Methylene Blue Dye-A Safe and Effective Alternative for Sentinel Lymph Node Localization
Breast Unit, St Bartholomew's Hospital, Queen Mary University of London, United Kingdom. The Breast Journal
(Impact Factor: 1.41).
12/2007; 14(1):61-7. DOI: 10.1111/j.1524-4741.2007.00519.x
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.
Available from: Samuel Adefeyisan
- "Several kinds of blue dyes are in use for sentinel node mapping, such as Patent Blue V , isosulfan blue , and methylene blue . Methylene blue is widely used in medicine  and has been used for sentinel node biopsy mapping since 2001 with generally favorable results  . However, several adverse reactions have been reported, such as interference with pulse oximetry  and skin complications (necrosis)   . "
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ABSTRACT: To identify the sentinel lymph node in melanoma patients, intradermal injection of a radiocolloid tracer and a blue dye are commonly used. Life-threatening side effects of isosulfan blue and Patent Blue V have been well described. However, to the extent of our knowledge, only two life-threatening events with intradermal methylene blue dye have been reported, and none has been reported in the pediatric population. We report a case of a 6-year-old white girl with spitzoid melanoma on her right forearm. She had lymphoscintigraphy under general anesthesia and was taken to the operating room intubated. Intradermal methylene blue (0.2 ml) was injected around the lesion, and after 5 minutes, wide complex bradycardia was noted and progressed to asystole within less than 1 minute. Cardiopulmonary resuscitation was started. Multiple doses of resuscitative drugs were administered, and electrical cardioversion was given twice as well. She recovered completely and transferred to the intensive care unit.
Available from: PubMed Central
- "The combination technique and the methylene blue dye technique had been compared after FNAB and core breast biopsies [17-19], but, we could not find any literature in English about the use of methylene blue alone after excisional breast biopsy. In these studies, it was reported that the success rate of the combination technique was higher than methylene blue dye alone (100% vs. 86%) [17-20]. "
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ABSTRACT: Sentinel lymph node biopsy (SLNB) in breast cancer patients with clinically negative axilla will ensure axillary dissection only for cases with lymph node metastasis and provide information about pathologic staging as accurate as the axillary dissection. It was shown that SLNB could be successfully performed regardless of the type of biopsy. The aim of this study was to investigate the feasibility of SLNB after excisional biopsy.
One hundred patients diagnosed with excisional biopsy or guide wire-localization and operated on with SLNB between February 2007 and March 2009 were retrospectively analyzed. SLNB was performed with 10 cc of 1% methylene blue alone or both methylene blue and 1 mCi of Tc-99m nanocolloid combination. Age, tumor localization and size, length of the biopsy incision, size of the biopsy specimen, multifocality, lymphovascular invasion, tumor grade, staining with methylene blue, localization, number and metastatic status of the lymph nodes stained, and success rate with a gamma probe were evaluated.
Sentinel lymph node (SLN) could not be identified in 9 (16.9%) of patients in the methylene blue group (n=53). In the combination group (n=47), SLN could not be identified in one patient. Of 32 patients with negative SLNB, metastatic involvement was found to be present in 5 patients after axillary lymph node dissection (false negatives). The average numbers of SLNs found in the methylene blue group and combination group were 1.4 and 1.6, respectively. SLN detection and false negative rates in the methylene blue group were 83% and 15.7%, respectively. The rates for the combination group were 98% and 6.4%, respectively. None of the parameters related to patient, tumor or process were found to affect detection rates of SLN.
Only SLNB using a combination method is a safe and reliable technique for breast cancer patients diagnosed with excisional biopsy.
Available from: Julie E Lang
- "Several publications advocate the use of subdermal MBD injections for SLN mapping without complications 1-3; however, several publications report complications ranging from blue staining of the skin and fat necrosis 4-6. "
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ABSTRACT: Introduction: Methylene blue dye has been used worldwide successfully with few complications in breast surgery. We present two different complications involving methylene blue: 1) skin and parenchymal necrosis when dye was injected in a subdermal fashion and 2) Mycoplasma infection caused by contaminated methylene blue in breast reduction surgery.
Methods: We present two cases seen at the University of Arizona during 2008 and referred to a breast surgeon for management. We evaluated and managed complications of methylene blue dye injected by 2 referring surgeons for different indications. A review of the literature was performed.
Results: The first case is a 67 year old female diagnosed with infiltrating ductal carcinoma of the left breast for which she was treated by her initial surgeon with left segmental mastectomy and sentinel node biopsy. The operating surgeon injected methylene blue in a subareolar subdermal fashion (distant from the primary tumor); unfortunately the patient suffered skin and breast necrosis requiring multiple surgical debridements and finally achieving delayed primary closure. The second case is a 45 year old female with infiltrating lobular carcinoma with a history of Mycoplasma infection secondary to methylene blue injected for breast reduction surgery. She required multiple debridements and had granulomas masquerading as cancer on MRI that confounded her extent of disease.
Conclusions: The use of methylene blue dye in breast surgery is not without risk. In both cases methylene blue was responsible for complications requiring surgical debridement for local wound problems. In each case severe necrosis and infection were present. Methylene blue may cause not only significant morbidity, but may also produce cosmetically unsatisfactory results.
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