Review
Clinical feasibility of Axillary Reverse Mapping and its influence on breast cancer related lymphedema: a systematic review

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Abstract

Breast cancer is the most common malignancy in women worldwide. Fortunately, the overall survival is good. Therefore it is important to focus on the morbidities related to breast cancer treatment. One of the most dreaded morbidities is lymphedema. In 2007 the Axillary Reverse Mapping (ARM) was introduced to limit the invasiveness in the axilla during breast cancer surgery. It is hypothesized that ARM is able to limit the incidence of breast cancer related lymphedema (BCRL) considerably. This systematic review aims to answer the following research questions: (1) which approaches for ARM are described? (2) Is ARM surgical feasible and oncological safe? (3) Does ARM decrease the incidence of lymphedema after sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND)?

In total 27 papers were retrieved using four electronic databases (PubMed, Web of Science, Medline and Cochrane clinical trials; assessed until May 13, 2015. 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.

Introduction

Breast cancer is the most common malignancy in women worldwide, with an increased incidence almost every year [1]. In Belgium about 12,000 women are diagnosed with breast cancer each year (www.cancerregistry.be). Rephrased, at some time during their life, breast cancer will be diagnosed in 1 out of every 8 women [2]. Nowadays the general survival after breast cancer treatment is good with a 5-year survival of 85% or more [3]. Because of the increasing survival the QoL becomes more and more important for breast cancer patients. QoL is impacted by the morbidities provoked by breast cancer treatment. Recent systematic reviews have clearly demonstrated that patients treated with axillary lymph node dissection (ALND) as well as sentinel lymph node biopsy (SLNB) experience a wide variety of morbidities like axillary web syndrome, numbness, loss of range of motion, pain, scapular winging, fatigue and lymphedema [4], [5], [6]. Lymphedema is one of the most dreaded morbidities because of the chronicity related to this morbidity. Although serious efforts have been made to reduce the invasiveness of the surgery, lymphedema is still a morbidity encountered by breast cancer patients [7], [8]. The reported incidence in the literature ranges from 11.8 to 53.5% or 0 to 15.8% for ALND and SLN-, respectively [9], [10]. Tremendous efforts have been made to limit the impact of surgery; a clear example is the introduction of the SLNB [11]. Although, when the SLN is negative the surgery in the axilla is limited to the removal of one or two lymph nodes; we still diagnose lymphedema in SLNB- patients. We also know that lymphedema cannot be prevented by means of a post-surgery physical therapy protocol consisting of manual lymph drainage (MLD), exercise, skin care and compression [12]. Therefore, the Axillary Reverse Mapping (ARM) was introduced in 2007 to limit the invasiveness in the axilla during breast cancer surgery [13]. The hypothesis of the ARM procedure is to map the lymphatics draining the arm into the axilla. It is postulated that the lymphatics draining the arm are not the same lymphatics that drain from the breast. When visible, the surgeon can spare these lymphatics during lymph node(s) surgery; limiting the possibility of breast cancer related lymphedema (BCRL). Since 2007, several publications concerning ARM have been published. Therefore, the current systematic review focuses on answering the following research questions (RQ): (1) which approaches for ARM are described? (RQ1), (2) is ARM surgical feasible and oncological safe? (RQ2), (3) does ARM decrease the incidence of lymphedema in SLN and ALND? (RQ3).

Section snippets

Methods

The literature was systematically reviewed, based upon the PRISMA guidelines, addressing the research questions mentioned above. Four electronic databases were screened online to identify eligible studies: PubMed, Web of Science, Medline and Cochrane clinical trial. All databases were consulted until the 13th of May 2015. In order to retrieve eligible studies, Medical Subject Headings (Mesh-terms) and key words were combined in a Boolean search strategy (PIC0) to describe the patient population

Results

A total of 27 unique full-texts were used to answer the research questions; 1 RCT [14] and 28 [13], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38] prospective cohort and 1 retrospective study [39]. Except the RCT who scored level 2 all other studies scored level 3 concerning their level of evidence [40].

Three different procedures were described to perform the ARM. First, multiple authors described

Discussion

To answer the postulated research questions, a substantial amount of studies were found (n = 27). Unfortunately, almost all studies [13], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39] had a low level of evidence (level 3) except the only RCT [14] that was included, which had a level 2. This means that the answers to the research questions still need to be interpreted with extreme precaution.

In

Conclusion

Overall the current review provides the first combined evidence concerning the ARM procedure. Based upon the level of evidence (mainly level 3) we are unable to draw definite conclusions. Technically, the procedure is feasible although ARM 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 the use

Funding

We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated and, if applicable, we certify that all financial and material support for this research (e.g., NIH or NHS grants).

Conflict of interest

The authors have no conflict of interest to declare.

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