Clinical application of axillary reverse mapping in patients with breast cancer: A systematic review and meta-analysis

Abstract

Background: The axillary reverse mapping (ARM) technique, identify and preserve arm nodes during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND), was developed to prevent breast-cancer related lymphedema (BCRL) remains controversial.

Methods: A comprehensive search of Medline Ovid, Pubmed, Web of Science and the Cochrane CENTRAL databases was conducted from the inception till January 2020. The key word including "breast cancer", "axillary reverse mapping", and "lymphedema". Stata 15.1 software was used for the meta-analysis.

Results: As a result, twenty-nine related studies involving 4954 patients met our inclusion criteria. The pooled overall estimate lymphedema incidence was 7% (95% CI 4%-11%, I² = 90.35%, P < 0.05), with SLNB showed a relatively lower pooled incidence of lymphedema (2%, 95% CI 1%-3%), I² = 26.06%, P = 0.23) than that of ALND (14%, 95% CI 5%-26%, I² = 93.28%, P < 0.05) or SLNB and ALND combined (11%, 95% CI 1%-30%). The ARM preservation during ALND procedure could significantly reduce upper extremity lymphedema in contrast with ARM resection (OR = 0.27, 95% CI 0.20-0.36, I² = 31%, P = 0.161). Intriguingly, the result favored ALND-ARM over standard-ALND in preventing lymphedema occurrence (OR = 0.21, 95% CI 0.14-0.31, I² = 43%, P = 0.153). The risk of metastases in the ARM-nodes was not significantly lower in the patients who had received neoadjuvant chemotherapy, as compared to those without neoadjuvant treatment (OR = 1.20, 95% CI 0.74-1.94, I² = 49.4%, P = 0.095).

Conclusions: ARM was found to significantly reduce the incidence of BCRL. The selection of patients for this procedure should be based on their axillary nodal status. Preoperative neoadjuvant chemotherapy has no significant impact on the ARM lymph node metastasis rate.

Keywords: Axillary reverse mapping; Breast cancer; Lymphedema; Meta-analysis.

Fig. 1

Flow diagram of studies selection.

Fig. 2

Forest plots of the clinical utility of ARM on BCRL. (A) the pooled incidence rate of lymphedema; (B) OR for ARM-preserved vs. ARM-resected group lymphedema incidence; (C) OR for ALND-ARM vs. standard-ALND lymphedema incidence.

Fig. 3

Forest plot of ARM feasibility. (A) the ARM identification rate during SLNB; (B) the ARM identification rate during ALND.

Fig. 4

Forest plot of ARM oncological safety. (A) the pooled identification rate of the SLN-ARM crossover rate during SLNB; (B) the pooled identification rate of the overall resected ARM metastatic rate; (C) the pooled resected ARM metastatic rate in the SLN⁺patient group; (D) the pooled resected ARM metastatic rate in the CP-N⁺patient group; (E) OR for the association between axillary status and the risk of ARM metastasis; (F) OR for the association between preoperative NAC and the risk of ARM metastasis.