Feasibility of Axillary Reverse Mapping (ARM) in cancer breast with positive axilla using sodium diethyl ammonium hydroxide (patent blue) dye

INTRODUCTION

Breast cancer represents the most frequent cancer in women globally and the most prevalent deadly malignancy, accounting for roughly 23% of all cancers in women and nearly 1,000,000 new instances every year.^{1, 2}

For decades, axillary lymph node dissection (ALND) was considered a beneficial procedure for ultimate axillary staging and loco-regional management in carcinoma patients. On the other hand, ALND is thought to be associated with morbidity, such as numbness, pain, or paraesthesia, arm and/or shoulder motion limitation, and, in particular, upper limb lymphedema.³ limb lymphedema has been documented in ALND patients and is thus the most common complication.³

Breast cancer-related lymphedema (BCRL) Breast cancer-related lymphedema (BCRL) has become one of the most prevalent and unpleasant consequences amongst post-surgical carcinoma survivors.⁴ The prevalence of which ranges from 13.5% to 42.0% and varies from study to study due to differences in target population, measurement duration, and other factors.⁵

The biopsy of sentinel lymph nodes (SLN) has been a generally established approach for the operative staging of axillary lymph nodes for carcinoma. In node-negative patients, this procedure may reduce arm lymphedema by avoiding unnecessary axillary lymph gland dissection (ALND). SLN biopsy, however, is disliked by node-positive individuals undergoing ALND; additionally, SLN biopsy doesn't completely remove arm lymphedema.⁶

The purpose of axillary reverse mapping (ARM) is to distinguish the lymphatics and arm lymph nodes from those of the breast during an axillary operation, allowing arm lymphatics to be preserved and decreasing arm lymphedema in node-positive patients.⁷

A multicenter patient- and assessor-blind randomized controlled trial was launched in the Netherlands in 2013 (Axillary Reverse Mapping trial). The goal was to determine the therapeutic safety and effectiveness of using Axillary Reverse Mapping to selectively preserve upper-limb axillary nodes as well as lymphatics in lymph node positive cases. ⁸

Blue dye injection and tracking are presently supported ARM techniques.⁹

The purpose of the work has been to check the feasibility of the axillary reverse mapping (ARM) technique in carcinoma patients with positive axillary lymph nodes using sodium diethyl ammonia (patent blue) dye.

PATIENTS AND METHODS

This study included 40 patients. All patients were underwent surgery in general surgery and surgical oncology departments of Al-Azhar university hospitals.

Inclusion criteria: patients who are histopathologically proved to have breast cancer, and patients with clinical and radiological positive axillary lymph nodes.

Exclusion criteria: Patients who have negative axillary lymph nodes, patients who were medically unfit for surgery, patients who are received neo adjuvant therapy, and patients who refused this technique.

The following procedures were carried out on all of the patients:

Medical history-taking and careful clinical examination.

Laboratory investigations: Full labs: Cbc, (Pt, Ptt, Inr), S.Creat, liver enzymes, and RBG.

Imaging: Bilateral sonomammography, plain chest-X-ray, pelvi- abdominal US, and further radiology whether local or systemic according to indication

Diagnostic pathology: Core biopsy or wedge biopsy.

Axillary reverse mapping procedure:

Type of dye: patent blue dye.( Sodium diethyl ammonium hydroxide)

Skin sensitivity test: intra dermal injection of 0.1 ml of the dye in the conteralateral forearm in the night before surgery and see if there was allergic reaction or not.

Dose of injected dye: 5ml.

Time of injection: 10 minutes preoperative

Site of injection: upper inner aspect of the ipsilateral arm intra dermal and subcutaneous (Figs. 1, 2).

Fig. 1: Site of injection of dye at the ipsilateral arm's upper inner aspect

Fig. 2: Site of injection of dye at the ipsilateral arm's upper inner aspect.

We sterilize the skin at site of injection then we introduce the needle by an angle of 10 to 15 degrees (intra dermal) or 45 degrees (subcutaneous).

Then we did: mastectomy (MRM) or (lumpectomy or quadrantectomy as a part of conserving breast surgery) both of them were subjected to ALND.

Management of the axilla:

All cases were subjected to ALND:

Identification of axillary vein.

Fig. 3: Stained axillary LNs.

Detection of stained LNs.

Determine the location of stained LNs (belong to which group).

Axillary clearance with preservation of identified arm lymphatics.

Fig. 4: Important contents of axilla: (A) Stained LNs (lateral group). (B) Thoraco dorsal nerve (nerve to latissimus dorsi muscle). (C) Long thoracic nerve.

Fig. 5: Important contentes of axilla: (1) Branched axillary veien. (2) Stained lateral axillary LNs. (3) Thoraco dorsal nerve (nerve to latissimus dorsi muscle). (4) Long thoracic nerve.

Statistical analysis:

To code, enter, and analyze data obtained during the history, basic clinical examinations, laboratory testing, and result measurements, the Microsoft Excel program was used. The data was then analyzed using the Statistical Package for the Social Sciences (SPSS) version 20.0 software. The following tests have been performed to evaluate differences for significance difference and connection of qualitative variables using the Chi-square test (X2), based on the kind of data qualitatively represented as numbers and percentages, and quantitatively described using mean ± SD. The t test has been employed to compare differences between quantitatively independent groups. For significant findings, the P value was set to < 0.05, and for highly significant findings, it was set at < 0.001.

RESULTS

Table 1: Age distribution and anthropometric measures distribution among studied group (N=40).

Age was distributed as 52.42±3.80 with minimum 45 and maximum 59 years. Weight was distributed as 80.30±10.65 with minimum 65 and maximum 100 Kg and height was distributed as 164.12±5.04 with minimum 155 and maximum 172 cm and regard BMI it was distributed as 29.83±3.89 with minimum 23.3 and maximum 36.0 (Table 1).

Table 2: Co-morbidities, Operation type distribution among studied group (N=40).

20.0% were diabetic and 155 were hypertensive. 72.5% of studied group managed by MRM and 27.5% by CBS (Table 2).

Table 3: Stain site distribution among studied group (N=40).

Majority were below axillary vein 62.5% and lateral to thoraco-dorsal nerve 57.5% and we had 5 cases not detected regard stain (Table 3).

Table (4): Complication distribution among studied group (N=40).

No case had anaphylaxis, 4 cases had infection, and 2 cases with ulceration and overall complicated cases were 6 (15.0%) (Table 4).

Table 5: Relation of complication with other parameters.

Complicated cases significantly elder and higher regard weight and BMI also significantly associated with DM (Table 5).