Higher Rates of Visualization for Axillary Reverse Mapping Using Indocyanine Green Fluorescence Compared With Blue Dye

Introduction: Successful axillary reverse mapping (ARM) during lymph node surgery for breast cancer has the potential to reduce risk of lymphedema. Standard of care uses blue dye for ARM; however, recent imaging advances with near-infrared indocyanine green (ICG) fluorescence has demonstrated potential to improve intraoperative ARM imaging. The objective was to determine the feasibility of using ICG fluorescence through the OnLume Avata System for ARM.

Methods: Breast cancer patients undergoing axillary lymph node dissection and were to undergo ARM were enrolled. Lymphatic structures were visualized using ICG fluorescence and blue dye. Real-time fluorescence images were acquired with the OnLume Avata System preincision, intraoperatively, and post dissection during the ARM. Preincision images were quantitatively analyzed for lymphatic fluorescence signal in terms of contrast-to-noise ratio. Imaging data were evaluated in terms of binary visualization rates and signal-to-background ratio.

Results: Lymph nodes, lymphatic vessels, and lymph pooling were observed with fluorescence more frequently than blue dye. For seven out of eight cases, at least one vessel was visualized near the axilla preincision. In all eight cases, ICG fluorescence was noted during the procedure with five cases visualizing intact lymphatics at the end of the procedure. The ambient-light compatibility of the imager allowed the surgeon to operate with image guidance throughout the ARM procedure.

Conclusions: The Avata demonstrated superior identification and visualization with ICG when compared to blue dye for visualizing lymphatic structures in real time with minimal disruption to the clinical workflow.