Kumar K Shiva, Hemanth G N, Panjwani Poonam K, Manjunath Suraj, Ramesh Rakesh S, Burrah Rajaram, Rout Pritilata, Ramu D, Joseph Elvis Peter, Chandran Ravi, Prasad C, Goel Vipin, Divya Supari
Department of Surgical Oncology, St. John's Medical College Hospital, Sarjapura Road, Bangalore, 560034 India.
Department of Pathology, St. John's Medical College Hospital, Sarjapura Road, Bangalore, 560034 India.
Indian J Surg Oncol. 2017 Jun;8(2):119-122. doi: 10.1007/s13193-016-0578-1. Epub 2016 Nov 18.
The axillary reverse mapping (ARM) technique has been described as an attempt to map and preserve the upper extremity lymphatic drainage during axillary lymph node dissection (ALND) and/or SLNB. This technique is based on the hypothesis that the lymphatic pathway from the upper extremity is not involved by metastasis from primary breast cancer. The ARM node/s however, has been found, in various studies, to be involved with metastatic foci in patients with extensive axillary lymph node metastases. Therefore, the oncological safety of this procedure has not yet been determined. In this pilot study, we assessed the ARM node intraoperatively for various parameters and compared it to final HPR, to try and determine the oncologic safety of preserving the ARM node. Seventy-two breast cancer patients were screened for this prospective pilot study which was planned to recruit 20 patients. The study was initiated on May 2014, 20 patients were recruited till July 2015. Eligibility criterion was as follows: patients requiring primary axillary lymph node dissection based on a clinically positive axilla. Forty-five patients were ineligible because they had either received neoadjuvant chemotherapy or underwent previous axillary surgery or axillary radiation (exclusion criteria). Seven patients refused to give consent. ARM node identification rate was 75%. The most common location of the ARM node was lateral to the latissimus dorsi pedicle (42.10%), none of them being malignant. None of the oval or firm nodes were malignant. Tumor deposits were identified in 13%. Fine-needle aspiration cytology (FNAC) had 100% specificity, 94.4% negative predictive value, 100% positive predictive value, and 50% sensitivity. ARM is feasible using blue dye alone, with an acceptable identification rate. Location, consistency, and intraoperative FNAC of the ARM node, put together, may be reliable parameters to predict involvement of the ARM node with metastasis.
腋窝反向映射（ARM）技术被描述为一种在腋窝淋巴结清扫术（ALND）和/或前哨淋巴结活检（SLNB）期间绘制和保留上肢淋巴引流的尝试。该技术基于这样的假设，即来自上肢的淋巴途径未被原发性乳腺癌转移累及。然而，在各种研究中发现，ARM淋巴结在腋窝淋巴结广泛转移的患者中与转移灶有关。因此，该手术的肿瘤学安全性尚未确定。在这项前瞻性研究中，我们在术中评估了ARM淋巴结的各种参数，并将其与最终的组织病理学结果（HPR）进行比较，以试图确定保留ARM淋巴结的肿瘤学安全性。对72例乳腺癌患者进行了筛查，以纳入这项计划招募20例患者的前瞻性研究。该研究于2014年5月开始，截至2015年7月招募了20例患者。纳入标准如下：基于临床腋窝阳性需要进行原发性腋窝淋巴结清扫的患者。45例患者不符合条件，因为他们要么接受了新辅助化疗，要么曾接受过腋窝手术或腋窝放疗（排除标准）。7例患者拒绝签署知情同意书。ARM淋巴结识别率为75%。ARM淋巴结最常见的位置是背阔肌蒂外侧（42.10%），均无恶性病变。椭圆形或质地硬的淋巴结均无恶性病变。在13%的病例中发现了肿瘤沉积物。细针穿刺细胞学检查（FNAC）的特异性为100%，阴性预测值为94.4%，阳性预测值为100%，敏感性为50%。仅使用蓝色染料进行ARM是可行的，识别率可接受。ARM淋巴结的位置、质地及术中FNAC综合起来可能是预测ARM淋巴结是否发生转移的可靠参数。
