An interventional study of Axillary Reverse Mapping (ARM) in Breast Cancer Lymphedema, sponsored by University Hospital of Ferrara. Status unknown at 1 site in Italy. Open to female participants aged 18 Years and older. Per ClinicalTrials.gov, last updated 2018-01-23.
Sponsored by University Hospital of Ferrara · Not applicable, Interventional, and Prevention
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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).
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:
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.).
124 studies on the registry are indexed under Breast Cancer Lymphedema; 39 are open to participants now.
This study's planned enrollment of 300 is above the median of 48 across 97 interventional studies indexed under Breast Cancer Lymphedema.
Browse Breast Cancer Lymphedema studies →University Hospital of Ferrara is the lead sponsor of 114 studies on the registry; 28 are open to participants now.
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Exclusion Criteria:
Underlined terms in the criteria open these too. Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
Cancer that has spread from where it began to other parts of the body. “Metastatic” cancer is cancer that has spread this way.
Neoadjuvant treatment is given before the main treatment (usually surgery), often to shrink a tumour. Adjuvant treatment is given after it, to lower the chance of the cancer coming back.
Metastases
Cancer that has spread from where it began to other parts of the body. “Metastatic” cancer is cancer that has spread this way.
Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
Adjuvant and neoadjuvant
Neoadjuvant treatment is given before the main treatment (usually surgery), often to shrink a tumour. Adjuvant treatment is given after it, to lower the chance of the cancer coming back.
Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
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.
Procedure: Axillary Reverse Mapping (ARM)
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.
Procedure: Axillary Reverse Mapping (ARM)
ARM lymph node preservation versus removal
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.
Time frame: From the day of surgery to 12 months after surgery
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.
Time frame: From the day of surgery to 12 months after surgery
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.
Time frame: Intraoperatively
Lymphoscintigraphic sub-clinical modifications of arm lymphatic drainage after ALND
Bilateral arms lymphoscintigraphy
Time frame: The day before ALND and at 60 days after ALND
Plan to share: Undecided — Formal requests will be evaluated.
Started Jan 2018 (actual). Primary completion is estimated for Dec 2020, 35 months after the start.
Of 66 non-industry interventional studies with no phase under Breast Cancer Lymphedema, half reached primary completion within 18 months of starting (the median), counting those still running; a quarter within 10 and three quarters within 34. This study's planned 35 months is above that.
Counting every sponsor, half of 69 studies reached it within 18 months; a quarter within 10 and three quarters within 34.
How these figures are worked out, and which studies are left out of them.
This study is status unknown, as verified in Jan 2018. You cannot join it, but the record below documents what was studied.
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