Wednesday, October 15, 2008

ARM Technique

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active and it was easier than checking each one.

I realize this is not a techniques that I or other plastic surgeons are likely to use, but the surgeon (V Suzanne Klimberg, MD) who developed this technique is from Little Rock, AR.  So I thought I would learn more about it and share it with you all. (photo credit)

The removal and analysis of the lymph nodes under the arm remains an important factor in determining the severity of disease in breast cancer patients, but can result in complications, including lymphedema of the arm.  Lymphedema of the arm can occur in 5-50 % of patients depending on the extent of the dissection.  The ARM technique was developed to try to prevent this complication.
ARM stands from Axillary Reverse Mapping.   This technique the way lymph fluid is drained from the arm rather than from the breast.  The nodes that “light up” are preserved, therefore preserving the lymph system that drains the arm.
"Mapping the drainage of the arm decreases the chances of unintended disruption of the lymph node system during surgery and reduces the risk of developing swelling in the arm," Klimberg said. "We are the first to study lymph node drainage in the arm and are now using the ARM procedure as standard procedure at UAMS."
Klimberg will soon begin conducting training seminars on the procedure throughout the country. The seminars will be sponsored by the global medical device company Ethicon, a branch of Johnson & Johnson

Clinical Trials such as this one at MD Anderson are being planned to test the validity of ARM’s claims to decrease lymphedema. 
Detailed Description:
Lymphazurin is a blue dye used usually in breast cancer surgery to trace the drainage pathway that flows to lymph nodes. The dye will travel to the lymph system and will end up in the lymph nodes that are draining the arm.
In this study, lymphazurin will be used to find the drainage routes from your arm, rather than your breast.
Before axillary lymph node surgery, your surgeon will inject lymphazurin into your arm. Your surgeon will watch how the dye flows and find the channels and nodes draining the arm. You will then have standard axillary lymph node (lymph nodes found under the arm) surgery. Any lymph nodes found that are dyed blue (lymph nodes that have traveled down the drainage pathways) that would normally be removed will be removed and sent to the pathology department. Pathologists will check the nodes to see if they have breast cancer cells in them. Also as part of routine care, all other axillary lymph nodes draining the breast will be removed and checked for breast cancer cells.
This is an investigational study. Lymphazurin is FDA approved and commercially available. The use of lymphazurin with axillary reverse mapping is investigational.
Up to 30 patients will take part in this study. All will be enrolled at M. D. Anderson.

Axillary Reverse Mapping (ARM): A New Concept to Identify and Enhance Lymphatic Preservation; Annals of Surgical Oncology 14:1890-1895 (2007);  Margaret Thompson, MD, Soheila Korourian, MD, Ronda Henry-Tillman, MD, Laura Adkins, MAP, Sheilah Mumford, MA, Kent C. Westbrook, MD and V Suzanne Klimberg, MD (abstract)
A New Concept Toward the Prevention of Lymphedema: Axillary Reverse Mapping; Journal of Surgical Oncology, Vol 97, No 7, pp 563-564, 2007; V. Suzanne Klimberg, MD 
Axillary Reverse Mapping: Mapping and Preserving Arm Lymphatics May Be Important in Preventing Lymphedema During Sentinel Lymph Node Biopsy;  J Am Coll Surg. 2008 May; Boneti C, Korourian S, Bland K, Cox K, Adkins LL, Henry-Tillman RS, Klimberg VS.
Breast Cancer Treatment Developed by UAMS Surgeon Shown in Clinical Trial to Reduce Repeat Surgery Following Lumpectomy by 86 Percent; UAMS News Bureau Release  Oct. 19, 2005


Anonymous said...

Thanks for sharing this technique, Ramona. I have worked a lot with breast cancer patients and Lymphoedema certainly is debilitating.

Do you have much knowledge of the interaction between ARM and sentinel node biopsy? Seems like best practice is likely to be sentinel node for early breast cancer. This might still be useful in mastectomy and advanced, or node positive disease.

Luckily for your great references, I can look up the articles to get some more information.

rlbates said...

Dr Cris, no I don't have that information. My understanding (and it may be wrong) is that when you do the ARM technique, you leave the nodes that light up and remove the others (a reverse-sentinal node, if you will). That way you only take the nodes that drain the breast/chest region). I think the Clinical Trials, like the one at MD Anderson, will answer that for us.