title: Axillary reverse mapping (ARM): a new concept to identify and enhance lymphatic preservation.
abstract: BACKGROUND
  Variations in arm lymphatic drainage put the arm lymphatics at risk for disruption during axillary lymph node surgery. Mapping the drainage of the arm with blue dye (axillary reverse mapping, ARM) decreases the likelihood of disruption of lymphatics and subsequent lymphedema.
  
  
  METHODS
  This institutional review board (IRB)-approved study from May to October 2006 involved patients undergoing SLNB and/or ALND. Technetium sulfur colloid (4 mL) was injected in the subareolar plexus and 2-5 mL of blue dye intradermally was injected in the ipsilateral upper extremity (ARM). Data were collected on variations in lymphatic drainage that impacted SLNB or ALND, successful identification and protection of the arm lymphatics, any crossover between a hot breast node and a blue arm node, and occurrence of lymphedema.
  
  
  RESULTS
  Of the 40 patients undergoing surgery for breast cancer, 18 required an ALND, with a median age of 49.7 years old. Fourteen patients had a SLNB + ALND, and four patients had ALND alone. In 100% of patients, all breast SLNs were hot but not blue, and the false negative rate was 0. In 11 of 18 ALNDs (61%) blue lymphatics or blue nodes were identified in the axilla. In the initial seven cases with positive lymph nodes in the axilla, the blue node draining from the arm was biopsied and all were negative.
  
  
  CONCLUSIONS
  ARM identified significant lymphatic variations draining the upper extremities and facilitated preservation in all but one case. ARM added to present-day ALND and SLNB further defines the axilla and may be useful to prevent lymphedema.
authors.affiliation: Division of Breast Surgical Oncology, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
authors.forename: Margaret
authors.initials: M
authors.lastname: Thompson
authors.forename: Soheila
authors.initials: S
authors.lastname: Korourian
authors.forename: Ronda
authors.initials: R
authors.lastname: Henry-Tillman
authors.forename: Laura
authors.initials: L
authors.lastname: Adkins
authors.forename: Sheilah
authors.initials: S
authors.lastname: Mumford
authors.forename: Kent C
authors.initials: KC
authors.lastname: Westbrook
authors.forename: V Suzanne
authors.initials: VS
authors.lastname: Klimberg
mesh_terms: D000328:Adult; D000368:Aged; D001365:Axilla / Q000473:pathology*; D001943:Breast Neoplasms / Q000601:surgery*; D004396:Coloring Agents; D005260:Female; D006801:Humans; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000000981:diagnostic imaging / Q000473:pathology*; D008207:Lymphatic Metastasis / Q000000981:diagnostic imaging; D042601:Lymphatic Vessels / Q000000981:diagnostic imaging / Q000473:pathology*; D008209:Lymphedema / Q000517:prevention & control; D008875:Middle Aged; D011446:Prospective Studies; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*; D013671:Technetium Tc 99m Sulfur Colloid
chemical_list: D004396:Coloring Agents; D019275:Radiopharmaceuticals; D013671:Technetium Tc 99m Sulfur Colloid