Gebruers, N., & Tjalma, W.A. (2016). Clinical feasibility of axillary reverse mapping and its influence on breast cancer related lymphedema: A systematic review. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 200, 117–122. 

DOI Link

Purpose

STUDY PURPOSE: To review current literature to (a) examine which approaches for axillary reverse mapping (ARM) are used, (b) determine the oncologic safety of ARM, and (c) determine whether ARM decreases the incidence of lymphedema after axillary lymph node dissection (ALND) and sentinel lymph node dissection (SLND).
 
TYPE OF STUDY: Systematic review

Search Strategy

DATABASES USED: PubMed, Web of Science, Medline, and Cochrane clinical trials.
 
INCLUSION CRITERIA: Studies were included if (a) ARM was performed in ALND or SLND surgeries, (b) a description of the ARM procedure was provided, (c) assessment and definition of lymphedema were reported, (d) a clear distinction between the type of dissection (ALND or SNLD) was presented, (d) follow-up time after surgery was reported, and (e) if they were in English or Dutch.   
 
EXCLUSION CRITERIA: Secondary sources were excluded (doctoral dissertations, letters to the editor or editorials, conference proceedings, reviews, case studies, postmortem studies).
 
 

Literature Evaluated

LITERATURE EVALUATED: Studies were independently evaluated by two reviewers for quality using the checklists from the Dutch Cochrane center with a 1, 0, or ? (1 = if sufficient information was available and no likelihood of bias, 0 = sufficient information but missing a criterion, ? = no information available). No meta-analysis was done.

TOTAL REFERENCES RETRIEVED: 108
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: The method used to evaluate quality is explained; however, the method for assigning levels of evidence and the definition of each level are not described. Randomized, controlled trial (RCT) was assigned at a Level 2 evidence score, and all other studies were scored as Level 3.

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED = 27 studies
  • TOTAL PATIENTS INCLUDED IN REVIEW = The number of patients was not provided for every article, so based on information provided, N = 959. Pooled results: ALND = 1,184, sentinel lymph node biopsy (SLNB) = 1,507
  • SAMPLE RANGE ACROSS STUDIES: 20–360 patients
  • KEY SAMPLE CHARACTERISTICS: Patient characteristics, ARM methodology, ARM feasibility (% on nodes found, % ARM crossover, tumor cells in ARM), assessment, definition, and incidence of lymphedema

Phase of Care and Clinical Applications

PHASE OF CARE: Diagnostic

Results

A total of 27 studies were systematically reviewed for content on the type of ARM, its safety, and whether it decreased the incidence of lymphedema. Three ARM procedures were described: (a) dermally injected blue dye, (b) injected radioisotope Tc-99m Nanocoll with subsequent lymphoscintigraphy, and (c) lymphofluoroscopic assessment using an intradermal injection of indocyanine green (ICG). The ARM detection rate was less in the sentinel lymph node biopsy (SLNB) cases (19.9%–100% with 100% representing one sample) than the ALND cases (46.6%–94.9%). Crossover nodes (those representing ARM and sentinel nodes) were identified in 5.6%–20% of ALND cases and 0%–14% of SLN cases. The recurrence of cancer in nodes that were ARM preserved would determine oncologic safety, in which studies from a referenced source deemed the ARM procedure as oncologically safe in clinically node negative, SLN positive cases, with the exception of the ARM and positive SLN being synonymous. The incidence of lymphedema reported for all ALND cases was 0%–30% and for all SLNB was 0%–4%. Lymphedema ranges for non-ARM ALND cases was 11.8%–53.5% and for SLN samples was 0%–15.8%.

Conclusions

No definite conclusions can be drawn because of the low level of evidence assigned to the studies reviewed, with the exception of one RCT with an assigned evidence level of 2. While feasibility appears to exist with the use of the ARM procedure, a vast range in the rate of ARM nodes and a decreased incidence of lymphedema were detected.  
 
Reviewer conclusion: The criteria for evidence is unclear; therefore, drawing conclusions from the study comparisons in regard to the use of the ARM procedure in reducing the incidence of lymphedema is difficult. The wide ranges of incidence are attributed to several limitations relevant to the lack of consistency in procedure, lymphedema assessment and definition, and varying follow-up intervals that were used to answer the research questions. Theoretically, the ARM procedure should be studied more rigorously in clinical trials, with uniform reporting in comparison with non-ARM lymphedema incidence. This study gives encouraging data in this regard; however, the limitations of the study prohibit generalization.

Limitations

  • Limited search
  • Low sample sizes
  • Lymphedema definition varied
  • Method of lymphedema measurement varied
  • Level of evidence for all studies except one RCT was low.
  • Oncologic safety was based on one source.
  • No information about the patient population and medical characteristics
  • Four indices were used for search.

Nursing Implications

The implications for nursing would be in the area of patient education, if and when the ARM procedure becomes a standard of care. For the present, nurses need to be knowledgeable of clinical trials involving ARM.

Legacy ID

6117