Annals of Surgical Oncology

, Volume 26, Issue 11, pp 3446–3454 | Cite as

Identification and Preservation of Arm Lymphatic System in Axillary Dissection for Breast Cancer to Reduce Arm Lymphedema Events: A Randomized Clinical Trial

  • Qianqian Yuan
  • Gaosong WuEmail author
  • Shu-Yuan Xiao
  • Jinxuan Hou
  • Yuqi Ren
  • Hongying Wang
  • Kun Wang
  • Dan Zhang
Breast Oncology



Controversy in axillary reverse mapping in axillary lymph node dissection (ALND) possibly results from incomplete recognition of the arm lymphatic system (ALS) and its compromise to oncological safety. The iDEntification and Preservation of ARm lymphaTic system (DEPART) technique facilitates complete identification of ALS; therefore, its use may decrease the occurrence of arm lymphedema. This study aimed to examine the arm lymphedema rate, locoregional recurrence, and feasibility to perform DEPART in ALND.


Patients from February 2013 to October 2017 from two tertiary referral centers were randomly assigned to two groups. In the study group, indocyanine green and methylene blue (MB) were utilized to identify arm sentinel nodes, and 0.1 ml MB was injected into the arm sentinel nodes to reveal the subsequent-echelon nodes and lymphatics. Gross arm lymph nodes were examined by intraoperative partial frozen section and were removed if positive. Arm lymphedema, local recurrence, regional recurrence, and distant metastasis were recorded at different follow-up examinations.


Arm sentinel nodes were identified in 573 (83.2%) patients. Subsequent-echelon nodes and lymphatics were visualized in 558 (97.4%) patients. Metastatic arm nodes were identified in 38 (6.8%) patients. The arm lymphedema rate was 3.3% (18/543) in the study group versus 15.3% (99/648) in the control group (p < 0.001) after 37-month median follow-up. Regional recurrence showed no difference between the two groups (1.4% and 1.2%, respectively) (p = 0.392).


DEPART can benefit breast cancer patients who undergo ALND, reducing the arm lymphedema rate without adversely affecting the morbidity of regional recurrence.



The authors thank the studied patients for their willingness to cooperate with our study.


The authors made no disclosures.

Supplementary material

10434_2019_7569_MOESM1_ESM.wmv (2.6 mb)
Supplementary Video 1. Navigation of the ICG fluorescence image (ICG indocyanine green). (WMV 2663 kb)
10434_2019_7569_MOESM2_ESM.pdf (118 kb)
Supplementary File 2.QuickDASH questionnaire. (PDF 118 kb)
10434_2019_7569_MOESM3_ESM.tif (14 mb)
Supplementary Fig. 3. Objective (a) and subjective (b) arm lymphedema rates at different follow-ups. DEPART iDEntification and Preservation of ARm lymphaTic system, ALND axillary lymph node dissection. (TIFF 14346 kb)
10434_2019_7569_MOESM4_ESM.tif (2.8 mb)
Supplementary Fig. 4. Identification and preservation of arm lymphatic system technique (right axilla). a Dual tracers for identifying arm sentinel nodes. b “Staged tracing” by injecting 0.1 ml methylene blue into arm sentinel nodes to reveal the complete arm lymphatic system. (TIFF 2861 kb)


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Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Qianqian Yuan
    • 1
  • Gaosong Wu
    • 1
    Email author
  • Shu-Yuan Xiao
    • 2
    • 3
  • Jinxuan Hou
    • 1
  • Yuqi Ren
    • 1
  • Hongying Wang
    • 1
  • Kun Wang
    • 4
  • Dan Zhang
    • 4
  1. 1.Department of Thyroid and Breast SurgeryZhongnan Hospital of Wuhan UniversityWuhanPeople’s Republic of China
  2. 2.Wuhan University Center for Pathology and Molecular DiagnosticsWuhanPeople’s Republic of China
  3. 3.Department of PathologyUniversity of Chicago Pritzker School of MedicineChicagoUSA
  4. 4.Department of Thyroid and Breast SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanPeople’s Republic of China

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