Simultaneous two-color spectral fluorescence lymphangiography with near infrared quantum dots to map two lymphatic flows from the breast and the upper extremity

Due to their small size and poor access, the lymphatic function has been difficult to study in vivo. Especially difficult is the mapping of lymphatic drainage from two basins into the same node. Quantum dots can be used to perform multicolor images with high fluorescent intensity and are of a nano-size size suitable for lymphatic imaging via direct interstitial injection. Here we show simultaneous two-color in vivo wavelength-resolved spectral fluorescence lymphangiography using two near infrared quantum dots with different emission spectra, which allow non-invasive and simultaneous visualization of two separate lymphatic flows draining the breast and the upper extremity and variations in the drainage patterns and the water sheds within the axillary node. Two-color spectral fluorescence lymphangiography can provide insight into mechanisms of drainage from different lymphatic basins that may lead to sentinel lymph nodes detection of the breast cancer as well as prevention of complications such as lymphedema of the arm. Yukihiro Hama and Yoshinori Koyama are contributed equally to this work.     

逆行腋窝淋巴示踪的动物研究

目的 研究逆行腋窝淋巴示踪(axillary reverse mapping,ARM)显影上肢引流入腋窝的淋巴通路,在腋窝淋巴结清扫和(或)前哨淋巴结活检时对上肢淋巴引流通路的保护作用,从而减少乳腺癌术后上肢水肿的发生率.方法 使用雌性新西兰大白兔,通过纳米炭混悬注射液(卡纳琳)显影乳腺至腋窝的淋巴管网、亚甲蓝显影上肢...     

Correction to: Secretomes reveal several novel proteins as well as TGF-β1 as the top upstream regulator of metastatic process in breast cancer

Purpose

We studied the lymphatic drainage of the upper limb and mammary region directing to the axilla to investigate whether independent pathways can be observed or whether anastomoses and shared drainage occur between them. This analysis aimed to assess the safety of axillary reverse mapping (ARM) in breast cancer treatment and to understand the development of lymphedema after sentinel lymph node biopsy (SLNB) alone.

Methods

Seven unfixed stillborn fetuses were injected with a modified Gerota mass in the peri-areolar area, palm and dorsum of the hands, formalin fixed, and then submerged in 10% hydrogen peroxide solution. Microsurgical dissection was then performed on the subcutaneous cellular tissue of the upper limb, axillary region, and anterior thorax to expose the lymphatic vessels and lymph nodes.

Results

The dye injected into the upper limb reached either the lateral axillary group, known to be exclusively responsible for upper limb drainage, or the anterior group, which is typically related to breast drainage. There was great proximity among the pathways and lymph nodes. Communicating lymphatic vessels among these groups of lymph nodes were also found in all studied cases.

Discussion

Lymphedema remains a challenging morbidity in breast cancer treatment. ARM and SLNB aim to avoid unnecessary damage to the lymphatic drainage of the upper limb. However, our anatomical study suggests that ARM may have potential oncological risks because preserved lymph nodes may harbor malignant cells due their proximity, overlapping drainage pathways, and connecting lymph vessels among lymph nodes.

     

Axillary reverse lymphatic mapping in breast cancer surgery: a comprehensive review

Axillary reverse lymphatic mapping (ARM) is a surgical technique that was first described in 2007 as a method for preserving the lymphatic drainage of the arm during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) for breast cancer. We found that the ARM technique had several limitations that include a poor success rate for identification of arm lymph nodes (ARM nodes) and lymphatics. The occurrence of common lymphatic drainage pathways of the arm and the breast in a subset of patients also raises concerns regarding its oncological soundness. Furthermore, the effectiveness of the ARM procedure in reducing lymphedema risk in breast cancer patients that undergo a variety of treatments, has yet to be clearly defined.     

Axillary reverse mapping using near-infrared fluorescence imaging in invasive breast cancer (ARMONIC study)

BackgroundAxillary lymph node dissection (ALND) in patients with breast cancer has potential side effects, including upper-limb lymphedema. Axillary reverse mapping (ARM) is a technique that enables discrimination of the lymphatic drainage of the upper limb in the axillary lymph node basin from that of the breast. We aimed to evaluate ARM node identification by near-infrared (NIR) fluorescence imaging during total mastectomy with ALND and then to analyze potential predictive factors of ARM node involvement.MethodsThe study enrolled 119 patients diagnosed with invasive breast cancer with an indication for ALND. NIR imaging using indocyanine green dye was performed in 109 patients during standard ALND to identify ARM nodes and their corresponding lymphatic ducts.Results94.5% of patients had ARM nodes identified (95%CI = [88.4–98.0]). The ARM nodes were localized in zone D in 63.4% of cases. Metastatic axillary lymph nodes were found in 55% in the whole cohort, and 19.4% also had metastasis in ARM nodes. Two patients had metastatic ARM nodes but not in the remaining axillary lymph nodes. No serious adverse events were observed. Only the amount of mitosis was significantly associated with ARM node metastasis.ConclusionsARM by NIR fluorescence imaging could be a reliable technique to identify ARM nodes in real-time when ALND is performed. The clinical data compared with ARM node histological diagnosis showed only the amount of mitosis in the diagnostic biopsy is a potential predictive factor of ARM node involvement.Clinical trial registrationNCT02994225.     

核素淋巴显像识别前哨淋巴结在乳腺癌治疗中的应用

目的评价核素淋巴显像和γ探针定位在乳腺癌中确定前哨淋巴结(SLN)的应用价值,验证前哨淋巴结活检替代腋窝淋巴结清除术用于乳腺癌治疗的安全性与价值。方法选择1999年6月至2009年11月本院住院的女性乳腺癌患者206例(体检时腋窝均未扪及肿块),应用99Tcm-DX37～74 MBq或99Tcm-SC74 MBq经皮下注射,行核素淋巴显像后,术中注射专利兰1 ml和(或)术中用γ探针定位并行前哨淋巴结活检,与术中冰冻病理检查结果对照。若术中冰冻发现有前哨淋巴结转移,则行腋窝淋巴结清除术,若前哨淋巴结阴性,则不做腋窝淋巴结清除,术后定期随访。结果 206例乳腺癌术中成功活检SLN204例,成功率为99.0%(204/206)。本组有64例仅行SLN切除,术后病理检查证实64例SLN均阴性,故未行腋窝淋巴结清除,其中仅1例于术后1年时出现腋窝淋巴结转移,其余63例患者在随访期间均未发现腋窝淋巴结转移,也未出现同侧上肢水肿、感觉及活动异常;另140例行腋窝淋巴结清除,其中6例经病理证实SLN阳性但腋窝淋巴结为阴性,134例经病理证实SLN阳性35例,阴性99例,腋窝淋巴结阳性37例,阴性97例。核素淋巴显像和γ探针定位法的灵敏度为94.6%(35/37例),准确率为98.5%(138/140),假阴性为5.4%(2/37)。结论核素淋巴显像和γ探针定位应用于乳腺癌是切实可行和可能的,对预测腋窝淋巴结转移有很大的临床实用价值。如技术方法规范,早期乳腺癌前哨淋巴结活检则能取代常规的腋窝淋巴结清除术,乳腺癌手术上肢并发症的发生率可大大降低。     

Delayed resolution of jaundice in the arm of a patient with impaired lymphatic drainage: a case report

A 40-year-old woman, 6 years after mastectomy, lymph node dissection, and locoregional radiation, presented with hepatic metastases, pruritus, and jaundice. Physical examination revealed uniformly jaundiced skin and no arm lymphedema. Ultrasonography confirmed progressive hepatic metastases with no evidence of intrahepatic or extrahepatic biliary dilatation. Eight weeks after starting chemotherapy, her pruritus and jaundice were markedly improved, but the jaundice on the skin of her left arm was substantially slower to clear than the other skin areas. With further therapy, serum bilirubin normalized and her left arm jaundice completely resolved. We hypothesize that the delayed resolution of jaundice on her left arm resulted from impaired lymphatic drainage after left axillary lymph node dissection and irradiation, and conclude that lymphatic drainage might play a key role in the transport and clearance of bilirubin and related pigments from peripheral tissues.     

腋窝逆向淋巴示踪预防乳腺癌患者上肢淋巴水肿的研究

目的：探讨乳腺癌前哨淋巴结活组织检查（ SLNB）或腋窝淋巴结清扫（ ALND）过程中,进行腋窝逆向淋巴示踪（ ARM）以保留引流上肢淋巴液的腋窝淋巴结的可行性,及其对术后上肢淋巴水肿的预防作用。方法选择2012年1月至2013年6月本科71例全乳房切除术＋前哨淋巴结活组织检查术患者（ SLNB组）和134例乳腺癌改良根治术患者（ ALND组）进行临床研究。将SLNB组和ALND组分别随机分为对照组和示踪组,即：SLNB对照组36例,SLNB示踪组35例;ALND对照组64例,ALND示踪组70例。 SLNB示踪组和ALND示踪组的手术方式除与其对照组相同外,还需进行ARM以保留引流上肢淋巴液的腋窝淋巴结（ ARM淋巴结）。前哨淋巴结和ARM淋巴结定位方法如下：术前2 h,在患者乳房肿块周围及患侧上臂内侧皮下注射^99Tc^m-Dx标记的同位素,并于术前5 min在患侧上臂内侧皮下注射2 ml亚甲蓝进行ARM淋巴结显色,术中用同位素γ探测仪探测放射性核素热点进行前哨淋巴结定位,并用γ探测仪结合蓝色染料定位ARM淋巴结。术中注意观察ARM淋巴结蓝染情况及其与前哨淋巴结有无重合,若无重合则保留所有蓝染的ARM淋巴结,若有重合则同时切除前哨淋巴结和ARM淋巴结;术后统计切除的淋巴结数量、术中出血量、置管时间、引流液体量及手术时间。术后6个月随访两组患者上肢淋巴水肿的发生情况。定量资料分析采用 t检验,定性资料比较采用秩和检验或χ^2检验。结果在SLNB示踪组35例患者中,26例（74．29%,26/35）术中检测到ARM淋巴结,其中1例患者前哨淋巴结与ARM淋巴结重合,此患者在SLNB过程中也接受了ARM淋巴结切除,因此SLNB示踪组ARM淋巴结保留率为71．43%（25/35）。在ALND示踪组70例患者中,67例（95．71%,67/70）术中检测到ARM淋巴结,其中5例患者前哨淋巴结与ARM淋巴结重合,此部分患者在ALND过程中同时接受ARM淋巴结切除,因此ALND示踪组ARM淋巴结保留率为88．57%（62/70）。在SLNB对照组与SLNB示踪组之间以及ALND对照组与ALND示踪组之间,腋窝淋巴结切除数量、术中出血量、术后引流液体量及置管时间的差异均无统计学意义（ t=-1．136、-0．570、0．032、0．903,P=0．264、0．570、0．975、0．370;t=1．149、0．416、1．405、-0．547,P=0．253、0．678、0．162、0．585）,但是SLNB示踪组和ALND示踪组的手术时间均长于其对照组[（90．26±6．04） min比（86．61±5．62） min,t=-2．616,P=0．011;（112．24±7．94） min比（92．33±6．88） min,t=-15．399,P=0．000]。术后随访6个月：SLNB对照组与SLNB示踪组上肢淋巴水肿发生率分别为11．11%（4/36）和8．00%（2/25）,两者间差异无统计学意义（P=1．000）;ALND对照组与ALND示踪组上肢淋巴水肿发生率分别为31．25%（20/64）和6．45%（4/62）,两者间差异有统计学意义（χ2=12．560,P=0．000）。结论乳腺癌患者行SLNB或ALND的过程中可以行ARM。 SLNB过程中保留ARM淋巴结对降低术后上肢淋巴水肿发生率无意义,而ALND过程中保留ARM淋巴结可有效降低术后上肢淋巴水肿发生率。     

乳腺癌腔镜腋窝淋巴结清扫术后患侧肢体功能的评价

目的评价腔镜腋窝淋巴结清扫术对乳腺癌患者患侧上肢功能的影响。方法 2005年10月至2009年10月在我院住院的乳腺癌患者,按腋窝淋巴结处理方式不同分为腔镜腋窝淋巴结清扫组（A组,123例）和常规腋窝淋巴结清扫组（B组,115例）,随访两组患者术后6、12、24及≥36个月以上患侧上肢活动受限、感觉障碍、疼痛、淋巴水肿以及腋窝部肿瘤复发的发病情况。结果腔镜腋窝淋巴结清扫组（A组）患者术后6、12、24及≥36个月以上其肩关节活动受限、感觉障碍、疼痛的发病情况与常规腋窝淋巴结清扫组（B组）比较,差异无显著性（P〉0.05）,但是,患侧上肢淋巴水肿的发生率则分别为13.5%比34.6%,17.6%比36.5%和18.2%比35.0%,差异有显著性（P〈0.05）。7～55个月的随访中两组患者均未发现腋窝部肿瘤复发。结论乳腺癌患者行腔镜腋窝淋巴结清扫术与常规腋淋巴结清扫术比较可降低患侧上肢淋巴水肿的发生率,而在肩关节活动、感觉障碍、疼痛及腋窝部肿瘤复发方面无差异。     

Short‐ and long‐term recovery of upper limb function after axillary lymph node dissection

DEVOOGDT N., VAN KAMPEN M., CHRISTIAENS M.R., TROOSTERS T., PIOT W., BEETS N., NYS S. & GOSSELINK R. (2011) European Journal of Cancer Care 20 , 77–86
Short‐ and long‐term recovery of upper limb function after axillary lymph node dissection All breast cancer patients, suspected with lymph node invasion, need an axillary lymph node dissection. This study investigated the short‐ and long‐term effects of the treatment for breast cancer on shoulder mobility, development of lymphoedema, pain and activities of daily living. Patients who had a modified radical mastectomy (33%) or a breast‐conserving procedure (67%) in combination with axillary lymph node dissection were included. Shoulder mobility, lymphoedema, pain and activities of daily living were evaluated at 3 months and at 3.4 years after surgery. At long term, 31% of the patients experienced impaired shoulder mobility, 18% developed lymphoedema, 79% had pain and 51% mentioned impaired daily activities. Between 3 months and 3.4 years after surgery, impaired shoulder mobility decreased from 57% to 31%. The incidence of lymphoedema increased from 4% to 18%. Patients experienced an equal amount of pain but fewer problems with daily activities. At 3.4 years, no significant differences between mastectomy and breast‐conserving procedure were found. In conclusion, at long term, significant number of breast cancer survivors still had impaired shoulder mobility, developed lymphoedema, had pain and experienced difficulties during daily activities. Shoulder mobility, pain and daily activities evolved positively, while the incidence of lymphoedema increased.     

A patient- and assessor-blinded randomized controlled trial of axillary reverse mapping (ARM) in patients with early breast cancer

BackgroundAxillary lymph node dissection (ALND) in breast cancer patients is infamous for its accompanying morbidity. Selective preservation of upper extremity lymphatic drainage and accompanying lymph nodes crossing the axillary basin - currently resected during a standard ALND - has been proposed as a valuable surgical refinement.MethodsPeroperative Axillary Reversed Mapping (ARM) was used for selective preservation of upper extremity lymphatic drainage. A multicentre patient- and assessor-blinded randomized study was performed in clinical node negative, sentinel node positive early breast cancer patients. Patients were randomized to undergo either standard-ALND or ARM-ALND. Primary outcome was the presence of surgery-related lymphedema at six, 12 and 24 months post-operatively. Secondary outcomes included patient reported and objective signs and symptoms of lymphedema, pain, paraesthesia, numbness, loss of shoulder mobility, quality of life and axillary recurrence risk.ResultsNo significant differences were found between both groups using the water displacement method with respect to measured lymphedema. ARM-ALND resulted in less reported complaints of lymphedema at six, 12 and 24 months postoperatively (p < 0.05). No axillary recurrence was found in both groups.ConclusionsIn contrast to results of volumetric measurement, patient reported outcomes support selective sparing of the upper extremity lymphatic drainage using ARM as valuable surgical refinement in case of ALND in clinically node negative, sentinel node positive early breast cancer. If completion ALND in clinically node negative, sentinel node positive early breast cancer is considered, selective sparing of upper extremity axillary lymphatics by implementing ARM should be carried out in order to reduce morbidity.     

低负荷前哨淋巴结阳性早期乳腺癌患者腋窝处理策略

前哨淋巴结阳性患者的常规处理是进一步行腋窝淋巴结清扫,但腋窝淋巴结清扫会带来血清肿、上肢功能障碍、水肿等并发症。Z0011、IBCSG 23-01和AMAROS的Ⅲ期随机对照临床研究探索均为在临床N0期患者中安全减免前哨淋巴结活检阳性后的腋窝淋巴结清扫,为这部分患者的腋窝处理提供了新选择,但也给辅助放疗决策带来了新问题。本文将主要基于上述三项临床研究和腋窝淋巴结转移复发风险相关最新文献,针对包括手术和辅助放疗在内的低负荷前哨淋巴结阳性患者腋窝处理策略进行综述。     

Lymphoscintigraphic and intraoperative detection of the sentinel lymph node in breast cancer patients: the nuclear medicine perspective

The concept of sentinel lymph node biopsy in breast cancer surgery relates to the fact that the tumor drains in a logical way via the lymphatic system, from the first to upper levels. Therefore, (1) the first lymph node met (the sentinel node) will most likely be the first one affected by metastasis, and (2) a negative sentinel node makes it highly unlikely that other nodes are affected. Sentinel lymph node biopsy would represent a significant advantage as a mini-invasive procedure, considering that, after operation, about 70% of patients are found to be free from metastatic disease, yet axillary node dissection can lead to significant morbidity. Although the pattern of lymphatic drainage from a breast cancer can be very variable, the mammary gland and the overlying skin can be considered as a biologic unit in which lymphatics tend to follow the vasculature. Considering that tumor lymphatics are disorganized and relatively ineffective, subdermal, and peritumoral injection of small aliquots of radiotracer is preferred to intratumoral administration. (99m)Tc-labeled colloids with most of the particles in the 100-200 nm size range would be ideal for radioguided sentinel node biopsy in breast cancer. Lymphoscintigraphy is an essential part of radioguided sentinel lymph node biopsy, as images are used to direct the surgeon to the site of the node. The sentinel lymph node should have a significantly higher count than background. After removal of the sentinel node, the axilla must be re-examined to ensure all radioactive sites are identified and removed for analysis. The success rate of radioguidance in localizing the sentinel lymph node in breast cancer surgery is about 94-97% in Institutions where a high number of procedures are performed, approaching 99% when combined with the vital blue dye technique. At present, there is no definite evidence that a negative sentinel lymph node biopsy is invariably correlated with a negative axillary status, except perhaps for T(1a-b) breast cancers, with size < or =1 cm. Randomized clinical trials should elucidate the impact of avoiding axillary node dissection in patients with a negative sentinel lymph node on the long-term clinical outcome of patients.     

Clinical and pathologic factors predicting axillary lymph node involvement in breast cancer

The diagnosis of axillary disease remains a challenge in the management of breast cancer and is a subject of controversy. In 1998, the Japanese Breast Cancer Society conducted a study assessing axillary lymph node involvement in breast cancer. The study included (a) clinical assessment by pre-operative imaging modalities, (b) histologic assessment for peritumoral lymphatic invasion, (c) biologic assessment by gelatinolytic activity using film in situ zymography, and (d) sentinel lymph node (SLN) biopsy. Clinical assessments by CT, PET, and US as well as biologic assessment were limited in their ability to detect axillary lymph node disease, although these imaging techniques may be useful to exclude node-positive patients from the need for SLN biopsy. Histologic assessment for peritumoral lymphatic invasion was useful, particularly for detecting false-negative cases by SLN biopsy. Nevertheless, the utility of SLN biopsy in assessing axillary nodal status was confirmed. Axillary lymph node dissection (ALND) can be avoided in patients with a small tumor and a negative SLN. However, further studies will be required to investigate the value of SLN biopsy for predicting regional control and survival before it can replace routine ALND as the optimal staging procedure for operable breast cancer.     

染料法腋窝反向淋巴作图300例临床研究

  目的  研究腋窝反向淋巴作图（axillary reverse mapping,ARM）对上肢淋巴回流管网的辨别和保护作用及对减少腋窝淋巴结清扫术后上肢水肿的作用。  方法  选取2009年6月至2011年5月蚌埠医学院第一附属医院肿瘤外三科300例单侧乳腺癌患者,在进行腋窝淋巴结清扫前,经上臂内侧肌间沟皮下注射亚甲蓝2~3 mL,对上肢来源的淋巴管和淋巴结进行染色,术中加以辨别和保护。术后2个月测量双上臂周径差异（患侧臂周径-健侧臂周径≥2 cm为淋巴水肿）,记录淋巴水肿的发生情况。  结果  300例患者中有195例作图成功,成功率65%。分别于术后6、12、18、24个月进行随访,发现和同期作图失败患者相比较,作图成功患者淋巴水肿的发生率明显降低,差异具有显著性统计学意义。  结论  通过腋窝反向淋巴作图（ARM）可以辨别保护上肢回流的淋巴管道,对预防乳腺癌腋窝淋巴结清扫术后上肢水肿具有临床意义。      

降低乳腺癌术后淋巴水肿新技术——腋窝反向淋巴制图的研究进展

腋窝反向淋巴制图(axillary reverse mapping, ARM)技术是指在腋窝淋巴结切除术(axillary lymph node dissection, ALND)和/或前哨淋巴结切除术(sentinel lymph node dissection, SLND)中显示上肢淋巴管道并对其予以保护, 从而降低术后上肢淋巴水肿发生率, 是针对乳腺癌手术治疗的一项新兴技术, 目前仍处于临床试验阶段。本文回顾了近年来国外相关临床试验, 分析ARM淋巴结和淋巴管的显示方法, 评估保留ARM淋巴结和淋巴管的可行性, 评价ARM技术对降低乳腺癌术后上肢淋巴水肿发生率的临床意义。      

前哨淋巴结活检在早期乳腺癌患者腋窝管理中的研究进展

传统的观点认为腋窝淋巴结清扫(axillary lymph node dissection,ALND)是前哨淋巴结(sentinellymph node,SLN)阳性乳腺癌患者的标准治疗方法,而ALND容易引起上肢水肿、功能障碍等术后并发症,影响患者生活质量.近几年研究显示,对于SLN阳性的早期乳腺癌,并非所有患者都需...     

Dynamics of lymphatic regeneration and flow patterns after lymph node dissection

Knowledge about the mechanisms of regeneration of the lymphatic vasculature after surgical trauma is essential for the development of strategies for the prevention and therapy of lymphedema. However, little is known about the alterations of lymphatic flow directly after surgical trauma. We investigated lymphatic function in mice using near-infrared imaging for a period of 4 weeks after surgeries that mimic sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND), by removal of the popliteal lymph node (LN) alone or together with the popliteal fat pad, respectively. SLNB-like surgery did not cause changes in lymphatic drainage in the majority of cases. In contrast, lymphatic drainage impairment shown by collecting vessel rupture, dermal backflow and rerouting of lymph flow via collateral vessels were observed after ALND-like surgery. All collateral vessels drained to the inguinal LN. These results indicate that less invasive surgery prevents lymphatic decompensation. They also reveal the development and maturation of collateral lymphatic vessels after extensive surgical trauma, which reroute the flow of lymph towards a different LN. These findings might be helpful for the development of strategies to prevent and/or treat post-surgical lymphedema.     

乳腺癌前哨淋巴结定位和活检

目的：难证乳腺癌前哨淋巴结定位和活检技术的可行性和前哨淋巴结的组织状况能否准确预告腋淋巴结的状况。方法：本研究使用专利蓝,对３３例乳腺癌患者进行了术中及术后前哨淋巴结定位和活检术。结果：３０例（９１％）找到前哨淋巴结,前哨淋巴结预告腋淋巴结的准确率为９６．７％,假阴性１例。结论：本研究结果证实,乳腺癌前哨淋巴结定位和活检技术是可行的,前哨淋巴结的组织学特征能够准确反映腑淋巴结的状况。我们相信在将来     

Axillary reverse mapping for breast cancer

The axillary reverse mapping (ARM) technique has been developed to map and preserve arm lymphatic drainage during axillary lymph node dissection (ALND) and/or sentinel lymph node (SLN) biopsy, thereby minimizing arm lymphedema. However, several problems remain to be resolved in the practical application of this technique. This article presents a review of current knowledge regarding ARM and discusses the practical applicability and relevance of this technique. Identification rates of ARM nodes were insufficient using blue dye. Although this was improved using radioisotopes, radioisotopes alone do not permit visual mapping of ARM lymphatics. Fluorescence imaging may be useful to improve the identification rate of ARM nodes and lymphatics. On the other hand, the ARM nodes may be involved with metastatic foci in patients with extensive axillary lymph node metastases. Moreover, the SLN draining the breast may be the same as the ARM node draining the upper extremity in a minority of patients. These issues represent important drawbacks of the ARM procedure. The success of ARM in reducing lymphedema has not yet been determined. Further studies are needed before this can be accepted as a standard procedure in surgical management of breast cancer.