Anaphylactic reactions to isosulfan blue dye during sentinel lymph node biopsy for breast cancer

Profound hypotension after an intradermal injection of indigo carmine for sentinel node mapping

Intradermal injections of indigo carmine for sentinel node mapping are considered safe and no report of an adverse reaction has been published. The authors described two cases of profound hypotension in women that underwent breast-conserving surgery after an intradermal injection of indigo carmine into the periareolar area for sentinel node mapping.

Hypersensitivity reactions to Patent Blue V in breast cancer surgery: a prospective multicentre study

BACKGROUND

An increasing number of immediate hypersensitivity reactions (HSR) have been reported after the use of Patent Blue V (PBV) for breast cancer surgery. This is the first study to publish prospective data with systematic allergological assessment.

METHODS

We conducted a multicentre study in 10 French cancer centres for over 6 months. All patients scheduled for breast surgery with injection of PBV were included in the study. Patients were screened for past medical history, atopy, and known food and drug allergies. When suspected HSR or unexplained reactions occurred after injection of PBV, blood samples were taken, and plasma histamine and serum tryptase concentrations were measured. HSR to PBV was suggested if skin tests performed 6 weeks later were positive.

RESULTS

Nine suspected HSR to PBV were observed in 1742 patients. Skin tests were positive in six patients, giving an incidence of 0.34%. Four grade I and two grade III HSR were observed, both requiring intensive care unit treatment. Mean onset time of the reaction was 55 ± 37 min. Plasma histamine was elevated in four patients, while serum tryptase was normal. We found no risk factors associated with HSR to PBV.

CONCLUSION

An incidence rate of one in 300 HSR to PBV was observed for patients exposed to PBV during sentinel lymph node detection. This rate is higher than rates reported after the use of neuromuscular blocking agents, latex or antibiotics.

Positron lymphography: multimodal, high-resolution, dynamic mapping and resection of lymph nodes after intradermal injection of 18F-FDG

The lymphatic system plays a critical role in the maintenance of healthy tissues. Its function is an important indicator of the presence and extent of disease. In oncology, metastatic spread to local lymph nodes (LNs) is a strong predictor of poor outcome. Clinical methods for the visualization of LNs involve regional injection and tracking of (99m)Tc-sulfur colloid ((99m)Tc-SC) along with absorbent dyes. Intraoperatively, these techniques suffer from the requirement of administration of multiple contrast media ((99m)Tc-SC and isosulfan blue), unwieldy γ-probes, and a short effective surgical window for dyes. Preclinically, imaging of transport through the lymphatics is further hindered by the resolution of lymphoscintigraphy and SPECT. We investigated multimodal imaging in animal models using intradermal administration of (18)F-FDG for combined diagnostic and intraoperative use. PET visualizes LNs with high sensitivity and resolution and low background. Cerenkov radiation (CR) from (18)F-FDG was evaluated to optically guide surgical resection of LNs.

METHODS

Imaging of (18)F-FDG uptake used PET and sensitive luminescent imaging equipment (for CR). Dynamic PET was performed in both sexes and multiple strains (NCr Nude, C57BL/6, and Nu/Nu) of mice. Biodistribution confirmed the uptake of (18)F-FDG and was compared with that of (99m)Tc-SC. Verification of uptake and the ability to use (18)F-FDG CR to guide nodal removal were confirmed histologically.

RESULTS

Intradermal injection of (18)F-FDG clearly revealed lymphatic vessels and LNs by PET. Dynamic imaging revealed rapid and sustained labeling of these structures. Biodistribution of the radiotracer confirmed the active transport of radioglucose in the lymphatics to the local LNs and over time into the general circulation. (18)F-FDG also enabled visualization of LNs through CR, even before surgically revealing the site, and guided LN resection.

CONCLUSION

Intradermal (18)F-FDG can enhance the preclinical investigation of the lymphatics through dynamic, high-resolution, and quantitative tomographic imaging. Clinically, combined PET/Cerenkov imaging has significant potential as a single-dose, dual-modality tracer for diagnostics (PET/CT) and guided resection of LNs (Cerenkov optical).

Sentinel lymph node biopsy using indigo carmine blue dye and the validity of '10% rule' and '4 nodes rule'

This is the study which assessed sentinel lymph node biopsy (SNB) using indigo carmine blue dye and the validity of the '10% rule' and '4 nodes rule'. Patients (302) were performed SNB using the combined radioisotope (RI)/indigo carmine dye method. Excised SLNs were confirmed whether they were stained and numbered in order of RI count and the percentage of radioactivity as compared to the hottest node was calculated. The relationship between histological diagnosis, dyeing and RI count was assessed. All the patients were detected SLN. Positive nodes were identified in 84 (27.8%) patients and were identified up to the third degree of hottest. All the hottest positive nodes were stained by indigo carmine. From the results, removing the three most radioactive SLNs identified all cases of nodal metastasis without complications. These stopping rules were valid and useful under indigo carmine use too.

Hands-free, wireless goggles for near-infrared fluorescence and real-time image-guided surgery

BACKGROUND

Current cancer management faces several challenges, including the occurrence of a residual tumor after resection, the use of radioactive materials or high concentrations of blue dyes for sentinel lymph node biopsy, and the use of bulky systems in surgical suites for image guidance. To overcome these limitations, we developed a real-time, intraoperative imaging device that, when combined with near infrared fluorescent molecular probes, can aid in the identification of tumor margins, guide surgical resections, map sentinel lymph nodes, and transfer acquired data wirelessly for remote analysis.

METHODS

We developed a new compact, wireless, wearable, and battery-operated device that allows for hands-free operation by surgeons. A charge-coupled device-based, consumer-grade night vision viewer was used to develop the detector portion of the device, and the light source portion was developed from a compact headlamp. This piece was retrofitted to provide both near infrared excitation and white light illumination simultaneously. Wireless communication was enabled by integrating a battery-operated, miniature, radio-frequency video transmitter into the system. We applied the device in several types of oncologic surgical procedures in murine models, including sentinel lymph node mapping, fluorescence-guided tumor resection, and surgery under remote expert guidance.

RESULTS

Unlike conventional imaging instruments, the device displays fluorescence information directly on its eyepiece. When employed in sentinel lymph node mapping, the locations of sentinel lymph nodes were visualized clearly, even with tracer level dosing of a near infrared fluorescent dye (indocyanine green). When used in tumor resection, tumor margins and small nodules invisible to the naked eye were visualized readily. In a simulated, point-of-care setting, tumors were located successfully and removed under remote guidance using the wireless feature of the device. Importantly, the total cost of this prototype system ($1200) is substantially less than existing imaging instruments.

CONCLUSION

Our results demonstrate the feasibility of using the new device to aid surgical resection of tumors, map sentinel lymph nodes, and facilitate telemedicine.

Peri-operative anaphylaxis

Peri-operative anaphylaxis is an important cause for mortality and morbidity associated with anaesthesia. The true incidence is unknown and is most likely under reported. Diagnosis can be difficult, particularly as a number of drugs are given simultaneously and any of these agents can potentially cause anaphylaxis. This review covers the clinical features, differential diagnosis and management of anaphylaxis associated with anaesthesia. The investigations to confirm the clinical suspicion of anaphylaxis and further tests to identify the likely drug(s) are examined. Finally the salient features of common and rare causes including non-drug substances are described.

Current trends and emerging future of indocyanine green usage in surgery and oncology: a literature review

Ever since Kitai first performed fluorescent navigation of sentinel lymph nodes (SLNs) using indocyanine green (ICG) dye with a charge-couple device and light emitting diodes, the intraoperative use of near infrared fluorescence has served a critical role in increasing our understanding in various fields of surgical oncology. Here the authors review the emerging role of the ICG fluorophore in the development of our comprehension of the lymphatic system and its use in SLN mapping and biopsy in various cancers. In addition, they introduce the novel role of ICG-guided video angiography as a new intraoperative method of assessing microvascular circulation. The authors attempt to discuss the promising potential in addition to assessing several challenges and limitations in the context of specific surgical procedures and ICG as a whole. PubMed and Medline literature databases were searched for ICG use in clinical surgical settings. Despite ICG's significant impact in various fields of surgical oncology, ICG is still in its nascent stages, and more in-depth studies need to be carried out to fully evaluate its potential and limitations.

Sentinel node biopsy in breast cancer using infrared laser system first experience with PDE camera

BACKGROUND

Sentinel node biopsy (SNB) is a gold standard in staging of early breast cancer. Nowadays, routine mapping of lymphatic tract is based on two tracers: human albumin with radioactive technetium, with or without blue dye. Recent years have seen a search for new tracers to examine sentinel node as well as lymphatic network. One of them is indocyanine green (ICG) visible in infrared light.

AIM

The aim of this study is to evaluate clinical usage of ICG in comparison with standard tracer, i.e. nanocoll, in SNB of breast cancer patients.

MATERIALS AND METHODS

In the 1st Department of Surgical Oncology and General Surgery, Greater Poland Cancer Centre, Poznań, 13 female breast cancer patients have benn operated since September 2010. All these patients had sentinel node biopsy with nanocoll (human albumin with radioactive technetium), and with indocyanine green. The feasibility of this new method was assessed in comparison with the standard nanocoll.

RESULTS

A lymphatic network between the place of injection of ICG and sentinel node was seen in infrared light. An area where a sentinel node was possibly located was confirmed by gamma probe. Sensitivity of this method was 100%.

CONCLUSION

SNB using ICG is a new, promising diagnostics technique. This procedure is not without drawbacks; nevertheless it opens new horizons in lymphatic network diagnostics.

Anaphylaxis and other Adverse Reactions to Blue Dyes: A Case Series

We report three cases of anaphylaxis during anaesthesia confirmed on intradermal testing to be related to patent blue V dye (Guerbet – Chemical Abstract Service 3536-49-0). All three cases were associated with moderate to severe hypotension. Two cases had delayed onset, and two were associated with a rash. None of the cases were associated with bronchospasm. In all three patients the interference with pulse oximetry readings contributed to difficulties in management. We recommend the use of a test dose of blue dye prior to surgery, as suggested in the manufacturer's product information. We also recommend high vigilance for possible allergic reactions when patent blue dyes are used for sentinel lymph node mapping, because the presentations may be atypical and the reduced pulse oximetry readings may be a distraction.

Sentinel lymph node biopsy in early breast cancer surgery--working with the risks of vital blue dye to reap the benefits

AIMS

Sentinel lymph node biopsy (SLNB) is an important method of staging early breast cancer because of the inherent benefits it confers on patients in terms of arm function and quality of life. Its success depends on a high level of accuracy in detecting the sentinel node. This is achieved by a dual mapping technique that employs a radio-labelled nanocolloid and a vital blue dye. The vital dyes however carry the risk of anaphylaxis, and as more surgeons employ SLNB in their daily practice, a proportionate rise in the number of anaphylactic reactions can be expected. A comprehensive review of risks and benefits associated with using vital blues dyes has not been published and therefore a retrospective review was undertaken of the different levels of anaphylaxis associated with vital dyes as well as their benefits in SLNB.

METHODS

An OVID MEDLINE search was performed of the English published literature using appropriate search terms to find published trial data and case series that focused on adverse reactions to vital blue dyes.

RESULTS

The risk of severe anaphylaxis (grade 3) can be as low as 0.06%, and up to 0.4% for patients undergoing SLNB when data is analysed from large trials. Furthermore, adverse reactions associated with blue dyes are reversible with appropriate management.

CONCLUSIONS

Surgeons should continue to use vital dyes to ensure that SLNB remains a highly sensitive procedure.

Increased post-operative complications with methylene blue versus lymphazurin in sentinel lymph node biopsies for skin cancers

BACKGROUND

Sentinel lymph node biopsy (SNLB) is the standard of care in staging of melanoma and other skin cancers. Early studies used lymphazurin (LZ) for SLNB. A national shortage of LZ promoted methylene blue (MB) as an alternate stain.

OBJECTIVE

This study compares complication rates between LZ and MB in SLNB patients, and the reliability dyes in locating sentinel lymph nodes.

METHODS

Charts were reviewed for patients who underwent SLNB for skin cancers between September 2006 and November 2008 at Penn State Hershey Medical Center. The type and quantity of dye, the presence of blue stained sentinel nodes, and any complications were recorded.

RESULTS

Ninety-three patients underwent SLNB (46 LZ, 47 MB). The amount of dye used was similar (avg. 0.93 ml LZ, 1.24 ml MB). The complication rate of LZ was 8.7%, and MB was 25.5%. There was significantly more (P = 0.003) skin graft complications in the MB patients (6/12) versus LZ (0/15).

CONCLUSIONS

There is a higher rate of complications with MB, especially with skin grafting. The reported risk of anaphylaxis with LZ has not been reported in volumes <2 ml. The sentinel lymph node identification rate is historically similar between dyes, and in this study was noted to be higher with LZ.

Cardiac Arrest after Patent Blue V Injection for Sentinel Lymph Node Biopsy in Breast Cancer

SUMMARY: BACKGROUND: Sentinel lymph node biopsy (SLNB) is a widely accepted method to determine lymph node status in for instance breast cancer, cervical cancer, or cutaneous melanomas. Although injection of blue dyes facilitates successful detection of sentinel nodes, they have also been shown to cause adverse reactions. CASE REPORT: A 62-year-old female patient was referred to the surgical department of the Atrium Medical Centre with a suspicious lesion located in the right breast, detected during population-based screening. Immediately after injection of patent blue V, the patient developed tachycardia on top of preexisting supraventricular tachycardia and showed an instant drop in blood pressure, after which cardiac arrest occurred. These clear symptoms of anaphylactic shock required prompt treatment, and the patient was treated accordingly. CONCLUSIONS: Anaphylactic shock after injection of patent blue V remains a serious adverse event and warrants awareness. Immediate action with ephedrine, antihistamines, and subsequently corticosteroids can stabilize the patient. Tc-99m, isosulphan blue, and methylene blue can alternatively be used for SLNB, although also not without side effects.

Does blue dye contribute to success of sentinel node mapping for breast cancer?

BACKGROUND

We sought to evaluate the utilization of blue dye in addition to radioisotope and its relative contribution to sentinel lymph node (SLN) mapping at a high-volume institution.

METHODS

Using a prospectively maintained database, 3,402 breast cancer patients undergoing SLN mapping between 2002 and 2006 were identified. Trends in utilization of blue dye and results of SLN mapping were assessed through retrospective review. Statistical analysis was performed with Student t test and chi-square analysis.

RESULTS

2,049 (60.2%) patients underwent mapping with dual technique, and 1,353 (39.8%) with radioisotope only. Blue dye use decreased gradually over time (69.8% in 2002 to 48.3% in 2006, p < 0.0001). Blue dye was used significantly more frequently in patients with lower axillary counts, higher body mass index (BMI), African-American race, and higher T stage, and in patients not undergoing skin-sparing mastectomy. There was no difference in SLN identification rates between patients who had dual technique versus radiocolloid alone (both 98.4%). Four (0.8%) of 496 patients who had dual mapping and a positive SLN had a blue but not hot node as the only involved SLN. None of these four had significant counts detected in the axilla intraoperatively. Nine (0.4%) of 2,049 patients who had dual mapping had allergic reactions attributed to blue dye.

CONCLUSIONS

Blue dye use has decreased with increasing institutional experience with SLN mapping. In patients with adequate radioactive counts in the axilla, blue dye is unlikely to improve the success of sentinel node mapping.

Near-Infrared Fluorescence Imaging in Humans with Indocyanine Green: A Review and Update

Near-infrared (NIR) fluorescence imaging clinical studies have been reported in the literature with six different devices that employ various doses of indocyanine green (ICG) as a non-specific contrast agent. To date, clinical applications range from (i) angiography, intraoperative assessment of vessel patency, and tumor/metastasis delineation following intravenous administration of ICG, and (ii) imaging lymphatic architecture and function following subcutaneous and intradermal ICG administration. In the latter case, NIR fluorescence imaging may enable new discoveries associated with lymphatic function due to (i) a unique niche that is not met by any other conventional imaging technology and (ii) its exquisite sensitivity enabling high spatial and temporal resolution. Herein, we (i) review the basics of clinical NIR fluorescence imaging, (ii) survey the literature on clinical application of investigational devices using ICG fluorescent contrast, (iii) provide an update of non-invasive dynamic lymphatic imaging conducted with our FDPM device, and finally, (iv) comment on the future NIR fluorescence imaging for non-invasive and intraoperative use given recent demonstrations showing capabilities for imaging following microdose administration of contrast agent.

Current applications and future prospects of fine-needle aspiration biopsy of locoregional lymph nodes in the management of breast cancer

Staging of disease is routine in the evaluation of patients newly diagnosed with breast cancer. Assessment of palpable and/or nonpalpable locoregional lymph nodes is an important component of the initial staging. Ultrasound (US) is the favored imaging modality for the initial investigation of lymph nodes and results in a significant increase in the specificity of the overall evaluation when used in conjunction with fine-needle aspiration (FNA). This review provides a concise summary, based on published literature, of the current applications and future prospects of FNA biopsy of locoregional lymph nodes in the initial staging and subsequent surgical management of patients with breast cancer. Patients undergo either sentinel lymph node (SLN) biopsy or complete axillary lymph node dissection, based on whether the axillary lymph node status is determined to be negative or positive in the initial staging process. The status of lymph nodes in the supraclavicular, infraclavicular, and internal mammary regions provides more accurate staging information and also impacts subsequent surgical management. The identification and evaluation of intramammary lymph nodes can add value in the overall assessment of patients with breast cancer. The feasibility of noninvasive imaging modalities for SLN mapping in animal models has indicated a good potential for FNA biopsy in the subsequent investigation of SLNs identified noninvasively in humans.

Adverse reactions to patent blue V dye - The NEW START and ALMANAC experience

BACKGROUND

Blue dye with or without isotope has been widely used to identify the sentinel lymph node(s) in breast cancer. Patent blue V is used in the UK while its isomer isosulfan blue is used in the US. The allergic potential of isosulfan blue is well documented (1.4% adverse reactions) but that of patent blue V is less clearly defined.

METHODS

In this paper we review the adverse reactions of patent blue V in 7,917 patients who participated in the NEW START training programme and the ALMANAC trial. All patients underwent sentinel lymph node biopsy for breast carcinoma using patent blue V in combination with (99m)Tc-albumin colloid.

RESULTS

In total, 72 of 7,917 (0.9%) patients experienced adverse reactions : non-allergic reactions were observed in 4 (0.05%) patients, 23 (0.3%) patients had minor grade I allergic skin reactions (urticaria, blue hives, pruritus, or generalised rash) and 16 (0.2%) had grade II reactions (transient hypotension/bronchospasm/laryngospasm). Severe Grade III reactions (severe hypotension requiring vasopressor support and/or change/abandoning of planned procedure and/or HDU/ITU admission) were noted in 5 (0.06%) patients. The type of adverse reaction was not specified in 24 (0.3%) patients. No mortality was recorded.

CONCLUSION

The allergic potential of patent blue V dye compares favourably with isosulfan blue however both the surgeon and anaesthetist need to be alert to the risk of allergic reactions.

Cancer-induced expansion and activation of CD11b+ Gr-1+ cells predispose mice to adenoviral-triggered anaphylactoid-type reactions

Intravascular delivery (1.5 x 10(9) particles and higher) of recombinant adenovirus (rAd) induces myeloid cell mediated, self-limiting hemodynamic responses in normal mice. However, we observed anaphylactoid-type reactions and exacerbated hemodynamic events following rAd injection in mice bearing malignant 4T1 mammary carcinoma. Because 4T1 tumors induce significant CD11b(+)Gr-1(+) myeloid cell expansion and activation, we set to determine whether this causes rAd-induced exaggerated responses. When treated with a single intravenous dose (1 x 10(10) particles) of rAd, mice implanted with 4T1 carcinoma succumbed due to the anaphylactoid-type reactions. In contrast, normal mice and mice implanted with a related mammary carcinoma (66cl4) that does not induce CD11b(+)Gr-1(+) cell expansion, showed minimal responses. Depletion of phagocytic CD11b(+)Gr-1(+) cells prior to rAd delivery protected 4T1 tumor-bearing animals, whereas passive transfer of CD11b(+)Gr-1(+) cells from 4T1 tumor-bearing animals was sufficient to convey susceptibility to anaphylactoid-type reactions in normal animals. We further show that there is upregulation of nitric oxide and leukotriene signaling pathways in the 4T1 tumor-induced CD11b(+)Gr-1(+) myeloid cells and that pretreating mice with inhibitors of nitric oxide synthetase and leukotrienes can attenuate the anaphylactoid-type reactions. These data show that malignant tumor growth can alter CD11b(+)Gr-1(+) myeloid cells, rendering hosts susceptible to anaphylactoid-type reactions upon intravascular treatment with rAd.

Intraoperative methylene blue sentinel lymph node mapping in colorectal cancer

BACKGROUND

Isosulfan blue is not available for clinical use in Malaysia. This study describes the use of methylene blue as an alternative to isosulfan blue in colorectal sentinel node mapping.

METHODS

Methylene blue dye was injected around colonic and rectal tumours and the first blue-stained nodes were suture tagged and harvested after standard colorectal resection. Standard histopathological examination was then carried out to detect nodal metastasis. All negative sentinel lymph nodes (SLN) were subjected to 10 further step sectioning and immunoperoxidase staining for cytokeratin 20 to detect tumour deposits.

RESULTS

Thirty-one patients were enrolled from August 2005 to July 2006. Twenty-five attempts at identifying the SLN were successful (80.7%). Of the 18 (58.1%) who had nodal metastases (stage III), 3 had negative SLN but positive other lymph nodes (false-negative rate of 21.4%). In one (4%), the SLN was the exclusive site of metastasis.

CONCLUSION

Methylene blue can be used as an alternative sentinel node marker for rectal cancer (above the peritoneal reflection) and colonic cancer.

Changes in pulse oximetry after patent blue dye injection into the uterine cervix

BACKGROUND

To evaluate changes in pulse oximetry readings in patients with cervical carcinoma after the injection of patent blue dye into the uterine cervix for sentinel lymph node detection.

METHODS

Fifty-six patients underwent radical hysterectomy and bilateral pelvic lymphadenectomy for the treatment of International Federation of Gynecology and Obstetrics stage I or II cervical cancer. Four milliliters of patent blue dye were injected into the cervix. On the eve of surgery, all patients also received an injection of Dextran 500 labeled with technetium 99 m (Tc-99 m Dextran, 600 to 800 muCi) into the cervix and subsequently underwent pelvic lymphoscintigraphy.

RESULTS

Of the 56 patients, 1 (1.79%) had an anaphylactic reaction, and in 13 (23.22%), pulse oximetry readings were <96%. The lowest median pulse oximetry reading in these patients was 87%. Pulse oximetry readings began to decrease between 2 and 10 minutes after patent blue dye injection into the cervix and lasted for approximately 5 minutes. No changes in blood pressure, heart rate, or electrocardiogram were found during the period in which this alteration was recorded by the pulse oximeter.

CONCLUSION

The decrease in pulse oximetry readings after patent blue dye injection into the cervix was associated with larger tumors and tumors that surrounded the external cervical os.

Biphasic anaphylactic reaction to blue dye during sentinel lymph node biopsy

Background

Lymphazurin 1% blue dye can cause a severe anaphylactic reaction in approximately 1–3% of patients.

Case presentation

We describe a case of intraoperative anaphylaxis resulting from Lymphazurin 1% blue dye. A 48-year old woman undergoing a mastectomy with sentinel lymph node biopsy experienced a biphasic anaphylactic reaction with two episodes of hypotension at 15 minutes and 2 hours, respectively, after injection of the blue dye. The late phase was initially refractory to epinephrine.

Conclusion

Early recognition, aggressive hemodynamic management, and prolonged monitoring are indicated in these patients to watch for a potential second phase anaphylactic reaction.

Sentinel lymphnode biopsy in early breast cancer using methylene blue dye and radioactive sulphur colloid - a single institution Indian experience

BACKGROUND

Axillary lymph node dissection is an established procedure in breast cancer staging. However, it is associated with unpleasant side effects. A promising alternative to assess axillary lymph node status in early breast cancer patients is Sentinel Lymph Node Biopsy (SLNB). Isosulfan blue has traditionally been the dye used to identify the Sentinel Lymph Node (SLN). This article is a validation study of SLNB using methylene blue dye and radioactive sulphur colloid in early breast cancer Indian patients. MATERIALS #ENTITYSTARTX00026;

METHODS

With written informed consent, 100 patients with cytology or biospy proven carcinoma breast, clinical stage T1/ T2 N0 M0, underwent SLNB using combination of methylene blue dye & radioactive technetium 99m sulphur colloid as a part of validation study from June 2003 to February 2006. After validation study, from March 2006 to February 2007, 35 patients have undergone SLNB followed by complete axillary clearance in only those patients with SLNB being positive for metastases.

RESULTS

In all 100 patients of the validation study SLN was identified. Total number of cases with positive axillary nodes was 27, out of which SLN was only positive node for metastases in 69% of cases. The overall sensitivity, specificity, positive predictive valve and negative predictive valve of SLNB 96.2%, 100%, 100% and 98.6% respectively with false negative rate of 3.7%. In subsequent 35 patients who underwent SLNB followed by complete axillary clearance, SLNs was identified in all the cases.

CONCLUSIONS

SLNB is effective in early breast cancer patients of Indian population. SLNB using combination of methylene blue dye and radio-active Tc99m sulphur colloid can stage the axilla with high accuracy & low risk of false negativity in early breast cancer patients.

New Therapeutic Options for Breast Cancer during Pregnancy

National and international guidelines for pregnant breast cancer patients recommend to treat pregnant patients as closely as possible to the standards for non-pregnant patients. Therefore, new treatment options like sentinel lymph node biopsy or taxane-based chemotherapy have to be carefully checked for their possible implementation even for pregnant patients. These patients need to be treated in a breast cancer center where a multidisciplinary team is ready to support the patient and her family and to serve her with the best up-to-date treatment for mother and child.

Sentinel lymph node detection in skin cancer patients using real-time fluorescence navigation with indocyanine green: preliminary experience

BACKGROUND

Sentinel lymph node (SLN) biopsy has become the most widely used procedure to determine the regional lymph node status of patients with cutaneous malignant melanoma, and its application has spread rapidly to other malignancies such as squamous cell carcinoma of the skin, breast cancer and gastric cancer.

OBJECTIVE

SLN detection was performed in skin cancer patients using a newly developed real-time fluorescence navigation system with indocyanine green (ICG).

METHODS

SLN biopsy was performed by this method in 10 skin cancer patients (seven with melanoma and three with squamous cell carcinoma). After ICG was injected intradermally around the tumours, the lymphatic drainage was detected and the SLNs were identified by real-time fluorescence imaging.

RESULTS

The SLNs and their associated subcutaneous lymphatics were successfully identified in all patients. Fluorescence from SLNs was detected by this system for at least 3 hours after the injection of ICG.

CONCLUSION

SLN biopsy using ICG fluorescence achieves a high identification rate and allows effective observation for several hours. This method may become a useful option for the detection of SLNs in patients with skin cancer.

Methylene blue dye--a safe and effective alternative for sentinel lymph node localization

Sentinel lymph node (SLN) biopsy has emerged as an effective diagnostic tool in axillary staging in breast cancer. The commonly used technique employs isosulfan blue/patent blue V combined with radioactive colloid tracer. Methylene blue (MB) is a less expensive and readily available alternative dye. The study evaluated the safety and efficacy of MB in SLN localization. A retrospective study of 329 patients with early breast cancer who had SLN localization as part of an ethically approved prospective evaluation study of SLN localization technique was carried out. Lymph node positive, tumors >2 cm on clinical and radiological evaluation, those with previous breast and axillary surgery, neo-adjuvant chemotherapy were excluded from the study. One hundred seventy three patients underwent SLN localization using 1 mL of 1% MB, and a combined MB-radio colloid tracer technique was used in the other 156 patients. Allocation to the groups was by simple randomization. Injection of the dye and radioisotope was into the subdermal plane in the sub-areolar region. Patients underwent breast conservation surgery or mastectomy with SLN directed four node axillary sampling +/- axillary clearance. The lymph node was examined by standard microscopy. There were no reported complications with the use of MB aside from temporary tattooing. The technique failed in eight patients giving an identification rate of 97.6%. Ten of the 258 (3.9%) patients had false-negative SLN, with negative predictive value of 96.1%, sensitivity of predicting further axillary disease of 73%, specificity of 87.3%, and overall accuracy of 85.7%. Reported adverse reaction to isosulfan blue/patent blue V varied from minor to severe anaphylactic reactions (1-3%) requiring vigorous resuscitation. Subdermal sub-areolar injection of MB is safe and effective readily available dye for SLN localization in axillary staging of breast cancer with no major adverse reaction.

A Cautionary Tale: Anaphylaxis to Isosulfan Blue Dye after 12 Years and 3339 Cases of Lymphatic Mapping

Sentinel node biopsy has become the standard method for lymphatic staging in early-stage breast cancer and melanomas. The most commonly used technique uses both a radioactive tracer as well as blue dye, usually isosulfan blue. In this report, we discuss two episodes of anaphylaxis to isosulfan blue during lymphatic mapping, occurring 12 years and 3339 lymphatic mapping cases after adoption of the technique, and discuss management issues raised by these events.

Current technical overviews of sentinel lymph node biopsy for breast cancer

Sentinel lymph node biopsy (SLNB) is based on the hypothesis that the sentinel lymph node (SLN) reflects the lymph-node status and a negative SLN might allow complete axillary lymph node dissection (ALND) to be avoided. Although the survival outcome is still unknown, this technique has already become a standard of care for breast cancer patients. However, it is still important to discuss current techniques and some controversies. This article reviews these issues for a variety of SLNB techniques.

Outcomes following sentinel lymph node biopsy for breast cancer

Evaluation of axillary lymph nodes for metastatic involvement is the most significant factor in gauging prognosis in breast cancer patients. Complete axillary dissection can be associated with significant morbidity. Therefore, sentinel node biopsy was developed to sample nodes and avoid dissection in patients without clinical evidence of nodal involvement. While most surgeons currently perform the procedure, the technique remains unstandardized. Sentinel node identification rates, false-negative rates and procedural complication rates are the main outcomes measured and can depend significantly on variations in technique. Future studies on sentinel lymph node biopsy will probably focus on clarifying accuracy of the procedure in different clinical settings, delineating standard technical practice guidelines and further achieving improved outcomes.

Aspectos técnicos de interés en la localización de drenajes linfáticos en la biopsia del ganglio centinela del cáncer de mama

OBJECTIVES

The sentinel node is defined as the node with the highest probability of being involved in the case of lymphatic spread from a tumor. Accurate identification and biopsy of this node can avoid unnecessary lymphadenectomies. The aim of this study was to determine if there are differences in the number of isolated sentinel lymph nodes in breast cancer according to whether a mixed technique (vital dye plus isotopic tracer) or radiotracer alone is used and if there are differences in the detection of more than one lymphatic basin and in the number of lymphatic nodes depending on the site of tracer injection.

PATIENTS AND METHOD

A total of 173 sentinel lymph node biopsies in 173 women with breast cancer were studied taking into account the technique (mixed [n = 109] or radiotracer alone [n = 64]) and the location of tracer injection (periareolar [n = 81], intra and/or peritumoral [n = 92]). The number of lymphatic basins and the number of sentinel nodes were compared among the distinct groups resulting from the combination of the 2 parameters.

RESULTS

Simultaneous drainage to both the axilla and internal mammary chain was more frequent with the intra-periareolar technique. The number of identified nodes was significantly higher when mixed techniques were compared, and was higher with periareolar injection than with the intra-peritumoral route.

CONCLUSIONS

In breast cancer sentinel lymph node biopsy, the number of identified nodes is not influenced by the use of a mixed technique or radiotracer alone. However, the number of identified nodes is higher with the periareolar route than with the intra-peritumoral route. Intra-peritumoral injection of the tracer shows a higher frequency of internal mammary chain drainage than periareolar injection, although this difference was not statistically significant.

A phase I/II trial of 125I methylene blue for one-stage sentinel lymph node biopsy

BACKGROUND

Sentinel lymph node biopsy can be associated with delays in operating room schedule and with significant pain during the preoperative Tc colloid injection. To avoid these problems, we developed a novel radiolabeled blue dye that can be injected intraoperatively.

METHODS

We performed a phase I/II trial (IND#70627) of sterile pyrogen-free I-methylene blue to identify sentinel nodes in patients with breast cancer. Twelve women were studied. Two women each were given peritumoral or circumareolar injections of 100, 200, 300, 400, 500, or 1000 microCi of I methylene blue.

RESULTS

Sentinel nodes were detected in 11 of 12 patients, with a low-dose 200 microCi patient being the single exception. The number of sentinel nodes detected per patient ranged from 0 to 3 (mean = 1.66 nodes/case). Radioactivity at the tumor injection site [counts per second (cps) averaged over 10 seconds] ranged from 3346 to 47,300 cps and was highly dose-dependent (r = 0.90, P = 0.0002). In contrast, the in vivo node counts ranged from 0 to 1228 cps, while ex vivo counts ranged from 0 to 1516 cps. The in vivo nodal counts were dose-dependent (r = 0.67, and P = 0.0231). Radiation was carefully monitored inside the operating room and in pathology. Even with the 1-mCi dose, the radioactive blue dye produced significantly lower personnel exposure than historically seen with Tc.

CONCLUSIONS

This method eliminates the painful preoperative injections of Tc colloid, is performed by the surgeon in the operating room, is associated with lower radiation exposures for personnel, and avoids the delays caused by nonoperating room personnel. These observations warrant a more extensive trial of this method using the 1000-microCi dose of I methylene blue dye for sentinel lymph node biopsies.

Is there an indication for sentinel node biopsy in patients with ductal carcinoma in situ of the breast? A review

Ductal carcinoma in situ (DCIS) of the breast is defined as a proliferation of malignant epithelial cells within breast ducts without evidence of invasion through the basement membrane. The detection rate of DCIS of the breast has dramatically increased since the mid-1980s as the result of the widespread use of screening mammography. DCIS currently represents about 15-25% of all breast cancers detected in population screening programmes. Although inherently a non-invasive disease, occult invasion with the potential of lymph node metastases may occur. Where performing an axillary lymph node dissection-or-not for DCIS used to be an important dilemma, the same now holds for the sentinel node biopsy. This article reviews the potential role of the sentinel node biopsy (SNB) in patients with DCIS. We conclude that based on the current literature, there is in general no role for a SNB in DCIS. A SNB should only be considered in patients with an excisional biopsy diagnosis of high risk DCIS (grade III with palpable mass or large tumour area by imaging) as well as in patients undergoing mastectomy after a core or excisional biopsy diagnosis of DCIS, although SNB may be contraindicated in many of the latter patients because of lesion size and/or multifocality. Even in these patients the value of a positive SN, containing mostly isolated tumour cells, is questionable.