Dr. Hunt on Axillary Reverse Mapping in Breast Cancer

Kelly K. Hunt, MD, FACS, FSSO, professor, chair, Department of Breast Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, discusses technical considerations for axillary reverse mapping in breast cancer for the reduction or prevention of lymphedema.

Axillary reverse mapping during axillary lymph node dissection uses radioactive isotopes in the form of blue dye injected into the arm to determine which sentinel lymph nodes drain the breast and which drain the arm so as to preserve the lymph node drainage system surrounding the breast and potentially prevent post-surgery lymphedema, Hunt says. However, sometimes lymph node drainage crossover occurs and the same lymph node drains both the breast and the arm, Hunt notes. Going forward, evolving considerations surrounding the role of axillary reverse mapping will be important because if a lymph node appears to be draining the arm but is also draining the breast tumor, it could harbor disease and should not be overlooked during surgery, Hunt emphasizes.

Newer surgical approaches for the prevention of lymphedema include lymphovenous bypass, or lymphovenous anastomosis, a microvascular technique that involves resecting the lymph nodes but sparing and reconstructing the lymphatic channels in the arm, Hunt explains. This method is technically challenging and usually requires a microscope, Hunt notes. Another effective technique involves the reapproximation of the lymphatics with branches of the axillary vein, Hunt explains.

Although several clinical trials have investigated the feasibility of lymphedema prevention using axillary reverse mapping and various lymphatic reconstruction techniques, further follow-up data are still needed to determine how many patients still develop lymphedema after undergoing these approaches, Hunt says. For instance, an ongoing, randomized phase 3 trial (NCT03927027) is comparing lymphedema prevention rates with axillary reverse mapping plus axillary lymph node dissection (ALND) vs ALND alone in patients with breast cancer. The findings from this study and others may support the use of axillary reverse mapping during initial breast surgery to prevent lymphedema, Hunt concludes.