Unexplained decrease in measured oxygen saturation by pulse oximetry following injection of Lymphazurin 1% (isosulfan blue) during a lymphatic mapping procedure

The Use and Technique of Sentinel Node Biopsy for Skin Cancer

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the indications for and prognostic value of sentinel lymph node biopsy in skin cancer. 2. Learn the advantages and disadvantages of various modalities used alone or in combination when performing sentinel lymph node biopsy. 3. Understand how to perform sentinel lymph node biopsy in skin cancer patients.

SUMMARY

Advances in technique used to perform sentinel lymph node biopsy to assess lymph node status have led to increased accuracy of the procedure and improved patient outcomes.

10 % fluorescein sodium vs 1 % isosulfan blue in breast sentinel lymph node biopsy

Background

Sentinel lymph node biopsy (SLNB) is well accepted to be a standard procedure in breast cancer surgery with clinically negative lymph nodes. Isosulfan blue is the first dye approved by the USA Food and Drug Administration for the localization of the lymphatic system. Few alternative tracers have been investigated. In this study, we aimed to compare the differences between 10 % fluorescein sodium and 1 % isosulfan blue in breast sentinel lymph node biopsy and to investigate the feasibility of using 10 % fluorescein sodium as a new dye for breast sentinel lymph node biopsy.

Methods

A total of 30 New Zealand rabbits were randomly divided into the fluorescein sodium group and the isosulfan blue group (15 rabbits per group). Fluorescein sodium or isosulfan blue was injected subcutaneously into the second pair of mammary areolas.

Results

The average fading time of the second lymph nodes in the isosulfan blue group was significantly shorter than that in the fluorescein sodium group. Moreover, the detection rates of SLNs were higher in the fluorescein sodium group than in the isosulfan blue group. No significant differences between the fluorescein sodium group and isosulfan blue group were observed regarding the distances between the detected sentinel lymph nodes and second pair of mammary areolas, the distances between the second lymph nodes and second pair of mammary areolas, the number of detected sentinel lymph nodes and second lymph nodes, the average dyeing time of the sentinel and the second lymph nodes, and the average fading time of the second lymph nodes.

Conclusions

In summary, we first reported that fluorescein sodium is a potential new tracer for breast sentinel lymph node biopsy.

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.

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.

Patent Blue Dye in Lymphaticovenular Anastomosis

Introduction: Lymphaticovenular anastomosis (LVA) has been described as a treatment of chronic lymphoedema. This microsurgical technique is new and technically difficult. The small caliber and thin wall lymphatic vessels are difficult to identify and easily destroyed during the dissection. Materials and Methods: We describe a technique of performing lymphaticovenular anastomosis with patent blue dye enhancement. Our patient is a 50-year-old lady who suffers from chronic lymphoedema of the upper limb after mastectomy and axillary clearance for breast cancer 8 years ago. Results: Patent blue dye is injected subdermally and is taken up readily by the draining lymphatic channels. This allows for easy identification of their course. The visualisation of the lumen of the lymphatic vessel facilitates microsurgical anastomosis. The patency of the anastomosis is also demonstrated by the dynamic pumping action of the lymphatic within the vessels. Conclusion: Patent blue dye staining during lymphaticovenular anastomosis is a simple, effective and safe method for mapping suitable subdermal lymphatics, allowing for speedier dissection of the lymphatic vessels intraoperatively. This technique also helps in the confirmation of the success of the lymphaticovenular anastomosis. Key words: Lymphaticovenular anastomosis, Lymphoedema, Patent blue dye, Supermicrosurgery

Multicenter Validation Study of the Sentinel Lymph Node Concept in Cervical Cancer: AGO Study Group

Purpose

Single-institution case series have demonstrated the feasibility of the sentinel concept in cervical cancer. However, the diagnostic accuracy remains to be validated. We evaluated detection rate and diagnostic accuracy to predict the histopathologic pelvic nodal status in patients with cervical cancer of all stages.

Patients and Methods

In a hypothesis-based, prospective, multicenter cohort study, patients underwent lymph node detection after labeling with technetium, patent blue, or both. After systematic pelvic and, if indicated, para-aortic node dissection, all lymph nodes were histopathologically examined. Detection rate, sensitivity, and negative predictive value (NPV) were calculated.

Results

According to the protocol, 590 patients were eligible. Detection rate of pelvic sentinel nodes was 88.6% (95% CI, 85.8% to 91.1%) and was significantly higher for the combination of technetium and patent blue (93.5%; 95% CI, 90.3% to 96.0%). Of 106 patients with pelvic lymph node metastases, 82 had pelvic sentinel node metastases. The overall sensitivity was 77.4% (95% CI, 68.2% to 85.0%), which was lower than 90%, the predefined noninferiority margin (P < .001). Sensitivity in women with tumors ≤ 20 mm (90.9%), with bilateral detection (87.2%), or with both substances applied (80.3%) was higher compared with the total population. The overall NPV was 94.3% (95% CI, 91.6% to 96.4%) and was higher in patients with tumors ≤ 20 mm (99.1%; 95% CI, 96.6% to 100%) compared with patients with tumors more than 20 mm (88.5%; 95% CI, 82.9% to 92.8%; P < .001).

Conclusion

In our cohort (all stages), sensitivity of the sentinel concept was low. However, patients with tumor diameter ≤ 20 mm may profit from this concept.

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.

The sentinel concept in patients with cervical cancer

The sentinel concept for patients with early cervical cancer has a high potential for decreasing morbidity and for increasing oncologic safety. The detection rate with technetium-labeling or a combination with blue dye varies between 84% and 92%. Sensitivity and negative predictive value depend on tumor size: the smaller the tumor, the higher the validity of the technique. Detection of circulating tumor cells in the sentinel node using HPVmRNA as marker may have a good prognostic value. Currently the sentinel concept should only be used in clinical studies before its validity has been proved.

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.

Anaphylaxis to isosulfan blue and cross-reactivity to patent blue V: case report and review of the nomenclature of vital blue dyes

BACKGROUND

Blue dyes used for lymphatic mapping in sentinel lymph node biopsy cause intraoperative anaphylactic reactions in up to 2.7% of patients. With increasing implementation of this technique, the incidence of anaphylaxis to these dyes can be expected to increase. In the literature, the chemically often unrelated and inconsistently designated dyes have been confused, adding to other inconsistencies in the nomenclature.

OBJECTIVE

To demonstrate the nomenclature, chemical and physiologic differences, and allergenicity of the various blue dyes used in a medical context.

METHODS

We describe a patient with an intraoperative grade IV anaphylactic reaction to isosulfan blue. Immediate-type hypersensitivity was proved by positive skin test reactions and CD63 expression to isosulfan blue and cross-reactivity to patent blue V.

RESULTS

A review of the literature clarified the exact nomenclature of the blue dyes and the possible pitfalls of confusing nomenclature in the context of structurally closely related dyes with different allergenic properties. For the detection of type I hypersensitivity, intracutaneous tests are valuable tools. An IgE-mediated mechanism has been shown recently. In most cases, sensitization exists without known previous exposure in a medical context. This may be due to the widespread use of such dyes in objects of everyday life. Preoperative antiallergic medication use does not prevent anaphylactic reactions but apparently reduces their severity.

CONCLUSION

For better comparison and precision, the Chemical Abstracts Service number of the respective dye should always be given.

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.

Evaluation of sentinel node identification with isosulfan blue in gastric cancer

AIMS

The aim of this study was to clarify whether the metastasis of gastric cancer can be detected by identifying the sentinel lymph nodes (SNs) using only lymphatic dye.

METHOD

The study was based on 101 patients clinically diagnosed with T1 and T2 gastric cancer. Isosulfan blue was intraoperatively injected within the submucosal layer around the lesion through an endoscope and blue stained nodes (BNs) were identified as SNs and harvested. Standard radical gastrectomy with D2 lymphadenectomy was performed on all patients and SNs and other nodes were evaluated.

RESULTS

Out of 101 patients, 21 had lymph-node metastases. The accuracy of SN identification was 97.0% (98/101) and the metastasis detection rate was 85.7% (18/21). With improvement of the manoeuvre in the latter 84 cases, the detection rate was elevated up to 100.0% (18/18), as was the accuracy (84/84).

CONCLUSION

The sentinel concept using lymphatic dye is applicable to gastric cancer, but the identification of SNs with lymphatic dye requires some practice. Furthermore, the issue of intraoperative metastasis detection remains to be resolved.

Isosulfan blue causes factitious methemoglobinemia in an infant

A 9 month-old girl was given subcutaneous isosulfan blue to outline lymphatic channels during surgery for thoracic duct ligation. Her pulse oximetry values rapidly declined to a nadir of 85%, 35 min after dye injection. Arterial blood gases revealed methemoglobinemia ([MetHb] = 6.5%). Although abnormal pulse oximetry has already been reported in association with isosulfan blue, methemoglobinemia has not previously been reported. The absorption spectrum for isosulfan blue was determined and when superimposed on that of methemoglobin it was found to have an overlying peak. Interference by the dye was postulated to have caused the abnormal methemoglobin result. The phenomenon was simulated in vitro by adding isosulfan blue to whole blood, and analysing it in the same blood gas analyser as was used for the case, as well as another for comparison. One blood gas analyser reported elevated methemoglobin concentration and the other did not. The samples were sent to a reference laboratory using a chemical method to detect methemoglobin to confirm that the elevated methemoglobin level was spurious.

Sentinel Node Mapping With Isosulfan Blue Dye in Endometrial Cancer

OBJECTIVE

To determine the feasibility of sentinel node mapping in endometrial cancer using hysteroscopic injection of isosulfan blue dye.

METHODS

Sixteen patients with endometrial cancer were enrolled in this pilot study. Hysteroscopy was performed at laparotomy to locate the tumour. Isosulfan blue dye was injected into the endomyometrium around the tumour by hysteroscopy, into the serosa overlying the tumour, or both. Blue lymph nodes were removed as sentinel nodes. Pelvic lymphadenectomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy were then performed.

RESULTS

Dye uptake into lymphatics occurred in 13 of the 16 cases (81%). Blue lymph nodes were identified in five cases with serosal injection alone (56%) and in two cases with combined serosal and hysteroscopic injection (50%). No blue lymph nodes were identified with hysteroscopic injection alone. The overall sentinel node identification rate was 44%, and the negative predictive value was 86%.

CONCLUSION

Although the concept of sentinel node mapping in endometrial cancer is appealing, the technique of hysteroscopic injection of isosulfan blue dye alone had minimal success in this study. Alternative methods should be explored.

Anaphylaxis to isosulfan blue dye during sentinel lymph node biopsy

We describe a case of intraoperative anaphylaxis resulting from isosulfan blue (IB) dye, an agent being increasingly used for identification of sentinel lymph nodes. A 45-year-old woman undergoing a left mastectomy with sentinel lymph node biopsy under general endotracheal anesthesia developed severe intraoperative hypotension and tachycardia 10 minutes after subcutaneous injection of IB dye for lymphatic mapping. This was associated with a reduction in pulse oximeter reading to 89%. She was successfully resuscitated using 1 mg of epinephrine intravenously (IV). Invasive arterial and central venous pressures were initiated; her lymph node biopsy was concluded, but the rest of her procedure was canceled. Postoperative workup revealed a high tryptase level indicative of an intraoperative anaphylactic reaction most probably related to the IB dye. Isosulfan blue dye can act as an antigen, causing a full-blown intraoperative anaphylactic reaction. Early recognition and aggressive hemodynamic interventions can reduce morbidity and mortality.

Lymphatic mapping and sentinel node detection in gynecologic malignancies of the lower genital tract

The utility of lymphatic mapping and sentinel lymph node biopsy in malignancies of the female lower genital tract-- vulvar, vaginal, and cervical cancers--is being explored in multiple centers internationally. For patients with these tumors, lymphatic mapping with sentinel lymph node biopsy holds the promise of increasing the identification of microscopically metastatic disease while decreasing the morbidity of complete lymphadenectomy. In this review article we present the published data on mapping techniques and discuss the advantages and pitfalls of these procedures.

Study of lymphatic mapping and sentinel node identification in early stage cervical cancer

OBJECTIVE

The aim of our study was to compare the identification of sentinel lymph nodes (SLN) by blue dye and (99m) Tc; to evaluate detection rate per patient and specific side detection rate (SSDR) of SLN, distribution of SLN and distribution of positive SLN and false negative rate of the methods.

PATIENTS AND METHODS

From February 2000 until September 2004, we included 183 women with early stage cervical carcinoma. We evaluated two methods of detection of SLN (100 cases by Patent blue, 83 cases by Patent blue with (99m)Tc). We stratified the group upon the size of the tumor and upon the type of surgical method (laparoscopy, laparotomy).

RESULTS

SLN identification increased in cases when we used combination of both methods (Tc + blue dye) SSDR = 93% versus the use of blue dye only SSDR = 71% (OR:5,76, CI 95% -2.9 -11.4, <0.0001). Distribution of 462 SLN-45.0% external iliac artery and vein, 42.6% supraobturator, 4.8 bifurcation and common illiac artery and vein, 4.6% praesacral, 3% medial part of lateral parametrium. Distribution of 44 positive SLN-approximately 38.6% external illiac artery and vein, 45.5% supraobturator, 6.8% bifurcation and common illiac artery and vein, 4.5% praesacral, 4.5% medial part of lateral parametrium. One false negative SN was in presacral area.

CONCLUSION

Detection of SLN by combination of (99m)Tc and blue dye was statistically significantly better than blue dye alone. Our study documents high sensitivity, specificity and low false negativity of the method.

Sentinel lymph node mapping in colon and rectal cancer: its impact on staging, limitations, and pitfalls

Sentinel lymph node (SLN) mapping has been widely applied in the staging of solid neoplasms including colon and rectal cancer. Since the first reported feasibility study in 1997, there have been numerous publications validating SLN mapping as a highly accurate and powerful upstaging technique for colon and rectal cancer. In addition to refining the technical aspects of this procedure, these studies have investigated the use of other tracers and operative techniques, while determining the indications, limitations, and pitfalls of SLN mapping in patients with colorectal cancers. This chapter reviews the rationale for performing SLN mapping for the accurate staging of colon and rectal cancers, and provides a brief review of the historical background of the development of the procedure. Landmark publications, which have contributed to the current status of the technique, are discussed. We will focus on the technical details of the procedure, and on the pathological evaluation of the specimen and the SLNs. The various tracers and techniques of SLN mapping in colon and rectal cancer will be discussed. We have performed SLN mapping in more than 240 consecutive patients over the past 7 years. The success rates for identifying at least one SLN for colon and rectal cancer were 100% and 90.6%, respectively. The accuracy rates were 95.8% and 100%, respectively. In terms of upstaging, 32.3% of colon cancer patients with nodal metastases and 16.7% of rectal patients with nodal metastases were upstaged by the detection of micrometastases found in the SLNs only. Finally, we will also discuss the current role as well as the future research directions for SLN mapping in colon and rectal cancer.

Sentinel lymph node mapping technique in colon cancer

Current conventional surgical and pathological techniques substantially understage colon cancer. This is evidenced by the fact that a significant subset of patients who are stage I and II at the time of colectomy return with distant metastases and ultimately succumb to the disease within the next 5 years. The identification of more nodes within a specimen and the detailed analysis of lymph nodes with advanced pathological techniques such as immunohistochemistry and reverse-transcriptase polymerase chain reaction (RT-PCR) can improve the staging of colon cancer, but are also associated with tremendous financial, time, and labor constraints. Sentinel lymph node (SLN) mapping has provided an avenue of staging colon cancer with high success rates and accuracy rates, while maintaining cost- and time-effectiveness. The ability to reproduce these results is dependent on adherence to the technical details of the procedure, and thereby providing the pathologist with the true SLNs, upon which the advanced pathological studies can be applied. We report our experience of SLN mapping for colon tumors in 209 patients, elaborating on the materials used, technical details, pitfalls, and results of the procedure. Our results show a success rate of 100% (209/209) and an overall accuracy rate for predicting positive or negative metastatic disease of 96.2% (201/209). Nodal metastases were identified in 46.2% (85/184) of patients with invasive disease (stage T1 to T4). The SLN was the exclusive site of metastases in 38.8% (33/85) of these patients, and the nodal disease was detected only as micrometastases in 22.4% (19/85). The skip metastases rate (false negatives) was 9.4% (8/85). SLN mapping is a powerful tool for accurate staging of colon cancer with a high success rate. The upstaging associated with this procedure may reveal disease that might otherwise go undetected by conventional surgical and pathological methods. Those patients who are upstaged can then benefit from adjuvant chemotherapy, which has been shown to improve survival of colon cancer patients with nodal disease by at least 33%.

Lymphazurin 1% versus 99mTc sulfur colloid for lymphatic mapping in colorectal tumors: a comparative analysis

BACKGROUND

The combination of isosulfan blue (Lymphazurin) 1% and 99(m)Tc sulfur colloid (TSC) may improve the feasibility and accuracy of lymphatic mapping for colorectal cancer.

METHODS

At laparotomy, 1 to 2 mL of isosulfan blue and 1 mCi of TSC were injected subserosally. Sentinel lymph node (SLN) designation was based on blue staining for isosulfan blue and increased radioactivity for TSC. Focused pathologic analysis of the SLNs and standard pathologic examination of the remaining specimen were performed.

RESULTS

A total of 57 consecutive patients were studied (median age, 71 years; 27 men and 30 women). Mapping was successful in 100% of patients with isosulfan blue and in 89% with TSC (P =.47). Lymphatic mapping was accurate in 93% of patients with isosulfan blue versus 92% with TSC (P =.53). The combined accuracy was 95%. A total of 709 lymph nodes were found (12.4 per patient): 553 non-SLNs (5.6% nodal positivity) versus 156 SLNs (16.7% nodal positivity; P <.0001). Isosulfan blue detected 152 SLNs, TSC detected 100, and both modalities detected 96. Of the SLNs detected by isosulfan blue only, 10.7% had nodal metastases, whereas 19.8% of SLNs detected with both modalities had nodal metastases (P =.028). Nodal disease was detected in 41% of patients with invasive carcinoma. Metastases were detected only in the SLNs in 26% and only by micrometastases in 11% of these patients.

CONCLUSIONS

These data confirm the efficacy of isosulfan blue and TSC for SLN mapping in colorectal tumors. No significant difference with respect to feasibility or accuracy exists between isosulfan blue and TSC. The metastatic yield is significantly higher in SLNs identified by both modalities compared with isosulfan blue only.

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.

Factitious Oxygen Desaturation after Isosulfan Blue Injection

Profound pulse oximetery desaturations are observed following isosulfan blue dye injection during breast sentinel node biopsy. The objective of this study was to examine the effect isosulfan dye has on oxygenation status and the reliability of pulse oximetery in evaluating this parameter. After study design, institutional review board approval was obtained. A prospective 5-month study was performed between January and April 2002. Twenty-one women with invasive breast cancer were monitored during breast sentinel node biopsies. Twenty-two operative cases were analyzed by pulse oximetry and arterial catheterization to record oxygen saturation. Time intervals of analysis were 0, 5, 10, 20, 30, and 40 minutes following injection of isosulfan blue dye. Simultaneous pulse oximetry and arterial blood gas analysis allowed comparison of indirect oximetry oxygen saturation (SpO2) to actual arterial oxygen saturation (SaO2). SpO2 values were decreased from baseline values at 10, 20, and 30 minutes without decrease in SaO2 saturation ( P < 0.001). The mean oximetry SpO2 desaturation was 5.6 per cent, with a range to 9 per cent. After injection with isosulfan blue dye, a significant SpO2 desaturation occurs. Clinicians must be aware of the factitious effect isosulfan blue dye has on SpO2 monitoring, to assess accurately the oxygenation status of the anesthetized patient.

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.

Staining of endotracheal tube with isosulfan blue dye after sentinel node mapping: a case report

Sentinel node mapping is successfully performed for the detection of cancer and nodal metastasis. There is a reported complication rate of 1.5%, most being mild allergic reactions, with a few rare reported cases of anaphylaxis. Isosulfan blue has been found to routinely create a modest artifactual desaturation via pulse oximetry, as well as a transient skin discoloration that may last for several hours to weeks. It causes discoloration of urine and has been detected in other body secretions, none of which have been found to be of clinical significance. This is a case report involving a 61-year-old woman who underwent sentinel node mapping and axillary dissection for breast adenocarcinoma. On postoperative extubation, the endotracheal tube was noted to be stained dark blue with isosulfan dye. This unusual complication is unreported to date and is likely the result of systemic absorption of the dye.

Intraoperative Hepatic Lymphatic Mapping in Patients with Liver Metastases from Colorectal Carcinoma

The survival of patients undergoing liver resection for colorectal metastases is poor in the presence of extrahepatic disease. Therefore identification of periportal and celiac lymph node metastases is central to proper patient selection. In this study we examined the technique of intraoperative hepatic lymphatic mapping with isosulfan blue dye in humans. Intrahepatic dye injection was performed in patients undergoing surgical exploration for colorectal liver metastases. The location of all blue-stained lymphatics and lymph nodes was recorded. All stained and unstained lymph nodes were biopsied for pathologic examination. Thirteen intraoperative lymphatic mapping procedures were performed in 11 patients. A blue-stained lymphatic was visualized in 11 of 13 injections (85%). A blue lymph node was visualized in seven of 13 injections (54%). Three of the seven blue nodes (43%) were not detected by the surgeon before the mapping procedure. There were no complications associated with the intrahepatic dye injections. All biopsied lymph nodes were negative for metastatic tumor. We conclude that intraoperative hepatic lymphatic mapping with isosulfan blue dye is a simple, rapid, and safe technique in humans. It may serve as an adjunct to random lymph node biopsy for the identification of periportal and celiac nodal metastases before liver resection in patients with metastatic colorectal carcinoma.

Lymphatic mapping and sentinel node identification in patients with cervix cancer undergoing radical hysterectomy and pelvic lymphadenectomy

PURPOSE

The purpose of this study was to determine the feasibility of sentinel node identification in patients with invasive cervix cancer undergoing radical hysterectomy and pelvic lymphadenectomy using preoperative and intraoperative lymphatic mapping.

PATIENTS AND METHODS

Thirty-nine patients at two institutions were enrolled onto this institutional review board-approved study. All underwent preoperative lymphoscintigraphy and intraoperative lymphatic mapping with blue dye and a handheld gamma probe. Radical hysterectomy was aborted in four patients because metastatic disease was discovered on frozen section analysis of the sentinel node.

RESULTS

Preoperative lymphoscintigraphy revealed at least one sentinel node in 33 patients (85%), including 21 (55%) with bilateral sentinel nodes. All 39 patients had at least one sentinel node identified intraoperatively. Eighty percent of sentinel nodes were in three pelvic locations: iliac, obturator, and parametrial (in descending order of frequency). The remaining sentinel nodes were in the common iliac and para-aortic nodal basins. A total of 132 nodes were identified clinically as sentinel nodes; 65 (49%) were both blue and hot, 35 (27%) were blue only, and 32 (24%) were hot only. Eight patients (21%) had metastatic disease. In five of these patients, sentinel nodes were the only positive lymph nodes. One patient had false-negative sentinel nodes. She had four microscopically positive parametrial nodes that were resected in continuity with the uterus. The sensitivity of the sentinel node was 87.5% and the negative predictive value was 97%.

CONCLUSION

Preoperative lymphoscintigraphy and intraoperative lymphatic mapping were highly successful at identifying sentinel nodes in patients undergoing radical hysterectomy.

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

BACKGROUND

Sentinel lymph node biopsy (SLNB) is an alternative to axillary dissection for many breast cancer patients. Cases of anaphylactic reaction to the isosulfan blue dye used during SLNB have recently been reported. No study on the incidence of serious anaphylactic reactions during SLNB for breast cancer has been reported.

METHODS

We reviewed 639 consecutive SLNBs for breast cancer performed at our institution. Sentinel lymph node biopsy was performed using both isosulfan blue dye and technetium-99m sulfur colloid. Cases of anaphylaxis were reviewed in detail.

RESULTS

Overall, 1.1% of patients had severe anaphylactic reactions to isosulfan blue requiring vigorous resuscitation. No deaths or permanent disability occurred. In patients with anaphylaxis, hospital stay was prolonged by a mean of 1.6 days. In 1 patient, the anaphylactic reaction required termination of the operation.

CONCLUSIONS

Prompt recognition and aggressive treatment of anaphylactic reactions to isosulfan blue are critical to prevent an adverse outcome. Lymphatic mapping with blue dye should be performed in a setting where personnel are trained to recognize and treat anaphylaxis.

Sentinel nodes in gynecologic malignancies

The concept of sentinel node identification and lymphatic mapping is already established as part of standard practice in the surgical management of breast cancer and melanoma. To reduce extensive radical procedures and decrease morbidity in gynecologic malignancies, much effort is being focused on implementing less aggressive interventions. By combining the use of radioactive tracers and blue dyes, investigators are identifying sentinel nodes. In vulvar and cervical carcinomas, sentinel node identification may significantly reduce the number of patients undergoing unnecessary, extensive lymphadenectomy in the absence of disease. The addition of novel techniques, such as histopathologic ultrastaging, immunohistochemistry staining, and reverse transcriptase polymerase chain reaction assays, will help increase the accuracy and rate of detection of disease.

Hepatic lymphatic mapping: a pilot study for porta hepatis lymph node identification

The status of the porta hepatis lymph nodes in patients with hepatic metastases from colorectal cancer affects their prognosis and management. Lymphatic mapping with isosulfan blue dye is well established in breast cancer and melanoma. An animal model consisting of three dogs receiving general anesthesia was utilized. Each dog underwent a laparotomy and increasing doses of isosulfan blue dye were injected into the right medial segment of the liver. Intraoperatively, the presence of blue dye in the porta hepatis region was determined and the lymph node identified. Continuous physiological monitoring was performed. Serum determination of liver function tests, amylase levels, and white blood cell count were performed preoperatively and on postoperative days 1, 2, 4, and 7. The animals were sacrificed on day 7. A portal lymph node was identified in each case and there was no perioperative morbidity or mortality. There were no significant alterations in blood pressure or heart rate in the animals. There was a dose-responsive decrease in the O2 saturation as measured by transcutaneous monitoring, but arterial blood gas analysis showed that pO2 levels remained stable. There were no significant changes in the liver function tests, amylase levels, or white blood cell counts. There was a small increase in alkaline phosphatase, which normalized by postoperative day 7. Hepatic injection of isosulfan blue dye appears to be safe and effective in identifying porta hepatis lymph nodes in the animal model and sets the basis for further study in human subjects.

Intraoperative decrease in pulse oximeter readings following injection of isosulfan blue

PURPOSE

Sentinel lymph node mapping, involving injection of isosulfan blue dye around a tumour, is beginning to be used in patients with carcinoma of the breast. Absorption of the dye into the circulation may interfere with pulse oximetry, causing falsely low readings. This report describes changes in pulse oximeter readings following injection of isosulfan blue for sentinel lymph node mapping in a patient with carcinoma of the breast.

CLINICAL FEATURES

An 83-yr-old female patient underwent sentinel node biopsy of the axilla followed by partial mastectomy for carcinoma of the left breast. Isosulfan blue was injected in the area of the tumour in the left breast. The SpO2 began to decrease 15 min after dye injection, reaching a nadir of 89-90% 30 min after injection. Arterial blood gas analysis showed normal arterial partial pressure of oxygen. Pulse oximeter readings did not return to normal until more than six hours after dye injection.

CONCLUSION

Review of the literature reveals a small number of case reports of similar occurrences of low pulse oximeter readings following injection of isosulfan blue or patent blue dye for lymphatic mapping. Data from these reports and the case described here suggest that the latency, magnitude and duration of effect on pulse oximeter readings following injection of these dyes is highly variable. It is important to rule out other causes of low pulse oximeter readings when this effect occurs; normal oxygenation can be verified with arterial blood gas analysis. Co-oximetry can be done to rule out methemoglobinemia as a cause of decreased SpO2.

Intraoperative lymphatic mapping in cervix cancer patients undergoing radical hysterectomy: A pilot study

OBJECTIVE

Intraoperative lymphatic mapping and sentinel lymph node identification (SLN) have been increasingly evaluated in the treatment of a variety of solid tumors, particularly breast cancer and melanoma. We sought to evaluate the feasibility of these procedures in patients undergoing radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer.

METHODS

Twenty patients with normal-appearing lymph nodes underwent intracervical injection of isosulfan blue dye (lymphazurin 1%) at the time of planned radical hysterectomy and bilateral pelvic/low paraortic lymphadenectomy (40 nodal basins). Regional lymphatic tissue was inspected for dye uptake into lymphatic channels and lymph nodes. Tumor characteristics, surgical findings, and specific locations of lymphatic dye uptake were recorded and correlated with final pathology results.

RESULTS

Sentinel lymph nodes were identified in 12 of 20 (60%) patients. A total of 23 sentinel nodes were identified in 17 of 40 (43%) nodal basins dissected (range: 0-2 per basin). Successful SLN identification was less likely in patients with tumors >4 cm compared with those with tumors </=4 cm (P = 0.035). Of 4 patients with metastatic nodal disease, 3 had tumor involving a SLN; the fourth had no identifiable SLN (inadequate study). In all, 3 of 8 lymph nodes with confirmed metastatic disease were identified using this technique.

CONCLUSION

SLN identification and intraoperative lymphatic mapping are feasible and safe. Lymphatic dye uptake appears to be less reliable in patients with larger tumors. Although sentinel node pathology was representative of the lymphatic basin sampled in all cases, the rate of SLN identification was low with this technique. Lymphatic mapping procedures should be further investigated in the treatment of early cervix cancer.

Adverse reactions to isosulfan blue during selective sentinel lymph node dissection in melanoma

BACKGROUND

Selective sentinel lymph node (SLN) dissection can spare about 80% of patients with primary melanoma from radical lymph node dissection. This procedure identifies the SLN either visually by injecting isosulfan blue dye around the primary melanoma site or by handheld gamma probe after radiocolloid injection.

METHODS

During selective SLN mapping, 1 to 5 ml of isosulfan blue was injected intradermally around the primary melanoma. From November 1993, to August 1998, 406 patients underwent intraoperative lymphatic mapping with the use of both isosulfan blue and radiocolloid injection. Three cases of selective SLN dissection, in which adverse reactions to isosulfan blue occurred, were reviewed.

RESULTS

We report three cases of anaphylaxis after intradermal injection with isosulfan blue of 406 patients who underwent intraoperative lymphatic mapping by using the procedure as described above. The three cases we report vary in severity from treatable hypotension with urticaria and erythema to severe cardiovascular collapse with or without bronchospasm or urticaria.

CONCLUSIONS

In our series, the incidence of anaphylaxis to isosulfan blue was approximately 1%. Anaphylaxis can be fatal if not recognized and treated rapidly. Operating room personnel who participate in intraoperative lymphatic mapping where isosulfan blue is used must be aware of the potential consequences and be prepared to treat anaphylaxis.