Axillary Reverse Mapping in Breast Cancer

Axillary lymph node dissection represents the standard surgical treatment for breast cancer patients with clinically or histologically involved axillary lymph nodes. However, it is associated with significant morbidity, including postoperative arm lymphedema and neuropathy of the involved extremity, and seroma formation in the axilla (Noguchi et al., 1997). Particularly, arm lymphedema develops in 7%77% of patients who undergo axillary lymph node dissection (Blanchard et al., 2003; Leidenius et al., 2005; Haid et al., 2002; Mansel et al., 2006; Ronka et al., 2005; Schijven et al., 2003; Schrenk et al., 2000; Swenson et al., 2002). At present, sentinel lymph node biopsy is accepted as the standard method of surgical staging for axillary lymph nodes in breast cancer. It can avoid unnecessary axillary lymph node dissection in node-negative patients, thereby minimizing arm lymphedema. Nevertheless, node-positive patients who undergo axillary lymph node dissection do not benefit from sentinel lymph node biopsy. Moreover, sentinel lymph node biopsy does not completely eliminate arm lymphedema. Several cooperative group trials have shown lymphedema rates in range of approximately 7% with sentinel lymph node biopsy alone (Sakorafas et al., 2006; Wilke et al., 2006). Recently, the axillary reverse mapping technique has been developed to map and preserve arm lymphatic drainage during axillary lymph node dissection and/or sentinel lymph node biopsy (Nos et al., 2007; Thompson et al., 2007). This technique is based on the hypothesis that the lymphatic pathway from the arm cannot be involved by metastasis of the primary breast cancer. The assumption is that the lymphatic drainage from the upper arm is different from that of the breast, allowing safe removal of only the lymphatics of the breast and protection of the lymphatic channels draining the upper extremity during axillary lymph node dissection or sentinel lymph node biopsy, thereby preventing arm lymphedema. However, several studies have shown that there are limits to the principle of non-overlap between breast and arm nodes, including: (a) the axillary reverse mapping nodes may be involved with metastatic foci in patients with extensive axillary lymph node metastases (Bedrosian et al., 2010; Kang et al., 2009; Noguchi et al., 2010b; Nos et al., 2008; Ponzone et al., 2009), and (b) the sentinel lymph node draining the breast may be the same as the axillary reverse mapping node draining the upper extremity in some patients (Boneti et al., 2009; Britton et al., 2009; Kang et al., 2009; Noguchi et al., 2010b). Therefore, the oncological safety of this procedure has not yet determined. This article presents a review of current knowledge regarding in the axillary reverse mapping procedure, and discusses its practical applicability and relevance.