Is axillary reverse mapping feasible in breast cancer patients?

In the surgical treatment of breast cancer, axillary lymph node dissection (ALND) can be avoided not only in sentinel lymph node (SLN)-negative patients but also in SLN-positive patients who undergo breast-conserving surgery with whole-breast irradiation and systemic therapy. However, it should be performed not only in clinically node-positive patients but also in other SLN-positive patients who do not meet the Z-0011 criteria. The axillary reverse mapping (ARM) technique has been developing for identifying and preserving lymphatic drainage from the arm during ALND, thereby expected to minimize arm lymphedema. Nevertheless, ARM nodes could be involved not only in clinically node-positive patients but also in clinically node-negative patients. Previously, it was considered that preservation of the ARM lymphatics or lymph nodes is not oncologically safe in patients with axillary lymph node metastases. However, recent studies have demonstrated that the ARM procedure is oncologically feasible in clinically node-negative, SLN-positive patients when ARM nodes do not coincide with SLNs. When ARM nodes do not coincide with SLNs, they are not involved even in SLN-positive patients. On the other hand, ARM lymphatics/nodes within the boundaries of a standard ALND should be resected in SLN-positive patients, when ARM nodes are SLN-ARM nodes. Therefore, surgical treatment of the axilla can be individualized on the basis of the axillary nodal status.