive nodes and Han et al. reported 2/17 positive ARM nodes during SNB, while Tausch et al. identified 13/58 metastases ARM nodes during ANC.

Conclusions:

The rate of lymphedema is lower in the majority of patients when ARM nodes are spared when sentinel lymph node (SLN) is negative and no crossover exists. However, given the risk for metastasis, ARM nodes or those in close proximity to SLN should be excised.  
 
Reviewer conclusion: RCTs using the same protocols and definitions for lymphedema are warranated. Length of follow-up is not long enough to encompass most often reported periods of onset.

Limitations:

  • Limited search
  • Low sample sizes
  • Short follow-up intervals did not allow a long enough interval to establish the oncologic safety of ARM
  • Standard SNB technique was not used in all studies.
  • Different definitions of lymphedema
  • Clinical diagnoses of lymphedema were made occasionally.
  • Inconsistent knowledge of number of nodes excised and if patients were undergoing adjuvant

Nursing Implications:

The implications for nursing would be in the area of low-level laser therapy (LLLT) patient education, understanding of the ARM technique, and evidence related to lymphedema rate. For the present, nurses need to be knowledgeable of clinical trials involving the ARM technique and stay current with lymphedema management.

Beek, M.A., Gobardhan, P.D., Schoenmaeckers, E.J., Klompenhouwer, E.G., Rutten, H.J., Voogd, A.C., & Luiten, E.J. (2016). Axillary reverse mapping in axillary surgery for breast cancer: An update of the current status. Breast Cancer Research and Treatment, 158, 421–432. 

doi: 10.1007/s10549-016-3920-y
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Purpose:

STUDY PURPOSE: To review the evidence for axillary reverse mapping (ARM) and discuss the feasibility, safety, and relevance of this procedure

TYPE OF STUDY: General review/"semi" systematic

Search Strategy:

DATABASES USED: PubMed
 
INCLUSION CRITERIA: Studies in the English language and studies including at least 10 patients

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 54
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: None specified

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 31 
  • TOTAL PATIENTS INCLUDED IN REVIEW = 2,747
  • SAMPLE RANGE ACROSS STUDIES: 23–327
  • KEY SAMPLE CHARACTERISTICS: All had breast cancer surgery involving ARM

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment

Results:

Evidence shows a wide range of visualization rates from 20%–90% and notes that rates are lower with sentinel lymph node biopsy (SNLB) than with axillary lymph node dissection (ALND). The definition of successful ARM, the volume of blue dye used, and the experience of the surgeon varied, all of which may affect these rates. Blue dye, flourescent dye, and radioisotopes have been used for visualization. No adverse events from the procedures have been noted. At present, no axillary recurrence has been reported in patients in whom lymph nodes were preserved. ARM may contribute to a reduction in upper extremity lymphedema, although current evidence is not strong enough to draw firm conclusions.

Conclusions:

The preservation of lymph nodes with ARM appears to be safe and may contribute to a reduction in the incidence of upper extremity lymphedema.

Limitations:

  • No quality evaluation
  • Most studies had a relatively short follow-up time frame.

Nursing Implications:

The preservation of axillary lymph nodes in women undergoing surgery for breast cancer with ARM appears to be safe. The evidence suggests that ARM with lymph node preservation may reduce the prevalence of arm lymphedema; however, multiple limitations in the available evidence exist. Ongoing research of the long-term effects on patient outcomes is needed and underway.

Gebruers, N., & Tjalma, W.A. (2016). Clinical feasibility of axillary reverse mapping and its influence on breast cancer related lymphedema: A systematic review. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 200, 117–122. 

doi: 10.1016/j.ejogrb.2016.03.014
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Purpose:

STUDY PURPOSE: To review current literature to (a) examine which approaches for axillary reverse mapping (ARM) are used, (b) determine the oncologic safety of ARM, and (c) determine whether ARM decreases the incidence of lymphedema after axillary lymph node dissection (ALND) and sentinel lymph node dissection (SLND).
 
TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: PubMed, Web of Science, Medline, and Cochrane clinical trials.
 
INCLUSION CRITERIA: Studies were included if (a) ARM was performed in ALND or SLND surgeries, (b) a description of the ARM procedure was provided, (c) assessment and definition of lymphedema were reported, (d) a clear distinction between the type of dissection (ALND or SNLD) was presented, (d) follow-up time after surgery was reported, and (e) if they were in English or Dutch.   
 
EXCLUSION CRITERIA: Secondary sources were excluded (doctoral dissertations, letters to the editor or editorials, conference proceedings, reviews, case studies, postmortem studies).
 
 

Literature Evaluated:

LITERATURE EVALUATED: Studies were independently evaluated by two reviewers for quality using the checklists from the Dutch Cochrane center with a 1, 0, or ? (1 = if sufficient information was available and no likelihood of bias, 0 = sufficient information but missing a criterion, ? = no information available). No meta-analysis was done.

TOTAL REFERENCES RETRIEVED: 108
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: The method used to evaluate quality is explained; however, the method for assigning levels of evidence and the definition of each level are not described. Randomized, controlled trial (RCT) was assigned at a Level 2 evidence score, and all other studies were scored as Level 3.

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 27 studies
  • TOTAL PATIENTS INCLUDED IN REVIEW = The number of patients was not provided for every article, so based on information provided, N = 959. Pooled results: ALND = 1,184, sentinel lymph node biopsy (SLNB) = 1,507
  • SAMPLE RANGE ACROSS STUDIES: 20–360 patients
  • KEY SAMPLE CHARACTERISTICS: Patient characteristics, ARM methodology, ARM feasibility (% on nodes found, % ARM crossover, tumor cells in ARM), assessment, definition, and incidence of lymphedema

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Diagnostic

Results:

A total of 27 studies were systematically reviewed for content on the type of ARM, its safety, and whether it decreased the incidence of lymphedema. Three ARM procedures were described: (a) dermally injected blue dye, (b) injected radioisotope Tc-99m Nanocoll with subsequent lymphoscintigraphy, and (c) lymphofluoroscopic assessment using an intradermal injection of indocyanine green (ICG). The ARM detection rate was less in the sentinel lymph node biopsy (SLNB) cases (19.9%–100% with 100% representing one sample) than the ALND cases (46.6%–94.9%). Crossover nodes (those representing ARM and sentinel nodes) were identified in 5.6%–20% of ALND cases and 0%–14% of SLN cases. The recurrence of cancer in nodes that were ARM preserved would determine oncologic safety, in which studies from a referenced source deemed the ARM procedure as oncologically safe in clinically node negative, SLN positive cases, with the exception of the ARM and positive SLN being synonymous. The incidence of lymphedema reported for all ALND cases was 0%–30% and for all SLNB was 0%–4%. Lymphedema ranges for non-ARM ALND cases was 11.8%–53.5% and for SLN samples was 0%–15.8%.

Conclusions:

No definite conclusions can be drawn because of the low level of evidence assigned to the studies reviewed, with the exception of one RCT with an assigned evidence level of 2. While feasibility appears to exist with the use of the ARM procedure, a vast range in the rate of ARM nodes and a decreased incidence of lymphedema were detected.  
 
Reviewer conclusion: The criteria for evidence is unclear; therefore, drawing conclusions from the study comparisons in regard to the use of the ARM procedure in reducing the incidence of lymphedema is difficult. The wide ranges of incidence are attributed to several limitations relevant to the lack of consistency in procedure, lymphedema assessment and definition, and varying follow-up intervals that were used to answer the research questions. Theoretically, the ARM procedure should be studied more rigorously in clinical trials, with uniform reporting in comparison with non-ARM lymphedema incidence. This study gives encouraging data in this regard; however, the limitations of the study prohibit generalization.

Limitations:

  • Limited search
  • Low sample sizes
  • Lymphedema definition varied
  • Method of lymphedema measurement varied
  • Level of evidence for all studies except one RCT was low.
  • Oncologic safety was based on one source.
  • No information about the patient population and medical characteristics
  • Four indices were used for search.

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.

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: 10.1586/14737140.2014.896209
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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.

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.

Pasko, J.L., Garreau, J., Carl, A., Ansteth, M., Glissmeyer, M., & Johnson, N. (2015). Axillary reverse lymphatic mapping reduces patient perceived incidence of lymphedema after axillary dissection in breast cancer. American Journal of Surgery, 209, 890–895. 

doi: 10.1016/j.amjsurg.2015.01.011
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Study Purpose:

To retrospectively examine how axillary reverse lymphatic mapping (ARM) affects patients perceived incidence of lymphedema compared to patients who did not receive ARM

Intervention Characteristics/Basic Study Process:

A retrospective review of 46 patients with breast cancer who had greater than 10 lymph nodes removed were recruited and surveyed to determine which patients identified as having lymphedema and whether they required treatment or therapy for it. Patients were also asked if they underwent the ARM procedure.

Sample Characteristics:

  • N = 46   
  • MEAN AGE = 57 years  
  • FEMALES: 100%
  • CURRENT TREATMENT: Not applicable
  • KEY DISEASE CHARACTERISTICS: Patients with breast cancer with axillary node dissection

Setting:

  • SITE: Retrospective (not applicable)
  • SETTING TYPE: Retrospective (not applicable)
  • LOCATION: Portland, Oregon

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Late effects and survivorship 
  • APPLICATIONS: Palliative care 

Study Design:

  • Retrospective review

Measurement Instruments/Methods:

A survey was created and sent to all women who qualified for the study from the Community Hospital Tumor Registry in Portland, Oregon.

Results:

Twenty-two patients reported undergoing the ARM procedure compared to 24 patients who did not undergo the ARM procedure. Of the 22 who did, 39% reported having lymphedema compared with 50% of the non-ARM patients. Eighteen percent of the ARM group reported requiring a compression sleeve for treatment of lymphedema compared to 45.8% of women in the non-ARM group.

Conclusions:

The incidence of patient perceptions of lymphedema and the use of compression sleeves were lower in the ARM group than in the non-ARM group.

Limitations:

  • Small sample (< 100)
  • Baseline sample/group differences of import
  • Risk of bias (no control group)
  • Risk of bias (no random assignment) 
  • Risk of bias (no appropriate attentional control condition)  
  • Risk of bias (sample characteristics)
  • Unintended interventions or applicable interventions not described that would influence results 
  • Selective outcomes reporting
  • Measurement/methods not well described
  • Measurement validity/reliability questionable 
  • Findings not generalizable
  • Fifty-seven percent of patients contacted for the retrospective study did not complete the survey.

 

Nursing Implications:

The effect of using the ARM procedure to decrease lymphedema cannot be ascertained from this study.

Tummel, E., Ochoa, D., Korourian, S., Betzold, R., Adkins, L., McCarthy, M., . . . Klimberg, V.S. (2016). Does axillary reverse mapping prevent lymphedema after lymphadenectomy? Annals of Surgery. Advance online publication.

doi: 10.1097/SLA.0000000000001778
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Study Purpose:

To further validate previous findings that an axillary reverse mapping (ARM) technique enabling the preservation of arm lymphatics can reduce the postoperative lymphedema rate in women having sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND)

Intervention Characteristics/Basic Study Process:

ARM was conducted intraoperatively with technetium in the breast and blue dye in the arm. Arm volume displacement measures were conducted preoperatively and every six months. Follow-up ranged from 3–54 months, with an average of 20 months. Lymphedema rates of sample cases were compared to those of a group that did not have ARM.

Sample Characteristics:

  • N = 504   
  • MEAN AGE = 57 years (SD = 13) 
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Of the participants, 90.6% had invasive cancer.

Setting:

  • SITE: Single site   
  • SETTING TYPE: Inpatient

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment

Study Design:

  • Single-arm, phase-II

Measurement Instruments/Methods:

  • Arm water displacement

Results:

SNLB mapping was successful in 98.5% of the patients, and ALND lymphatics or blue nodes were identified in 71.8% of the procedures. After SLND, 0.8% had findings of lymphedema, and 6.5% had lymphedema after ALND. In cases where blue lymphatics were identified and able to be preserved, the SLNB lymphedema rate was 1.2%; the lymphedema rate in ALND cases was 6.9%. These rates were compared to reported rates with SLNB ranging from 0%–13%.

Conclusions:

ARM may help preserve lymphatic structures and reduce the rates of postoperative lymphedema.

Limitations:

  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Unintended interventions or applicable interventions not described that would influence results
  • Measurement/methods not well described
  • No other interventions for the prevention or treatment of lymphedema were reported.
  • Actual measurements used for rate determination were not clear.

Nursing Implications:

A variety of surgical techniques aimed at reducing postoperative lymphedema are being examined. This study describes one method of ARM that may be beneficial. Further research is needed to determine efficacy with concurrent comparison, the techniques that are most effective, and the role of ARM in overall lymphedema prevention and management.

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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