Intraoperative Evaluation of Axillary Lymphatics for Breast Cancer Patients Undergoing Axillary Surgery
Phase: NA
Conditions: Lymphedema, Surgery, Breast Cancer
Sponsor: University of Wisconsin, Madison

 
 
 
 
Intraoperative evaluation of axillary lymphatics for breast cancer 
patients undergoing axillary surgery 
NCT05094102 
11-3-2022 
 

 
1
Intraoperative evaluation of axillary lymphatics for breast cancer patients undergoing 
axillary surgery 
 
Principal Investigator:  
Heather B. Neuman, MD, MS 
University of Wisconsin School of Medicine and Public Health  
Associate Professor, Department of Surgery 
600 Highland Avenue 
K6/142 
Madison, WI 53792-7375 
(608) 262-2025 
neuman@surgery.wisc.edu 
 
 
Protocol Version Date: November 3, 2022 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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1. Project Summary  
Lymphedema is an incurable and chronic condition where damage or blockage to the lymphatic system 
leads to swelling, pain, numbness, recurring infections, and fibrosis.1-3 Women diagnosed with breast 
cancer undergoing axillary lymph node surgery may develop lymphedema due to damage or blockage 
of the lymphatic vessels that drain the arm. Rates range from 6-46% depending on the extent of axillary 
surgery.1-3 
Axillary reverse mapping (ARM) is a technique performed by breast surgical oncologists as a way to 
potentially decrease the risk of lymphedema from axillary surgeries.4-14 ARM identifies the lymphatic 
channels draining from the arm during primary breast tumor resection and axillary lymph node surgery, 
thereby differentiating those draining the breast vs those draining the arm. To date, ARM is most 
commonly performed using either a blue dye4-7,10 or immunofluorescence9-15. At the time of axillary 
node surgery, the dye is injected in the subcutaneous fat in the upper arm, resulting in enhanced 
visualization of lymphatics. These lymphatics may then be spared, reducing the risk of lymphedema. 
However, significant limitations to the use of blue dye in lymphatic mapping exist. To visualize blue dye, 
the surgeon must dissect through the soft tissue directly to a blue lymphatic, which can result in 
variable success in identifying the ARM nodes and/or lymphatics, as well as a persistent blue stain at 
the site of injection.9,11,12  
Compared to blue dye, fluorescence-guided surgery (FGS) with indocyanine green (ICG) dye 
represents an opportunity to greatly enhance the potential of the ARM procedure to increase the 
surgeon’s confidence in identifying the lymphatic architecture before focusing on the operative field. 
FGS allows the surgeon to visualize lymphatics without the need to dissect directly to the lymphatic 
channels; rather than directly exposing the lymphatics with surgical dissection, the lymphatics can be 
viewed on the imaging platform. In one prospective study evaluating the ARM procedure, patients 
underwent injection with both isosulfan blue dye and ICG.  This study reported that blue dye and ICG 
identified a similar number of lymph nodes but ICG identified greater number of lymphatics draining the 
arm.10 However, challenges also exist in the use of FGS with ICG for ARM surgery. Commercially 
available imaging platforms to support fluorescence-guided surgery do not work with ambient lighting. 
Ambient room light contamination of near-infrared fluorescence (NIRF) signal emitted from 
fluorescence dye injected into the patient typically requires ambient lights in the operating room to be 
dimmed or turned off to capture the fluorescence images. This limits surgeons’ ability to use FGS in 
real-time. Some FGS imagers attempt to compensate for ambient light through background subtraction, 
which leads to reduced image quality due to dynamic range compression, reduced sensitivity due to 
shorter effective collection times, and added display latency.16   
In this proposal, we will assess the feasibility of using the Asimov Imaging Platform for fluorescence-
guided surgery along with ICG in the operating room for the ARM procedure. FGS with ICG is an 
acceptable approach to performing the ARM procedure nationally and internationally9-15. Theoretical 
benefits to the Asimov Imaging Platform exist, specifically that it can be used without altering external 
(i.e., room) light functionality or levels, which will enable real-time visualization of lymphatics using both 
fluorescence and familiar anatomical reference points to support ARM. 
The objective of this study is to assess the feasibility of using fluorescence-guided surgery with ICG dye  
through the Asimov Imaging Platform for the axillary reverse mapping procedure. We will use blue dye 
to guide clinical decision making.  We will compare the ICG fluorescence findings (research) with the 
blue dye (standard of care).  Nationally and internationally, both blue dye and FGS with ICG dye are 
used4-14. In this study, we are specifically evaluating the feasibility of the Asimov Imaging Platform for 
fluorescence-guided surgery with ICG dye.   

 
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2. Background and Significance  
Breast cancer is the most common cancer among women globally, with more than 2 million new cases 
diagnosed annually. In the United States, more than 250,000 women a year are diagnosed with breast 
cancer. Surgery is central to cancer treatment, with more than 90% of these patients undergoing 
surgery for tumor resection, mastectomy, or breast reconstruction.17 Survival of breast cancer patients 
has increased substantially as a result of improved, multidisciplinary treatment approaches which 
means that survivors are also living longer with any morbidity resulting from treatment, including 
lymphedema.  
Lymphedema is an incurable and chronic condition where damage or blockage to the lymphatic system 
leads to swelling, pain, numbness, heaviness, recurring infections, and fibrosis.18 Women undergoing 
axillary lymph node surgery may develop lymphedema due to damage or blockage of the lymphatic 
vessels that drain the arm. In affected breast cancer patients, lymphedema often manifests in the arm 
weeks to years after the removal of the primary tumor or radiation therapy. Rates of lymphedema range 
from 6%-46%, depending on the extent of axillary surgery.1-3 A recent systematic review of 72 clinical 
studies (N=29,612 women) revealed that approximately 1 in 5 women who survive breast cancer will 
develop arm lymphedema.3 Not only does lymphedema reduce quality of life, it has long been a feared 
complication of surgical cancer treatment impacting survivorship: fear stems from a patient’s concerns 
regarding the chronic, progressive nature of the condition and the clinician’s relative inability to predict 
or prevent it from occuring.19 Further, associated per patient costs range from $3000 to $16,000 
annually.18 
Because lymphedema may result from iatrogenic damage to upper limb lymphatics during axillary 
lymph node surgery, identification and preservation of arm lymphatics decreases the likelihood of 
lymphatic disruption during axillary lymph node surgery, leading to a lower incidence of upper limb 
lymphedema.4,5,8 Axillary surgery has historically consisted of an axillary lymph node dissection (ALND) 
where between 15 to 20 lymph nodes were removed from the axilla. Lymphedema rates for an ALND 
range between 20% and 40% in published studies.1-3,19 Because of the associated morbidity rates, this 
procedure is now only performed for patients with confirmed axillary disease. For women with clinically 
negative axillary lymph nodes, axillary staging is performed with a sentinel lymph node (SLN) biopsy. 
The SLN biopsy procedure involves pre-operative mapping of the lymphatics to identify one or two 
lymph nodes where the breast would drain to first if the disease had spread. These lymph nodes are 
then removed through a small incision. Lymphedema rates are lower with this procedure, but still range 
from 5% to 7% in prospective randomized controlled trials.20 
Axillary reverse mapping (ARM) is a technique performed by breast surgical oncologists as a way to 
potentially improve the quality of axillary surgeries.4-14 As shown in Figure 1, ARM is utilized to identify 
the lymphatic channels from the arm and differentiate them from the breast lymphatics during primary 
tumor resection and axillary lymph node surgery. To date, ARM is most commonly performed using a 
blue dye or immunofluorescence, which is injected in the subcutaneous fat in the upper arm, resulting 
in enhanced visualization of lymphatics at the time of axillary node surgery.5 Studies have shown that 
lymphedema rates decrease three-fold when using ARM.4-6,8  
Significant limitations to the use of blue dye in lymphatic mapping exist, including its low optical depth 
penetration, insufficient identification rates of the ARM nodes and/or lymphatics, as well as a persistent 
blue stain at the site of injection. Most importantly, the blue lymphatics can only be identified with direct 
dissection onto the lymphatic, something that is challenging when using a small incision (as for a SLN 
biopsy) or in obese patients (where the blue lymphatics are deeper and surrounded by adipose tissue 
making them more difficult to identify). Finally, the blue lymphatics from the arm may actually drain 
outside the operative field and never be visualized due to its low visual penetration depth; in these 
situations, the breast surgeon is less confident whether the blue lymphatic was inadvertently divided, or 
whether it was tracking along a different route. 

 
4
A 
B 
C 
 
Figure 1. Axillary reverse mapping (ARM). 
(A) Sentinel lymph nodes and typical 
lymphatic drainage patterns from the breast 
are identified (green).21 Lymphography with 
(B) blue dye is challenging due to the non-
specific binding to the lymphatics (blue) and 
poor signal retention.8 (C) Lymphatic vessels 
are shown clearly with ICG lymphography 
(white).22 Although ICG easily highlights 
large lymphatic vessels, small and critical 
lymphatic vessels, which can be as small as 
1 mm in diameter, are unable to be seen. 
The clinical need in spatial and sensitivity 
resolution highlights the need for improved 
FGS imaging systems.  
Fluorescence-guided surgery (FGS) with indocyanine green (ICG) represents an opportunity to greatly 
enhance the potential of the ARM procedure to increase the surgeon’s confidence in identifying the 
lymphatic architecture before focusing on the operative field.16 As ICG has shown to offer deeper 
optical penetration than blue dye with ability to detect lymphatic channels located up to 2 cm deep, 
surgeons can follow the route of drainage from the injection site through lymphatic vessels to preserve 
its patency.  
In this proposal, we will use the Asimov Imaging Platform for fluorescence-guided surgery in the 
operating room. The Asimov can be used without altering external (i.e., room) light functionality or 
levels. This will enable real-time visualization of lymphatics to support ARM and would represent a 
significance advancement.  
Technical gaps in the literature limit our understanding of ICG fluorescence for ARM that impact 
implementation of this approach within the clinical workflow. Specifically, we need to quantify the critical 
image acquisition parameters that provide 1) surgeons’ detection contrast (CNR) of post-injection time 
and 2) fluorescence signal retention of lymphatic vessels. The post-injection time is valuable for 
elucidating the optimal clinical workflow. Although some studies inject more than two hours before 
surgery, others inject immediately before the axillary surgery.9 In healthy patients, ICG typically reaches 
the nearest draining lymph node within 15 minutes,23 but because lymphatic clearance and backflow 
are dependent on the damage to vasculature, the optimal post-injection imaging time point will vary 
depending on the severity of damage to lymphatic vasculature. Thus, the clinical workflow is difficult to 
establish and optimize. 
The fluorescence signal retention is necessary to enable surgeons to identify and be able to see these 
lymphatic vessels during surgery. Previous studies have not provided these parameters, largely due to 
inherent limitations in quantification capabilities of existing fluorescence imaging technology. 
Furthermore, existing fluorescence imaging technology does not provide fluorescence overlay on the 
white light reflectance image. This visualization is critical to provide surgeons with familiar anatomical 
reference points seen with white light that are further enhanced with fluorescence. This fluorescence 
illuminates the lymphatic flow and its location to support appropriate navigation around critical 
structures to preserve patency when possible. 
3. Study Objective and Specific Aims  
Specific Aim 1: To determine the feasibility of using ICG fluorescence through the Asimov Imaging 
Platform for axillary reverse mapping by comparing lymphatic visualization using blue dye (standard of 
care) versus ICG fluorescence imaging.  

 
5
Specific Aim 2: To define optimal image acquisition parameters of using ICG fluorescence through the 
Asimov Imaging Platform for axillary reverse mapping to inform the clinical workflow. 
2a. To define dynamic range of ICG fluorescence signal in lymphatic vessels and background. 
2b. To assess image contrast as a function of ICG dose and time post-injection. 
4. Research Design and Methods 
4.1. Study Overview 
Lymphatic drainage from the upper arm is often different from that of the breast, allowing safe removal 
of only the lymphatics of the breast and protection of the lymphatic channels draining the upper 
extremity during axillary dissection (AD) or sentinel lymph node (SLN) biopsy, thereby reducing the risk 
of arm lymphedema.4-14 In this prospective study, breast cancer patients undergoing SLN biopsy (n=0-
20) or axillary lymph node dissection (n=0-15) will be enrolled to undergo axillary reverse mapping 
(ARM) using isosulfan blue dye. Patients will also receive ICG injection with visualization through the 
Asimov Imaging Platform to allow comparison of blue dye versus ICG lymphatic identification.  
We will also define optimal image acquisition parameters of using ICG fluorescence through the Asimov 
Imaging Platform for ARM. We will use quantitative fluorescence to define optimal image acquisition 
parameters. In order to elucidate injection technique superiority, the critical image acquisition 
parameters that provide surgeons detectable contrast (CNR) of post-injection time, and fluorescence 
signal retention of lymphatic vessels will be measured. The post-injection time is valuable for 
elucidating the optimal clinical workflow. The fluorescence signal retention is necessary to enable 
surgeons to identify and be able to see these lymphatic vessels during surgery.  
4.2. Selection of Participants 
Inclusion criteria:  
• 
≥ 18 years of age 
• 
Diagnosis of breast cancer requiring surgical lymph node evaluation either by sentinel lymph node 
biopsy or axillary lymph node dissection 
• 
Surgery at University of Wisconsin Hospital and Clinic 
Exclusion criteria: 
• 
Pregnant or breast feeding  
• 
Unable to provide informed consent 
• 
Allergy to indocyanine green 
• 
Patients with clinically positive lymph nodes undergoing sentinel lymph node biopsy, with or 
without axillary lymph node dissection, after neoadjuvant chemotherapy 
4.3 Screening and recruitment: 
Patients being cared for by Dr. Neuman within the UW Breast Center will be eligible for consideration.  
Dr. Neuman will identify eligible patients from her clinical practice and introduce the study to them at the 
time of their clinic visit. A clinical research coordinator will then discuss the study in detail and obtain 
informed consent. Participants will have sufficient time to consider participating in this study.  
4.4. Consent Process 
The consent process will occur at the Breast Center. Subjects will be consented in a closed private 
room by a member of the study team. As much time as needed will be given for potential subjects to 
decide whether or not to participate in this study. Subjects will receive a copy of the consent form and 

 
6
will be given contact information for study coordinator and PI for any additional questions. Subjects will 
be informed that they are not obligated to participate in the study.  
 
4.5. Study procedures: 
Standard of Care Procedures: 
Axillary surgery: Axillary lymph node dissection or sentinel lymph node biopsy will be performed as 
indicated by the patient’s clinical history. For patients enrolled in the study, sentinel lymph node 
mapping and biopsy will be performed using technetium-99m sulfur colloid only (no injection of 
isosulfan blue dye in the breast), which is an acceptable standard of care. The participating surgeon will 
otherwise follow their usual practice for performing these routine procedures. 
Axillary reverse mapping: Axillary reverse mapping is an acceptable standard of care and has been 
used internationally (including at the UWHC) to reduce the risk of lymphedema for women undergoing 
axillary surgery.4-14 ARM is also currently being studied in an NCI funded trial to determine the extent to 
which ARM reduces lymphedema risk (NCT039270127). We will use the ARM procedure for both the 
axillary lymph node dissection and the sentinel lymph node biopsy. Although the risk of lymphedema is 
lower after a sentinel lymph node biopsy than with an axillary lymph node dissection, it can still occur 
(estimated 5-7%). 
To perform ARM, 2.5 ccs of 1% isosulfan blue dye (10 g/L concentration) will be injected 
subcutaneously in the volar surface of the ipsilateral upper extremity at the bicipital sulcus after 
induction of anesthesia. Participating surgeons at UW Health have experience performing ARM with 
isosulfan blue dye.  During the axillary surgery, identification of lymphatics will be attempted. If 
lymphatics are visualized in the surgical field, lymphatics draining the arm that do not also have 
crossover breast drainage will be spared or reapproximated. Importantly, the ARM procedure does not 
influence the extent of an axillary surgery, as it does not determine whether or not lymph nodes are 
involved with cancer. Rather, the dye maps the pathway of arm lymphatic flow so that these lymphatics 
can potentially be spared during an axillary surgery.  The breast surgeon will use the blue dye to guide 
clinical decision-making for the ARM procedure.  
 
Research Procedures: 
ARM mapping with ICG fluorescence using the Asimov Platform: The research procedures will include 
using ICG fluorescence for the ARM mapping. OnLume will provide a sterile drape designed specifically 
for the OnLume Asimov.  25 mg of ICG and 10 mg Sterile Water will be dispensed for injection by UW 
Health pharmacy. Before the image acquisition of each patient, ICG will be reconstituted under sterile 
conditions with Sterile Water for Injection(2.5 mg/1 ml). Shake the vial gently to dissolve. Reconstituted 
ICG must be used within 6 hours after reconstitution. The total dose of dye will be kept below 2 mg/kg 
of patient body weight.  
ICG dosing described in the literature has varied significantly (Table 1). A total dose of 1 ml (2.5 mg) of 
ICG will be injected subdermally, in divided doses. 0.5 ml will be injected in the subcutaneous fat in the 
volar surface of the upper arm at the bicipital sulcus and 0.5 ml in the 2nd interdigital space. The two 
injection protocol follows the published experience by Abacci, et al. with the goal to improve ICG’s 
circulation through the lymphatic vessels.24 The upper arm injection will be performed within 1 cm of the 
isosulfan blue dye injection and will occur after induction of anesthesia. At least two minutes of 
massage will be performed to promote upper limb lymph flow. Visualization of the lymphatics using the 
Asimov Platform will be attempted  
 

 
7
Table 1.  Summary of Injections Methods for ICG in ARM Procedure 
Author 
Dose of ICG injected 
Injection Location 
Noguchi12 
0.1 ml (0.25 mg) 
Inner wrist 
Noguchi11 
0.1 ml (0.25 mg) 
Inner wrist 
Ikeda25 
0.5-1ml (5 mg) 
Upper inner arm 
Ikdea26 
0.5-1 ml (5 mg) 
Upper inner arm 
Sakurai13 
0.15 ml 
Interdigital area 
Foster10 
0.5-3 mg/ml  
Upper arm 
Ma15 
1 ml (0.5 mg/ml) 
Upper arm 
Yuan14 
1 ml (2.5 mg) 
Upper arm 
Abacci24 
1 ml (2.5 mg/ml) in divided doses 
Upper arm, 2nd interdigital space 
 
Subjects will receive fluorescence imaging using the Asimov Imaging Platform. Beginning at the time of 
ICG injection, image and video capture of white light reflectance and fluorescence will be collected.  
Impact on clinical care of the ICG mapping: The objective of this study is to evaluate the feasibility of 
using ICG fluorescence through the Asimov Imaging Platform. Compared to other platforms, the 
Asimov Imaging Platform allows real time imaging without altering ambient light. The presence of ICG 
fluorescence visualized lymphatics will be documented per the research protocol, but will not be used to 
influence surgical decision making. 
4.5. Data Collection 
Operative data related to ARM: For each case, we will also assess whether blue dye identified 
lymphatics were visualized (yes/no) in the nodal basin and whether the blue lymphatic was spared 
(yes/no). We will also assess whether ICG identified lymphatics were visualized (yes/no) in the nodal 
basin and whether the ICG lymphatics were spared (yes/no). Surgical decision making will be guided 
by the blue dye only and the ICG fluorescence will not be considered. However, we will still document 
whether or not the ICG fluorescent lymphatics were spared. We will assess whether intact lymphatic 
channels were present at the completion of the axillary surgery via both techniques (yes/no/not 
assessable). We will record time at start of case, any fluorescent imaging, and completion of axillary 
surgery (defined as removal of last lymph node).  
Chart review demographics and tumor characteristics: We will record other limited demographics about 
the patient including: Age, race/ethnicity, BMI, type of axillary surgery, type of breast surgery, receipt of 
neoadjuvant systemic therapy, prior axillary surgery, prior receipt of radiation, clinical and pathologic 
cancer stage (tumor size and lymph node status), and receptor status (estrogen receptor, progesterone 
receptor, her2neu). We will record the number of lymph nodes removed. We will indicate whether 
removed lymph nodes had radiotracer, blue dye, or fluorescence. For patients undergoing SLN biopsy, 
this will allow us to assess whether the SLN is the same as the ARM identified node. We will evaluate 
for any additional axillary surgeries or complications related to axillary surgery (infection, lymphedema) 
until 1 year post-surgery. We will document receipt of post-operative radiation. 
Technical data related to ICG fluorescence imaging: Beginning at the time of ICG injection, image and 
video capture of white light reflectance and fluorescence will be collected. Following the operation, 
post-processing will be conducted to elucidate injection technique superiority. Physicians will confirm 
software-assisted lymphatic labels in the video and measure vessel diameters. 
We will use quantitative fluorescence to define optimal image acquisition parameters. In order to 
elucidate injection technique superiority, the critical image acquisition parameters that provide surgeons 
detectable contrast (CNR) of post-injection time, and fluorescence signal retention of lymphatic vessels 
will be measured.  

 
8
 
4.6. Analysis Plan: 
1. Aim 1: To determine the feasibility of using ICG fluorescence for axillary reverse mapping 
through the Asimov Imaging Platform by comparing lymphatic visualization using blue dye 
(standard of care) versus ICG fluorescence imaging: Given the increased optical penetration 
with the ICG lymphatics, we anticipate greater visualization with the ICG. The proportion of 
cases where blue dye visualized lymphatics can be seen after 5 minutes post-injection will be 
reported along with the corresponding 95% confidence interval, which will be constructed using 
the Wilson score method. The same proportion will be reported for the ICG lymphatics. 
Comparisons between visualization of lymphatics by blue dye versus ICG fluorescence imaging 
will be made using test of two proportions. We will also compare whether lymphatics were able 
to be spared and whether intact lymphatic channels were able to be confirmed via both 
techniques. We will also generate descriptive statistics of patient characteristics associated with 
visualization of lymphatics with each approach to explore clinical scenarios when an approach 
may be less effective. For comparisons, the blue dye is considered the standard of care 
comparison.  
 
2. Aim 2: To define optimal image acquisition parameters of using ICG fluorescence through the 
Asimov Imaging Platform for axillary reverse mapping. 
Aim 2a. To define dynamic range of ICG fluorescence signal in lymphatic vessels and 
background: Imaging acquisition parameters generated from image snapshots and videos 
will be summarized using standard descriptive statistics, including means, standard 
deviations, medians and interquartile ranges to characterize the dynamic range of ICG 
fluorescence signal in lymphatic vessels and the background. Nonlinear regression analyses 
will be conducted to statistically model CNR as a function of ICG dose and time.  
Aim 2b. To assess image contrast as a function of ICG dose and time post injection: Image 
contrast (CNR) will be measured for these lymphatics vessels and a time-curve will be 
developed that demonstrate the change in contrast over time. The magnitude of 
fluorescence signal retention of ICG in the lymphatic vessels, which is a function of both 
pharmacokinetics/pharmacodynamics of ICG and the sensitivity of the imaging platform, will 
be measured. Detectable contrast is defined by the Rose criterion: CNR>3.  
 
4.7. Sample Size: 
We will plan to enroll approximately 0-20 patients undergoing SLN biopsy and 0-15 patients undergoing 
an ALND for a total of about 25 patients. The proposed total sample size is sufficient to generate 
descriptive statistics with an adequate level of precision.16 Specifically, the proportion of cases where 
lymphatics can be seen after 5 minutes post-injection will be estimated with a standard error of less 
than 12% and the corresponding 95% confidence interval will be no wider than 40%. 
No power calculation is calculated for this feasibility study. 
4.8. Risks and Benefits to the Participant 
Potential risks: Potential risks from ICG are minimal as it is a well-known, FDA-approved dye that has a 
very good safety profile (adverse event rate: 1 in 42,000) when administered intravenously.9,16,27 
Adverse events can range from a redness of the skin or hives, up to cough or difficulty swallowing.  In 
the operating room, these would be treated with medication such as antihistamines, H2 blockers, 

 
9
and/or epinephrine. Although ICG is approved for intravenous administration, it has been safely injected 
into interstitial, subcutaneous (SC) or intradermal locations in hundreds of patients, including breast 
tissue. A summary of ICG risks by publication on ARM Procedures are shown below in Table 2, 
indicating the low risk profile:  
Table 2. Summary of ICG risks for ICG in ARM Procedure 
Author 
Patient population 
Number of adverse 
reactions/allergies 
Noguchi12 
Review article 
 
Noguchi11 
131 patients 
None reported 
Ikeda25 
98 patients 
Zero. 
Ikeda26 
60 patients 
None reported 
Sakurai13 
372 patients 
Zero. 
Foster10 
23 patients 
Zero. 
Ma15 
44 patients 
None reported 
Yuan14 
689 patients 
None reported 
 
Potential risks from the use of the OnLume Asimov Imaging platform are low since the imaging device 
will be used in a similar manner as its FDA 510(k) clearance. The duration of the surgery is not 
expected to be significantly longer in duration (<20 minutes) with the additional use of the OnLume 
System imaging than with just the standard of care. Per discussions with anesthesia staff, the additional 
time for anesthesia poses no foreseeable additional risk to the patient. The risk associated with the 
injection of the dye will be minimized by close observation of the patient after injection. Injection will 
occur in the OR when extensive monitoring is already occurring. 
As with any study, there is a remote risk of breach of confidentiality. This risk has been minimized 
through data protection efforts. Only approved study personnel will have access to the direct identifiers. 
Patients enrolled in this study who are undergoing the sentinel lymph node biopsy will have lymphatic 
mapping of the breast performed using technetium-99m sulfur colloid only (no injection of isosulfan blue 
dye in the breast). The sentinel lymph node biopsy was initially described with blue dye only, but quickly 
incorporated the technetium-99m sulfur colloid as it increased the ease of use and decreased mapping 
failure rates. In current clinical practice, surgeons may choose to perform lymphatic mapping with blue 
dye only, technetium-99m sulfur colloid only, or both. All methods are considered an acceptable 
standard of care. Use of technetium-99m sulfur colloid only represents a negligible risk to participants. 
Potential benefits: This project has the potential to benefit future breast cancer patients by providing 
imaging that enhances ability to identify small vessels in the body, thereby decreasing the risk of 
accidental damage to the vessels and increasing the possibility of effective repair (i.e., anastomosis). 
Potential benefits to science and society in general include refinement of a surgical technique with the 
potential to reduce the risk of lymphedema for breast cancer patients undergoing axillary surgery. 
7. Data and Safety Monitoring Plan  
The PI and study team will be involved in ongoing monitoring for data and safety concerns.   
 
Our proposed phase II, non-blinded clinical trial represents a low risk of adverse events, and the 
described DSMP is commensurate with this level of risk. The PI and study team will meet weekly to 
discuss recruitment, accrual and retention of participants. They will also review any safety concerns 
during these meetings. The study team will discuss data quality monthly.   
 

 
10
We feel that the risks to participating in this study are minimal and our research team will be continually 
reviewing data and subject safety at weekly study team meetings to discuss study progress including 
recruitment/enrollment, data integrity, and adverse events (AEs). This study will utilize the Common 
Terminology Criteria for Adverse Events (CTCAE) version 5.0 for routine toxicity and adverse event 
(AE) reporting. Incisional pain, breast seromas, and breast/arm swelling are expected events after 
breast and axillary surgery. We will consider injection site reactions, such as redness of the skin or 
hives, to be unexpected adverse events. We also consider allergic reactions to the dye (such as cough 
or difficulty swallowing) to be unexpected adverse events. We will submit any unanticipated adverse 
effects to sponsor and to the IRB as soon as possible, but no event later than 10 working days after the 
investigator first learns of the effect. 
The focus of this study is to test the feasibility of ICG mapping through the Asimov Imaging Platform. 
Potential advantages to the Asimov Imaging Platform compared to other means of immunofluorescence 
detection is that it allows real time imaging without altering ambient light.  
Only coded data related to the imaging acquisition will be stored on the OnLume off campus data 
server. Data will be transferred on an encrypted USB drive to OnLume. After confirmation that the data 
has transferred and is not been corrupted, the source data will be deleted from the imaging platform.  
Imaging data will also be stored on the surgery servers using the same method of encrypted USB. No 
PHI will be stored outside of the UW Department of Surgery secure server (see section that follows). 
8. Data and Record Keeping 
The PI will manage and oversee all study activities including the collection and protection of research 
data. All UW-Madison personnel and external collaborators involved in the study will have completed 
University-provided human subjects and HIPAA training. The study staff is trained to protect research 
documents and all precautions will be taken to keep records confidential. Any identifying personal 
information collected during the project will be kept secure by the research team in accordance with 
IRB requirements. Only UW investigators and key personnel will have access to these files with PHI. 
Imaging data will be coded with a unique sample ID # (e.g., 123) and will be stored on the secure 
surgery server and on the OnLume’s off-campus data server. Data will be transferred using an 
encrypted USB drive. No PHI will be stored on the OnLume data server. The subject code is linked to a 
separate spreadsheet, which lists the subject number and the patient identifiable information including 
medical record number. The code will be stored separately from the research data on the secure 
Department of Surgery server. All electronic data is password and firewall security protected. When a 
patient is imaged through the Asimov Imaging Platform, only the subject ID will be entered into the 
system. In this way, the imaging will always be “coded” from the time of image acquisition. From the 
OnLume system, the imaging data will be transferred using an encrypted USB hard drive. Once data is 
confirmed to be successfully transferred to OnLume and the secure Dept. of Surgery server, it will be 
permanently deleted from the imaging platform. 
Datasets containing patient identifiers will not be copied or shared with others for analysis. Only 
datasets without identifiers can be shared for analysis. Upon completion of this research, the link to 
identifiable information will be destroyed, permanently de‐identifying the data. 
 
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Ahn S, Port ER. Lymphedema Precautions: Time to Abandon Old Practices? J Clin Oncol. 
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Rockson SG. Lymphedema after Breast Cancer Treatment. N Engl J Med. 2018;379(20):1937-
1944. 

 
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3. 
DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast 
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Beek MA, Gobardhan PD, Klompenhouwer EG, et al. A patient- and assessor-blinded 
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Han C, Yang B, Zuo WS, Zheng G, Yang L, Zheng MZ. The Feasibility and Oncological Safety 
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