The Application of 1% Methylene Blue Dye As a Single Technique in Breast Cancer Sentinel Node Biopsy

Summary

In Indonesia, sentinel node biopsy (SNB) is not routinely performed for breast cancer surgery because of the limitation to provide radioisotope tracer and isosulfan or patent blue dye (PBD). To overcome this obstacle, we applied 1% methylene blue dye (MBD) as a single agent to map the sentinel nodes (SNs).

Abstract

In this study, we injected 1% methylene blue dye (MBD) into the subareolar or peritumoral space of the breast. In the case of breast conserving surgery (BCS), a separate incision in the lower axilla hairline was made to find the sentinel nodes (SNs). In mastectomy, the SNs were identified through the same mastectomy incision. The SNs were described as blue nodes or nodes with lymphatic blue channels. An anatomical landmark in the axilla was used to facilitate SNs identification. The SNs metastases were evaluated by intraoperative frozen section analysis and histopathology examination as it is a gold standard. Here, we described the MBD as the lone technique in breast cancer sentinel node biopsy (SNB) which could be useful when radioisotope tracer or patent or isosulfan blue dye (PBD) cannot be provided.

Introduction

The status of axillary lymph nodes (ALNs) metastasis is the most important prognostic factor in breast cancer. Axillary lymph node dissection (ALND) was the conventional procedure to assess metastatic status of ALNs^1,2. Unfortunately, ALND results in morbidities to the patients which decreases the quality of life, especially by increasing the risk of lymphedema after this procedure^3,4. Nowadays, sentinel node biopsy (SNB) has replaced ALND for axillary staging because of its minimal morbidities among patients⁵. The most common m....

Protocol

All procedures including human subjects have been approved by Dharmais Cancer Hospital Ethics Committee with certificate number of 040/KEPK/VII/2017. All patients signed the consent forms and expressed agreement to participate in this study.

NOTE: The inclusion criteria are patients with diagnosis of early breast cancer, with tumor stage T1-T2 without palpable and ultrasonography lymph nodes enlargement (cNo). The exclusion criteria are locally advanced breast cancer, received neo adjuvant chemo or hormonal therapy, and pregnancy.

1. Preparation of 1% methylene blue dye and the injection technique

1. Ste....

Results

Here, we describe the results from the presented technique. Two milliliters of 1% MBD were injected at the deep subareolar space as the standard technique of injection (Figure 1A). If the peritumoral injection is indicated, it should be performed under ultrasound guidance (Figure 1B). The blue nodes or lymphatic blue tracts were seen after entering the axillary space. Following the lymphatic blue tracts lead to finding the SNs (<.......

Discussion

In the modern era of breast cancer surgery, SNB has replaced ALND as the standard of care for axillary staging in early breast cancer and ALND should be abandoned if the SNs are free from metastasis^14,15. The lymphatic mapping technique which is commonly used in developed countries is the application of radioisotope tracer and PBD as a combined or single technique^16,17. The question on how to perform SNB .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Metiblo 50mg/5ml	Laboratories Sterop NV	BE475217	Methylene Blue Dye
Disposable syringe with needle - 3mL (Luer Lock Tip)	Terumo Europe NV	dvr-3414	Syringe for Injection
ForceTriad energy platform	Medtronic	ForceTriad	Surgical cautery
Shandon Cryomatrix embedding resin	Thermo (scientific)	6769006	Frozen Section
Cryotome FSE	Thermo (scientific)	77210153
HistoStar Embedding Workstation	Thermo (scientific)	A81000001	Histopathological Examination
Finesse Me+	Thermo (scientific)	A77510272
Gemini AS	Thermo (scientific)	A81500002
Benchmark GX	Ventana Medical Systems	750-850	Immunohistochemistry
Benchmark XT	Ventana Medical Systems	750-700
Microscope	Olympus	Model BX53
Ultrasound	Phillips	HD 7XE