Blue urticaria: a previously unreported adverse event associated with isosulfan blue

Blue Wheals and Blue Angioedema Induced by Blue Dyes: A Systematic Review

BACKGROUND

Blue wheals and blue angioedema, the adverse reactions to blue dye injections with or without anaphylaxis, are poorly defined.

OBJECTIVE

The objective is to review the characteristics (ie, sex and age at onset, interval between blue dye injection and symptom onset, clinical manifestations, duration of blue wheals or angioedema), natural courses, and treatments of blue dye adverse reactions.

METHODS

A review of the articles published through July 2021 was performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations.

RESULTS

Across 523 patients (175 studies) with any adverse reactions to blue dye injections, wheals, angioedema, or both occurred in 193 patients (36.9%). Of these 193 patients, 68 patients (35.2%) developed blue wheals or angioedema, 118 (61.1%) had ordinary wheals or angioedema (nonbluish), and 7 had both (3.6%). We reviewed 169 patients with available data (99 with ordinary lesions and 70 with blue lesions). Patent blue violet had the highest rate of inducing blue wheals or angioedema (odds ratio 4.9). Almost half of the patients with blue wheals or angioedema developed systemic symptoms; and of those with systemic symptoms, all except 1 progressed to anaphylaxis. On-demand treatments with antihistamines, corticosteroids, and epinephrine were commonly used and effective.

CONCLUSIONS

Using blue dyes can lead to blue wheals or angioedema and systemic reactions. In patients with a history of a severe allergic reaction to a blue dye, repeat administration of a blue dye should be used only after carefully weighing all the risks and benefits.

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.

Blue dye for identification of sentinel nodes in breast cancer and malignant melanoma: a systematic review and meta-analysis

The combined technique (radioisotope and blue dye) is the gold standard for sentinel lymph node biopsy (SLNB) and there is wide variation in techniques and blue dyes used. We performed a systematic review and meta-analysis to assess the need for radioisotope and the optimal blue dye for SLNB. A total of 21 studies were included. The SLNB identification rates are high with all the commonly used blue dyes. Furthermore, methylene blue is superior to iso-sulfan blue and Patent Blue V with respect to false-negative rates. The combined technique remains the most accurate and effective technique for SLNB. In order to standardize the SLNB technique, comparative trials to determine the most effective blue dye and national guidelines are required.

The effect of subareolar isosulfan blue injection on pulse oximeter readings

Besides several side effects including anaphylaxis, blue dyes are also known to cause false pulse oximeter readings. We aimed to examine the effects of subareolar isosulfan blue injection on pulse oximeter (SpO2) readings. The study group included 27 patients undergoing SLNB using both radiocolloid and isosulfan blue. Another group of 27 patients constituted the control group. Pulse oximeter readings were compared. SpO2 decline ≥4 % was defined as significant. All but one (96.2 %) of the patients in the study group showed SpO2 declines, compared to only one patient in the control group. Median ± Interqartile Range (IR) SpO2 decrease was 3.0 ± 4.0 % in the study and 0.0 ± 1.0 % in the control group (p < 0.001). There were significant (≥4 %) SpO2 decreases in 13 (48.1 %) patients in the study group. Statistically significant differences were noted between the two groups in all recordings between 15 and 180 min (p < 0.001). Initial time for SpO2 fall and the time to the lowest SpO2 recording were 10.0 ± 10.0 and 40.0 ± 30.0 min respectively. Using subareolar injection, the frequency of false readings is comparable with intraparenchymal injections, and is higher than intradermal injections. Time to peak SpO2 fall, and the recovery period, are delayed in the subareolar technique.

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.

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.

Blue angioedema of eyelip after patent blue injection for lymphatic mapping procedure

Sentinel node biopsy using patent blue dye in breast cancer is a well-documented procedure to assess the axillary status. We presented an unusual and previously unreported complication of simple blue angioedema over bilaterally periorbital tissue after blue dye injection.

Complications in Breast Surgery

Most breast operations are categorized as low-morbidity procedures, but a variety of complications can occur in association with diagnostic and multidisciplinary management procedures. Some of these complications are related to the breast itself, and others are associated with axillary staging procedures. This article first addresses some general, nonspecific complications (wound infections, seroma formation, hematoma). It then discusses complications that are specific to particular breast-related procedures: lumpectomy (including both diagnostic open biopsy and breast-conservation therapy for cancer), mastectomy; axillary lymph node dissection, lymphatic mapping/sentinel lymph node biopsy, and reconstruction.

Properties and characteristics of the dyes injected to assist axillary sentinel node localization in breast surgery

AIMS

A review of the safety profile of dyes injected to assist in sentinel lymph node biopsy (SLNB) in breast cancer.

METHODS

A literature search was performed of the medline database 1966-2005 using the Ovid web Gateway detailing the words sentinel node, breast cancer, allergic reactions, blue dye, isosulfan blue, patent blue and methylene blue.

RESULTS

There are reported side-effects from the parenteral administration of dyes, which range from minor to life threatening in severity. There are differences between the dyes as regards their effects. These aspects are discussed.

CONCLUSION

Many dyes have been used for SLNB with acceptable identification rates. There are variable side-effects for each of those dyes. Further research is needed to clarify the safety profile of these dyes.

Adverse Drug Reactions during Lymphatic Mapping and Sentinel Lymph Node Biopsy for Solid Neoplasms

Currently, 1 per cent isosulfan blue dye and technetium-99-labeled sulfur colloid (SC) are used in lymphatic mapping (LM). Several reports have suggested that the incidence of adverse drug reactions (ADRs) during LM is high. We report our experience with LM for solid neoplasms in order to determine the incidence and risk factors for development of ADRs. Seven hundred fifty-three patients (90% women, mean age 57) underwent LM with blue dye alone or in combination with SC from 1998 to 2004. The most common malignancy was breast cancer (83%). One hundred ten patients (14%) had injection of both mapping agents. Most patients (87%) underwent intraparenchymal injection of LM agent. Eight patients (1.1%) had an ADR during LM; none had prior exposure to LM. Of these, 7 had limited reactions (mostly blue hives) that quickly resolved. One patient (0.1%) developed anaphylaxis. The ADR incidence in patients with a sulfa allergy was not significantly different than that in patients without a sulfa allergy (3.4 vs 1%, P = 0.12). No risk factors for development of ADR were identified. Overall, the incidence of ADR during LM is low. Patients with sulfa allergies and prior exposure to LM did not demonstrate an increased incidence of ADR. Anaphylaxis, though rare, can occur during LM.

Is Blue Dye Indicated for Sentinel Lymph Node Biopsy in Breast Cancer Patients With a Positive Lymphoscintigram?

BACKGROUND

The use of isosulfan blue dye in sentinel node biopsy for breast cancer has been questioned because of its risk of allergic reaction. We hypothesized that blue dye could be safely omitted in the subgroup of patients who have evidence of successful sentinel node localization by lymphoscintigraphy.

METHODS

A retrospective review of patients with breast cancer and sentinel node biopsy was conducted. Information was collected on lymphoscintigraphy results, use of blue dye, and intraoperative and pathologic findings of sentinel nodes.

RESULTS

We identified 475 patients with breast cancer who underwent 478 sentinel node biopsies. Both dye and isotope were given in 418 cases, of which 380 had a positive lymphoscintigram. In 5 of the 380 cases with a positive lymphoscintigram, the sentinel nodes obtained were blue but not hot, for a 1.3% marginal benefit of dye in the technical success of the procedure. Sentinel nodes positive for metastasis were found in 102 of 380 cases; in 3 cases, the only positive sentinel node was blue but not hot. Omission of the blue dye tracer would have increased the false-negative rate of the sentinel node procedure by approximately 2.5%.

CONCLUSIONS

Even in sentinel node biopsy cases with a positive lymphoscintigram, the use of blue dye is beneficial for both improving the technical success of the procedure and reducing the false-negative rate of the procedure. Because the marginal benefits of dye justify its routine use, strategies to minimize the toxicity of blue dye are warranted.

A comparison of the adverse reactions associated with isosulfan blue versus methylene blue dye in sentinel lymph node biopsy for breast cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) is an established means of staging the axilla in patients with breast cancer. Recently, methylene blue dye has been shown to be an efficacious and cost-effective alternative to isosulfan blue. With the increasing popularity of SLNB, the potential complications of isosulfan blue use must be appreciated.

METHODS

A literature search for English language articles available on MEDLINE from 1985 to November 2002 using the search terms allergy, allergic reaction, anaphylactic reactions, anaphylaxis, blue dye, breast cancer, isosulfan blue, methylene blue, and sentinel lymph node biopsy identified 24 reports.

CONCLUSIONS

The use of isosulfan blue due for SLNB is associated with a significant number of allergic reactions, some of which are life-threatening. Because methylene blue dye has been shown to be equally effective and does not pose a serious risk of serious allergic reactions, it offers an improved technique above isosulfan blue dye for SLNB.

Adverse events associated with the intraoperative injection of isosulfan blue

STUDY OBJECTIVE

To describe the adverse events associated with the intraoperative injection of isosulfan blue in a large group of patients having a wide range of surgical procedures, and to identify risk factors for these events.

DESIGN

Retrospective chart review.

SETTING

University-affiliated institution specializing in malignancies

PATIENTS

1835 patients representing a total of 1852 surgical procedures.

MEASUREMENTS

Incidence, type, severity, onset time, duration, management, and the presence of potential risk factors for adverse events. Events were considered "major" if potentially life-threatening hypotension occurred.

MAIN RESULTS

Adverse events occurred in 28 procedures (1.5%) and 14 of these adverse events (0.75%) were classified as major. The types of events were: skin reactions in 21 patients, hypotension in 14 patients, edema in 1 patients, and unspecified in 1 patient. The time of onset for adverse events was 42.2 +/- 53.9 minutes (median, 17.5; range, 1 to 180 min) after isosulfan blue injection, and was significantly longer for minor reactions compared with major events (p = 0.015). The longest adverse event lasted at least 21 hours. Treatment was successful with usual antiallergy/antianaphylaxis medications. Ten patients received diphenhydramine alone, and four patients received intravenous epinephrine infusions. Factors associated with a significantly increased incidence of adverse events were isosulfan blue injection in the vulvar area (p = 0.000038), and the chronic preoperative use of angiotensin-converting enzyme inhibitors or angiotensin receptor-blocking agents (p = 0.043). Trends toward an increased risk of an adverse event were noted with isosulfan blue injection in the breast area (p = 0.19), and having more than one surgical procedure with isosulfan blue (p = 0.14).

CONCLUSIONS

Although the most frequent adverse event associated with injection of isosulfan blue was a skin reaction, potentially life-threatening hypotension occurred in 0.75% of all procedures. Anesthesiologists must be aware of the variable onset time and potentially prolonged duration of the adverse events. They should recognize the need for extra vigilance in patients with potential risk factors, and have the usual antiallergy/antianaphylaxis medications available for administration if necessary.

Lymphatic mapping and sentinel lymphadenectomy for breast cancer

Lymphatic mapping and sentinel lymphadenectomy has become an important tool for axillary lymph node staging in women with early-stage breast cancer. This review examines data regarding the staging accuracy, indications and technical aspects of the procedure, and clinical trials investigating the technique. Multiple studies now confirm that sentinel lymphadenectomy accurately stages the axilla and is associated with less morbidity than axillary dissection. Blue dye, radiocolloid, or both can be used to identify the sentinel node, and several injection techniques may be used successfully. Many patient factors previously thought to affect accuracy of the procedure have now been shown to be of limited significance. The indications for the procedure are expanding, and the histopathologic evaluation of the sentinel node and the role of lymphoscintigraphy have been clarified. Clinical trials are now underway that will determine the prognostic significance of micrometastases and the therapeutic benefit of axillary dissection in women with and without sentinel node metastases. Incorporation of sentinel lymphadenectomy into routine clinical practice will maintain accurate axillary staging with lower morbidity and improved quality of life for women with early-stage breast cancer.

Laparoscopic sentinel node mapping in early-stage cervical cancer

OBJECTIVE

We aimed to determine the feasibility and accuracy of sentinel node (SN) mapping and its ability to predict the status of the regional nodal basin.

METHODS

From October 2000 to September 2002, 70 patients undergoing radical surgery for early-stage cervical cancer (stage IA, IB, and IIA) were offered lymph node mapping for identification of the sentinel node. All patients underwent SN identification laparoscopically followed by a complete laparoscopic pelvic node and parametrial dissection. The SN mapping was done after intracervical blue dye injection in all cases and was combined with preoperative lymphoscintigraphy following intracervical Tc-99 injection and intraoperative SN detection with a miniaturized laparoscopic gamma probe in 29 cases (42%).

RESULTS

The blue dye technique alone (n = 70) identified at least 1 SN in 61 (87%) of the patients. The rate of SN detection by side of dissection was 74%, 70% on the left side and 77% on the right side. Bilateral SN were identified in 60% of cases. In the subgroup of patients who had the combined technique (n = 29), the rate of SN detection increased from 79 to 93% (P = 0.04). The bilateral SN detection rate increased from 55 to 72% when adding lymphoscintigraphy (P = 0.03). In the last 15 cases of the series, the SN detection rate reached 93% (14/15) and this was statistically significant compared to the detection rate of the first 55 cases (P < 0.01). A total of 135 SN were identified, with the majority (88%) being located at three main sites: the external iliac, obturator, and bifurcation. Thirty-six patients (51%) had 2 SN identified, and 16 (24%) had 3 SN or more. Twelve (17%) patients had positive lymph nodes. In those cases, the rate of SN detection per side of dissection in patients with normal appearing nodes at laparoscopy was 75%, whereas it was only 56% in patients with macroscopically involved lymph nodes (P = NS). The false negative rate was 0. The negative predictive value of SN mapping was 100% and the sensitivity was 93% with the combined technique. Two patients had allergic reactions to the blue dye (3%).

CONCLUSION

Sentinel node mapping with the combined blue dye technique and lymphoscintigraphy in patients with cervical cancer is laparoscopically feasible and is highly accurate. The detection rate improves significantly with experience and with the use of lymphoscintigraphy.

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

IMPLICATIONS

Intraoperative use of isosulfan dye for lymphatic mapping may result in anaphylaxis. Furthermore, in some patients, intravascular absorption of isosulfan may induce serum discoloration causing interference with pulse oximetry function.

Adverse skin lesions after methylene blue injections for sentinel lymph node localization

BACKGROUND

Methylene blue dye (MBD) is being used as an alternative to isosulfan blue dye in sentinel lymph node (SLN) biopsies for breast cancer patients. Complications using MBD for SLN localization have not previously been reported.

METHODS

A retrospective study was conducted of 24 consecutive patients who received MBD. Patients were given 3 to 5 cc of 1% MBD as peritumoral injections within the breast parenchyma and intradermally. Patients who developed local skin lesions at the injection site were queried regarding lesion appearance and when subsequent adjuvant therapy was initiated.

RESULTS

Five of the 24 patients (21%) developed skin lesions at the injection site. Intradermal injections were discontinued, and only deep parenchymal injections were performed. All 5 patients had improvement of their skin lesions with silver sulfadiazine cream and no patient required debridement. Each patient received adjuvant therapy after surgery without delay.

CONCLUSIONS

Our institution has experienced patients who developed skin lesions at the MBD injection site when using combined deep parenchymal and intradermal injections. With the increased use of MBD, caution should be used to avoid intradermal injections with SLN localization.