title: Feasibility study of axillary reverse mapping lymphoscintigraphy in carcinoma breast: A concept toward preventing lymphedema.
abstract: OBJECTIVE
  In the surgery of breast cancer, axillary reverse mapping (ARM) is the identification and preservation of arm draining lymph node (ARM node) during an axillary dissection. The assumption is that the ARM node is different from node draining breast and is unlikely to be involved even in the patients with axillary nodal metastases. If we can identify and preserve ARM node using lymphoscintigraphy; morbidity of lymphedema, as seen with axillary dissection, may be avoided.
  
  
  METHODS
  Pathologically proven 50 breast cancer patients undergoing initial surgery (cTx-4, cN0-2, and Mx-0) were included in this study. Less than 37 MBq, 0.5 ml in equally divided doses of filtered 99mTc sulfur colloid was injected intradermally into the second and third web spaces. ARM nodes in the axilla were identified with the help of Gamma Probe intraoperatively; however, their location was noted with the reference to specific anatomical landmarks and sent for histopathological examination after excision.
  
  
  RESULTS
  The ARM node was successfully identified in 47/50 cases (sensitivity - 94%). In 40 out of 47 cases (85%), the location of the ARM node was found to lateral to the subscapular pedicle, above the second intercostobrachial nerve and just below the axillary vein. Of the 47 patients in whom ARM node/s were identified, metastasis was noted in 5 of them (10%). Four out of these 5 patients had the pN3 disease.
  
  
  CONCLUSIONS
  ARM node exists, and it is feasible to identify ARM node using radio isotope technique with an excellent sensitivity. ARM node seems to have a fairly constant location in more than 80% cases. It is involved with metastasis (10% cases) only when there are multiple lymph nodal metastases in the axilla.
authors.affiliation: Department of Nuclear Medicine and PET CT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.
authors.forename: Sunny J
authors.initials: SJ
authors.lastname: Gandhi
authors.affiliation: Department of Surgical Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.
authors.forename: C
authors.initials: C
authors.lastname: Satish
authors.affiliation: Department of Nuclear Medicine and PET CT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.
authors.forename: Palaniswamy Shanmuga
authors.initials: PS
authors.lastname: Sundaram
authors.affiliation: Department of Nuclear Medicine and PET CT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.
authors.forename: Padma
authors.initials: P
authors.lastname: Subramanyam
authors.affiliation: Department of Surgical Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.
authors.forename: D K
authors.initials: DK
authors.lastname: Vijaykumar
keywords: 99mTc sulfur colloid; axillary reverse mapping; breast cancer; lymphedema; sentinel lymph node scintigraphy