Analysis of direct oil contrast lymphography of upper limb lymphatics traversing the axilla - A lesson from the past - Contribution to the concept of axillary reverse mapping

Introduction: Axillary reverse mapping (ARM) is a method to preserve upper extremity (UE) lymphatics during axillary surgery in breast cancer patients. This may reduce the 'incidence of lymphedema. Very precise method to demonstrate lymphatic drainage is direct X-ray lymphography. Materials and methods: The evaluation of direct lymphography X-ray images of the axilla and proximal part of the upper extremity was performed in 9 subjects. As contrast was used Lipiodoil injected on the dorsal side of hand. Results: The lymph from UE is drained by 2-4 main afferent collectors, which in 5 of 9 cases entered into one node in the lateral axilla (ARM node). This node was considered to be the sentinel lymph node for the UE. In 4 cases a cranial collector was shown, which led directly to nodes in the upper part of the axilla. This collector had numerous anastomoses with other collectors before entering the axillary nodes. The most important finding is the demonstration of numerous lymphatic anastomoses that take place between all imaged nodes in the axilla including the caudal nodes, which is the most frequent localization of the breast sentinel lymph node. Conclusion: The relationship of lymphatic drainage of the UE and breast are closely related and share numerous connections. These connections represent the main problem of the ARM concept because they may pose potencional route for metastatic cancer cells in sentinel node positive breast cancer patients. Further studies are necessary to improve understanding of this method. Axillary reverse mapping - breast cancer - lymphedema - sentinel node biopsy. (c) 2012 Elsevier Ltd. All rights reserved.