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A helping ARM 

Breast surgeon’s technique designed to reduce lymphedema.

KLIMBERG: Bedside to bench and back.
  • KLIMBERG: Bedside to bench and back.

Dr. Suzanne Klimberg's office is alive with “ideaphoria.” That's what a colleague calls it, a creative bubbling up of ideas, in Klimberg's case for new ways to make breast cancer surgery less painful, less complicated and with fewer side effects.

For example: When patients complained of pain after breast reconstruction, Klimberg and her team thought up a solution: They could inject the area with botox, which helps by stopping muscle spasms. To reduce the need for second surgeries, Klimberg designed a lumpectomy technique using radiofrequency ablation to cauterize the margins around the tumor, a strategy that in her experience reduces recurrence by 75 percent. She's developed a skin-sparing mastectomy procedure that preserves the patient's own skin shell.

Now, Klimberg is training doctors outside Arkansas in a technique she's been using for a year to reduce lymphedema, the swelling of the arm that can occur after the removal of axillary lymph nodes to test for the spread of cancer.

Klimberg's technique, called ARM, or axillary reverse mapping, uses a blue dye to better identify which axillary nodes are draining the breast and which are arm lymphatics. (Lymphatic fluid is waste from tissue and blood and helps the immune system function.) During sentinel node surgery, the dye tells her what not to remove (hence “reverse”).

The size of a breast tumor is not an indicator of whether the cancer has spread; the lymph nodes closest to the breast are. The strategy to test the “sentinel node” — the lymph nodes first to accumulate drainage from the breast — can reveal whether the breast cancer has spread into the patient's body and was a great advance when it was introduced in the early 1990s. It reduced the number of axillary nodes removed from the patient and reduced nerve damage and lymphedema.

But removal of the nodes was still imprecise, leaving as many as one in five patients with lymphedema — sometimes right away, sometimes years down the road. The uncomfortable swelling can be so great that patients can't wear clothing on the arm; the arm can become so heavy that it starts to strain the back and shoulder muscles. Some of Klimberg's patients complained that the lymphedema “was worse than the mastectomy,” the surgeon said. Massage and drain pumps give some relief, but only temporarily.

When sentinel nodes prove positive, more axillary nodes are removed for diagnostic purposes. But Klimberg wanted to know — what if the arm lymphatics weren't diagnostic? What if they were always free of cancer? Sparing those nodes would reduce the number of lymphedema cases even more.

Klimberg's lymphatic “ideaphoria” came about five years ago. She asked her colleagues — she knew the names of the nodes within the axilla, their anatomical position, but which did what? Wasn't there a way to distinguish between breast and arm systems, even though they're all clumped up together?

Klimberg ordered and read piles of textbooks. No luck. No one, apparently, had actually tracked the axillary system. “I couldn't believe no one knew,” she said. (It complicates things that not everybody's system of nodes is the same; some have one or two that drain the breast, some have as many as six.)

So Klimberg decided she would distinguish the nodes using a blue dye (injected into the arm) and radioactive fluid (injected into the breast). Now, she can both hear and see which nodes are draining the breast — by the Geiger clicks — and which drain the arm — by the blue dye. In a clinical trial she conducted last year, she found that all of the sentinel nodes were “hot,” or containing the radioactive fluid, and that none of the blue nodes were. The breast nodes and blue nodes were two separate systems. She reported her results in the February issue of the “Annals of Surgical Oncology.”

Klimberg has now used the ARM technique on 120 cases. “So far, so good,” she said.

Because some patients don't develop lymphedema until several years out, Klimberg can't say how much the ARM method will reduce lymphedema. But she's confident. “It makes sense that if I don't cut a blood vessel to my finger, my finger won't die.”

Klimberg does not take full credit for her ground-breaking treatments. “In all of our clinic, we foster creativity. We look at the things that bother the patient.” Instead of bench to bedside — research to patient — Klimberg says she's bedside to bench.

“I have a lot of talents, none great in any one area,” the surgeon said. Breast surgery allows her to use them all, and they add up to more than the sum of the parts. “And I assembled a great team.”

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