A Prospective Trial Comparing 1% Lymphazurin vs 1% Methylene Blue in Sentinel Lymph Node Mapping of Gastrointestinal Tumors

Lymphatic Mapping in Colon Cancer Depending on Injection Time and Tracing Agent: A Systematic Review and Meta-Analysis of Prospective Designed Studies

An optimized lymph node yield leads to better survival in colon cancer, but extended lymphadenectomy is not associated with survival benefits. Lymphatic mapping shows several colon cancers feature aberrant drainage pathways inducing local recurrence when not resected. Currently, different protocols exist for lymphatic mapping procedures. This meta-analysis assessed which protocol has the best capacity to detect tumor-draining and possibly metastatic lymph nodes. A systematic review was conducted according to PRISMA guidelines, including prospective trials with in vivo tracer application. The risk of bias was evaluated using the QUADAS-2 tool. Traced lymph nodes, total resected lymph nodes, and aberrant drainage detection rate were analyzed. Fifty-eight studies met the inclusion criteria, of which 42 searched for aberrant drainage. While a preoperative tracer injection significantly increased the traced lymph node rates compared to intraoperative tracing (30.1% (15.4, 47.3) vs. 14.1% (11.9, 16.5), p = 0.03), no effect was shown for the tracer used (p = 0.740) or the application sites comparing submucosal and subserosal injection (22.9% (14.1, 33.1) vs. 14.3% (12.1, 16.8), p = 0.07). Preoperative tracer injection resulted in a significantly higher rate of detected aberrant lymph nodes compared to intraoperative injection (26.3% [95% CI 11.5, 44.0] vs. 2.5% [95% CI 0.8, 4.7], p < 0.001). Analyzing 112 individual patient datasets from eight studies revealed a significant impact on aberrant drainage detection for injection timing, favoring preoperative over intraoperative injection (OR 0.050 [95% CI 0.010-0.176], p < 0.001) while indocyanine green presented itself as the superior tracer (OR 0.127 [95% CI 0.018-0.528], p = 0.012). Optimized lymphatic mapping techniques result in significantly higher detection of aberrant lymphatic drainage patterns and thus enable a personalized approach to reducing local recurrence.

Patent Blue dye allergy and the deep inferior epigastric perforator free flap: a unique interaction

Patent Blue dye for sentinel lymph node biopsy is associated with systemic allergic response and generalized blue hue. We report a unique case of successful free flap transfer in this setting. Despite inotropic support and abnormal blue hue, allergic response does not preclude safe flap transfer and monitoring.

Advantages of day-before lymphoscintigraphy and undiluted methylene blue dye injections for sentinel lymph node biopsies for melanoma

BACKGROUND AND OBJECTIVES

Lymphatic mapping (LM) and blue dye injections are essential to identification of sentinel lymph nodes (SLN) for melanoma. LM is performed the day before (DB) or the same day (SD) of surgery, but the optimal timing is unknown. Similarly, methylene blue (MB), used during SLN biopsy (SLNB), is administered diluted (dMB) or undiluted (uMB), but the relative efficacies are unknown.

METHODS

Patients who underwent SLNB for melanoma from 2009 to 2013 at our institution were evaluated. Outcomes included operative correlation with LM, SLN identification, and postoperative complications.

RESULTS

One hundred seventy-one patients underwent SLNB. Sixty-seven (39%) had DB LM. Sixty-seven (39%) received uMB. Operative findings correlated with both LM groups, though the DB patients had lower background count (P = 0.018) and lower highest SLN radioactive signal count (P = 0.046). More uMB patients had blue SLNs (90% vs. 68%, P = 0.001). There was no difference in the total number of SLNs or complication rates in the LM and MB groups.

CONCLUSIONS

This is the first study to compare the use of DB LM with SD LM and the efficacy of uMB versus dMB. DB LM and uMB offer advantageous alternatives for patients and their surgeons without loss of accuracy or increased morbidity. J. Surg. Oncol. 2016;114:947-950. © 2016 Wiley Periodicals, Inc.

Adverse reaction; patent blue turning patient blue

The authors report a severe anaphylactic reaction to Patent Blue V dye used in sentinel node biopsy for lymphatic mapping during breast cancer surgery to stage the axilla. Patent Blue dye is the most widely used in the UK; however, adverse reactions have been reported with the blue dye previously. This case highlights that reactions may not always be immediately evident and to be vigilant in all patients that have undergone procedures using blue dye. If the patients are not responding appropriately particularly during an anaesthetic, one must always think of a possible adverse reaction to the dye. All surgical patients should give consent for adverse reactions to patent blue dye preoperatively. Alternative agents such as methylene blue are considered.

Selective sentinel lymph node dissection for melanoma: importance of harvesting nodes with lower radioactive counts without the need for blue dye

BACKGROUND

Determining how many sentinel lymph nodes (SLNs) should be removed for melanoma is important. The purpose of this study is to determine the frequency at which nodes that are less radioactive than the "hottest" node (which is negative) are positive for melanoma, how low of a radioactivity should warrant harvest, and if isosulfan blue is necessary.

METHODS

We reviewed 1,152 melanoma patients who underwent lymphoscintigraphy with technetium, with or without blue dye, and SLN dissection from 1996 to 2008. SLNs with radioactivity ≥10% of the "hottest" SLN, all blue nodes, and all suspicious nodes were removed and analyzed. The miss rate was calculated as the proportion of node positive cases in which the "hottest" SLN was negative.

RESULTS

SLNs were identified in 1,520 nodal basins in 1,152 patients. SLN micrometastases were detected in 218 basins (14%) in 204 patients (18%). In 16% of SLN-positive patients (33/204 patients), the positive SLN was found to have a lower radioactive count than the "hottest" SLN, which was negative. In 21 of these cases, the positive SLNs had radioactivity ≤50% of the "hottest" SLN. The 10% rule significantly reduced the miss rate to 2.5% compared with removal of only the "hottest" SLN (miss rate = 16%). Also, blue dye did not significantly decrease the miss rate compared with radiocolloid alone using the 10% rule.

CONCLUSIONS

To decrease the miss rate, all SLNs with ≥10% of the ex vivo radioactivity of the "hottest" SLN should be removed and blue dye is not essential.

Modifiable factors that influence colon cancer lymph node sampling and examination

INTRODUCTION

Colorectal cancer is the fourth most common malignancy in the United States. Its single most important prognostic factor is lymph node involvement. Multiple guidelines recommend sampling a minimum of 12 nodes, to ensure accurate staging and treatment. However, this standard of care is not always achieved. The objective of this study was to identify potential modifiable factors that may explain this inadequacy between the optimal approach and routine practice.

PATIENTS AND METHODS

The medical charts of all patients treated for colorectal cancer stages I-III at the Albert Einstein Medical Center from 1999-2007 were reviewed. Associations between multiple surgical and pathologic variables and the presence of >or= 12 lymph nodes in the final pathology report were examined.

RESULTS

In total, 337 patients were included in this study. The mean number of nodes reported was 12.7 (standard deviation, +/- 7.6), and 173 patients (51%) had >or= 12 lymph nodes. Regarding patients' demographic characteristics, 78% were more than 60 years of age; 47.8% were male; and 27% were white, 67% were African American, and 6% were of other ethnic groups. Using a univariate analysis, several variables were statistically associated with the >/= 12 lymph nodes reported: colon length (Pearson r = 0.384; P < .001); thickness of the mesocolon (Pearson r = 0.294; P < .001); size of tumor (Pearson r = 0.154; P = .005); site of tumor (right vs. left, P < .001); type of surgery (right or subtotal colectomy vs. others, P < .001), experience of pathologist (P = .02); pathologist's assistant (P = .006); and experience of surgeon (P < .001). Using a multivariate logistic regression analysis, adjusting for age, sex, and race, colon length (P = .001), type of surgery (odds ratio [OR], 3.37; 95% confidence interval [CI], 2.0-5.6; P < .001), surgeon's experience (OR, 2.33; 95% CI, 1.4-3.9; P = .001), pathologist's experience (OR, 1.9; 95% CI, 1.1-3.2; P = .01), and role of the pathologist's assistant (OR, 2.5; 95% CI, 1.4-4.3; P = .001) remained as significant predictors.

CONCLUSION

This study showed that multiple factors influence the number of lymph nodes sampled. The roles of the surgeon, the pathologist, and especially the pathologist's assistant comprise significant variables that could be modified with appropriate education.