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.     

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.     

Anaphylactic reaction to patent blue V after sentinel lymph node biopsy

BACKGROUND: We report a documented grade III IgE-mediated hypersensitivity reaction associated with the use of 2.5% patent blue V dye for sentinel lymph node biopsy during breast cancer surgery. METHODS: Immediately after the reaction, when hemodynamic stability was obtained, plasma histamine was measured whereas serum tryptase was not. Six weeks later, with the patient's consent, cutaneous tests to patent blue V dye, methylene blue dye, latex and all drugs used during surgery were performed according to standardized procedures. RESULTS AND CONCLUSION: Clinical symptoms, biological assessment results and cutaneous tests positivity confirmed the onset of an anaphylactic reaction due to patent blue V. Of interest, the positivity of the cutaneous tests observed with patent blue V was not found with methylene blue which might be proposed for further investigations in our patient. This case report confirms the need for systematic allergological investigation of all drugs and substances administered during the peri-operative period in case of an immediate hypersensitivity reaction occurring during anesthesia.     

应用亚甲蓝行乳腺癌前哨淋巴结活检276例分析

目的 探讨以亚甲蓝作为示踪剂行乳腺癌前哨淋巴结(SLN)活检的临床应用及影响因素.方法 分析了276例临床T1-T2 N0-M0乳腺癌患者前哨淋巴结活检(SLNB)结果,对SLN检出率及假阴性率影响因素进行了初步分析.结果 276例患者中,成功检出SLN者246例(检出率为89.1%).共检出SLN 423枚,每例1～4枚.前哨淋巴结对腋窝淋巴结转移情况预测的敏感性为77.3%(68/88),假阴性率为8.1%(20/246),假阳性率为0,准确率为91.9%(226/246).临床T2N0M0SLNB成功率高于临床T1N0M0乳腺癌患者(P=0.046);年龄<50岁者SLNB检出成功率高于年龄≥50岁病例(P=0.000),SLNB假阴性率年龄<50岁者显著低于高龄患者(P=0.037);外上象限和外下象限肿瘤SLNB检出成功率明显高于其他象限(P=0.000).内上象限肿瘤SLNB假阴性率高于外上及外下象限(P=0.018).临床TMN分期、EB、PR表达情况及病理类型对SLNB成功率及假阴性率无影响.结论 以亚甲蓝作为示踪剂行乳腺癌SLNB,患者年龄、临床TNM分期、肿瘤部位对SLN检出率有一定影响,患者年龄、肿瘤部位可影响SLNB假阴性率.     

手术中蓝染法鉴别前哨淋巴结及其意义

目的 探讨手术中用亚甲蓝染色法鉴别乳癌前哨淋巴结（SLN）的可行性及准确性。方法 术中于癌块周围注射1％亚甲蓝4－6ml,5-10min后开始手术，凡术中发现被蓝染的淋巴结即认定为SLN，单独切除送病检；相应腋窝行淋巴结清扫，所得淋巴结既为非SLN，亦送常规病检。结果 50例中发现SLN者45例，检出率为90.0%；45例中SLN共计117枚，其中位于第Ⅰ站淋巴站111枚，占95.0%，位于第Ⅱ站淋巴结6枚，占5.0%。在鉴别SLN失败的5例中，4例癌块位于下象限，仅1例癌块位于上象限（P＜0.05），而与癌块大小之间差异无显著意义（P＞0.05）。SLN病检结果预测腋窝状况的准确率达91.0%；4例SLN病检阴性，但非SLN病检阳性，假阴性率为8.9%。结论 术中亚甲蓝染色法能较准确鉴别SLN；SLN可准确反映乳癌患者腋窝状况。SLN与原发癌瘤的位置有关，而与其大小及以胶是否行乳腺手术无关。     

非溶脂腔镜技术在乳腺外科中的应用及展望

<正>使用腔镜的外科技术开始于腹部外科,运用于乳腺手术最早开始于1992年,Kompatscher~([1])首先报道了使用腔镜行乳房内挛缩假体取出术。目前,已经广泛应用于乳腺腺体的切除、腋窝淋巴结的清扫、乳腺重建手术等乳腺外科领域。腔镜技术的一个很明显的优势在于切口小,可以将手术切口很好地隐蔽起来,使得患者对术后的接近自然的切口外观更加满意;同时,还具有术后疼痛比较轻、住院时间缩短的优点。腔镜技术的难点在于手术腔隙的建立,目前常用的方法有牵拉法和二氧化碳法。     

乳腺癌前哨淋巴结亚甲蓝示踪活检术的临床价值

采用 2 %亚甲蓝作示踪剂 ,经根治术同一切口 ,对 85例I～IIIa期乳腺癌患者进行前哨淋巴结活检 (SLNB)。结果示SLNB的成功检出率为 90 .6% (77/85 ) ,准确性为 96.1% (74/77) ,假阴性率为 3 .9% (3 /77)。SLN的转移阳性率为 3 6.4% (2 8/77) ,阴性率为 63 .6% (4 9/77) ,与腋窝淋巴结 (ALN )的转移阳性率 (3 8.8% ,3 3 /85 )和阴性率 (61.2 % ,5 2 /85 )均无统计学差异 (P >0 .0 5 )。SLNB失败的 8例中 ,原发肿瘤位于内上象限 4例 ,中央部 2例 ,外下和外上象限各 1例。假阴性 3例均为T2 N1 期 ,原发肿瘤位于外上象限 ,经洞式探查发现腋尖组 (III组 )淋巴结均有转移。提示应用亚甲蓝示踪的SLNB ,可准确预测乳腺癌ALN的病理学状态。洞式探查III组淋巴结 ,可以弥补SLNB出现假阴性的不足     

国产亚甲蓝行早期乳腺癌前哨淋巴结活检的观察

目的：探讨前哨淋巴结活检术（sentinel lymph node biopsy，SLNB）反映早期乳腺癌腋淋巴结转移情况，并指导临床腋淋巴结阴性（cN0）乳腺癌腋窝淋巴结清除范围的可行性。方法：使用国产1％亚甲蓝对120例cT1.2N0M0期乳腺癌病人进行前哨淋巴结活检，于原发肿瘤边缘上、下、左、右选取4个注射点．将1％亚甲蓝4m1分别注射到乳腺实质及皮下组织内，已行术中活检则注射于残腔壁周围及其表面的皮下组织内。注射后从注射点向腋窝方向轻按摩5～10min，以利于淋巴管和淋巴结的染色，随后行乳腺癌改良根治手术或保乳手术。SLN常规HE染色病理检查．阴性者通过免疫组化方法行淋巴结微转移检查。结果：确定SLN87例，成功率为72．50％。SLNB的特异度为100％．假阳性率为0％，假阴性率为1．5％，准确率为98．85％；阴性前哨淋巴结的微转移率为4．44％。结论：前哨淋巴结转移状况基本上可反映乳腺癌腋淋巴结转移的状况；SLNB有望成为指导cN0，期乳腺癌腋淋巴结清除范围的方法。     

Early experience of sentinel lymph node biopsy in breast cancer with blue dye technique

Objective: Sentinel lymph node biopsy (SLNB) is a minimally invasive staging procedure for breast cancer. Results of the first 30 cases of SLNB performed at Kwong Wah Hospital, Hong Kong, were reviewed. Design: This feasibility study applied and assessed a new procedure in Chinese patients. The study was carried out at the Breast Centre, Kwong Wah Hospital, Hong Kong. Sentinel lymph node biopsy was performed with a blue dye technique alone. All patients had full axillary dissection after SLNB. Patients: Female patients with invasive carcinoma of breast and no clinical palpable axillary lymph node were included. Main outcome measures: Pathological results of both the SLN and the remaining axillary content were compared. Results and Conclusion: Sentinel lymph nodes were successfully biopsied in 83% of cases. Sensitivity was 75% and accuracy was 88%. With experience, sentinel lymph node biopsy is feasible in Chinese patients.     

Meta-analysis of sentinel lymph node biopsy in breast cancer.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is a minimally invasive way to diagnose axillary lymph node (ALN) metastases in breast cancer. The most important features are ability to identify the SLN (I.D. rate), how often the SLN and ALN pathology match (concordance), and how often the SLN is negative for cancer when the ALNs are positive (false negative). Technique and patient criteria for SLNB vary among studies. This study performed meta-analysis of published studies to determine the I.D., concordance, and false negative rate (1) overall and for (2) both blue dye and radiocolloid, (3) the injection method, (3) palpable and nonpalpable ALNs, and (4) invasive and in situ disease. METHODS: Inclusion criteria were patients with breast cancer who had SLNB followed by ALN dissection with H&E staining. Meta-analysis was performed using analysis of variance with each observation weighted inversely to its variance. P < 0.05 was considered significant. RESULTS: Eleven studies (n = 912) met the inclusion criteria. Overall, 762 (84%) SLNs were identified, concordance was 747/762 (98%), and 15/296 (5%) were falsely negative. Highest I.D. rates (P < 0.05) were reported with albumin radiocolloid or dye + radiocolloid (97 and 94%, respectively), with injection around an intact tumor (96%), with invasive cancer (95%), and in the clinically negative axilla (96%). Concordance and false negative rates did not vary. CONCLUSIONS: The SLN can be identified in over 97% of patients if certain techniques and inclusion criteria are used. SLNB reflects the status of the axilla in 97% of cases and has a 5% false negative rate.     

Allergic reaction to nanocolloid during lymphoscintigraphy for sentinel lymph node biopsy

Editor—We read with interest the case report by Stefanuttoand colleagues,¹ concerning an anaphylactic reaction to isosulphanblue dye during routine sentinel lymph node biopsy for breastsurgery. We agree that anaesthetists must be aware of the potentialserious risks of anaphylaxis in this group of patients. However,this is not a new finding; anaphylaxis to the blue     

Axillary lymph node clearance in patients with positive sentinel lymph node biopsy

Introduction

The use of adjuvant radiotherapy is standard practice following breast conserving surgery and mastectomy in selected patients. Prospective clinical trials are currently being designed to assess the effect of omitting axillary lymph node clearance (ALNC) in selected patients. The aim of this study was to identify the percentage of patients understaged and not considered for postmastectomy radiotherapy (PMRT) and/or supraclavicular fossa radiotherapy (SCFRT) with positive sentinel lymph node (SLN) macrometastasis if the proposed prospective trial inclusion/exclusion protocols are followed.

Methods

A total of 38 women who were found negative for axillary metastases preoperatively but positive at SLN biopsy and who had ALNC were analysed. PMRT or SCFRT was offered to patients if ≥4 positive lymph nodes (including sentinel nodes) were positive for macrometastasis and/or a tumour size of ≥5cm was detected. Fisher’s exact test was used to determine the statistical significance of omitting ALNC.

Results

The mean age of the 38 patients was 55 years. A fifth (21.1%) of patients had T1, 76.3% had T2 and 2.6% had T3 disease. The percentage of positive SLNs was 52.6% (1 node), 34.2% (2 nodes) and 13.1% (3 nodes). The number of positive nodes at clearance was 0–3. If the inclusion criteria for trials that consider omitting ALNC are followed (eg POSNOC trial), 23.7% of patients (p=0.0001) with ≥4 positive nodes (including SLNs) would not be offered SCFRT and PMRT. Similarly, if multicentric disease were to be excluded from the trial criteria, the proportion of undertreated patients would reduce by 15.7%.

Conclusions

Our study has shown a significant risk of missing patients for PMRT or SCFRT if no ALNC is offered in the presence of SLN macrometastasis. Tumour multicentricity is an important factor in predicting high axillary nodal involvement. Consequently, exclusion of T2 tumours with multicentric involvement in trials considering omitting ALNC may be more appropriate.     

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.