Axillary reverse mapping with indocyanine fluorescence imaging in patients with breast cancer

Abstract

BACKGROUND: The ARM technique was proposed to prevent arm lymphedema after ALND and/or SLN biopsy. However, several problems remain to be resolved in the practical application of this technique. METHODS: The fluorescent ARM nodes and/or lymphatics were identified using a fluorescence imaging system with subdermal injection of indocyanine green into the upper limb. ALND was performed in patients with clinically involved nodes, and the ARM nodes were separately removed during ALND. SLN biopsy was performed in patients with clinically uninvolved nodes. If SLN was positive, ALND was performed with removal of ARM nodes. Otherwise, identified ARM nodes were preserved unless they were the same as SLN. RESULTS: ARM nodes and/or lymphatics were identified in 7 (88%) of 8 patients who underwent ALND, whereas they were identified in 9 (75%) of 12 patients who underwent SLN biopsy alone. ARM nodes were involved with tumors in 3 (43%) of the former patients, and SLN was the same as the ARM node in 2 (14%) of 14 patients who underwent SLN biopsy. CONCLUSIONS: Fluorescence imaging was sensitive for identification of ARM nodes and/or lymphatics. However, further studies are needed before efforts to preserve these nodes can be safely implemented.