Combined axillary reverse mapping (ARM) technique for breast cancer patients requiring axillary dissection.

BACKGROUND: The objective of axillary reverse mapping (ARM) is to preserve the main lymphatic chain-with both the nodes and the ducts-in relation to lymphatic arm drainage (LAD) during an axillary dissection (AD). METHODS: From July 2006 to March 2008, 23 patients with stage II or III breast carcinoma requiring an AD underwent an ARM procedure. Identification of the ARM nodes relied on an isotope injection into the web space of the ipsilateral hand. During AD, the radioactive ARM node was localized above the second intercostal brachial nerve, and blue dye was directly injected inside the node to visualize the efferent ducts, constituting the lymphatic ARM chain. The blue and radioactive nodes constituted the ARM sampling, while other nodes were considered part of the AD. RESULTS: Metastatic lymph node involvement was identified in the AD in 20 of 23 patients, with an average of 4.4 (1-11) nodes involved and an average of 10.7 (7-20) lymph nodes removed. The ARM sampling was performed in 21 of 23 patients (91%), with an average of 1.6 ARM nodes removed. In 18 of these 21 patients (86%), the nodes relating to ARM sampling had no metastatic involvement. There were 3 patients (14%) who demonstrated metastatic involvement of the ARM sampling, and all had pN3a (N+ > 9) involvement of the axilla. CONCLUSION: This technique of combined isotopic and blue dye ARM and findings must now be validated. A multicentric study is planned to confirm this data.

Simplified technique of radioguided occult lesion localization (ROLL) plus sentinel lymph node biopsy (SNOLL) in breast carcinoma.

BACKGROUND: Radioguided occult lesion localization (ROLL) is a new technique to detect nonpalpable breast tumors. We report our experience using injection of a single radiotracer to localize occult lesions together with sentinel lymph node (SLN) biopsy (SNOLL). The aim of this series was to evaluate the feasibility of the technique, its efficacy, and the rate of reoperation. METHODS: Under sonographic guidance, a nanocolloidal tracer was injected peritumorally above and below the lesion. A handheld gamma probe detector was used to locate and to guide its surgical removal. An intraoperative (IO) macroscopic examination of the specimen with margins evaluation and IO imprint cytology of SLN was always performed. RESULTS: The targeted lesion was localized and removed in all cases. Final pathological diagnosis identified invasive in 70 patients and ductal carcinoma in situ (DCIS) in 2 patients. The average size of the resected lesion was 11 mm (4-50 mm). In 61 out of the 72 patients (85%), the breast specimen had clear and large margins. Sentinel lymph node (SLN) biopsy was performed in 70 patients with an identification rate of 90%. Final pathological SLN metastasis rate approached 25% (pN1 14%, pN1(mi) 11%). Despite intraoperative examination of the specimen, a total of 29% (21 out of 72) patients had to be reoperated (8 patients for involved margins, 10 patients for an involved SLN, and 3 for both). CONCLUSION: This technique with a single nanocolloid tracer used both for ROLL and SLN detection is reliable for removing nonpalpable lesions. The use of this technique may have implications for further reducing reoperation rates.