pISSN 1738-6756   eISSN 2092-9900
Open Access, Peer-reviewed
    J Breast Cancer. 2007 Sep;10(3):223-229. Korean.
    Published online Sep 30, 2007.
    https://doi.org/10.4048/jbc.2007.10.3.223
    Copyright © 2007 Korean Breast Cancer Society
    Original Article

    The Experiences of Performing Sentinel Lymph Node Biopsies with the Use of Methylene Blue Dye in Patients with Invasive Breast Carcinoma

    Hee-Moon Song, Yang-Soo Lim, Min-Hee Jeong,1 Sun-Mi Paik,2 and Jin-Gu Bong3
      • Department of Surgery, Wallace Memorial Baptist Hospital, Busan, Korea.
      • 1Department of Pathology, Wallace Memorial Baptist Hospital, Busan, Korea.
      • 2Department of Radiology, Wallace Memorial Baptist Hospital, Busan, Korea.
      • 3Department of Surgery, Catholic University of Deagu, Deagu, Korea.
    Received July 09, 2007; Accepted August 16, 2007.

    Abstract

    Purpose

    Isosulfan blue has been traditionally used as a tracer to map the lymphatic system during identification of the sentinel lymph node (SLN). However, this vital dye is difficult to obtain in Korea. Radioisotopes such as technetium-labeled sulfur colloid or albumin colloid are also expensive and complex to use. The purpose of this study is to evaluate usefulness of a sentinel lymph node biopsy (SLNB) using methylene blue dye in breast cancer patients.

    Methods

    We evaluated the sentinel node mapping experience using methylene blue dye from July 2003 to January 2007. Fifty-eight patients with clinical T1-T2 breast cancer without palpable axillary lymph nodes were enrolled. All SLNs were submitted for intraoperative frozen section and hematoxyline and eosin (H & E) stain analysis. For the negative SLNs, serial sections of each SLN specimen were examined by permanent H & E staining and by immunohistochemical techniques (IHC) using cytokeratin. Regardless of the results of a frozen section for the SLNs, a backup level II or III axillary lymph node dissections (ALND) was performed.

    Results

    Of the 58 patients that underwent a SLNB using methylene blue dye, an SLN was identified in 56 patients (96.6%), and metastatic SLNs were detected in 14 cases. Axillary lymph node metastasis found in 18 out of 58 patients. Thus, the false negative rate for a SLNB was 22.2% (4/18). Two patients had a micrometastasis (pN1mi) and two patients had clusters of isolated tumor cells (pN0[i+]) that were identified in the SLNs by IHC with the additional use of cytoketatin. The sensitivity, specificity, and accuracy of the SLNBs were 77.8%, 100%, and 92.9%, respectively. The false negative rate improved with the accumulation of experience for performing a SLNB (12.5% vs 30.0%). The sensitivity, specificity, positive predictive value, and accuracy of preoperative ultrasonography (USG) for an axillary lymph node metastsis were 50.0%, 95.5%, 81.8% and 81.0% respectively.

    Conclusion

    Based on our initial experience, methylene blue dye is safe, inexpensive, and a readily available tracer for the SLN mapping, and it could be an effective alternative to the use of isosulfan blue dye for accurately identifying SLNs in early breast caner patients. We expected that the findings of preoperative USG could serve as useful adjuncts to a SLNB.

    Keywords
    Methylene blue; Sentinel lymph node; Breast cancer

    Figures

    Fig 1
    Stained lymphatics and lymph node during sentinel lymph node biopsy.

    Fig 2
    Ultrasonographic findings of metastatic axillary lymph node. This lymph node was not palpable. But, this round lymph node had increased vascular flow at perinodal area and cortex on doppler examination and did not display hilar structures.

    Fig 3
    Cytokeratin immunohistochemical staining of sentinel lymph nodes. (A) isolated tumor cells (pN0[i+]) (×400) and (B)1.5 mm sized micrometastasis (pN1mi) (×100).

    Tables

    Table 1
    Clinicopathologic characteristics of patients of the study (N=58)

    Table 2
    Numbers of identified sentinel and axillary lymph nodes

    Table 3
    Sentinel and axillary lymph node status on permanent sections (N=56)

    Table 4
    Metastatic lymph nodes found in sentinel and nonsentinel lymph nodes

    Table 5
    Outcomes of sentinel lymph node biopsy in learning periods and after learning periods

    Table 6
    Correlation* between USG findings of axillary lymph node and pathologic results

    References

      1. Cunningham DK, Mancino AT, Edwards MJ. Axillary staging. In: Singletary SE, Robb GL, Hortobagyi GN, editors. Advanced Therapy of Breast Disease. 2nd ed. Hamilton: BC Decker Inc; 2004. pp. 349-360.
      1. Whitworth P, McMasters KM, Tafra L, Edwards MJ. Stage-of-the-art lymph node staging for breast cancer in the year 2000. Am J Surg 2000;180:262–267.
      1. The Korean Breast Cancer Society. Nationwide korean breast cancer data of 2004 using breast cancer registration program. J Breast Cancer 2006;9:151–161.
      1. Simmons R, Thevarajah S, Brennan MB, Christos P, Osborne M. Methylene blue dye as an alternative to isosulfan blue dye for sentinel lymph node localization. Ann Surg Oncol 2003;10:242–247.
      1. Eldrageely K, Vargas MP, Khalkhali I, Venegas R, Burla M, Gonzalez KD, et al. Sentinel lymph node mapping of breast cancer: a case-control study of methylene blue racer compared to isosulfan blue. Am Surg 2004;70:872–875.
      1. Masannat Y, Shenoy H, Speirs V, Hanby A, Horgan K. Properties and characteristics of the dyes injected to assist axillary sentinel node localization in breast surgery. Eur J Surg Oncol 2006;32:381–384.
      1. Tuttle TM. Technical advances in sentinel lymph node biopsy for breast cancer. Am Surg 2004;70:407–413.
      1. Yang WT, Chang J, Metreweli C. Patients with breast cancer: Differences in color Doppler flow and gray-scale US features of benign and malignancy axillary lymph nodes. Radiology 2000;215:568–573.
      1. Lee CS, Bong JG, Park JH, Lee YS, Paik SM, Shin MJ, et al. The accuracy of the physical examination, mammography, and ultrasonography in the assessment of tumor size and axillary lymph node metastasis in breast cancer patient. J Korean Breast Cancer Soc 2003;6:87–94.
      1. Giuliano AE, Male PS, Turner RR, Morton DL, Evans SW, Krasne DL. Improved axillary staging of breast cancer with sentinel lymphadenectomy. Ann Surg 1995;222:394–401.
      1. Wong JH, Cagle LA, Morton DL. Lymphatic drainage of skin to a sentinel lymph node in a feline model. Ann Surg 1991;214:637–641.
      1. Tsopelas C, Sutton R. Why certain dyes are useful for localizing the sentinel lymph node. J Nucl Med 2002;43:1377–1382.
      1. Giulliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994;220:391–401.
      1. O'Hea BJ, Hill AD, El-Shirbiny AM, Yeh SD, Rosen PP, Coit DG, et al. Sentinel lymph biopsy in breast cancer: initial experience of Memorial Sloan-Kettering Cancer Center. J Am Coll Surg 1998;186:423–427.
      1. Derossis AM, Fey J, Yeung H, Yeh SD, Heerdt AS, Petrek J, et al. A trend analysis on the relative value of blue dye and isotope localization in 2,000 consecutive cases of sentinel node biopsy for breast cancer. J Am Coll Surg 2001;193:473–478.
      1. Hill AD, Mann GB, Borgen PI, Cody HS. Sentinel lymph node mapping in breast cancer. J Am Cancer Soc 1999;188:545–549.
      1. Simmons RM, Smith SM, Osborne MP. Methylene blue dye as an alternative to isosulfan blue dye for sentinel lymph node localization. Breast J 2001;7:181–183.
      1. Cimmino VM, Brown AC, Szocik JF, Pass HA, Moline S, De SK, et al. Allegic reactions to isosulfan blue during sentinel node biopsy-a common event. Surgery 2001;130:439–442.
      1. Thevarajah S, Huston TL, Simmons RM. A comparison of the adverse reactions associated with isosulfan blue versus methylene blue dye in sentinel lymph node biopsy for breast cancer. Am J Surg 2005;189:236–239.
      1. Montgomery LL, Thorne AC, Van Zee KJ, Fey J, Heerdt AS, Gemignani M, et al. Isosulfan blue dye reactions during sentinel lymph node mapping for breast cancer. Anesth Analg 2002;95:385–388.
      1. Stradling B, Aranha G, Gabram S. Adverse skin lesion after methylene blue injections for sentinel lymph node localization. Am J Surg 2002;184:350–352.
      1. BIT Druginfo. [accessed Jul 5, 2007].
        http://www.druginfo.co.kr.
      1. Tafra L, McMasters KM, Whitworth P, Edwards MJ. Credentialing issues with sentinel lymph node staging for breast cancer. Am J Surg 2000;180:268–273.
      1. Lee CS, Bong JG, Park JH, Lee YS, Paik SM, Jeong MH, et al. The accuracy of the physical examination, mammography, and ultrasonography in the assessment of tumor size and axillary lymph node metastasis in breast cancer patient. J Korean Breast Cancer Soc 2003;6:87–94.
      1. Hwang SE, Moon WK, Cho N, Han WS, Kim SW, Shin HJ, et al. Preoperative evaluation of lymph node metastasis with using ultrasonography for examining the axilla in early stage breast cancer. J Breast Cancer 2006;9:115–120.
    MeSH Terms
    Biopsy*
    Breast Neoplasms*
    Breast*
    Colloids
    Eosine Yellowish-(YS)
    Frozen Sections
    Hematoxylin
    Humans
    Keratins
    Korea
    Lymph Node Excision
    Lymph Nodes*
    Lymphatic System
    Methylene Blue*
    Neoplasm Metastasis
    Neoplasm Micrometastasis
    Radioisotopes
    Sensitivity and Specificity
    Sentinel Lymph Node Biopsy
    Sulfur
    Ultrasonography
    Metrics
    Share
    Figures
    slide
    slide
    slide

    1 / 3

    Tables
    slide
    slide
    slide
    slide
    slide
    slide

    1 / 6

    PERMALINK