Axillary Reverse Mapping (ARM)

Axillary Reverse Mapping (ARM)

PEP Topic 

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.


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.


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.


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.


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


  • 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.