Ahmed, M., Rubio, I.T., Kovacs, T., Klimberg, V.S., & Douek, M. (2016). Systematic review of axillary reverse mapping in breast cancer. The British Journal of Surgery, 103, 170–178. 

DOI Link

Purpose

STUDY PURPOSE: To discuss the usefulness and safety of axillary reverse mapping (ARM) of the arm and breast during surgery on the development of breast cancer-related lymphedema

TYPE OF STUDY: Systematic review

Search Strategy

DATABASES USED: PubMed, Embase, and Cochrane Library
 
INCLUSION CRITERIA: Original studies published up until March 2015, using only the search terms axillary reverse mapping and breast cancer. Reference lists were hand searched. Studies were chosen if (a) they included the performance of ARM with or without completion of axillary node clearance (ANC) or ANC alone, (b) data were collected prospectively, (c) had a minimum of 50 patients, (d) oncologic and lymphedema outcomes were assessed, (e) patient follow-up was performed at a minimum of six months, (f) a satisfactory quality assessment score was attained (4 of 6 or greater for cohort, 5 of 8 for randomized controlled trials [RCTs]), and (g) they were written in English.
 
EXCLUSION CRITERIA: Review articles, letters to editor, editorial reports, case reports, abstracts, and duplicate publications were excluded. Studies that did not report outcomes of interest or did not include full text were excluded.

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 109
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: STROBE recommendations were used to assess the quality of cohort studies. Six statements were considered suitable for quality evaluation. The studies included had an overall STROBE score of 4–6. Cochrane risk-of-bias was used to determine the suitability of RCTs. A data extraction tool was developed to include publication details, study design, number of patients, number of patients undergoing either sentinel node biopsy (SNB) alone or followed by ANC, or ANC alone; ARM technique; follow-up period; ARM node or lymphatics identification and preservation rate; ARM crossover node-positive rate; incidence of lymphedema; and breast cancer recurrence rate information from selected studies. A total of eight studies were included for review.

Sample Characteristics

FINAL NUMBER STUDIES INCLUDED = 8 (7 prospective cohort, 1 randomized, controlled trial [RCT])
 
TOTAL PATIENTS INCLUDED IN REVIEW = 1,142
 
SAMPLE RANGE ACROSS STUDIES: 52–360 patients
 
KEY SAMPLE CHARACTERISTICS: Studies published between 2009–2015. Technical differences existed in all studies of the ARM technique. All subjects were breast cancer survivors. Definitions of lymphedema, follow-up period, SNB, ARM feasibility (%) nodes found, ARM crossover, and tumor cells in ARM were provided.

Phase of Care and Clinical Applications

PHASE OF CARE: Late effects and survivorship

Results

This review showed that the ARM technique is feasible and can result in low rates of lymphedema, and identification of ARM lymphatics and nodes was higher with ANC than SNB. The rate of lymphedema during SNB was 0%–6% and 5.9%–24% during lymphatic preservation at ANC, both of which are still lower than previously stated rates. Ochoa et al. reported a lymphedema rate of 2.5% for SNB alone and 2% with ARM. Casabona et al. reported no cases of lymphedema. Crossover nodes were identified in four studies assessing ARM in SNB, two of which were metastases. Kuusk et al. identified 1/ 5 nodes, and Ochoa et al. identified 2/14 nodes, thereby suggesting that crossover nodes are not common during ARM and however many metastases are present (0%–20%). Metastases were detected at the same rate (0%–19%) in patients where ARM nodes were not preserved when identified. Ochoa et al. reported 5/27 ARM positive nodes and Han et al. reported 2/17 positive ARM nodes during SNB, while Tausch et al. identified 13/58 metastases ARM nodes during ANC.

Conclusions

The rate of lymphedema is lower in the majority of patients when ARM nodes are spared when sentinel lymph node (SLN) is negative and no crossover exists. However, given the risk for metastasis, ARM nodes or those in close proximity to SLN should be excised.  
 
Reviewer conclusion: RCTs using the same protocols and definitions for lymphedema are warranated. Length of follow-up is not long enough to encompass most often reported periods of onset.

Limitations

  • Limited search
  • Low sample sizes
  • Short follow-up intervals did not allow a long enough interval to establish the oncologic safety of ARM
  • Standard SNB technique was not used in all studies.
  • Different definitions of lymphedema
  • Clinical diagnoses of lymphedema were made occasionally.
  • Inconsistent knowledge of number of nodes excised and if patients were undergoing adjuvant

Nursing Implications

The implications for nursing would be in the area of low-level laser therapy (LLLT) patient education, understanding of the ARM technique, and evidence related to lymphedema rate. For the present, nurses need to be knowledgeable of clinical trials involving the ARM technique and stay current with lymphedema management.

Legacy ID

6115