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Axillary Reverse Mapping (ARM) in Breast Cancer Surgery to Prevent Lymphedema. (ARMtrial)

Primary Purpose

Breast Cancer Lymphedema

Status
Unknown status
Phase
Not Applicable
Locations
Italy
Study Type
Interventional
Intervention
Axillary Reverse Mapping (ARM)
Sponsored by
University Hospital of Ferrara
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional prevention trial for Breast Cancer Lymphedema focused on measuring Breast Neoplasms, Sentinel Lymph Node Biopsy, Lymph Node Excision, Technetium Tc 99m, Indocyanine Green, Lymphatic System, Secondary Prevention

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)FemaleDoes not accept healthy volunteers

Inclusion Criteria:

  • T1-T2 stage breast cancer

Exclusion Criteria:

  • axillary lymph node metastasis;
  • previous surgery on the ipsilateral axilla;
  • neoadjuvant chemo-radiotherapy;
  • presence of primitive lymphedema of the arm;
  • allergy to Iodine, thyroid disease, renal and hepatic impairment (for issues related to Indocyanine Green)
  • pregnancy;
  • patients refusing to participate in the study.

Sites / Locations

  • Azienda Ospedaliero Universitaria S. AnnaRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Active Comparator

Arm Label

ARM lymph node preservation

ARM lymph node removal

Arm Description

All patients will be sent to both rSLNB and photodynamic Axillary Reverse Mapping (ARM) to evaluate the crossover between SLN and ARM lymph node. In case of SLN metastases, an ALND with ARM lymph node preservation will be performed.

All patients will be sent to both rSLNB and photodynamic Axillary Reverse Mapping (ARM) to evaluate the crossover between SLN and ARM lymph node. In case of SLN metastases, an ALND with ARM lymph node removal will be performed.

Outcomes

Primary Outcome Measures

Incidence of Breast Cancer Related Lymphedema (BCRL) after Axillary Lymph Node Dissection (ALND)
Incidence of BCRL in patients in whom the ARM lymph node is preserved compared to those in which it is removed. Clinically follow-up will include the clinical presentation (pain, integumentary abnormalities, paresthesia, hypoesthesia, neuro-vascular deficits), standardized measurement of 7 records [diameters of the upper limb (hand, wrist, 15 cm and 10 cm distally to olecranon, elbow (olecranon), 10 cm and 15 cm proximally to olecranon)] and final conversion into volumes.

Secondary Outcome Measures

Incidence of Breast Cancer Related Lymphedema (BCRL) after Sentinel Lymph Node Biopsy (SLNB) alone
Clinically follow-up will include the clinical presentation (pain, integumentary abnormalities, paresthesia, hypoesthesia, neuro-vascular deficits), standardized measurement of 7 records [diameters of the upper limb (hand, wrist, 15 cm and 10 cm distally to olecranon, elbow (olecranon), 10 cm and 15 cm proximally to olecranon)] and final conversion into volumes.
Crossover between Sentinel Lymph Node (SLN) of the Breast and the ARM lymph node
Intraoperatively, the radioguided technique (Tc-99m Nanocoll) will be used to identify the SLN of the breast; at the same time, the Axillary Reverse Mapping (ARM) of the upper limb will be carried out by Indocyanine Green, and the ARM lymph node will be identified and preserved. If a crossover between SLN of the breast and the arm's lymph node will be find, the ARM lymph node identified by the photodynamic technique will be excised for pathological evaluation.
Lymphoscintigraphic sub-clinical modifications of arm lymphatic drainage after ALND
Bilateral arms lymphoscintigraphy

Full Information

First Posted
November 2, 2017
Last Updated
January 18, 2018
Sponsor
University Hospital of Ferrara
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1. Study Identification

Unique Protocol Identification Number
NCT03333226
Brief Title
Axillary Reverse Mapping (ARM) in Breast Cancer Surgery to Prevent Lymphedema. (ARMtrial)
Official Title
Axillary Reverse Mapping (ARM). Identification of the Arm Lymphatic Pathways in Breast Cancer Surgery to Prevent Breast Cancer Related Lymphedema (BCRL): a Randomized Clinical Trial.
Study Type
Interventional

2. Study Status

Record Verification Date
January 2018
Overall Recruitment Status
Unknown status
Study Start Date
January 17, 2018 (Actual)
Primary Completion Date
December 2020 (Anticipated)
Study Completion Date
December 2020 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
University Hospital of Ferrara

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
No

5. Study Description

Brief Summary
Breast cancer related lymphedema (BCRL) is a debilitating and distressing condition affecting approximately one out of five breast cancer survivors. BCRL is a chronic swelling of the upper arm following axillary lymph nodes dissection, and it is associated to a significant functional, psychological and social morbidity, with an heavy impact on life quality. Several studies reported BCRL incidence between 6.7% and 62.5% for different population cohorts. Randomized clinical trials (RCTs) reported that sentinel lymph node biopsy (SLNB) when compared with axillary lymph node dissection (ALND) leads to a significant reduction in postoperative complications. However, the advent of SLNB does not solve the problem of BCRL with a concrete chance to develop a lymphedema after single SLNB around 7%. Health care cost of BCRL rehabilitative treatment is not available in literature yet. Few studies considered incidence, risk factors and treatment costs of BCRL among working-age women after breast cancer treatment, reporting that BCRL population had significantly higher rehabilitative medical costs ($14,877 to $23,167) with twice as much risk to develop BCRL complications, such as lymphangitis or cellulitis when compared to "BCRL free" population (OR = 2.02, P = .009). Axillary reverse mapping (ARM) procedure claims to map and preserve arm lymphatic drainage during ALND and/or during SLNB, reducing BCRL development. ARM is developed as result of assumption that arm's lymphatic pathway is not involved by metastatic tumor cells of the primary breast cancer. However, when the arm lymph node correspond to the SLN it should be removed for correct tumor staging, thus a lymphatic drainage disruption onset will be expected with BCRL risk increase. During the ARM procedure, a fluorescence imaging technique (photodynamic procedure) is useful for detecting lymphatic drainage of the upper limb and it allows in differentiating the fluorescent ARM node from the SLN identified by the radioguided technique (99mTC-Nanocoll).
Detailed Description
The investigators will conduct a randomized clinical trial (RCT) at the S. Anna University Hospital of Ferrara (Italy) on consecutive patients undergoing SLNB for breast cancer and subsequent ALND in case of SLN metastases. Eligible patients for radioguided sentinel lymph node biopsy (rSLNB) will be randomly divided in two groups: 1) experimental group in which patients undergoing rSLNB and ARM photodynamic procedure; and, in case of SLN metastases, subsequent ALND with ARM node preservation; 2) control group in which patients undergoing rSLNB and ARM photodynamic procedure; and, in case of SLN metastases, subsequent ALND with ARM node removal. Consent procedure Patients will be visited in the outpatient clinic by one of the treating surgeon, who will approach the subject and explain the study. If the patient is interested in participating, further details will be provided and consent will be obtained. Experimental design Step 1 Patients enrolled in both groups will be subjected to rSLNB associated to ARM photodynamic procedure. Radioguided SLNB technique: The day before surgery, four peri-areolar subcutaneous injections of Tc-99m Nanocoll® will be performed for an overall volume of 0.4 ml (standard activity of 74 MBq). Pre-operative imaging of SLN consists of an anterior and lateral static acquisition, generally performed between 1 and 5 hours post-injection (max. 18 hours), by means of a double head gammacamera (Siemens, ECAM). The gamma camera energy selection peak is centered on the 140 KeV of 99mTc (with a window of ± 10%), and the use of high-resolution collimators and of a 256x256 acquisition matrix. Acquisition time varies between 2 and 8 minutes. Cutaneous projection of SLN will be marked with a skin-marking pen. The day of surgery, after intraoperative routine prep and drape, a handheld gamma probe (EuroProbe III, EURORAD, Chennevières-sur-Marne, France) will be used to localize radioactivity before skin incision and during axillary dissection to identify SLN, that is defined by counts >10% of background. ARM photodynamic procedure: The day of surgery, 15 minutes before surgical incision, patients will be subjected to injection of 1 ml of ICG (5mg/ml) in the upper forearm and during SLNB we will perform an evaluation of lymphatic arm pathways with fluorescence (IC-Flow Diagnostic Green, SEDA S.p.a., Milano, Italy). If a crossover between SLN of the breast and the arm's lymph node will be find, the ARM lymph node identified by the photodynamic technique will be excised for pathological evaluation. Step 2 Patients with tumor positive SLN, eligible for ALND, will undergo to preoperative arm lymphoscintigraphy in order to asses possible changes in lymphatic drainage pathways of the arm after rSLNB. The day before ALND, an injection of a volume of 0.4 ml of Tc-99m Nanocoll® in each hand will be performed, fractioned in all interdigital space. The subsequent scintigraphic planar acquisition is performed using a double head gamma-camera (Siemens, Ecam) according the following protocol: 5 minutes post injection: imaging acquisition on hands and forearms positioned over collimator with a marker near right arm; 10 minutes post injection :anterior acquisition with gamma camera head 1 on elbows and shoulders; 15 minutes post injection : anterior acquisition on both axilla and thorax using cobalt wires markers drawing cranium profile; 20 minutes post injection :marking with skin-marking pen of skin projection of most radioactive axillary nodes; 120/180 minutes post injection : acquisition in the same position for checking of possible number and/or site changes of nodes marked before. Step 3 Experimental group: In case of SLN metastases, during radical ALND (I, II,III levels of Berg), the ARM lymph node identified with both radioguided and photodynamic methods will be isolated from the other axillary lymph nodes and preserved. Photodynamic method will also allow us to visualize the lymphatic drainage of the arm that will be preserved. Control group: In case of SLN metastases, during radical ALND (I, II,III levels of Berg), the ARM lymph node identified with both radioguided and photodynamic method will be isolated from the other axillary lymph nodes and removed. Step 4 The post-operative follow up will be conducted in inpatient setting and after discharge in outpatient setting (surveillance for early and delayed surgical complications). All patients will be clinically evaluated at 10, 30, 60, and 180 days after surgery and undergoing bilateral arms lymphoscintigraphy at 60 days after surgery to determine possible lymphoscintigraphic changes underlying a subclinical BCRL. Clinically follow-up will include the clinical presentation (pain, integumentary abnormalities, paresthesia, hypoesthesia, neuro-vascular deficits), measurement of 7 records [diameters of the upper limb (hand, wrist, 15 cm and 10 cm distally to olecranon, elbow (olecranon), 10 cm and 15 cm proximally to olecranon)] and final conversion into volumes. In case of BCRL diagnosis patients will be addressed to rehabilitative center for therapy. Statistical analysis A prospective analysis will be obtained from database in which patients data will be collected, with details of the patients and tumors characteristics, lymphatic drainage of the upper extremity, intra- and post-operative outcome, and follow up. The power analysis, based on preliminary results, reports that 150 women in each group are required to achieve a power of 0.9 and to detect a significant difference (p<0.05). Data will be expressed as mean ± standard deviation or median (interquartile range - IQR 25-75) according to the distribution. The Shapiro-Wilk test will be used to assess the assumption of normality. Categorical data will be presented as number (%). Data will be analyzed using the Chi-square test to compare percentages, t-Student test will be used to compare the means and Mann-Whitney test to compare non parametric data. Logistic regression analysis will be employed to construct a model predicting BCRL using factors regarding the patient [age, gender, BMI, American Society of Anesthesiology (ASA) classification], the tumor (size, stage, bio-molecular characteristics ), crossover, type of intervention (preservation of ARM lymph node vs. dissection), and post-operative treatment (chemotherapy, radiotherapy). Significance will be considered for values of p<0.05. Statistical analysis will be performed with IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp. Armonk, NY: IBM Corp.).

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Breast Cancer Lymphedema
Keywords
Breast Neoplasms, Sentinel Lymph Node Biopsy, Lymph Node Excision, Technetium Tc 99m, Indocyanine Green, Lymphatic System, Secondary Prevention

7. Study Design

Primary Purpose
Prevention
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Model Description
Eligible patients for radioguided sentinel lymph node biopsy (rSLNB) will be randomly divided in two groups: experimental group in which all patients will be sent to both rSLNB and photodynamic Axillary Reverse Mapping (ARM) to evaluate the crossover between SLN and ARM lymph node. In case of SLN metastases, an ALND with ARM lymph node preservation will be performed. control group in which all patients will be sent to both rSLNB and photodynamic Axillary Reverse Mapping (ARM) to evaluate the crossover between SLN and ARM lymph node. In case of SLN metastases, an ALND with ARM lymph node removal will be performed.
Masking
ParticipantOutcomes Assessor
Masking Description
Patients will be randomized before the SLNB procedure. Due to the type of intervention, the blinding of the treating surgeon will not be possible, thus the surgeon will be aware of both the intraoperative crossover between ARM lymph node and SLN (secondary outcome) and the allocation to ARM lymph node preservation or removal. Data about BCRL (primary outcome) will be collected by the physiatrist and the physiotherapist that will be blinded about the allocation (ARM lymph node preservation/removal) and the crossover between SLN of the breast and the arm's lymph node. The assessment of lymphoscintigraphic subclinical modification in the arm lymphatic drainage after SLNB and ALND (secondary outcomes) will be performed by a blinded nuclear medicine physician that will not be aware of the allocation (ARM lymph node preservation/removal) and the crossover between ARM lymph node and breast's SLN.
Allocation
Randomized
Enrollment
300 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
ARM lymph node preservation
Arm Type
Experimental
Arm Description
All patients will be sent to both rSLNB and photodynamic Axillary Reverse Mapping (ARM) to evaluate the crossover between SLN and ARM lymph node. In case of SLN metastases, an ALND with ARM lymph node preservation will be performed.
Arm Title
ARM lymph node removal
Arm Type
Active Comparator
Arm Description
All patients will be sent to both rSLNB and photodynamic Axillary Reverse Mapping (ARM) to evaluate the crossover between SLN and ARM lymph node. In case of SLN metastases, an ALND with ARM lymph node removal will be performed.
Intervention Type
Procedure
Intervention Name(s)
Axillary Reverse Mapping (ARM)
Intervention Description
ARM lymph node preservation versus removal
Primary Outcome Measure Information:
Title
Incidence of Breast Cancer Related Lymphedema (BCRL) after Axillary Lymph Node Dissection (ALND)
Description
Incidence of BCRL in patients in whom the ARM lymph node is preserved compared to those in which it is removed. Clinically follow-up will include the clinical presentation (pain, integumentary abnormalities, paresthesia, hypoesthesia, neuro-vascular deficits), standardized measurement of 7 records [diameters of the upper limb (hand, wrist, 15 cm and 10 cm distally to olecranon, elbow (olecranon), 10 cm and 15 cm proximally to olecranon)] and final conversion into volumes.
Time Frame
From the day of surgery to 12 months after surgery
Secondary Outcome Measure Information:
Title
Incidence of Breast Cancer Related Lymphedema (BCRL) after Sentinel Lymph Node Biopsy (SLNB) alone
Description
Clinically follow-up will include the clinical presentation (pain, integumentary abnormalities, paresthesia, hypoesthesia, neuro-vascular deficits), standardized measurement of 7 records [diameters of the upper limb (hand, wrist, 15 cm and 10 cm distally to olecranon, elbow (olecranon), 10 cm and 15 cm proximally to olecranon)] and final conversion into volumes.
Time Frame
From the day of surgery to 12 months after surgery
Title
Crossover between Sentinel Lymph Node (SLN) of the Breast and the ARM lymph node
Description
Intraoperatively, the radioguided technique (Tc-99m Nanocoll) will be used to identify the SLN of the breast; at the same time, the Axillary Reverse Mapping (ARM) of the upper limb will be carried out by Indocyanine Green, and the ARM lymph node will be identified and preserved. If a crossover between SLN of the breast and the arm's lymph node will be find, the ARM lymph node identified by the photodynamic technique will be excised for pathological evaluation.
Time Frame
Intraoperatively
Title
Lymphoscintigraphic sub-clinical modifications of arm lymphatic drainage after ALND
Description
Bilateral arms lymphoscintigraphy
Time Frame
The day before ALND and at 60 days after ALND

10. Eligibility

Sex
Female
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: T1-T2 stage breast cancer Exclusion Criteria: axillary lymph node metastasis; previous surgery on the ipsilateral axilla; neoadjuvant chemo-radiotherapy; presence of primitive lymphedema of the arm; allergy to Iodine, thyroid disease, renal and hepatic impairment (for issues related to Indocyanine Green) pregnancy; patients refusing to participate in the study.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Paolo Carcoforo, MD
Phone
0039 0532 236123
Email
paolo.carcoforo@unife.it
First Name & Middle Initial & Last Name or Official Title & Degree
Mattia Portinari, MD
Phone
0039 0532 236100
Email
mattia.portinari@unife.it
Facility Information:
Facility Name
Azienda Ospedaliero Universitaria S. Anna
City
Cona
State/Province
Ferrara
ZIP/Postal Code
44124
Country
Italy
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Paolo Carcoforo, MD
Phone
0039 0532 236123
Email
paolo.carcoforo@unife.it
First Name & Middle Initial & Last Name & Degree
Mattia Portinari, MD
Phone
0039 0532 236100
Email
mattia.portinari@unife.it

12. IPD Sharing Statement

Plan to Share IPD
Undecided
IPD Sharing Plan Description
Formal requests will be evaluated.
Citations:
PubMed Identifier
17187979
Citation
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Results Reference
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Citation
McWayne J, Heiney SP. Psychologic and social sequelae of secondary lymphedema: a review. Cancer. 2005 Aug 1;104(3):457-66. doi: 10.1002/cncr.21195.
Results Reference
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PubMed Identifier
15994144
Citation
Purushotham AD, Upponi S, Klevesath MB, Bobrow L, Millar K, Myles JP, Duffy SW. Morbidity after sentinel lymph node biopsy in primary breast cancer: results from a randomized controlled trial. J Clin Oncol. 2005 Jul 1;23(19):4312-21. doi: 10.1200/JCO.2005.03.228.
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PubMed Identifier
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Axillary Reverse Mapping (ARM) in Breast Cancer Surgery to Prevent Lymphedema. (ARMtrial)

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