Occurrence of breast‐cancer–related lymphedema after reverse lymphatic mapping and selective axillary dissection versus standard surgical treatment of axilla: A two‐arm randomized clinical trial

BACKGROUND: The need for axillary dissection (AD) is declining, but it is still essential for many patients with nodal involvement who risk developing breast‐cancer–related lymphedema (BCRL) with lifelong consequences. Previous nonrandomized studies found axillary reverse mapping and selective axillary dissection (ARM‐SAD) a safe and feasible way to preserve the arm's lymphatic drainage. METHODS: The present two‐arm prospective randomized clinical trial was held at a single comprehensive cancer center to ascertain whether ARM‐SAD can reduce the risk of BCRL, compared with standard AD, in patients with node‐positive breast cancer. Whatever the type of breast surgery or adjuvant treatments planned, 130 patients with nodal involvement met our inclusion criteria: 65 were randomized for AD and 65 for ARM‐SAD. Twelve months after surgery, a physiatrist assessed patients for BCRL and calculated the excess volume of the operated arm. Lymphoscintigraphy was used to assess drainage impairment. Self‐reports of any impairment were also recorded. RESULTS: The difference in the incidence of BCRL between the two groups was 21% (95% CI, 3‐37; p = .03). A significantly lower rate of BCRL after ARM‐SAD was confirmed by a multimodal analysis that included the physiatrist's findings, excess arm volume, and lymphoscintigraphic findings, but this was not matched by a significant difference in patients' self‐reports. CONCLUSIONS: Our findings encourage a change of surgical approach when AD is still warranted. ARM‐SAD may be an alternative to standard AD to reduce the treatment‐related morbidity.