Aswin Puthangot

Vardhman Mahavir Medical College & Safdarjung Hospital, India

Title: Evaluation of axilla with sentinel lymphnode biopsy using blue dye and axillary reverse mapping using fluorescein dye in patients with breast cancer


Introduction: There is a paradigm shift in the management of breast cancer over last few decades. Although surgery has remained the cornerstone of management, the approach has become more conservative of late. In breast we have moved from radical surgeries like mastectomy to breast conservation. 
Axillary Lymphnode dissection (ALND) was the only way of addressing axilla in the past. However, this procedure is now reserved only for node positive axillae due to associated morbidities like lymphedema, neuropathy and shoulder rigidity. Most common and dreaded morbidity is lymphedema. For clinically node negative axilla, Sentinel Lymph node biopsy (SLNB) is now the procedure of choice and the patients with SLNB negative axilla could be spared the morbidity of ALND. Axillary Reverse Mapping (ARM) is a relatively new entity that was introduced in 2007.  It was developed with the intention of tracing lymphatics that drain the upper arm, present in the axilla. In ARM tracing of lymphatics is retrograde and intention was to spare what was identified. tracers in the breast and identified lymphnodes were removed. 
Aim: To evaluate axilla with the help of sentinel lymphnode biopsy using methylene blue and axillary reverse mapping using fluorescein dye.
Material & methods: Patients diagnosed with histopathologically proven breast cancer who were scheduled for surgery (Modified Radical Mastectomy or Breast Conservation Surgery ) were included in the study. 
Periareolar intradermal (MRM) or subcutaneous (BCS, to prevent staining of skin)  injection of 1ml, methylene blue dye was  given. Fluorescein dye (1ml) was injected in upperarm subcutaneously, 10 cm lateral to acromion process. Both injection sites were massaged for 5 minutes. Incision was given and upper and lower flaps were raised. All lymphnodes that stained blue was removed and was subjected frozen section.
After SNLB, mastectomy and ALND, axilla was visualised under blue light. Nodes and lymphatics that took up the dye produced greenish fluorescence. Location of fluorescent lymphatics were mapped with respect to upper most intercostobrachial nerve. 
Results: Identification rate of sentinel lymphnodes and ARM lymphatics was 100%. Fluorescent node positive for malignancy 0%. Arm lymphatics were above superior most intercostobrachial nerve in 86.7% of cases. False negative rate of sentinel lymphnode biopsy as compared to ALND was 13%.
Conclusions: Sentinel lymphnode biopsy using single dye technique has results comparable with dual agent studies that utilise blue dye and radioactive colloid. It can be of particular use in resource constrained setting. The study also demonstrate the utility of fluorescein dye for mapping arm lymphatics. 
Even after following standard boundaries of ALND, lymphatics draining arm were preserved as evident by fluorescent nodes visualised during ARM. Also with almost 86.7 % of arm lymphatics lying above it, upper most ICBN could help in redefining superior limit of axillary dissection. However studies with larger sample size would be requires to establish a definitive role of ARM.


To be updated.