The document discusses the axillary reverse mapping (ARM) technique used during surgical procedures for breast cancer, highlighting its method, safety, and potential to reduce lymphedema rates. Studies cited show that while ARM is feasible and helps identify arm lymphatics, concerns exist regarding crossover nodes and oncological safety, particularly in patients with clinically positive breast cancer. Overall, although ARM has a theoretical benefit for lymphedema prevention, the evidence supporting its efficacy is limited due to variability in study methods and definitions.

1. R A M I N S A D E G H I , M D
M A S H H A D U N I V E R S I T Y O F M E D I C A L
S C I E N C E S
Axillary Reverse Mapping:
Technique and safety

2. Technique
 ARM/SLNB: patient will be injected with technetium-99
radiolabelled colloid (Tc-99) into the subareolar area of breast, then
1-2 mls of blue dye (patent blue dye) injected subcutaneously into
the medial ipsilateral arm, just proximal to the medial epicondyle of
the elbow, at the start of the surgical procedure. the SLN(s) will be
identified ("hot node") and removed, and any blue lymph nodes and
lymphatics will be preserved intact, and only removed or disrupted
if there is 'crossover" (i.e. the blue node is also the SLN) or if
clinically suspicious for metastatic disease. ARM/ALND: 1-2 mls of
blue dye will be injected subcutaneously into the medial ipsilateral
arm at the start of the surgical procedure. Surgeons will perform a
standard level I and II axillary dissection and any blue lymph nodes
or lymphatics will be preserved intact, and only removed or
disrupted if blue nodes are suspicious for metastatic disease.

3. Technique

4.  Foster, Deshka, et al. "Axillary reverse mapping with
indocyanine green or isosulfan blue demonstrate
similar crossover rates to radiotracer identified
sentinel nodes." Journal of surgical oncology 117.3
(2018): 336-340.
 Nearly one-third of patients showed crossover between breast
and arm draining nodes, which provides insight as to why
some patients develop lymphedema symptoms after SLN
biopsy. ICG and ISB identify similar numbers of SLNs. As such
ICG could substitute for ISB in ARM procedures

5.  Tummel, Evan, et al. "Does axillary reverse mapping
prevent lymphedema after
lymphadenectomy?." Annals of surgery265.5 (2017):
987-992.
 ARM allows frequent identification of arm lymphatics in
the axilla, which would have been transected during routine
surgery. Rates of metastases in noncrossover nodes
and axillary recurrences are low. Lymphedema rates are
dramatically reduced using ARM when compared with
accepted standards

6.  Han, Chao, et al. "The feasibility and oncological
safety of axillary reverse mapping in patients with
breast cancer: a systematic review and meta-analysis
of prospective studies." PloS one 11.2 (2016):
e0150285.
 The ARM procedure was feasible during ALND. Nevertheless,
it was restricted by low identification rate of ARM nodes
during SLNB. ARM was beneficial for preventing lymphedema.
However, this technique should be performed with caution
given the possibility of crossover SLN-ARM nodes and
metastatic ARM nodes. ARM appeared to be unsuitable for
patients with clinically positive breast cancer due to
oncological safety concern

7.  Gebruers, Nick, and Wiebren AA Tjalma. "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 (2016): 117-122.
 The level of evidence of these studies was low (mostly level 3).
Therefore the conclusions are that the ARM procedure is feasible
although ARM-node rates have a broad range. Additionally, from a
theoretical point there is a clear benefit from ARM in terms of
lymphedema prevention. From a practical point there is little
scientific data to support this due to the lack of studies; and
especially because of the different methods and definitions for
lymphedema used in the different studies.

10.  Noguchi M, et al., Is axillary reverse mapping
feasible in breast cancer patients?, Eur J Surg Oncol
(2015), http://
dx.doi.org/10.1016/j.ejso.2015.01.029